• ... pre-neurologic symptoms (stage one) consisting of erythema chronicummigrans (ECM), fever, arthralgias, myalgias, malaise, and fatigue.

• ...[headaches] usually frontal or occipital, and itcharacteristically fluctuated in intensity over a period of weeks.
• ...signs often present inpurulent meningitis were absent.
• It should be stressed that meningitis may be the first manifestation of Lyme disease.
• ... mild encephalitic symptoms - lethargy, difficulty in concentrating, fatigue, emotional lability, irritability, and poor memory.
• Symptoms also varied from day to day but did not necessarilycorrelate with the severity of headache and stiff neck.
• Although a few patients madeoccasional mistakes in their mental status testing,none had a definite organic brainsyndrome, obtundation,or coma.
• Neither the CT scan nor the EEG was helpful insupporting the diagnosis of encephalitis.
• ... patients with encephalitic symptoms had abnormalelectroencephalograms, which showed mild generalized slowing or some sharp activity.
• LP consistently revealed a lymphocytic pleocytosis with normal opening pressure.
• Median CSF white count was 166 with a range of 5-700.
• Median protein was 79 with a range of 8-400.
• CSF glucose was usually normal.
• Intermittent diplopia without clinicaly evident extra ocular movement palsy.
• Intense pain or pressure within the distribution of dermatomes.
• Radiculoneuritis involved more than one extremity.
• Mononeuritis multiplex- different sites became affected days to weeks apart.
• Peripheral nerve lesions may occur at the root,plexus, or distal nerve.
• Denervation changes in the infraspinatus muscle.
• Neurological involvement may be confused with a number of other disorders.
• Most common misdiagnosis is viral meningitis which rarelyruns the protracted and relapsing course of Lyme meningitis.
• In Lyme radiculoneuritis,the Guillain-Barre syndrome has been considered.
• Three major types of lesions comprise the neurological manifestations of Lymedisease: meningitis, cranial neuropathy, and radiculoneuritis [1]. These three mayoccur alone or in combination.
  • We believe that this constellation of symptoms is unique among neurological diseases. (Yale)
• Half of the patients also had facial palsies, which were unilateral in 12 and bilateral in seven.
• In addition, 12 patients had motor and/or sensory radiculoneuropathies; asymmetric weakness of extremities was the most common finding.
• Although incomplete presentations of neurologic involvement of Lyme disease may be confused with other entities, the typical constellation of neurologic symptoms represents a unique clinical picture.
• Other relapsing-remittingdiseases like multiple sclerosis sometimes appear in the differential diagnosis.
• Headache and mild neck stiffness, which fluctuated in intensity, and lymphocytic pleocytosis were the common findings.
• Other relapsing-remittingdiseases like multiple sclerosis sometimes appear in the differential diagnosis.
• Lyme disease- nerve involvement is rarely ascending or symmetrical.
• In Lyme radiculoneuritis,the Guillain-Barre syndrome has been considered.
• Lyme disease- nerve involvement is rarely ascending or symmetrical.
• Meningitis, frequently accompanied by cranial and/orperipheral radiculoneuritis
• With all three antibiotic agents, nearly half of patients had minor late symptoms.
• Seven of the 20 penicillin-treated patients (35%) were apparently cured.
• Of 20 arthritis patients treated with intravenous penicillin G, 11 (55%) were apparently cured.
• All 3 stages of Lyme disease can be treated with antibiotic therapy, but some patients with late disease may not respond.
• Infectious-toxic nature of the condition.
• Late stage Lyme borreliosis can occur in children without a history of tick bite or ECM
• The arthritis syndrome can mimic oligoarticular juvenile rheumatoid arthritis
• The diagnosis of Lyme borreliosis depends upon clinical recognition
• Lyme keratitis characterized by multiple focal, nebular opacities at varying levels of the stroma which may progress to edema, neovascularization, and scarring.
• 10
• Brain biopsy specimen showed microgliosis without an inflammatory infiltrate and spirochetes morphologically compatible with Borrelia burgdorferi.
• All six patients had elevated antibody titers to B burgdorferi in serum, but none had selective concentration of specific antibody in the cerebrospinal fluid.
• All six patients were treated with high-dose intravenous penicillin; four had complete recoveries and two did not.
• Lyme disease may affect the central nervous system causing organic brain disease or syndromes suggestive of demyelination.
• Lyme disease is a multisystem infectious, inflammatory, and immune-related disorder.
• Neurological symptoms can occur from weeks to many years following the primary infection and can be quite devastating.
• The majority of patients will not recall a tick bite or characteristic rash.
• When the nervous system has been affected by Lyme disease, aggressive antibiotic treatment is usually necessary, often using IV preparations.
• Usually, there will be significant improvement following the use of antibiotics, but there are some patients who will continue to have persistent, probably irreversible, nervous system abnormalities.
• Children aged five to 14 years had the highest incidence.
• 20
• Of persons with arthritis, 92 percent of those less than 20 years of age, compared to 68 percent of older persons, did not have antecedent erythema migrans.
• Affected joints were the knee (89 percent), hip (9 percent), shoulder (9 percent), ankle (7 percent),and elbow (2 percent).
• The positivity rate for the first serum specimen for those with erythema migrans was only 30 percent by IFA and 24 percent by ELISA.
• In view of the low sensitivities of serologic testsduring early Lyme disease, it is particularly important for physicians to re-evaluateclinical data when antibodies are not detected.
• Seropositive children with aseptic meningitis and without initial signs of an infectious aetiology should be checked for a neuroborreliosis even when CSF negative in the first lumbar puncture.
• A 3-year-old boy with typical clinical features of Lyme disease, including erythema chronicum migrans and arthritis... the clinical picture evolved into juvenile chronic myelocytic leukemia.
• Lyme borreliosis is the main cause of peripheral facial palsy in childhood.
• All cases of facial palsy with a tick bite and/or an erythema migrans in the head-neck region showed ipsilateral neurological affection suggesting direct invasion via the affected nerve by Borrelia burgdorferi.
• Only about 50% of patients with longstanding (1 to 12 months) untreated EM were IgG seropositive.
• Lyme disease during pregnancy- the child was born with a ventricular septal defect.
• Of six affected children, two had hyperbilirubinaemia, one muscular hypotonia, one was underweight for gestational age, one was macrocephalic, and one had supra ventricular extrasystoles.
• Acute hemorrhagic leukoencephalitis with renal insufficiency that had been diagnosed at the terminal stage.
• Convulsions, hemiplegia and consciousness disorders... detection of IgM and IgG specific serum antibodies raised against Borrelia burgdorferi.
• Tick-borne annular erythema (TAE) are much like those of Laim disease.
• Lyme borreliosis affecting the central nervous system does exist.
• Early diagnosis of children with Lyme is difficult- the bite of the ixodid tick often goes unnoticed.
• Erythema chronicum migrans occurs in less than 50% of cases.
• Brief intermittent attacks of swelling and pain in one or more joints.
• In most cases, pain is not severe enough to debilitate the patient or prevent weight-bearing activity.
• An elevated sedimentation rate is the only consistently abnormal routine laboratory finding in Lyme disease.
• 40
• Lyme disease shares symptoms in common with septic arthritis and juvenile rheumatoid arthritis.
• Erythema chronicum migrans (63%), neurological involvement (47%) and arthritis (22%), frequently in combination.
• Lyme disease can also involve the brain parenchyma.
• First manifestation was an acute, focal meningoencephalitis with signs and symptoms such as fever, headache, slurred speech, hemiparesis, seizure, and CSF pleocytosis.
• 17 patients presented with acute Lyme disease and received prompt treatment with oral antibiotics, but chronic Lyme disease subsequently developed.
• Clinically active disease- none had diagnostic levels of antibodies to B. burgdorferi.
• On Western blot analysis reactivity against B. burgdorferi from chronic Lyme patients was no greater than that in serum from normal controls.
• Presence of chronic Lyme disease cannot be excluded by absence of antibodies against B. burgdorferi.
• 58 (64%) developed neurological abnormalities and four (4%) patients developed monoarticular or oligoarticular arthritis.
• Lyme disease is now recognized as an infectious process capable of involving multiple organs including the cardiovascular system.
• 50
• Symptomatic heart block may be the sole presenting complaint of Lyme Disease in children.
• Oligoarthritis appearing in part of the leg where the cutaneous or neurological complications, or both, of Lyme disease developed before arthritis.
• Twenty nine patients had neurological disorders as the only manifestation of Lyme disease.
• Patients with neuropsychiatric manifestations, focal CNS lesions, or profound fatigue appearing in the third stage of Lymedisease, many months to years after the initial infection.
• Arthritis was the presenting feature in more than half of the children.
• Half of the children had initially consulted an orthopaedic surgeon, none of whom made the correct diagnosis.
• Sweden- Skin lesions were of longer duration (median 5-6 weeks), but less often multiple (8%) than in the USA.
• 72 patients with erythema migrans disease (EMD) had 1 to 10 constitutional symptoms besides the erythema migrans.
• Patients with ACA developed signs and symptoms consistent with neurologic, cardiac and joint involvement, and 2 had a history of erythema migrans disease (EMD).
• 60
• Borreliae were found in brain and liver of a newborn.
• Early erythema migrans disease (EMD) appears to be quite similar to early Lyme disease.
• Spirochetes were localized in dermal papilles and subepidermal zones of skin sections of ECMA, in lymph vessels and collagen fibres.
• In synovia of patients with arthritis spirochetes were found beneath the synovial lining cells and perivascularly.
• In the lymphnode of patient with arthritis and lymphadenitis spirochetes were localized in and round the blood vessels and in the lymph vessels.
• (52%) children had no history of erythema chronicum migrans or other rash.
• Temperatures as high as 41 degrees C (105.8 F) for up to 2 months before the onset of arthritis.
• Ten (40%) children, seven had no rash, were hospitalized for presumed septic arthritis.
• Four had diagnoses of pauciarticular juvenile rheumatoid arthritis for as long as 3 years.
• Seven patients had less acute, recurrent episodes of synovitis.
• 70
• Two children had seventh nerve palsies 2 months before onset of arthritis.
• Lyme arthritis may be confused with acute bacterial septic arthritis or recurrent "pauciarticular juvenile rheumatoid arthritis".
• Individuals with ECM rash who are treatedimmediately develop Lyme diseaseantibody only 40 per cent to 50 per cent of the time.
• In many instances the diagnosis is a clinical rather than a serologic one.
• Clinical expressions of the disease vary widely.
• Some patients have very mild disease and others develop severe and prolonged illness.
• Different subtypes of this organism may infect man.
• Most commonly affecting the brain or meninges, other skin sites, lymph nodes, or joints.
• Of 40 blood cultures, only one, from a patient with disseminated infection, yielded spirochetes.
• Due to low yield of cultures and delay in antibody response, recognition of clinical picture remains very important in diagnosing early Lyme disease.
• 80
• Spirochetes were seen in and around blood vessels.
• Lyme spirochete may survive for years in affected synovium and may be directly responsible for the microvascular injury.
• Nonspecific villous hypertrophy, synovial cell hyperplasia, prominent microvasculature, lymphoplasmacellular infiltration, and sometimes lymphoid follicles.
• Larger surgically obtained specimens also showed striking deposition of fibrin in synovial stroma and a form of endarteritis obliterans.
• Joint involvement is typically intermittent and oligoarticular.
• Lyme may become chronic, with erosion of cartilage and bone.
• Lyme synovia often showed greater proliferative changes in arterioles.
• Spirochetes were seen near these vessels (arterioles).
• Joint involvement was intermittent, but became chronic (>6 months) in the knees.
• Vascular microangiopathy, which resembled lupus"onion-skinning"inspleens,was seen.
• 90
• Spirochetes were seen within edematous vascular beds and in vessel walls.
• This finding implies that that the Lyme spirochete may survive for years in affected synovium.
• Chronic, with erosion of cartilage and bone.
• The importance of a sufficient antibiotic therapy to prevent late manifestations is stressed.
• Although there are many similarities between erythema chronicum migrans Afzelius and Lyme disease, the results of the present study also point to differences.
• Decreased suppression may permit damage to tissues because of autoimmune phenomena or a heightened response to the Lyme spirochete.
• (75%) had single EM lesions, 13 patients (25%) had multiple lesions.
• Meningitis, cranial neuropathy, and radiculoneuritis, alone or in combination, lasting for months.
• NO good statements
  • CDC, Yale, et. al- The recent description of Amblyomma americanum as a probable vector.
  • 1985- "Rare disease"

• Another name for it- 1985
• erythema chronicum migrans Afzelius
• Medication side effects
• Ceftriaxone-induced autoimmune hemolytic anemia
• Ceftriaxone- Sonographical evidence for ceftriaxone induced cholelithiasis after a treatment of at least 10 days
• Doxycycline was associated with more photo-sensitivity reactions and cefuroxime axetil with more diarrhea and Jarisch-Herxheimer reactions.

HOW NOT TO DO A STUDY!

Community of Health Sciences Study, Sweden- In this study we required not only a positive result on a routine ELISA, but also verification with a second ELISA before a case was included as Lyme disease.

Community of Health Sciences Study, Sweden- Patients with arthralgia, myalgia, and the fibromyalgia syndrome alone were excluded.

Community of Health Sciences Study, Sweden- Headache, fatigue, paresthesia, or mild neck stiffness alone was not accepted as evidence of neurologic involvement.

Community of Health Sciences Study, Sweden- Palpitations, bradycardia, bundle-branch block, and myocarditis as single symptoms were not accepted.

Community of Health Sciences Study, Sweden- Cases with negative Western blots were excluded.

Community of Health Sciences Study, Sweden- Twenty-seven of 85 patients had negative Western blot tests and were therefore classified as not having Lyme disease.

Community of Health Sciences Study, Sweden- A lumbar puncture was performed in 284 of 369 patients with neurologic symptoms.

Community of Health Sciences Study, Sweden- Patients with increased numbers of lymphocytes had no detectable antibodies to B. burgdorferi in cerebrospinal fluid or in serum and were therefore classified as not having Lyme disease.

Community of Health Sciences Study, Sweden- Results/Conclusions- Most of the patients had benign symptoms.

Turku University Central Hospital, Finland- Only patients with culture- or PCR-proven disease were enrolled in the study.

Turku University Central Hospital, Finland- Avoid patients with post-Lyme syndrome (1993).

Just plain old nasty

The committee recommends that insurance companies do not pay for laboratory assessments that are not indicated.

In addition, the committee asks laboratories not to recommend further serological assessments after a few weeks or months when interpreting serological results.

The belief that chronic Lyme disease exists is not supported by the evidence. It is a disservice to patients with unexplained symptoms to pastethat label on them and treat them with potentially harmful long-termantibiotics. They are suffering, and they deserve our compassion and the bestthat science-based medicine has to offer, not bogus treatments by charlatans orwell-meaning but misguided LLMDs. American Lyme Disease Foundation (ALDF)

German Committee for Infectious Diseases and Vaccinations- The committee recommends that insurance companies donot pay for laboratory assessments that are not indicated.This includes serological tests without well-founded clinical suspicion, tests for borrelial antigens or genomicsequences in ticks, and lymphocyte transformation assays.

The committee recommends that insurance companies do not pay for laboratory assessments that are not indicated.

In addition, the committee asks laboratories not to recommend further serological assessments after a few weeks or months when interpreting serological results.

Proof of spirochetes- children and/or adults

1985

Eyes- Blindness- Unilateral iritis followed by panophthalmitis- spirochetes found in specimens of vitreous debris obtained at surgery

Dangerous and Stupid

"Within endemic regions of the United States, selected states have higher Lyme rates, and within those states, there is significant variation by county. Our findings support a general approach of estimating clinical risk of disease at the point of care, accounting for recent spatial incidence.

This approach emphasizes applying epidemiologic context to the clinical decision making process rather than relying solely on history, physical exam, heuristics and preliminary diagnostic test results.9, 32, 33

Improved collaboration between public health departments and clinicians, the maturation of electronic health records, and advances in disease surveillance and automated reporting now increase the feasibility of delivering readily available and easily computed relevant public health information to clinicians at the point of care.34–36

An important goal of national efforts to promote health information technology should be to foster electronic bidirectional communication of data and messaging between public health and clinical sites."

Integrating Spatial Epidemiology into a Decision Model for Evaluation of Facial Palsy in Children

Link- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644029/

Costs

The mean cost estimate of CLD per patient in the US, of $16,199 per annum in 2002 dollars [8], reflects the toll on human health and cost to society. The annual per-patient cost of CLD is substantially higher than the cost for other common chronic illnesses: $10,911 for fibromyalgia [21], $ 10,716 for rheumatoid arthritis [21], and $13,094 for lupus [22]. Eighty-eight percent of the cost ($14,327) of Lyme disease consisted of indirect medical cost, nonmedical cost, and productivity losses. Cutting medical cost would save, at most, only 12% or $1,872 per annum. In 2002, the annual economic cost of LD in the US, based on the 23,000 cases reported to the CDC that year, was estimated to be $203 million [8]. Considering that the actual number of LD cases is believed to be 10 times higher than the number of cases reported to the CDC, the actual annual cost could be $2 billion [23, 24]. Source Here

The total cost of NB-related healthcare was estimated to be euro500,000 for the entire study group (euro3300 per patient), and the cost of social benefits was estimated to be euro134,000 (euro2000 per patient). Source Here

Pregnancy & Lyme

Syphilis and lyme borreliosis have similar etiologic, clinical, and epidemiologic characteristics- therapy of pregnant women with syphilis and lyme borreliosis should follow the same strategy.

Add to list

Statements Proven False or Counterproductive

Patients with chronic pain, fatigue, or mental state disturbances should not be tested for Lyme borreliosis.

Just plain old nasty

My notes

The authors conducted a selective review of the literature, including various national and international guidelines.