Internal Medicine

0521779407-13 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:15

Lyme Disease 929

management

■If tick available, identify as Ixodes (2–4 mm with black legs and red

body); if still attached, remove with fine tweezers by pulling firmly on

the mouth where it enters the skin; tick analysis to see if it is infected

not indicated

■Prophylactic antibiotics NOT indicated except in highly endemic

areas, following bite by nymphal or adult engorged Ixodes tick

■Serologic tests early in disease are often negative and should not be

done.

specific therapy

■Localized erythema migrans or disseminated erythema migrans

in the absence of third-degree heart block or neurologic

manifestations-doxycycline or amoxicillin for 14–21 days; cefurox-

ime axetil equally as efficacious, but more costly; macrolides less

effective and not recommended as first line therapy

■First and second-degree heart block treated as erythema migrans;

third-degree block treated with ceftriaxone for 14–21 days

■Bell’s palsy, if not associated with CNS involvement, treated like ery-

thema migrans; if associated with CNS involvement, ceftriaxone for

14–28 days (lumbar puncture may be required to determine if CNS

involvement present)

■Meningitis, encephalopathy and peripheral neuropathy treated with

ceftriaxone for 14–28 days; cefotaxime or penicillin (18–24 million

units in equally divided doses every 4 hours) are alternatives

■Arthritis treated initially with oral regimens of doxycycline or amox-

icillin for 28 days; failures or recurrences treated with ceftriaxone for

14–28 days

follow-up

■After adequate therapy of early disease, nonspecific symptoms

(fatigue, arthralgias, myalgias) may persist for weeks or months;

therapy is symptomatic – additional antibiotic therapy NOT indi-

cated

■Symptoms of arthritis slow to resolve; after initial therapy, if symp-

toms persist, wait several months before retreating; if symptoms per-

sist after second course of antibiotics, treat symptomatically, not with

additional or prolonged courses of antibiotics

■Coinfection with Ehrlichia species or Babesia microti, on rare occa-

sions, can cause prolonged symptoms and should be excluded.