November 29, 2021
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Source:
Nigrovic LE. New guidelines for Lyme disease. Presented at: Symposium on Infectious Diseases in Children; 20.-21. November 2021; New York (hybrid meeting).
Disclosure:
Nigrovic says he serves as a consultant for Lyme disease studies conducted by Adaptive Biotechnologies and Tarsus Pharmaceuticals.
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Lyme disease affects more than 300,000 people annually, an expert told participants at the Infectious Diseases in Children Symposium.
The geographic distribution of Lyme disease is spreading, and without a vaccine, cases are increasing Lise E. Nigrovic, MD, MPH, a senior adjunct doctor in medicine at Boston Children’s Hospital and an adjunct professor of pediatrics and emergency medicine at Harvard Medical School, said. To help clinicians manage these patients, Nigrovic shared five key findings from guidelines recently published by the Infectious Diseases Society of America, the American Academy of Neurology, and the American College of Rheumatology.
At the Infectious Diseases in Children Symposium, an expert gave tips on how to implement the guidelines for Lyme disease.
Photo source: Adobe Stock
Post exposure prophylaxis
According to Nigrovic, doctors should consider prophylaxis in patients presenting with an Ixodes tick bite after the tick has been in place for about 24 hours. The guidelines recommend that adults receive a single dose of 200 mg doxycycline orally within 72 hours of removal of the tick, while children should start with a dose of 4.4 mg / kg and titrate to a maximum dose of 200 mg. This is a strong recommendation with medium-quality evidence, said Nigrovic.
Facial nerve paralysis
When patients present with facial palsy, “the first rule is to find out whether it is central or peripheral,” said Nigrovic. Patients with peripheral facial palsy lose movement of their eyebrows, forehead, and nasolabial folds; can’t close their eyes; and experience sagging eyelids and lower lips, according to Nigrovic. With central facial palsy, the eyebrow and forehead functions are not affected, she said.
The guidelines do not recommend the use of corticosteroids in conjunction with antibiotics in patients with Lyme disease-associated facial palsy. A current lack of evidence hinders any recommendation in this area, Nigrovic said.
“There are some studies going on to look into this more closely,” she said. “In northern Europe, where Lyme disease is also being observed, there was a study that just released a protocol and they are going to be taking in children with Lyme disease facial palsy to answer the question … but it will take a while . ”
Manifestations of the peripheral nervous system
The latest guidelines on Lyme disease also address neurological manifestations. According to Nigrovic, ceftriaxone, cefotaxime, penicillin G, or oral doxycycline should be used to treat Lyme disease-associated meningitis, cranial neuropathy, radiculoneuropathy, or other manifestations of the peripheral nervous system versus other antibiotics.
She said an important part of implementing this recommendation is distinguishing between aseptic meningitis and Lyme meningitis. The latter condition can be determined using the rule of sevens, Nigrovic said. This rule places children at low risk for Lyme disease-associated meningitis based on the absence of three factors: headache for 7 days or more, paralysis of the seventh or other cranial nerve, and mononuclear cell counts of 70% or more.
“The rule works pretty well,” said Nigrovic. “The sensitivity is 98% … the specificity was only moderate at 40%, but the negative predictive value is high at 100%.”
Lyme disease
Nigrovic noted that Lyme disease can cause carditis, which is often indicated by a prolonged QT interval.
In hospitalized patients with Lyme carditis, guidelines recommend iv ceftriaxone as the first line of treatment. Then, if evidence suggests the patient is getting better, oral antibiotics can be used, Nigrovic said.
Lyme arthritis
For patients with swollen joints, clinicians suspected of having Lyme disease should rule out septic arthritis before prescribing treatment, Nigrovic said.
Patients with septic arthritis usually have absolute neutrophil counts of 10,000 cells / mm3 or more and an erythrocyte sedimentation rate of 40 mm or more per hour, Nigrovic said.
For patients diagnosed with Lyme arthritis, the guidelines recommend oral antibiotics for 28 days. Doxycycline is used widely, Nigrovic said.
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