Lyme borreliosis (disseminated and late infection)

Last Updated: 2021-11-19

Author(s): Anzengruber F., Navarini A.

ICD11: 1C1G.1Z

Disseminated and late infection of Lyme disease.

  • Mostly found in Europe and America.
  • Up to 30-40% of all ticks are infected with Borrelia. 
  • In Switzerland, approx. 10000 people contract Lyme disease per year.
  • In Germany, an incidence of 100-150 infections/100000/year is assumed.
  • Seasonally, infections occur from May-July.

  • Pathogen
    • Borrelia burgdorferi sensu lato (Europe).
    • Borrelia burgdorferi sensu stricto (North America).

3 stages

  • Stage I (localised early infection of the skin).
  • Stage II (disseminated early infection).
  • Stage III (late infection with organ manifestation).
  • Stage I:
    • Erythema chronicum migrans.
    • Ggl. pruritus.
    • Borrelia lymphocytoma.
    • Stage II:
      • Partially asymptomatic.
      • In some cases, flu-like symptoms begin only a few days after the onset of erythema chronicum migrans.
      • Locoregional lymph node adenopathy.
      • If applicable, reduced general condition, febrile temperatures, cephalgias.
      • Multiple erythema migrantia.
      • Unspecific exanthema.
      • Borrelia lymphocytoma.
      • Meningopolyneuritis Garin-Bujadoux-Bannwarth: cephalgias, possibly meningitis or encephalitis, unilateral radiculitis (painful paralyses) and cranial nerve palsies.
      • Arthralgias, myalgias, myo-/pericarditis.
      • Iritis, chrioretinitis.
      • Carditis.
    • Stage III
      • Acrodermatitis chronica atrophicans.
      • Acrodermatitis acuta.
      • Malignant B-cell lymphoma.
      • Peripheral neuropathy.
      • Subacute encephalopathy.
      • Chronic encephalomyelitis.
      • Recurrent chronic arthritis (arthritides are typical in patients from the USA).
      • Fibromyalgias.
      • Chronic pain syndrome.
      • Neurological symptoms are observed mainly in Europe.
      • Acrodermatitis chronica atrophicans (leading symptom). 
      • Nodular Panniculitis (rare).
      • Early summer meningoencephalitis in the context of a double infection (very rare).
      • Progressive encephalomyelitis.
      • CAVE: Stages can be skipped.
      • Post-infectious Lyme disease syndrome (post Lyme disease):
      • Persistent feeling of illness with myalgias and arthralgias after symptoms have subsided and adequate antibiotic therapy.

         

  • Anamnesis: Tick bite remembered? Erythema migrans remembered?
  • In about 60% of patients, circulating immune complexes can also be detected.
  • Borrelia serology (antibodies are not detectable from the beginning).
  • IgM: Detectable after 2 weeks in 50% of patients, after >4 weeks in 80%.
  • IgG: Detectable after 2-3 months.
  • Clinical>pathogen detection (serum, CSF, synovial fluid, tissue)
  • Blood culture.
  • If necessary, CSF puncture (CSF serum index).
  • If necessary. Detection of Borrelia in joint fluid.
  • If necessary, biopsy with pathogen detection.
  • Stage II: long-term ECG, neurological presentation.

Plasma cell-rich, perivascular infiltrates are typical.

Early therapy is important!

Therapy according to Lebwohl

Evidence level

Early stage

 

Doxycycline p.o. 100 mg 2x daily for 14 days

A

Amoxicillin p.o. 500 mg 3x daily for 14 days

A

Cefuroxime p.o. 500 mg 2x daily for 14 days

A

In case of neurological symptoms

 

Cefuroxime i.v. 2g daily for 14 days

B

Penicillin G i.v. 18-24 million IU daily (in 4 ED) for 14 days

B

In case of cardiological symptoms

 

Both oral and intravenous therapy (see.o. possible)

C

Lyme arthritis without neurological involvement

 

Doxycylcline p.o. 100 mg 2x daily for 14 days

 

Amoxicillin 500 mg 3x daily for 14 days

 

Lyme arthritis with neurological symptoms

 
Ceftriaxone 2 g i.v. daily for 2-3 weeks

 

B

Penicillin G 18-24 mIU i.v. (in 4 ED) for 2-3 weeks

 

Chron.-.Recurrent arthritides

 

Recurrent antibiotic therapy for 28 days

D

Late manifestation of neurological symptoms

 

Ceftriaxone 2 g i.v. daily for 2-3 weeks

B

Penicillin G 18-24 million IU i.v. (in 4 ED) for 2-3 weeks

B

  • Early infection
  • Doxycycline p.o. 100 mg 2x daily for 21 days.
  • Alternatively: amoxicillinandclavulanic acid p.o. 500/125 mg 3x daily (adults and children > 40 kg), 50-100 mg/kg bw in 3-4 ED daily (≤ 40 kg and ≥ 8 days); i.v. 250/62.5 mg suspension: 20-60 mg/kg bw 3x daily (2-12 yrs and ≤40 kg) or 20-40 mg/kg bw 3x tgl (1-2 yrs) for 21 days.
  • Alternatively: azithromycin p.o. 500 mg 1x daily for 10 days.
  • Alternatively: cefuroxime p.o. 250-500 mg 2x daily (> 12 yrs), 125 mg 2x daily (5-12 yrs and ≥ 15 kg); i.v. 750 mg-1.5 g 3-4x daily for 12-18 days.

     

  • Disseminated and late infection
  • PenicillinG i.v. 4 million IU 6x daily for 2-3 weeks.
  • Alternative: Ceftriaxone i.v. 2g (max. 4g) 1x daily for 2-3 weeks.
  • Alternative: Cefotaxime i.v. 1g 4x daily for 2-3 weeks.

     

  • Without neurological symptoms
  • Doxycycline p.o. 100 mg 2x daily for 30 days.

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