Diagnose treat based on clinical finding of typical erythema migrans EM lesion testing necessary only if skin findings suggestive of EM but not typical

Submitted by vgreene on Thu, 06/03/2021 - 16:02
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<sup>1</sup> <b>CDC 2021.</b> Lyme Disease. Last reviewed 3/5/21. <a href=https://www.cdc.gov/lyme/index.html><u>Accessed 5/17/21</u></a>
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<sup>2</sup> <b>IDSA/AAN/ACR 2020.</b> Lantos PM, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. <i>Clin Infect Dis</i>. 2021. Jan 23;72(1):1-8. <a href=https://www.idsociety.org/practice-guideline/lyme-disease/><u>Accessed 5/17/21</u></a>
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<sup>3</sup> <b>NICE 2018.</b> Lyme Disease - NICE Guideline (NG95). National Institute for Health and Care Excellence. Published 4/11/18. Last updated 10/17/18. <a href=https://www.nice.org.uk/guidance/NG95><u>Accessed 5/17/21</u></a>
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<sup>4</sup> <b>IDSA/AAN/ACR 2020.</b><br>
Use azithromycin as 2nd-line agent in pts w/ contraindications to all others; concern about &darr;efficacy and macrolide resistance<br>
• azithromycin 500 mg (10 mg/kg/dose, up to max 500 mg in children) PO qd – 5-10 days (7 days pref’d in U.S.)
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<sup>5</sup> <b>IDSA/AAN/ACR 2020.</b><br>
Characteristic lab abnormalities in both anaplasmosis & babesiosis incl:<br>
• thrombocytopenia<br>
• leukopenia<br>
• neutropenia<br>
• anemia
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Evidence of hemolysis (anemia, &uar;indirect bili, ↑LDH) particularly suggestive of babesiosis.
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<sup>6</sup> <b>CDC 2021.</b><br>
Examples of unvalidated tests include:<br>
• Capture assays for antigens in urine<br>
• Culture, immunofluorescence staining, or cell sorting of cell wall-deficient or cystic forms of <i>B burgdorferi</i><br>
• Lymphocyte transformation tests<br>
• Quantitative CD57 lymphocyte assays<br>
• “Reverse Western blots”<br>
• In-house criteria for interpretation of immunoblots<br>
• Measurements of antibodies in joint fluid (synovial fluid)<br>
• IgM or IgG tests w/o previous ELISA/EIA/IFA<br>
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<sup>*</sup> <b>ILADS 2014.</b><br>
ILADS diverges from CDC, IDSA, & NICE, recommending extended tx of at least 4-6wk w/ doxycycline, amoxicillin, or cefuroxime axetil. They also recommend that azithromycin be used for a minimum of 21 days, and that, regardless of abx used, tx be extended indefinitely until all sx are completely resolved.
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Cameron DJ, et al. Evidence Assessments and Guideline Recommendations in Lyme Disease: The Clinical Management of Known Tick Bites, Erythema migrans Rashes and Persistent Disease. <i>Expert Rev Anti Infect Ther.</i> 2014. Sept;12(9):1103-1135. <a href=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196523/pdf/ERZ-12-1103.pdf><u>Free full-text PDF @ PubMed® Central</u></a>
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<b>Concern has been raised about the quality, validity, and inherent bias of International Lyme and Associated Diseases Society (ILADS) guidance by numerous groups, incl the Infectious Diseases Society of America (IDSA). ILADS guidance does not meet epocrates editorial standards. We include their recommendations here not as an endorsement of their validity, but in order to help provide context when confronted w/ pt questions arising from ILADS recommendations.</b>

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Diagnose & treat based on clinical finding of typical erythema migrans (EM) lesion; testing necessary only if skin findings suggestive of EM, but not typical