Pediatric Lyme Disease

Pediatric Lyme DiseaseInfections and children seem to go hand in hand (seriously, their little hands are like petri dishes!). We have covered many common infections (ex, Abscess, Pneumonia, Otitis Externa, UTI)and some unusual ones as well (ex, Rabies, Mumps, Measles). Aside form the common vectors (i.e., kids putting everything in their mouths) there are also other unique vectors to consider when dealing with infections in children, particularly in the Summer months. Tick Related infections (ex, RMSF, Tick Paralysis) are formidable foes and warrant our vigilance. Let us review another tick borne illness that is becoming more prevalent: Lyme Disease.

 

Lyme Disease: Basics

  • ~30,000 cases of Lyme disease occur each year in the US.
    • More than 90% occur in two regions: [Orloski, 2000]
      • Northeast (Mid-Atlantic and New England states)
      • North Central (Wisonsin and Minnesota)
    • The geographic regions involved are expanding! [Lantos, 2017]
    • Travel to endemic areas also influences patients involved.
  • Lyme disease is caused by spirochete:
    • Borrelia burgforferi sensu stricto in the US
    • Borrelia afzelii and Borrelia garinii in Europe and Asia
  • Vector is the Ixodes scapularis tick.
  • School-aged children and adolescents are at greatest risk (cuz they like to play in the woods).

 

Lyme Disease: Presentations

  • Clinical presentation in the US differs from that of Europe and Asia.
  • In the United States, Lyme disease has three distinct stages: [Lipsett, 2016]
    • Early – single erythema migrans lesion
    • Early Disseminated – multiple erythema migran lesions, cranial nerve palsy, and carditis
    • Late – arthritis
  • Early Disease [Lipsett, 2016]
    • Erythema migrans is the initial presenting sign.
      • Appears within first 1-2 weeks after tick bite.
      • Expanding annular region of redness
      • May have a peripheral ring that is slightly paler.
      • May have small vesicles or ulcers in center.
    • Majority of untreated early disease will have later manifestations.
    • Can be mistaken for cellulitis, contact dermatitis, local insect bite reaction, or erythema multiforme.
  • Early Disseminated Disease [Lipsett, 2016]
    • Majority of patients will not have a known tick exposure.
    • May develop systemic manifestations:
      • Carditis
      • Cranial Nerve Palsy
        • Unilateral or Bilateral facial nerve palsy (Bell’s Palsy) is the most common cranial neuritis associated with Lyme disease.
        • CN 6 palsy and optic neuritis have also been seen.
        • Unilateral/bilateral facial nerve palsy in a child in an endemic area and no history of HSV – think Lyme and consider empiric antibiotics.
      • Meningitis [Lipsett, 2016]
        • Can cause aseptic meningitis.
        • Consider this with subacute headache in endemic area.
        • “Rule of 7’s”  – 3 predictors of high-risk for Lyme meningitis
          • 7 days (or more) of symptoms
          • 7th CN (or other) palsy
          • 70% (or greater) CSF mononuclear cells
      • Other Neurologic Involvement (Neuroborreliosis)[Celik, 2016]
  • Late Disease [Lipsett, 2016; Bachur, 2015]
    • ~60% of untreated Lyme disease will develop late disease / arthritis.
    • Can develop after days or months.
    • Typically is a monoarticular arthritis.
    • Most commonly the knee, but also seen to affect the hip in children.
    • Can be present similarly to septic arthritis.
      • Unlike septic arthritis, can be treated with oral antibiotics and without surgical intervention.
      • In endemic areas, isolated hip effusion is more likely to be Lyme disease than septic arthritis if: [Cruz, 2017]
        • No history of fever
        • Decreased WBC count

 

Lyme Disease: Diagnosis

  • The presence of erythema migrans is sufficient to make the diagnosis of Lyme disease.
  • If erythema migrans is not seen, then diagnosis requires a two-tiered serologic testing strategy to detect antibody response to Borrelia species (i.e., we are not making the definitive diagnosis in the ED).
    • Step 1 – Enzyme Immunoassay (EIA) or Immunofluorescence assay
    • If Step 1 positive or equivocal, perform Step 2.
    • Step 2 – IgG Western Blot, add IgM Western blot if symptoms < 30 days
  • Testing should not be done if there is a low pretest probability. [Lipsett, 2016; Rouster-Stevens, 2014]
    • Non-specific symptoms (ex, fatigue, malaise) should not lead to investigation on their own.
    • False positives are more likely in these cases.

 

Moral of the Morsel

  • Remain vigilant! EM providers play an important role in detection of this disease!
  • Don’t test haphazardly! Fatigue alone does not warrant Lyme testing! False positives can be harmful also.
  • In endemic area and new arrhythmia, cranial nerve palsy, arthritis? Consider Lyme disease.

 

References

Cruz AI Jr1, Aversano FJ, Seeley MA, Sankar WN, Baldwin KD. Pediatric Lyme Arthritis of the Hip: The Great Imitator? J Pediatr Orthop. 2017 Jul/Aug;37(5):355-361. PMID: 26469686. [PubMed] [Read by QxMD]

Applegren ND1, Kraus CK2. Lyme Disease: Emergency Department Considerations. J Emerg Med. 2017 Jun;52(6):815-824. PMID: 28291638. [PubMed] [Read by QxMD]

Lantos PM1,2, Tsao J3,4, Nigrovic LE5, Auwaerter PG6, Fowler VG7, Ruffin F7, Foster E8, Hickling G9. Geographic Expansion of Lyme Disease in Michigan, 2000-2014. Open Forum Infect Dis. 2017 Jan 9;4(1):ofw269. PMID: 28480261. [PubMed] [Read by QxMD]

Celik T1, Celik U2, Kömür M1, Tolunay O3, Yildizdas RD4, Yagci-Kupeli B5, Kücük F3, Eroglu İ3. Pediatric Lyme Neuroborreliosis: Different clinical presentations of the same agent; Single center experience. Neuro Endocrinol Lett. 2016;37(2):107-13. PMID: 27179572. [PubMed] [Read by QxMD]

Bachur RG1, Adams CM2, Monuteaux MC2. Evaluating the child with acute hip pain (“irritable hip”) in a Lyme endemic region. J Pediatr. 2015 Feb;166(2):407-11. PMID: 25444013. [PubMed] [Read by QxMD]

Rouster-Stevens KA1, Ardoin SP, Cooper AM, Becker ML, Dragone LL, Huttenlocher A, Jones KB, Kolba KS, Moorthy LN, Nigrovic PA, Stinson JN, Ferguson PJ; American College of Rheumatology Pediatric Rheumatology Core Membership Group. Choosing Wisely: the American College of Rheumatology’s Top 5 for pediatric rheumatology. Arthritis Care Res (Hoboken). 2014 May;66(5):649-57. PMID: 24756998. [PubMed] [Read by QxMD]

Feder HM Jr1. Lyme disease in children. Infect Dis Clin North Am. 2008 Jun;22(2):315-26, vii. PMID: 18452804. [PubMed] [Read by QxMD]

Orloski KA1, Hayes EB, Campbell GL, Dennis DT. Surveillance for Lyme disease–United States, 1992-1998. MMWR CDC Surveill Summ. 2000 Apr 28;49(3):1-11. PMID: 10817483. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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3 Responses

  1. Brisson Muia says:

    Very comprehensive approach to lyme disease approach

  2. Over 300,000 cases your numbers are wrong and that is a low estimate

  1. August 23, 2017

    […] Pediatric Lyme on Pediatric EM Morsels […]

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