A Quick Synopsis of AFP's "Diagnosis and Management of Lyme Disease"

Diagnosis and Management of Lyme Disease
WILLIAM F. WRIGHT, DO, MPH; DAVID J. RIEDEL, MD; ROHIT TALWANI, MD; 
and BRUCE L. GILLIAM, MD, University of Maryland, Baltimore, Maryland
Am Fam Physician. 2012 Jun 1;85(11):1086-1093. 
http://www.aafp.org/afp/2012/0601/p1086.pdf

    Lyme disease is a tick-borne infection of Borrelia burgdorferi from the deer tick Ixodes scapularis. It is commonly found in wooded areas of the northeast US as well as Wisconsin and Minnesota. It occurs more often in the late spring and summer. Once the tick attaches to the skin, it begins to swell with blood. After 36-48 hours,the tick can infect the patient with the spirochete.  
     There are three stages of lyme disease. The early localized stage begins within 2 weeks after exposure. Symptoms include the the "bulls eye" rash of erythema migrans and nonspecific symptoms such as fever, chills, malaise, headache, myalgia, and fatigue. If untreated, it can progress to an early disseminated stage, which includes heart, skin, muscle and neurologic symptoms.  Cardiac involvement can present as chest pain, dyspnea on exertion, fatigue, palpitations, or syncope. AV block may occur as well. Musculoskeletal symptoms include arthralgia, myalgia, and joint swelling. An inflammatory process may present in the synovial fluid over time. Neurologic symptoms are seen in a classic triad of meningitis, cranial neuropathy, and radiculopathy. Involvement may also be seen as neck pain, headaches, facial nerve palsy and ataxia. Late stage lyme disease may present as chronic arthritis or severe neurologic symptoms such as encephalopathy and peripheral neuropathy. 
     Diagnosis can be made with a history of a tick bite and the classic rash, without lab tests. As far as lab tests are concerned, direct methods include testing for specific proteins and nucleic acids, and indirect  methods includes serology and antibody detection. Cultures are no longer performed. When testing is needed, the EIA is performed first with a confirmatory western blot to be done afterwards. It is important to remember that both IgG and IgM will be present in the patient for years and does not an indication of disease course. Treatment it typically doxycycline. Ceftriaxone, amoxicillin, cefuroxime, and azithromycin may be considered in special situations. 
    Prevention consist of avoiding tick infested areas such as forests and high grass areas. A tick check should be done after the activity as well as bathing within two hours of the event. Ticks, if found, should be removed with a tweezer placed as close to the skin as possible without squeezing the abdomen. For ticks that are engorged and that may have been attached for longer than 36 hours, prophylaxis antibiotics can be used (one dose of doxycycline 200 mg).