Lyme borreliosis (early infection)

Last Updated: 2021-10-15

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

ICD11: -

Lyme disease, tick borreliosis borreliosis, erythema migrans disease, Lyme borreliosis, Lyme disease, Borrelia burgdorferi infection, European tick borreliosis.

Early phase of Lyme borreliosis.

  • It occurs mainly in Europe and America.
  • Up to 30-40% of all ticks are affected by Borrelia.
  • In Switzerland, about 10,000 people suffer from Lyme disease every year.
  • In Germany an incidence of 100-150 infections/100'000/year is assumed.
  • Infections occur seasonally from May to July.

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

3 stadiums

  • Stage I (localized early infection of the skin).
  • Stage II (disseminated early infection).
  • Stage III (late infection with organ manifestation).
  • Stage I erythema chronic: 
    • Erythema chronicum migrans.
    • Ggl. Pruritus.
    • Borrelia lymphocytoma.
  • Stage II:
    • Partially asymptomatic.
    • In some cases, flu symptoms begin only a few days after the onset of erythema chronicum migrans.
    • Locoregional lymph nodeadenopathy.
    • Possibly reduced general condition, febrile temperatures, cephalgias.
    • Multiple erythema migrantia.
    • Nonspecific exanthema.
    • Borrelia lymphocytoma.
    • Meningopolyneuritis Garin-Bujadoux-Bannwarth: Cephalgias, possibly meningitis or encephalitis, unilateral radiculitis (painful paralysis) and cerebral nerve paralysis.
    • Arthralgia, myalgia, 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).

    • Fibromyalgia.

    • Chronic pain syndrome.

    • Neurological symptoms are mainly observed 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.

    • Postinfectious Lyme disease syndrome (post Lyme disease):

    • Continued feeling of illness with myalgia and arthralgia after

    • symptoms subside and adequate antibiotic therapy. 

  • Medical history: Tick bite rememberable? Erythema migrans rememberable?
  • Circulating immune complexes can also be detected in about 60% of patients.
  • Borrelia serology (antibodies are not detectable from the beginning).
  • IgM: After 2 weeks in 50% of patients, after >4 weeks in 80% detectable.
  • IgG: Detectable after 2-3 months.
  • Clinic>Pathogen detection (serum, cerebrospinal fluid, joint fluid, tissue)
  • Blood culture.
  • If necessary, cerebrospinal fluid puncture (cerebrospinal fluid-serum index).
  • If necessary, detection of Borrelia in joint fluid.
  • If necessary, biopsy with pathogen detection.
  • Stage II: Long-term ECG, neurological presentation.

Perivascular infiltrates rich in plasma cells are typical.

  • Early therapy is important!

Therapy after Lebwohl

Early stage

Level of evidence

 

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

For neurological symptoms

 

Cefuroxim intravenously 2g daily for 14 days

B

Penicillin G intravenously 18-24 Mio. IU daily (in 4 ED) for 14 days

B

For cardiological symptoms

 

Both oral and intravenous therapy (see above 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 intravenously daily for 2-3 weeks

B

Penicillin G 18-24 Mio. IU intravenously (in 4 ED) for 2-3 weeks

 

Chronic recurrent arthritides

 

Renewed antibiotic therapy for 28 days

D

Late manifestation of neurological symptoms

 

Ceftriaxon 2 g intravenously daily for 2-3 weeks

B

Penicillin G 18-24 Mio. IU intravenously (in 4 ED) for 2-3 weeks

B

  • Early infection
  • Doxycycline p.o. 100 mg 2x daily for 21 days.
  • Alternative: 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); intravenously 250/62.5 mg suspension: 20-60 mg/kg bw 3x daily (2-12 years and ≤ kg) or 20-40 mg/kg bw 3x daily (1-2 years) for 21 days.
  • Alternative: Azithromycin p.o. 500 mg 1x daily for 10 days.
  • Alternative: cefuroxime p.o. 250-500 mg 2x daily (> 12 years), 125 mg 2x daily (5-12 years and ≥ 15 kg); intravenously 750 mg-1.5 g 3-4x daily for 12-18 days. 

 

  • Disseminated and late infection
  • PenicillinG intravenously 4 Mio. IE 6x daily for 2-3 weeks.
  • Alternative: Ceftriaxon intravenously 2g (max. 4g) 1x daily for 2-3 weeks.
  • Alternative: Cefotaxim i.v. 1g 4x daily for 2-3 weeks.  ​​​​​​​

 

  • Without neurological symptoms 

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