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Therapeutic Strategies

Borreliosis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Overview

Infection with various Borrelia species will cause cutaneous and systemic infections. Early Lyme disease (erythema migrans) and late Lyme disease (acrodermatitis chronicum atrophicans) are the classic cutaneous complications of these infections. In Europe, patients may also develop lymphocytoma as a complication of borrelial infection.

Erythema Chronicum Migrans - Primary Lyme Disease

Erythema migrans is the cutaneous eruption of early borreliosis caused by the tickborne spirochete Borrelia burgdorferi. The therapeutic strategy is to eradicate the pathogenic organism. Solitary lesions are treated with shorter durations of therapy. When patients have multiple erythema migrans lesions, they often have paucisymptomatic involvement of the nervous system or other sites and may require longer courses of treatment. Patients with multiple erythema migrans lesions may require complete neurologic evaluation and lumbar puncture prior to treatment, or they should be treated as if they have neuroborreliosis.

First Steps

  1. Doxycycline 100 mg orally twice daily for 10-21 days. (In a comparative trial, 10 days of doxycycline was equivalent to 20 days, although rare treatment failures can occur with any duration of oral therapy.)
  2. Amoxicillin, 500 mg three times daily for 14-21 days; in children 250 mg 3 times daily or 50 mg/kg/day in 3 divided doses. This is the preferred medication in pregnancy.
  3. Patients with first-degree heart block or facial palsy as their only manifestation may be treated with 14-21 days of any of the above antibiotic regimens.
  4. For lymphocytoma associated with borreliosis, use the standard antibiotics above for 20-30 days.

Alternative Steps

  1. In patients allergic to or intolerant of doxycycline and amoxicillin, use cefuroxime axetil 125 mg twice daily or 30 mg/kg per day in two divided doses for 14-21 days.
  2. Only in patients unable to take all three of the above medications, erythromycin 250 mg 3 times daily or 30 mg/kg/day in 3 divided doses for 14-21 days.

Subsequent Steps

  1. Regular follow up of these patients for potential cardiac, neurologic, or arthritic sequelae is important. For arthritis, 30-60 days of an oral regimen or intravenous treatment as below for 14-28 days is recommended. For neurologic involvement or cardiac involvement of more than first-degree heart block, ceftriaxone 2 g IV once a day for 14 days, cefotaxime 2 g IV every 8 hours for 14-21 days, or penicillin G sodium 3.3 million units IV every 4 hours (20 million U/day) for 14-28 days.

Ancillary Treatment

  1. In endemic areas, persons at risk may consider immunization with 3 doses of L-OspA.
  2. A single dose of doxycycline 200 mg is effective prophylaxis after a tick bite in high endemicity regions.
  3. Protective clothing and insect repellents containing DEET should be worn in endemic areas.

Complications and Undesired Consequences

  1. Erythema migrans is a clinical diagnosis, as serologic testing may be negative at this stage. Treatment should not be withheld if the diagnosis is uncertain. Seek consultation or treat presumptively.
  2. Once chronic musculoskeletal or neurocognitive symptoms or fatigue develop in patients with documented borreliosis, prolonged duration antibiotic therapy (beyond that listed above) is unlikely to lead to symptomatic improvement.

Acrodermatitis Chronica Atrophicans and Solitary Lymphocytoma Cutis - Cutaneous Late Lyme Disease

Occurring almost exclusively in Europe, this disorder is a late sequel of infection with Borrelia afzelii, a spirochete that is tick-transmitted by Ixodes ricinus.

Initial Steps

Doxycycline 100 mg twice daily for 20-30 days.

Subsequent Steps

For patients who fail to respond to oral doxycycline:

  1. Intravenous or intramuscular ceftriaxone 2 g daily for 14-28 days, or
  2. Intravenous penicillin 20 x 106 unit/day for 14-28 days.

Pitfalls

The atrophic lesions of acrodermatitis chronica atrophicans may be permanent.

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