Case Study Presentation:Lyme Disease

By Ana Corona, FNP-C

More presentations @

www.nurseana.com

Objectives

1. Identify at least 3 signs and symptoms associated with Lyme Disease.

2. Describe at least 2 laboratory test to screen for Lyme Disease.

3. Understand the Pathophysiology of the disease.

4. Identify at least 2 preventive measures related to Lyme Disease.

Identifying Information

Patient Initials: H.R. Age: 10 year old Race: Hispanic Sex: Female Three Generation Genogram:

Subjective Data

Chief Complaint:

“My daughter has had a painful itching rash on her right thigh for 2 days”

“I am not feeling well”

History of Present Illness

OPQRST O= Other associated manifestations:

fever and joint pain P= Precipitating/palliating/aggravating factors:

Upon exertion Q= Quality/type of symptom:

Moderate R= Region/Radiation:

None S= Severity of symptoms:

6/10 (pain scale 1-10) T= Time of onset:

chief complaint began 2 days ago, 10 days after hiking trip

Review of Systems

Skin: visible rash with pain and itching present on right anterior mid thigh

Patient applied alcohol and petroleum jelly at affected area without relief.

Patient denies prior injuries. Denies eye, ears, nose and throat complaints. Denies cough, shortness of breath, or chest pain. Upper and lower extremities: complains of tenderness

on elbows and knees. Denies history of trauma. No edema present. Peripheral pulses: regular and

strong. Denies numbness, tingling, twitching or paralysis.

Relevant Past History

Allergies: no history of allergies Habits: likes to play outdoors Environmental exposure and pertinent travel:

Recent hiking trip 10 days ago. Illnesses, surgeries, traumas: denies Mental Health: alert and oriented Lifestyle Issues: child is a girl scout Family History: grandfather has diabetes Immunizations are up-to-date

Relevant Psychosocial History

Family Relations: Impact of illness on health and integrity of family:

mother very concerned due to low income. Values, beliefs, stressors: value family, cultural and

religious beliefs. Education: child is a student, 4th grader Economics, financial problems: underserved

population, unable to receive public assistance, uninsured,

Current living environment: family of 4 in a one bedroom home

Perception of illness: mother thinks child has leukemia

Objective Data: Physical Examination

Symmetrical facial features No bony deformities Eyes symmetrical, pupils equal, reactive to light Ears: non-tender mastoid process, canal walls pink and uniform with

tympanic membrane visible. Tympanic membrane intact, pearly gray shiny and translucent.

Oropharanx: tonsillar pillars are pink and symmetrical without exudate present.

No drooling or neck weakness present. Neck and Axillary Lymph nodes: pea size, mild tenderness present Lungs: bilateral clear, respirations regular in rhythm and rate. Heart: S1 S2, no audible murmurs present Abdomen: soft and subtle, no tenderness present, bowel sounds present

on all four quadrants. Musculoskeletal: mild tenderness on elbows and knees upon palpation, no

heat or deformities present. Skin warm to touch. Rash measures 50 cm; is warm to touch with tenderness upon palpation.

Objective Data:

Vital signs: Blood pressure

100/60 Pulse

92 Respirations

22 Temperature

100.8 F

What is Lyme Disease?

Infection caused by the bacterium Borrelia burgdorferi

Transmitted by the bite of certain species of ticks

The disease often starts as a skin rash and can progress to more serious stages involving joint, nerve, or heart tissue.

Lyme disease is the most common vector borne disease in the United States.

Lyme Disease: Pathophysiology

Lyme disease is caused by a coiled bacterium – a spirochete called Borrelia burgdorferi.

The bacterium enters the skin at the site of a tick bite and may spread in lymph, producing regional adenopathy, or disseminate in blood to organs or other skin sites.

Distribution of Lyme Disease

According to the Centers for Disease Control and Prevention (CDC), in 1996 there were 16,461 cases of Lyme Disease reported in the United States.

The majority of cases have occurred in four endemic regions: the Northeast, the Mid-Atlantic, Minnesota, Wisconsin, California and Oregon.

Animal Reservoirs

Immature ticks become infected by feeding on small rodents such as mice and also on other mammals: deer, birds, horses, dogs and cats that are infected with the bacterium Borrelia burgdorferi.

In later stages, these ticks then transmit the Lyme disease bacterium to humans and other mammals during the feeding process.

Lyme disease bacteria are maintained in the blood systems and tissues of small rodents.

Ticks

Tick Bite

Begins as a red macule or papule.

Usually on the proximal portion of an extremity or on the trunk (thigh, buttock, or axilla) between 3 and 32 days after a tick bite.

The area expands, often with central clearing to a diameter of up to 50 cm.

Objective Findings

The “Bulls eye” or Erythema Migrans (EM) rash is an early symptom of Lyme disease.

Usually appears 7 to 10 days after the bite of an infected tick.

Proper treatment with antibiotics is mandatory.

If untreated, Lyme disease may progress to chronic stage that can be disabling and difficult to cure.

Secondary Lesions

Soon after onset, nearly ½ of untreated U.S. patients develop multiple, lesions without indurated centers.

Cultures of biopsies of these secondary lesions have been positive, indicating dissemination of infection.

Lyme Disease: Late Stage

Over time the central portion of the rash may become necrotic or vesicular

During this stage, patients may complain of flu-like symptoms, such as fatigue, chills, fever, headache, muscle and joint pain.

Other symptoms may include regional lymphadenopathy, facial nerve paralysis and irregularities of heart rhythm.

Laboratory and Radiology Findings

Diagnosis of early Lyme disease in a patient with typical Erythema Migrans in an endemic area does not require laboratory confirmation.

ELISA Titers of specific antispirochetal antibodies-IgM, then IgG are preferably determined.

Indirect immunofluorescence: is less useful before patient has made antibodies.

Western blot: confirmation of positive titers is needed. In Skin Biopsy: all layers of the dermis are heavily infiltrated with

mononuclear cells around blood vessels and skin appendages. CSF: elevated titers ESR: elevated AST and LDH: slightly elevated X-ray findings usually are limited to soft tissue swelling, but a few

patients have had erosion of cartilage and bone. Hematocrit and WBC and differential counts usually are normal.

Differential Diagnosis

Lyme disease must be distinguished from Juvenile Rheumatoid Arthritis in children.

In adults, from Reiter’s syndrome and atypical Rheumatoid Arthritis.

Ehrlichiosis-is an emerging infection transmitted by the same the tick.

Spondyloarthropathies Idiopathic Bell’s Palsy Other CNS syndromes

Therapeutic Plan:

Antibiotic treatment for 3 – 4 weeks with doxycycline or amoxicillin is generally effective in early disease.

Cefuroxime axetil or erythromycin can be used for persons allergic to penicillin or who cannot take tetracyclines.

Intravenous ceftriaxone or penicillin for 4 weeks or more may be required for patients with neurologic manifestations.

In later disease, treatment failures may occur and retreatment may be necessary.

Lyme Disease: Prevention

As of February 25, 2002 the vaccine manufacturer announced that the LYMErix Lyme disease vaccine will no longer be commercially available.

CDC Advisory Committee on Immunization Practices recommendations regarding LYMErix Vaccine:

Persons who reside, work, or recreate in areas of high or moderate risk.

Educative and Prevention Plan: Personal Protection

Avoidance of tick habitat: persons should avoid entering areas that are likely to be infested with ticks. Ticks favor moist, shaded environment, provided by leaf litter and low-lying vegetation in wooded, brushy or overgrown grassy habitat.

Personal Protection: wear light-colored clothing so that ticks can be spotted more easily and removed before becoming attached.

By wearing long-sleeved shirts and tucking pants into socks or rubber boot tops may help keep ticks from reaching the skin.

Application of insect repellents containing DEET (n,n-diethylm toluamide) to clothes and exposed skin, and permethrin which kills ticks on contact to clothes.

Prevention: Tick Check

Prompt removal of ticks will help prevent infection, since transmission of B burgdorferi from an infected tick is unlikely to occur before 36 hours of tick attachment.

Embedded ticks should be removed using fine-tipped tweezers.

DO NOT use petroleum jelly, a hot match, nail polish or other products.

Grasp the tick firmly and as closely to the skin as possible.

Pull the tick’s body away from the skin with a steady motion.

Cleanse the area with an antiseptic. Seek medical attention.

Plan: Referrals and Follow-up

Internal Medicine: Joint pain presentNeurology: CNS involvementCardiology: Chest pain, heart murmur

involvedReported to Centers for Disease Control

and Prevention

Questions?