Lyme Disease

Treat a patient with one or more classic erythema migrans lesions in an endemic area clinically, without laboratory confirmation. Serology is often insensitive early in infection, whereas an atypical expanding lesion or extracutaneous syndrome warrants validated two-tier testing because these presentations overlap with other illnesses. Nature+2NatureRapid single-tier serodiagnosis of Lyme disease | Nature CommunicationsPubMedLaboratory Diagnosis of Lyme Disease - Advances and ChallengesPubMedLyme Disease - StatPearls - NCBI Bookshelf

Obtain a 12-lead ECG promptly for palpitations, presyncope or syncope, dyspnea, chest pain, or other concern for Lyme carditis. Lyme carditis affects the cardiac conduction system and can produce arrhythmia, poor cardiac function, hypotension, or syncope; symptomatic patients or those with clinically important conduction disease need hospital-level monitoring rather than outpatient empiric treatment alone. PubMedPubMedLyme disease: diagnosis and management

For acute facial palsy, painful radiculopathy, peripheral neuropathy, or meningitic symptoms after compatible tick exposure, distinguish peripheral neuroborreliosis from alternative infectious and inflammatory neuropathies. Neurologic manifestations have been reported in 3%-12% of Lyme disease cases and may occur with intense pain, facial palsy, radiculopathy, neuropathy, or meningitis. NatureNatureLyme Disease Patient Trajectories Learned from Electronic Medical Data for Stratification of Disease Risk and Therapeutic Response | Scientific Reports

An acute or subacute large-joint inflammatory effusion, particularly a knee-predominant pattern, raises Lyme arthritis but should not defer arthrocentesis when septic arthritis remains plausible. Serology is the preferred diagnostic test for suspected Lyme arthritis; antibody testing of synovial fluid is not recommended. PubMed+1PubMedLaboratory Diagnosis of Lyme Disease - Advances and ChallengesIDSALyme Disease

Use the CDC two-step algorithm for patients whose presentation requires laboratory confirmation. Standard two-tier testing uses a first-tier EIA followed, when the screen is positive or equivocal, by IgM and IgG immunoblotting; modified two-tier testing uses two different EIAs. The overall result is positive only when both tiers meet the assay-specific positivity criteria. If the first-tier test is negative, do not perform additional serologic testing in that specimen. CDC+1CDCClinical Testing and Diagnosis for Lyme Disease | Lyme Disease | CDCIDSALyme Disease

Modified two-tier algorithms offer sensitivity comparable to conventional EIA-immunoblot testing and avoid subjective immunoblot interpretation. Their key limitation in late manifestations is that polyvalent EIAs may not distinguish IgM from IgG or show whether the IgG response is expanded, information that can be useful when evaluating suspected late Lyme arthritis. PubMed+1PubMedLaboratory Diagnosis of Lyme Borreliosis - PMCIDSALyme Disease

Time serology to the biology of the syndrome. Two-tier testing has low sensitivity in early infection, so a negative result does not exclude early erythema migrans; initially seronegative infected patients typically become strongly seropositive when retested several weeks later. Conversely, current assays do not distinguish active from remote infection, and seropositivity may persist for years. PubMed+1PubMedLaboratory Diagnosis of Lyme Disease - Advances and ChallengesIDSALyme Disease

Do not diagnose late Lyme disease from isolated IgM reactivity. IgM is relevant primarily during illness of less than 1 month; CDC case-definition criteria direct low-incidence states to disregard IgM results obtained more than 30 days after symptom onset. For conventional immunoblots, IgM positivity requires at least two of three designated bands, while IgG positivity requires at least five of ten designated bands. PubMed+1PubMedLaboratory Diagnosis of Lyme Disease - Advances and ChallengesCDCLyme Disease (Borrelia burgdorferi) 2022 Case Definition | CDC

For erythema migrans without cardiovascular or neurologic involvement, use doxycycline for 10 days or amoxicillin or cefuroxime axetil for 14 days. Azithromycin for 5-10 days is a second-line option when the preferred agents cannot be used. Erythema migrans usually resolves within 1-2 weeks, while systemic symptoms can improve more slowly. PubMed+1PubMedLyme Disease - StatPearls - NCBI BookshelfPubMedCommissioned Papers - Critical Needs and Gaps in Understanding Prevention, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases - NCBI Bookshelf

Treat Lyme carditis for 14-21 days. Patients who do not require hospitalization can receive oral doxycycline, amoxicillin, or cefuroxime. Symptoms indicating conduction-system involvement require ECG-based triage and inpatient management when severe conduction disease or hemodynamic consequences are present. BMJ+1BMJLyme disease - Management Approach | BMJ Best PracticePubMedLyme disease: diagnosis and management

Treat Lyme arthritis with oral doxycycline for 28 days. A partial response can justify a second oral course, whereas minimal or absent response supports intravenous ceftriaxone for 2-4 weeks. After an oral course and an intravenous course, persistent inflammatory arthritis is postantibiotic Lyme arthritis; refer to rheumatology for consideration of intra-articular corticosteroid injection, disease-modifying antirheumatic therapy, or other advanced anti-inflammatory treatment rather than serial antibiotic courses. PubMedPubMedLyme Disease - StatPearls - NCBI Bookshelf

Counsel patients beginning antibiotics about Jarisch-Herxheimer reaction: transient fever, chills, myalgias, headache, and worsening of skin lesions can begin within 1-12 hours, usually resolves within 24-48 hours, and occurs in approximately 5%-15% of treated patients. Continue antibiotics and use acetaminophen or an oral NSAID for symptom control unless another acute process is suspected. PubMed+1PubMedLyme disease: diagnosis and managementPubMedLyme Disease - StatPearls - NCBI Bookshelf

Offer antibiotic prophylaxis only when all high-risk criteria are satisfied: the removed tick is identified as adult or nymphal Ixodes scapularis, estimated attachment exceeds 36 hours, local tick infection prevalence with Borrelia burgdorferi exceeds 20%, doxycycline can be started within 72 hours of removal, and doxycycline is not contraindicated. The recommended regimen is a single dose of doxycycline. PubMedPubMedCommissioned Papers - Critical Needs and Gaps in Understanding Prevention, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases - NCBI Bookshelf

Do not substitute another antibiotic for prophylaxis when doxycycline cannot be used, including pregnancy, lactation, or children younger than 8 years in the guideline criteria. Instead, provide symptom surveillance and instruct the patient to seek evaluation for erythema migrans, fever, facial palsy, new monoarthritis, or cardiopulmonary symptoms. PubMedPubMedCommissioned Papers - Critical Needs and Gaps in Understanding Prevention, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases - NCBI Bookshelf

A negative history of a recognized tick bite should not exclude Lyme disease when an epidemiologically compatible syndrome is present; patient-recognized attachment is an imperfect exposure marker. Conversely, treating all nonspecific symptoms after a bite drives false-positive testing and unnecessary antibiotics because test specificity matters most in low-pretest-probability populations. PubMedPubMedLaboratory Diagnosis of Lyme Disease - Advances and Challenges

Follow erythema migrans by lesion evolution and systemic symptom trajectory, carditis by symptoms and ECG findings, and arthritis by joint examination and function. Do not order serial serology to document response because antibodies can persist for years and available assays cannot distinguish active from inactive infection. PubMedPubMedLaboratory Diagnosis of Lyme Disease - Advances and Challenges

If fever is prominent with thrombocytopenia or other laboratory abnormalities after Ixodes exposure, evaluate for tick-borne coinfection rather than attributing all findings to Lyme disease. A reported tick-borne case with fever and thrombocytopenia illustrates potential diagnostic overlap with ehrlichial illness, and Ixodes ticks may harbor Borrelia miyamotoi in addition to Lyme spirochetes. The Lancet+1The LancetSupplementary appendix 1CDCPDF - 8.24 MB - 183 pages

For persistent or recurrent symptoms, re-anchor the diagnosis to objective evidence: a new erythema migrans lesion, a documented conduction abnormality, a compatible neurologic syndrome, or persistent inflammatory synovitis. In the absence of objective evidence, broaden the differential rather than using an isolated positive serologic result as proof of ongoing infection. PubMed+1PubMedLaboratory Diagnosis of Lyme Disease - Advances and ChallengesIDSALyme Disease