Lyme Disease Case Study
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Lyme Disease Case Study
Lyme Disease Case Study
A 38-year-old male had a 3-week history of fatigue and lethargy with intermittent complaints of headache, fever, chills, myalgia, and arthralgia. According to the history, the patient’s symptoms began shortly after a camping vacation. He recalled a bug bite and rash on his thigh immediately after the trip. The following studies were ordered:
| Studies | Results |
| Lyme disease test, | Elevated IgM antibody titers against Borrelia burgdorferi (normal: low) |
| Erythrocyte sedimentation rate (ESR), | 30 mm/hour (normal: ≤15 mm/hour) |
| Aspartate aminotransferase (AST), | 32 units/L (normal: 8-20 units/L) |
| Hemoglobin (Hgb), | 12 g/dL (normal: 14-18 g/dL) |
| Hematocrit (Hct), | 36% (normal: 42%-52%) |
| Rheumatoid factor (RF), | Negative (normal: negative) |
| Antinuclear antibodies (ANA), | Negative (normal: negative) |
Diagnostic Analysis
Based on the patient’s history of camping in the woods and an insect bite and rash on the thigh, Lyme disease was suspected. Early in the course of this disease, testing for specific immunoglobulin (Ig) M antibodies against B. burgdorferi is the most helpful in diagnosing Lyme disease. An elevated ESR, increased AST levels, and mild anemia are frequently seen early in this disease. RF and ANA abnormalities are usually absent.
Critical Thinking Questions
1. What is the cardinal sign of Lyme disease? (always on the boards) 2. At what stages of Lyme disease are the IgG and IgM antibodies elevated?
3. Why was the ESR elevated?
4. What is the Therapeutic goal for Lyme Disease and what is the recommended treatment.
Lyme disease is a multisystem sickness caused by the spirochete “Borrelia burgdorferi” strains, which are transmitted by different species of the tick “Ixodes.”
[1] The erythema chronicum migrans (ECM) eruption at the site of inoculation is a frequent early manifestation, and infection spread can cause disease of the nervous system, heart, and joints, as well as other dermatoses.
[2]
Despite the fact that the disease has been predominantly recorded in temperate regions, the incidence has increased globally as a result of increased travel and changing vector habitats.
Only a few cases had previously been documented from India.
[3]
This case of Lyme borreliosis in a young kid from Himachal Pradesh with both classical and atypical ECM lesions is described in this paper.
Go to: Case Studies
In April 2016, a 10-year-old kid from a hilly town presented with a 3-day history of a painful brownish elevated lesion across the back of his left thigh, accompanied by surrounding redness that was gradually expanding.
There was no fever or other systemic symptoms in the toddler.
He described an excursion to a neighboring forest a few days prior to the onset of the lesion.
On inspection, there was an erythematous annular plaque of approximately 6 5 cm in diameter on the back of the left lower thigh, with a central brownish fluid-filled blister [Figure 1].
Over the lesion, there was induration and discomfort, as well as localized popliteal lymphadenopathy.
A lymphangitic streak was also present on the inner part of the thigh [Figure 2a].
Petechiae over the scapular areas [Figure 2b] were also present, as were a few maculopapular lesions on the dorsum of the hands and ankles.
The results of the systemic assessment were ordinary.
The diagnosis of ECM was made clinically.
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Figure 1 Erythematous annular plaque measuring 6 5 cm in diameter with a central blister on the back of the left leg (IDOJ-8-124-g001.jpg).
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Figure 2 Atypical erythema chronicum migrans (ECM) lesions; (a) ECM lesion on the antero-medial part of the thigh with lymphangitic streak, (b) atypical lesions in the form of petechiae on the right scapular area.
The patient underwent baseline tests, including a full hemogram and a peripheral blood smear, which were both normal.
The enzyme-immunoassay approach was used to test for Borrelia burgoderferi Ospc (23 KDa) antigen.
IgM levels were elevated to 4.4 U/ml (normal 0.90), but IgG levels were normal [0.3 U/ml (normal 0.90)], indicating an acute infection.
Due to funding constraints, a Western blot could not be done.
Biopsy of the active edge of the lesion revealed a considerable perivascular lymphocytic infiltration with a spongiosis center and extravasation of red blood cells in the papillary dermis [Figure 3].
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IDOJ-8-124-g003.jpg (H and E, 100) Figure 3 Perivascular lymphocytic infiltration with red blood cell extravasation into the papillary dermis
Doxycycline 100 mg tablets twice day were started right away, along with additional symptomatic treatments.
The lesion did not grow beyond its initial size after one week of treatment, and the erythema and induration were reduced.
The above-mentioned properties linked with skin exfoliation improved even more after two weeks [Figure 4a].
The drugs were continued for a total of three weeks, and the lesion was clinically resolved [Figure 4b].
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IDOJ-8-124-g004.jpg is the name of the object.
(a) After 2 weeks of treatment, erythema has improved, the advancing margin has vanished, and exfoliation has occurred.
(b) After 3 weeks, the erythema chronicum migrans lesion has resolved and the blister has healed.
Navigate to: Discussion
B. burgdorferi sensu stricto, afzelli, garinii, bavariensis, and speilmanni are pathogenic genospecies of B. burgdorferi sensu lato (comprising at least 20 genospecies, both pathogenic and non-pathogenic), among which B. garinni and B. afzelli have been most regularly implicated as pathogens in Asia (mainly central Asia).
[3]
Though the disease is more usually found in temperate climates, Ixodes ticks are known to be present in the Himalayan region, therefore it could exist in our country.
Ixodes acutitarsus, Ixodes granulatus, Ixodes himalayensis, Ixodes kashmericus, and Ixodes ovatus are some of the Ixodes species found in this area.
[4]
I. persulcatus (reported from Central Asia) is the tick species thought to be responsible for disease transmission in Asia, however it has not been detected in India.
The most usually affected organ is the skin, and the symptoms are known as “dermatoborreliosis.”
Early localized disease, disseminated disease, and chronic disease are the three stages of the disease.
Early localized illness is characterized by ECM, which is commonly regarded as pathognomonic.
It appears as a target lesion at the site of a tick bite and can take one of two forms: growth with varied hues of erythema or centrifugal spread with core clearing and bull’s eye.
Vesicles, erythematous papules, purpura, and lymphangitic streaks have all been recorded as atypical ECM lesions.
Tinea corporis, urticaria, erythema multiforme, erythema annulare centrifugum, and fixed drug eruptions are all differential diagnoses for ECM.
The presence of a perivascular dermal lymphohistiocytic infiltration with few interspersed plasma cells is characteristic of histopathology.
Spirochetes can be seen in 50% of primary ECM lesions using the Warthin-Starry stain.
[3]
ECM is diagnosed mostly through clinical examination, with laboratory evidence serving as a supplement.
In suspected clinically unusual ECM symptoms, detection of B. burgdorferi by culture (expensive and low sensitivity) and/or polymerase chain reaction from skin biopsy is helpful in proving infection.
The most practicable and widely used method for diagnosing Lyme borreliosis is serology, which is required in all instances with clinically suspected Lyme borreliosis except ECM.
It uses a two-step process that starts with an initial screening test (typically an ELISA) and then moves on to a Western blot for reactive and ambiguous samples.
In the future, single-step ELISA using recombinant proteins (such as C6 peptide) may replace the traditional two-tiered method.
[5]
Various antibiotics have been used to treat the condition with success.
In early localized disease, doxycycline (4 mg/kg/day in divided doses; maximum 200 mg/day; after 8 years of age) for two weeks is the treatment of choice.
Alternatives to amoxycillin include cefuroxime axetil and amoxycillin.
Parenteral treatment with ceftriaxone, cefotaxime, or benzyl penicillin is frequently required for disseminated illness.
[6]
Lyme Disease Case Study
In the past, just a few instances of Lyme disease had been documented from India.
Table 1 summarizes an overview of several cases/studies from around the country.
[7,8,9,10,11,12,13]
In this case, the patient had both the typical centrifugally spreading ECM lesion as well as atypical lesions such as lymphangitic streaks, petechiae, and maculopapular lesions.
This case report raises the likelihood of future Lyme disease outbreaks in Himachal Pradesh, and it is important for treating physicians to be informed of the illness’s presence in this region.
Early detection of cutaneous characteristics can aid in the prevention of the progression of severe illness.
Various preventive techniques must be made more widely known to the public.
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