Complications
Peripheral nervous system involvement in early Lyme disease includes radiculopathy, cranial neuropathy, and mononeuropathy multiplex.
Facial palsy (cranial nerve VII) is the most common type of cranial nerve involvement.
Central nervous system involvement includes lymphocytic meningitis and rarely encephalomyelitis.
Neurologic complications occur in 3% to 12% of untreated patients with Lyme disease; however, incidence is decreasing in recent years because of early diagnosis and treatment.[70]
Includes acute onset of varying degrees of intermittent atrioventricular (AV) block. Myopericarditis occurs rarely. Cardiac complications occur in 4% to 10% of untreated patients in the US.[74]
Hospitalization and continuous monitoring are required for patients with chest pain, syncope, dyspnea, second- or third- degree AV block, or first-degree block with PR interval greater than or equal to 300 milliseconds. Although there are no clinical trials comparing different methods of treatment, intravenous antibiotics are generally recommended to treat patients who require hospital admission. Temporary pacing is recommended for patients with symptomatic bradycardia who cannot be managed medically.[25]
Rare cutaneous manifestation seen in Europe. It presents as solitary bluish-red swelling a few centimeters in diameter and is commonly seen on the ear lobe in children and near the nipple area in adults.[25]
Treatment consists of doxycycline, amoxicillin, or cefuroxime for 14-21 days.[25]
Macrolides are not recommended for first-line treatment but reserved for patients who are intolerant to all 3 first-line antibiotics.
This usually manifests as monoarticular or oligoarticular arthritis, commonly involving knee joints. Large knee effusions are common, usually resolving in a few weeks to a few months if untreated. Previously, the incidence of Lyme arthritis was 60% in untreated patients in the US, but this has decreased to 10% in recent years because of early treatment.[59][60]
Nonsteroidal anti-inflammatory drugs can be used in conjunction with antibiotic treatment, but intra-articular corticosteroid injections are not recommended because of lack of additional benefit.[25][59][60]
This usually manifests as encephalomyelitis, peripheral neuropathy, or encephalopathy. Peripheral neuropathy presents as mild diffuse polyneuropathy in a glove and stocking distribution. Cerebrospinal fluid (CSF) shows lymphocytic pleocytosis with moderately elevated protein and normal glucose level. Seropositivity confirmed by enzyme-linked immunosorbent assay and Western blot assays is present. CSF polymerase chain reaction (PCR) is positive for Borrelia burgdorferi antibody or DNA. PCR has low sensitivity.[25][72][73]
Once antibiotic therapy is completed, retreatment is not recommended without objective evidence of infection.[72][73]
A minority of patients with Lyme disease treated with appropriate antibiotics may complain of subjective symptoms for several months. This has also been sometimes referred to as "chronic Lyme disease" or "post-treatment Lyme disease syndrome."
Patients may describe persistent or recurring nonspecific symptoms such as fatigue, diffuse musculoskeletal pains, and cognitive difficulties for more than 6 months after the appropriate antibiotic therapy.[25] However, multiple studies have failed to show that these symptoms are in excess of what is expected in noninfected patients.[64][65]
There is no biologic evidence that B burgdorferi persists after receiving the appropriate course of antimicrobial treatment. Antibiotic therapy is not recommended for patients with only subjective symptoms.[25][64] Re-treatment with antibiotics has been found to be of no benefit and may cause serious side effects.[75][76]
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