A 48-year-old woman with a past medical history of complex regional pain syndrome, anxiety, and hypertension presented with four weeks of flu-like symptoms and a rash for 10 days. The patient also complained of weeks of malaise, loss of appetite, myalgias, arthralgias, and mild headache.
She noted increased polyarthralgias without a fever or upper respiratory infection symptoms. She had progressively worsening neck pain and stiffness that accompanied her headache. Her chief concern was a nonpruritic rash that had developed three days earlier over her face with new, similar spots on her chest and back. The patient stated that she lived in rural southern Ohio and frequented the outdoors.
The patient was sitting up in bed in distress due to neck pain and headache. Her temperature was 36.5°C, her pulse was 95 bpm, her blood pressure was 127/78 mm Hg, and her respiratory rate and pulse oxygenation were normal. Her cardiopulmonary exam was also normal, and her abdomen was soft. The patient was oriented and interactive, but refused to flex or rotate her neck. Brudzinski's and Kernig's signs were negative. The remainder of her neurologic exam was without deficits, but she did have a fine resting tremor.
Her joint exam was unremarkable, and she had multiple erythematous macules on the face, chest, and back. A laboratory workup demonstrated a mild transaminitis with an AST level of 55 and an ALT level of 68. Her CBC, basic metabolic panel, and creatine kinase were unremarkable.
What is causing her symptoms?
Find the diagnosis and case discussion on the next page.
Diagnosis: Disseminated Lyme Disease with Erythema Migrans and Aseptic Meningitis
Lyme disease, caused by the spirochete Borrelia burgdorferi, is the most common vector-borne disease (95% of all reported U.S. vector-borne illnesses), and is carried by ticks. (OSHA. https://bit.ly/3dRFRH6.) It is commonly found in the Northeast, upper Midwest, and the Pacific Coast. (MMWR Surveill Summ. 2017;66:1; https://bit.ly/2AtyEyD.) Significant complications besides rash and febrile illness include meningitis, arthritis, and facial palsy. (Cureus. 2019;11:e4300; https://bit.ly/2N1mGPz.)
Once a patient is infected, it may take weeks before spirochetemia develops. Lyme disease has three stages: early localized (constitutional symptoms, erythema migrans), early disseminated (joint, neurologic, or cardiac manifestations, most commonly heart block), and late (persistent arthritis and neurologic abnormalities) disease. (Rosen's Emergency Medicine: Concepts and Clinical Practice. 2018. 9th Edition. Philadelphia: Elsevier; pp. 1657-1681.)
Erythema migrans is classic for Lyme disease, and usually starts at the site of the tick bite with a blanching, well-demarcated, erythematous macule. Central clearing of the lesions may occur, but is not a diagnostic necessity, and patients may describe no or minimal tenderness. Neurologic symptoms can appear on average one month after the rash. Neck pain, headache, and tremor are concerning for central neurologic involvement such as meningitis. Lyme meningitis is aseptic in nature. The neurologic examination and cerebrospinal fluid assessment are usually normal. Another common neurologic manifestation of the disease is facial palsy. (Rosen's Emergency Medicine; pp. 1657-1681.)
Treatment for Lyme disease includes a 10-day course of oral doxycycline (100 mg twice daily) for treating erythema migrans. Longer courses of oral doxycycline, such as 14-21 days, are recommended if in the early localized phase and 21-28 days if in the early disseminated stage. Other oral options include amoxicillin and cefuroxime axetil. IV ceftriaxone is recommended for 28-60 days if the disease is in the late stage. A single dose of oral doxycycline can be given within 72 hours of a high-risk tick bite to prevent Lyme disease. (Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 2020. 9th edition. New York: McGraw-Hill Education; Ch. 161; JAMA. 2016;315:1767; https://bit.ly/3ffqY1M.)
Our patient had Lyme serology ordered and was seen by an infectious disease specialist in the emergency department who agreed that she had disseminated Lyme disease with aseptic meningitis, but said cerebral imaging and lumbar puncture were not clinically indicated because she did not exhibit encephalopathy. The patient was discharged home with empiric oral doxycycline and follow-up with ID as an outpatient.
Ultimately, our patient's Lyme serology confirmed anti-Borrelia burgdorferi IgM greater than IgG presence, consistent with active infection. By day 12, her only symptoms were tremor and mild intermittent headache. Her antibiotic course was extended by ID for a total of 28 days with complete resolution of her symptoms
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Dr. Coppiis a third-year emergency medicine resident at the Case Western Reserve University, MetroHealth Medical Center, and Cleveland Clinic Emergency Medicine Residency Program. Dr. Smalleyis associate staff and the associate ultrasound director at the Emergency Services Institute at the Cleveland Clinic. Follow her on Twitter@SmallsSono. Read past Quick Consult columns athttp://bit.ly/EMN-QuickConsult.