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Diagnostic challenges of early Lyme disease: lessons from a community case series.

Aucott J, Morrison C, Munoz B, Rowe PC, Schwarzwalder A, West SK - BMC Infect. Dis. (2009)

Bottom Line: All patients had acute symptoms of less than or equal to 12 weeks duration.Among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients whose rash was subsequently confirmed.Failure to recognize erythema migrans or alternatively, viral-like presentations without a rash, can lead to missed or delayed diagnosis of Lyme disease, ineffective antibiotic treatment, and the potential for late manifestations.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. jaucott2@jhmi.edu.

ABSTRACT

Background: Lyme disease, the most common vector-borne infection in North America, is increasingly reported. When the characteristic rash, erythema migrans, is not recognized and treated, delayed manifestations of disseminated infection may occur. The accuracy of diagnosis and treatment of early Lyme disease in the community is unknown.

Methods: A retrospective, consecutive case series of 165 patients presenting for possible early Lyme disease between August 1, 2002 and August 1, 2007 to a community-based Lyme referral practice in Maryland. All patients had acute symptoms of less than or equal to 12 weeks duration. Patients were categorized according to the Centers for Disease Control and Prevention criteria and data were collected on presenting history, physical findings, laboratory serology, prior diagnoses and prior treatments.

Results: The majority (61%) of patients in this case series were diagnosed with early Lyme disease. Of those diagnosed with early Lyme disease, 13% did not present with erythema migrans; of those not presenting with a rash, 54% had been previously misdiagnosed. Among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients whose rash was subsequently confirmed. Of all patients previously misdiagnosed, 41% had received initial antibiotics likely to be ineffective against Lyme disease.

Conclusion: For community physicians practicing in high-risk geographic areas, the diagnosis of Lyme disease remains a challenge. Failure to recognize erythema migrans or alternatively, viral-like presentations without a rash, can lead to missed or delayed diagnosis of Lyme disease, ineffective antibiotic treatment, and the potential for late manifestations.

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Classic bull's eye EM with initial misdiagnosis as urinary tract infection. A 78 year old women presented to an urgent care center with 3 days of fever, mild headache and the absence of rhinitis, cough or typical upper respiratory viral symptoms. The physical exam showed a temperature of 102 degrees Fahrenheit and a skin rash was not noted. Urinalysis showed 5–10 WBCs, a diagnosis of pylonephritis was made, and ciprofloxacin was initiated. The patient returned the following day when she noticed a large, red rash on her side. The patient was referred to one of the authors (JA) who confirmed the diagnosis of Lyme disease. Ciprofloxacin was discontinued, doxycycline initiated and the rash resolved. Serology returned with a positive ELISA and confirmatory western blot.
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Figure 6: Classic bull's eye EM with initial misdiagnosis as urinary tract infection. A 78 year old women presented to an urgent care center with 3 days of fever, mild headache and the absence of rhinitis, cough or typical upper respiratory viral symptoms. The physical exam showed a temperature of 102 degrees Fahrenheit and a skin rash was not noted. Urinalysis showed 5–10 WBCs, a diagnosis of pylonephritis was made, and ciprofloxacin was initiated. The patient returned the following day when she noticed a large, red rash on her side. The patient was referred to one of the authors (JA) who confirmed the diagnosis of Lyme disease. Ciprofloxacin was discontinued, doxycycline initiated and the rash resolved. Serology returned with a positive ELISA and confirmatory western blot.

Mentions: EM was the most common presentation of early Lyme disease in our series. However, prior misdiagnosis remained common, confirming previous reports from other endemic areas [6]. Patients and physicians often saw the EM but were unaware of its significance, understandable considering the substantial variation in its morphology [5]. While 80% of EM in the United States are uniformly red, only 19% have the stereotypical bull's eye appearance [5]. While typically circular or oval, it can also be triangular, rectangular or distorted in other ways when occurring in areas such as the neck [6]. Atypical features may include erythema with central induration, urticarial like lesions, confluent red-blue lesions mimicking ecchymosis, vesicles mimicking shingles, and central necrosis mimicking spider bites [6,25,26]. Examples of typical and atypical lesions are shown in Figures 2, 3, 4, 5 and 6. In our series, the most common misdiagnosis for EM was spider bite, consistent with observations that spider bites may be commonly over-diagnosed [27].


Diagnostic challenges of early Lyme disease: lessons from a community case series.

Aucott J, Morrison C, Munoz B, Rowe PC, Schwarzwalder A, West SK - BMC Infect. Dis. (2009)

Classic bull's eye EM with initial misdiagnosis as urinary tract infection. A 78 year old women presented to an urgent care center with 3 days of fever, mild headache and the absence of rhinitis, cough or typical upper respiratory viral symptoms. The physical exam showed a temperature of 102 degrees Fahrenheit and a skin rash was not noted. Urinalysis showed 5–10 WBCs, a diagnosis of pylonephritis was made, and ciprofloxacin was initiated. The patient returned the following day when she noticed a large, red rash on her side. The patient was referred to one of the authors (JA) who confirmed the diagnosis of Lyme disease. Ciprofloxacin was discontinued, doxycycline initiated and the rash resolved. Serology returned with a positive ELISA and confirmatory western blot.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2698836&req=5

Figure 6: Classic bull's eye EM with initial misdiagnosis as urinary tract infection. A 78 year old women presented to an urgent care center with 3 days of fever, mild headache and the absence of rhinitis, cough or typical upper respiratory viral symptoms. The physical exam showed a temperature of 102 degrees Fahrenheit and a skin rash was not noted. Urinalysis showed 5–10 WBCs, a diagnosis of pylonephritis was made, and ciprofloxacin was initiated. The patient returned the following day when she noticed a large, red rash on her side. The patient was referred to one of the authors (JA) who confirmed the diagnosis of Lyme disease. Ciprofloxacin was discontinued, doxycycline initiated and the rash resolved. Serology returned with a positive ELISA and confirmatory western blot.
Mentions: EM was the most common presentation of early Lyme disease in our series. However, prior misdiagnosis remained common, confirming previous reports from other endemic areas [6]. Patients and physicians often saw the EM but were unaware of its significance, understandable considering the substantial variation in its morphology [5]. While 80% of EM in the United States are uniformly red, only 19% have the stereotypical bull's eye appearance [5]. While typically circular or oval, it can also be triangular, rectangular or distorted in other ways when occurring in areas such as the neck [6]. Atypical features may include erythema with central induration, urticarial like lesions, confluent red-blue lesions mimicking ecchymosis, vesicles mimicking shingles, and central necrosis mimicking spider bites [6,25,26]. Examples of typical and atypical lesions are shown in Figures 2, 3, 4, 5 and 6. In our series, the most common misdiagnosis for EM was spider bite, consistent with observations that spider bites may be commonly over-diagnosed [27].

Bottom Line: All patients had acute symptoms of less than or equal to 12 weeks duration.Among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients whose rash was subsequently confirmed.Failure to recognize erythema migrans or alternatively, viral-like presentations without a rash, can lead to missed or delayed diagnosis of Lyme disease, ineffective antibiotic treatment, and the potential for late manifestations.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. jaucott2@jhmi.edu.

ABSTRACT

Background: Lyme disease, the most common vector-borne infection in North America, is increasingly reported. When the characteristic rash, erythema migrans, is not recognized and treated, delayed manifestations of disseminated infection may occur. The accuracy of diagnosis and treatment of early Lyme disease in the community is unknown.

Methods: A retrospective, consecutive case series of 165 patients presenting for possible early Lyme disease between August 1, 2002 and August 1, 2007 to a community-based Lyme referral practice in Maryland. All patients had acute symptoms of less than or equal to 12 weeks duration. Patients were categorized according to the Centers for Disease Control and Prevention criteria and data were collected on presenting history, physical findings, laboratory serology, prior diagnoses and prior treatments.

Results: The majority (61%) of patients in this case series were diagnosed with early Lyme disease. Of those diagnosed with early Lyme disease, 13% did not present with erythema migrans; of those not presenting with a rash, 54% had been previously misdiagnosed. Among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients whose rash was subsequently confirmed. Of all patients previously misdiagnosed, 41% had received initial antibiotics likely to be ineffective against Lyme disease.

Conclusion: For community physicians practicing in high-risk geographic areas, the diagnosis of Lyme disease remains a challenge. Failure to recognize erythema migrans or alternatively, viral-like presentations without a rash, can lead to missed or delayed diagnosis of Lyme disease, ineffective antibiotic treatment, and the potential for late manifestations.

Show MeSH
Related in: MedlinePlus