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Questions & answers
1. What diagnosis do you suspect? This patient’s history includes several clues that should help lead to a diagnosis. These clues are as follows: time of year (summer), geographic location (northeastern United States, specifically Cape Cod), an earlier complaint of joint pains (even though it appeared to be transient), and his primary complaint (fatigue). A specific disease that should be included in your differential diagnosis is Lyme disease. 2. What other questions would you ask? If Lyme Disease is a consideration, questions should be asked concerning an unusual appearing rash in a bull’seye pattern, exposure to tick-infested areas, any appearance of an insect bite, and other accompanying symptoms such as fever or headache. On further questioning you find that when he returned from camp, his mother had noticed a small oval bite on his back that was red and bumpy, It had resolved 6 days later, but now you note a 7 cm ecchymotic ring at the site of the bite. 3. What other physicalfindings find?
might you
The clinical manifestations of Lyme disease are divided into the 3 following stages: early localized, early disseminated, and late disease. Early localized disease, termed erythema, is manifested by a distinctive rash, migrans, at the site of a recent tick bite. Erythema migrans begins as a red macule or papule and usually expands during days to weeks to form a large annular erythematous lesion that is 5 cm or more in diameter, sometimes with partial central clearing. Localized erythema migrans can vary greatly in size and shape and may have vesicular or necrotic areas in its
228
center. Fever, malaise, headache, mild neck stiffness, and arthralgia often accompany the rash. In untreated persons, these associated symptoms may be intermittent and variable during a period of several weeks. The most common manifestation of early disseminated disease is multiple erythema migrans. This rash usually occurs 3 to 5 weeks after the tick bite, and consists of secondary annular erythematous lesions similar to, but usually smaller than, the primary lesion. These lesions reflect spirochetemia with dermal dissemination. Other common manifestations of early disseminated illness (which may occur with or without a rash) are palsies of the cranial nerves (especially seventh nerve palsy, ie, Bell’s palsy), meningitis, and conjunctivitis. Systemic symptoms such as arthralgia, myalgia, headache, and fatigue also are common in the early disseminated stage. Late disease is characterized most commonly by recurrent arthritis that usually is pauciarticular and affects the large joints, particularly the knees. Chronic arthritis is uncommon in children who have been treated with antibiotics in the early stages of the disease. Arthritis may occur without a history of manifestations of earlier stages of illness (including erythema migrans). Central nervous system manifestations also occur in late disease, and include encephalopathy and neuropathy, including one or more peripheral nerves (American Academy of Pediatrics, Redbook, 1997).
M.‘s examination reveals a rightsided Bell’s palsy, tender right cervical nodes, and slight nuchal rigidity M. is sent for evaluation by the infectious disease division of the tertiary care facility. Results of his lumbar puncture are positive, and he is admitted with a diagnosis of Lyme encephalitis. His neurologic examination also revealed palsies of the peripheral cranial nerves 7, 9, and 11. Because he is allergic to penicillin, he is treated with a 3-week course of intravenous ceftriaxone. The Bell’s palsy resolves after 2 weeks, and he has no residual arthritis or neurologic effects. 4. What types of illnesses should you review, based on this case? Other tickborne diseases should be reviewed because ticks are the single most important cause of vectorborne disease in the United States (Moskowitz & Meissner, 1997). Specific diseases, besides Lyme disease, include Rocky Mountain spotted fever, Colorado tick fever, tularemia, ehrlichiosis, babesiosis, relapsing fever, and tick paralysis. A comprehensive guide is contained in the Contemporary Pediatrics article listed in the references (Moskowitz & Meissner, 1997).
REFERENCES American Academy Of Pediatrics. (1997). RedBook, Report qfthe Committee ox Infectious Disease (24th ed., pp. 329-333). Elk Grove Village (IL): Author. Moskowitz, H., 81 Meissner, C. (1997). Tick-borne diseases: Warm weather worry. Contemponzry Pediatrics, 14,33-49.
J Pediatr Health Care. (I 998). 12,228. Copyright
0 1998 by the National
0891-5245/98/$5.00
+ 0
Association
of Pediatric Nurse Associates
& Practitioners
25/8/90726
July/August
1998
might you
The clinical manifestations of Lyme disease are divided into the 3 following stages: early localized, early disseminated, and late disease. Early localized disease, termed erythema, is manifested by a distinctive rash, migrans, at the site of a recent tick bite. Erythema migrans begins as a red macule or papule and usually expands during days to weeks to form a large annular erythematous lesion that is 5 cm or more in diameter, sometimes with partial central clearing. Localized erythema migrans can vary greatly in size and shape and may have vesicular or necrotic areas in its
228
center. Fever, malaise, headache, mild neck stiffness, and arthralgia often accompany the rash. In untreated persons, these associated symptoms may be intermittent and variable during a period of several weeks. The most common manifestation of early disseminated disease is multiple erythema migrans. This rash usually occurs 3 to 5 weeks after the tick bite, and consists of secondary annular erythematous lesions similar to, but usually smaller than, the primary lesion. These lesions reflect spirochetemia with dermal dissemination. Other common manifestations of early disseminated illness (which may occur with or without a rash) are palsies of the cranial nerves (especially seventh nerve palsy, ie, Bell’s palsy), meningitis, and conjunctivitis. Systemic symptoms such as arthralgia, myalgia, headache, and fatigue also are common in the early disseminated stage. Late disease is characterized most commonly by recurrent arthritis that usually is pauciarticular and affects the large joints, particularly the knees. Chronic arthritis is uncommon in children who have been treated with antibiotics in the early stages of the disease. Arthritis may occur without a history of manifestations of earlier stages of illness (including erythema migrans). Central nervous system manifestations also occur in late disease, and include encephalopathy and neuropathy, including one or more peripheral nerves (American Academy of Pediatrics, Redbook, 1997).
M.‘s examination reveals a rightsided Bell’s palsy, tender right cervical nodes, and slight nuchal rigidity M. is sent for evaluation by the infectious disease division of the tertiary care facility. Results of his lumbar puncture are positive, and he is admitted with a diagnosis of Lyme encephalitis. His neurologic examination also revealed palsies of the peripheral cranial nerves 7, 9, and 11. Because he is allergic to penicillin, he is treated with a 3-week course of intravenous ceftriaxone. The Bell’s palsy resolves after 2 weeks, and he has no residual arthritis or neurologic effects. 4. What types of illnesses should you review, based on this case? Other tickborne diseases should be reviewed because ticks are the single most important cause of vectorborne disease in the United States (Moskowitz & Meissner, 1997). Specific diseases, besides Lyme disease, include Rocky Mountain spotted fever, Colorado tick fever, tularemia, ehrlichiosis, babesiosis, relapsing fever, and tick paralysis. A comprehensive guide is contained in the Contemporary Pediatrics article listed in the references (Moskowitz & Meissner, 1997).
REFERENCES American Academy Of Pediatrics. (1997). RedBook, Report qfthe Committee ox Infectious Disease (24th ed., pp. 329-333). Elk Grove Village (IL): Author. Moskowitz, H., 81 Meissner, C. (1997). Tick-borne diseases: Warm weather worry. Contemponzry Pediatrics, 14,33-49.
J Pediatr Health Care. (I 998). 12,228. Copyright
0 1998 by the National
0891-5245/98/$5.00
+ 0
Association
of Pediatric Nurse Associates
& Practitioners
25/8/90726
July/August
1998