Consider the diagnosis of Lyme disease (LD) in any patient with arthritis
Consider the diagnosis of Lyme disease (LD) in any patient with arthritis: Excerpt from Avoiding Common Pediatric Errors
Author:
Sonya Burroughs, MD
What to Do - Interpret the Data
LD has become the most common vector-borne disease in North America.
The highest prevalence occurs in patients aged 2 to 15 years and 30 to 59
years. In the United States, most LD is localized to three highly endemic
areas: (a) the Northeast (Maine to Maryland), (b) the Midwest (Minnesota
and Wisconsin), and (c) the West (Northern California and Oregon).
LD or lyme borreliosis is caused by members of the genus Borrelia. B.
burgdorferi is the only species causing disease in the United States. B. afzelii
and B. garinii are the predominant species infecting humans in Europe and
Asia. B. burgdorferi is the most arthritogenic of the three Borrelia species that
result in human disease. Pathogenic Borrelia are carried and transmitted by
the Ixodes ricinus complex of ticks. The clinical manifestations of LD vary
based on the stage of infection. Infection is divided into three stages: early
localized, early disseminated, and late chronic. Table 113.1 provides the
clinical features at different stages.
Symptoms typically develop between 7 to 10 days after a tick bite, but
ranges of 1 to 36 days have been reported. The most common manifestation
in children is erythema migrans rash followed by arthritis, facial nerve palsy,
carditis, and aseptic meningitis.
Lyme meningitis in children may be subtle and usually occurs without
meningismus. The presentation typically involves less fever, when compared
with viral meningitis. As mentioned previously, arthritis is a common symptom found in LD. This diagnosis should be considered in any patient with
arthritis, especially if they live or have recently traveled to an endemic area.
Early diagnosis is essential because untreated infection may lead to more
advanced disease involving the heart, central nervous system, and joints.
Lyme arthritis may impersonate juvenile idiopathic arthritis. The
arthritis associated with LD is a monoarthritis or oligoarthritis, usually affecting the knee. Sudden pain and swelling with massive effusions are common, and attacks are usually intermittent. Even without antibiotic therapy,
arthritic flares due to LD gradually become less severe, occur less often,
and eventually resolve completely. It is distinctly rare to have flares beyond
5 years of the diagnosis. Juvenile idiopathic arthritis is a clinical diagnosis
made in a child younger than 16 years of age with arthritis for >6 weeks' duration, withotheridentifiable causesofarthritis excluded.Serology testing is
necessary to rule out a diagnosis of LD or other arthritic-causing infections
in the clinical scenario of arthritis.
The diagnosis of Lyme arthritis is based primarily on clinical findings.
An estimate of the likelihood of LD is based on geographic location and the
signs and symptoms of the patient, referred to as the pretest probability of
disease; it is a key factor in the diagnosis of this disease. It also assists with
the decision making on when to order tests and how to interpret laboratory
findings (Table 113.2).
When laboratory testing is utilized, enzyme-linked immunoabsorbent
assay (ELISA) is used primarily for screening, and the Western blot is used
as confirmation. Synovial fluid should be obtained from all patients with
suspectedLymearthritis.Whitebloodcellcountsofthesynovialfluidusually
ranges from 1,000 to 50,000 cells/mm.
Suggested Readings
DePietropaolo DL, Powers JH, Gill JM, et al. Diagnosis of Lyme disease. Am Fam Physician
2005;72:297–304.
Hu L. Lyme arthritis. Infect Dis Clin North Am. 2005;19:947–961.
Foy AJ, Studdiford J. Lyme disease. Clinics in family practice. 2005;7:191–208.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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