Lyme Disease Presentation and Treatment in the Pediatric Population A. Hope Tobey

Lyme Disease Presentation and
Treatment in the Pediatric
Population
A. Hope Tobey
Assistant Professor of Pediatrics VCOM
VOMA 2010
Objectives
• Review regional trends in Lyme disease
prevalence.
• Become familiar with common presentations
of Lyme disease in children.
• Discuss age appropriate treatment.
• LYME DISEASE was recognized in Sweden as
long ago as 1908.
• It was first identified in the United States in
1975, after a mysterious outbreak of arthritis
among the residents of Lyme, Connecticut.
• In 1978 It was realized Lyme was a tick borne
illness.
• In 1982 B. burgdorferi was identified.
• Since that time incidence has increased
dramatically.
Number of reported Lyme disease cases, by year - United States, 1995-2009
National Surveillance case definition revised in 2008 to include probable cases;
details at http://www.cdc.gov/ncphi/disss/nndss/casedef/lyme_disease_2008.htm
0
Year
2008
2009
2006
2007
2005
2004
2003
2002
2000
2001
1999
1998
1997
1995
1996
1993
1994
1992
1991
1990
1989
Lyme Disease Cases per
100,000 Population
Lyme Disease Cases in Virginia, 1989 - 2009
14
12
10
8
6
4
2
Reported Cases of Lyme Disease in
Virginia, 2009 (n=908)
So How is VA doing in 2010?
• “As of mid September, we will have counted
about 700 Lyme disease cases and this will
probably put Virginia somewhere over 1000
cases when the counting for 2010 is
complete.”
David N. Gaines, Ph.D.
State Public Health Entomologist
Virginia Department of Health
Average Annual Incidence of Reported Cases of Lyme
Disease by Age Group and Sex , United States, 19922004.
Reported Cases of Lyme Disease by Month of Illness Onset
United States, 1992-2004
Which tick is our vector ?
A
B
C
D
• Vector: Ixodes scapularis (or Ixodes
pacificus)
• Spirochete: Borrelia burgdorferi
• Co-Infection: babesiosis and
ehrlichiosis.
• The larval and nymphal stages of the tick are
less then 2mm (no bigger than a pinhead)
• The risk of exposure to ticks is greatest in the
woods and garden fringe areas of properties,
but ticks may also be carried by animals into
lawns and gardens.
• Ticks wait for host animals from the tips of
grasses and shrubs and transfer to animals or
persons who brush against vegetation.
Adult
Nymph
Female
• They usually attach themselves
in areas that are more hidden or
hairy, such as the groin, armpits
and scalp.
Adult
Larva
Male
• Most Children do not know they have been
bitten by a tick.
• Due to the small size the tick often goes unnoticed.
Transmission
• Borrelia burgdorferi lives in the tick midgut.
• Upon attachment it is initially immobile.
• The tick must have ingested blood for B.
burgdorferi to be mobile.
• Once it becomes mobile, it is excreted through
the saliva of the tick into the host. 10
• Ticks need at least 24-36hrs to transmit Lyme
• Incubation period from bite to
infection 1-55 days average 11
days.
Does this patient have Lyme disease?
Does this patient have Lyme disease?
Does this patient have Lyme disease?
Does this patient have Lyme disease?
Does this patient have Lyme disease?
Reported Clinical Findings Among
Lyme Disease Patients, 1992-2004
Clinical Manifestations
• Stage 1 (early localized) – erythema migrans,
fever, vomiting, malaise, neck stiffness, myalgia,
arthralgia. (3-30 days)
• Stage 2 (early disseminated) – multiple
erythema migrans, facial nerve palsy, meningitis,
conjunctivitis, carditis, arthralgia, myalgia,
headache, fatigue. (1-4 months)
• Stage 3 (late disease) – recurrent arthritis,
peripheral neuropathy, cognitive disorders
(months – years)
ALWAYS Be Suspicious
• Children with early localized disease often
prevent with a fever and mild illness that is
misdiagnosed as a viral illness.
• Children may initially present with early
disseminated disease and complain only of
fatigue, myalgias and arthralgias.
• Children may initially present with arthritis
and already have Late disseminated disease.
Facial Nerve Palsy
• Lyme is the most common cause of acquired
facial nerve palsy among children in endemic
areas. 1
• Positive Predictors : Fever, Headache, Peak
Lyme season, no previous herpetic lesions. 1
• In children with FN palsy serology and emperic
antibiotics should be strongly considered
• Recovery is very good and similar to idiopathic
facial nerve palsy or bell’s palsy 6
Meningitis
• Occurs in 2-12% of kids with Lyme disease. 2
• CSF will show an aseptic meningitis
• Positive predictors: Headache >7 days at
diagnosis, Predominance of lymphocytes and
monocytes in CSF (>70%) and presence of
cranial nerve palsy (CN7). 2,3
Carditis
• In children with early disseminated Lyme disease
16% had carditis 11
• Children >10 years of age, those with arthralgias,
and those with cardiopulmonary symptoms
were more likely to have carditis. 11
• The spectrum of presentation for children with
Lyme carditis is broad, ranging from
asymptomatic, first-degree heart block to
complete block or myocarditis.
• 89% of children have complete resolution of
cardiac dysfunction and arrhythmias. 11
Arthritis
• 6% of new diagnosis Lyme disease presents with
arthritis 5
• Typically presents as oligoarthritis of the large
joints, classically the knee.
• ESR, CRP and serum WBC are often elevated.
• Synovial WBC count is widely variable.
• Lack of fever and Knee involvement may be
predictive 4
• Children rarely progress to chronic arthritis and
long term prognosis is excellent5
Diagnosis
• Early Localized Disease – Clinical diagnosis is best.
– Antibodies to B burgdorferi are not detectable in
the first few weeks post infection. Patients treated
early may never develop antibodies.
• Early or Late Disseminated Disease – Diagnosis
should be based on clinical findings and serologic
testing.
– Antibodies are present in most patients with Early
and all patients with late Disseminated disease. Once
a pt develops antibodies they will persist for years if
not life.
What Test Should We Order?
• A 2 step approach to testing is recommended.
– Serum antibodies by EIA or IFA
– Western immunoblot.
• Patients with suspected Lyme meningitis
should have CSF PCR sent.
Western Blot
• For early disseminated you need to look at both
IgM and IgG for late only IgG is necessary.
• Positive test - 5 or more IgG bands positive or
- 2 or more IgM bands are positive
Treatment
• Early Localized
>8yo = Doxycycline 100 mg PO BID x 14-21
< 8yo = Amoxicillin 50mg/kg/day BID x 14-21
(Max Dose 1g/ day)
PCN All = Cefuroxime 30mg/kg/day BID x 14-21
(Max dose 1g/day)
Treatment
• Early and Late Disseminated
- Multiple EM = Same PO as early local but x 21 d
- Isolated facial palsy = Same PO as early local but
x 21 -28d
- Arthritis = Same PO as early local but x 28 d
Treatment
• Persistent or recurrent arthritis, carditis,
meningitis, encephalitis:
- Ceftriaxone 75-100 mg/kg IV or IM Qday x 1428d (Max 2g/day)
OR
- Penicillin 300,000 U/Kg/Day IV Q4hr x 14-28d
(Max 20 Million U/day)
Chemoprophylaxis?
• Is not currently recommended. Even
in highly endemic areas. 9
• Doxycycline 200mg po x 1dose in
children >12y (4.4 mg/kg if < 45kg)
Prevention
• Avoid Tick habitat
• Wear light colored clothing that covers arms and
legs.
• Tuck pant legs into boots
• Insect repellants such as DEET
• Checking clothes and body after possible tick
exposure.
• Tick repellants and daily tick checks for pets.
• 1998 Vaccine licensed for patients age 15y-70y. Early
2002 it was removed from the market due to side
effects and questionable efficacy
Tick Removal
• Do NOT use:
- A match
- Vaseline
- Nail polish remover
- Alcohol
- Gasoline
Tick Removal
Special Populations - Pregnant or
Breastfeeding
• Lyme can be transmitted to the fetus and may
result in stillbirth.
• No harm has been shown to occur to a fetus
of a properly treated mother.
• Lyme can NOT be transmitted by human milk.
Special Populations – Blood Donation
• People being treated for Lyme disease should
not donate blood as Lyme can live in stored
blood and result in Lyme disease in the
recipient
Special Population - Hunters
• You will not get Lyme disease from eating
venison or squirrel meat
• Hunting and dressing deer or squirrels may
bring you into close contact with infected ticks
and at higher risk for tick bites.
Long Term Cognitive Complications?
• Research has shown no differences between LD and control
groups performance on neuropsychologic testing. 6
• There was also no difference in testing results between groups
of patients LD who received different antibiotic regiments or
who started treatment at different stages. 6
• No predisease versus postdisease difference in academic
performance was found. 6
• No perceived long-term deterioration in cognitive, social, or
personality areas was reported by parents. 6
• Children with CN7 palsy also have shown no difference in
cognitive outcome compared to children who did not have LD. 7
• Conclusion. Children appropriately treated for LD have an
excellent prognosis for unimpaired cognitive functioning. 6,7
Resources
• CDC
http://www.cdc.gov/ncidod/dvbid/lyme/index.h
tm
• Committee on Infectious Diseases 2009 Red
Book 28th ed. American Academy of Pediatrics
• VA Dept Health
http://www.vdh.virginia.gov/epidemiology
• American Lyme Disease Foundation
www.aldf.com
References
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Lise E. Nigrovic, Amy D. Thompson, Andrew M. Fine, and Amir Kimia Clinical Predictors of Lyme Disease Among
Children With a Peripheral Facial Palsy at an Emergency Department in a Lyme Disease–Endemic Area
Pediatrics, Nov 2008; 122: e1080 - e1085. (1)
Aris C. Garro, Maia Rutman, Kari Simonsen, Jenifer L. Jaeger, Kimberle Chapin, and Gregory Lockhart Prospective
Validation of a Clinical Prediction Model for Lyme Meningitis in Children Pediatrics, May 2009; 123: e829 e834. (2)
Robert A. Avery, Gary Frank, Joseph J. Glutting, and Stephen C. Eppes Prediction of Lyme Meningitis in Children
From a Lyme Disease–Endemic Region: A Logistic-Regression Model Using History, Physical, and Laboratory
Findings Pediatrics, Jan 2006; 117: e1 - e7. (3)
Amy Thompson, Rebekah Mannix, and Richard Bachur Acute Pediatric Monoarticular Arthritis: Distinguishing
Lyme Arthritis From Other Etiologies Pediatrics, Mar 2009; 123: 959 - 965. (4)
Michael A. Gerber, Lawrence S. Zemel, and Eugene D. Shapiro Lyme Arthritis in Children: Clinical Epidemiology
and Long-term Outcomes Pediatrics, Oct 1998; 102: 905 - 908. (5)
Marietta Vázquez, Sara S. Sparrow, and Eugene D. Shapiro Long-Term Neuropsychologic and Health Outcomes of
Children With Facial Nerve Palsy Attributable to Lyme Disease Pediatrics, Aug 2003; 112: e93 - e97. (6)
Wayne V. Adams, Carlos D. Rose, Stephen C. Eppes, and Joel D. Klein Cognitive Effects of Lyme Disease in
Children Pediatrics, Aug 1994; 94: 185 - 189. (7)
Henry M. Feder, Jr, Michael A. Gerber, Peter J. Krause, Eugene D. Shapiro, and Raymond Ryan Early Lyme
Disease: A Flu-Like Illness Without Erythema Migrans Pediatrics, Feb 1993; 91: 456 - 459. (8)
Committee on Infectious Diseases Treatment of Lyme Borreliosis Pediatrics, Jul 1991; 88: 176 - 179. (9)
http://www.sciencedaily.com/releases/2009/11/091116180134.htm (10)
John M. Costello, Mark E. Alexander, Karla M. Greco, Antonio R. Perez-Atayde, and Peter C. Laussen Lyme
Carditis in Children: Presentation, Predictive Factors, and Clinical Course Pediatrics, May 2009; 123: e835 - e841
(11)
Additional References
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Holly Rothermel, Thomas R. Hedges III, and Allen C. Steere Optic Neuropathy in Children With Lyme
Disease Pediatrics, Aug 2001; 108: 477 - 481.
J. H. Oliver, Et al Isolation and transmission of the Lyme disease spirochete from the southeastern United
States Proc. Natl. Acad. Sci. USA Vol. 90, pp. 7371-7375, August 1993
Committee on Infectious Diseases Prevention of Lyme Disease Pediatrics, Jan 2000; 105: 142 - 147.
Carlos D. Rose, Paul T. Fawcett, Bernhard H. Singsen, Sharon B. Dubbs, and Robert A. Doughty Use of
Western Blot and Enzyme-Linked Immunosorbent Assays to Assist in the Diagnosis of Lyme Disease
Pediatrics 1991;88;465-470
Henry M. Feder and Jr, MD Lyme Disease Vaccine: Good for Dogs, Adults, and Children? Pediatrics, Jun
2000; 105: 1333 - 1334.
James M. Moses, Robyn S. Riseberg, and Jonathan M. Mansbach Lyme Disease Presenting With Persistent
Headache Pediatrics, Dec 2003; 112: e477 - e479.
Stephen C. Eppes and Judith A. Childs Comparative Study of Cefuroxime Axetil Versus Amoxicillin in
Children With Early Lyme Disease Pediatrics, Jun 2002; 109: 1173 - 1177.
Thomas Murray and Henry M. Feder, Jr Management of Tick Bites and Early Lyme Disease: A Survey of
Connecticut Physicians Pediatrics, Dec 2001; 108: 1367 - 1370.
Vijay K. Sikand, Neal Halsey, Peter J. Krause, Sunil K. Sood, Richard Geller, Christian Van Hoecke, Charles
Buscarino, Dennis Parenti, and for the Pediatric Lyme Vaccine Study Group Safety and Immunogenicity of a
Recombinant Borrelia burgdorferi Outer Surface Protein A Vaccine Against Lyme Disease in Healthy
Children and Adolescents: A Randomized Controlled Trial Pediatrics, Jul 2001; 108: 123 - 128.
http://ento.psu.edu/extension/urban/lyme-disease
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