Lyme Disease: The Daily PANCE Blueprint
You notice this skin lesion (see picture below) on a patient who presents with flu-like symptoms. Which of the following would you use to treat this patient?
A. IV Penicillin G
B. Oral Doxycycline
C. Oral metronidazole
D. Oral Azithromycin
Answer and topic summary
The answer is B: Oral Doxycycline
The lesion shown is erythema migrans seen in the early stage of Lyme disease. Doxycycline is used in treating the early stage (erythema migrans) of Lyme disease. Amoxicillin and cefuroxime axetil can also be used.
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Pearls
Transmission via tick bite (Ixodes) → enters blood → spreads to tissues and organs; especially joints, heart, nervous system
The infection progresses through three stages
Localized disease
- (occurs 3–30 days after exposure) – Non-painful, gradually expanding erythema migrans (EM) “bull’s-eye” rash appearing at the site of tick bite; feels warm to palpation; may itch; Constitutional: Low-grade fever, chills, headache, fatigue, myalgia, arthralgia, lymphadenopathy
Disseminated disease
- (days to months after exposure; multisystem involvement): musculoskeletal, flu-like syndrome, consisting of malaise, fatigue, chills, fever, headache, stiff neck, myalgias, and arthralgias that may last for weeks, cardiac (AV block).
Late/chronic disease
(months to years after exposure): Presence of nonspecific symptoms (e.g. headache, fatigue, joint pain) that persists after treatment for Lyme disease
Diagnosis
CDC testing criteria – Two-tiered testing for Lyme disease
- First test: enzyme immunoassay (EIA) or immunofluorescence assay (IFA)The second test (as needed): IgM and/or IgG western blot
Other laboratory findings
- Blood chemistry:↑ ESR, serum creatine phosphokinase, aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT)Blood studies: Anemia, leukocytosis, thrombocytopenia
Treatment
Antibiotic treatment with doxycycline or amoxicillin (10-21 days) is started immediately after diagnosis.
- Prophylaxis: doxycycline 200 mg x 1 dose within 72 hours if Ixodes tick
- Amoxicillin or cefuroxime are the medications of choice for early localized Lyme disease when doxycycline is contraindicated such as in pregnant women or children less than 8 years old
- For patients with late Lyme neurologic disease – intravenous therapy with ceftriaxone, cefotaxime, or penicillin G. The typical duration of therapy is 28 days
Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Infectious Disease (6%) ⇒ ⇒
