I recently posted about my son’s sudden knee effusion. https://drcremers.com/2017/05/sterile-knee-effusion.html
A covering MD for his usual pediatrician saw him 5 days ago. This doctor seemed a bit lost of what to order so I asked for a Rheumatoid factor and Lyme titer, CBC, ESR, CRP. I must confess I drew the blood as their phlebotomist was late and my son was very upset at the idea of being late to school. Given the choice of waiting 15 minutes for the phlebotomist or having mom draw the blood, he reluctantly chose mom: ugh.
The following day, I called the covering MD who saw him to request a Doxycycline Rx just in case it was positive, as it takes days for the Lyme titer to come back . This doctor became very annoyed as if to say, “who are you to tell me what to prescribe.” That was not fun.
My son got much worse and yesterday we had to take him to the ER as he could not walk and was very upset and having more pain. Wonderful Dr. Theiss at Inova Children’s ER took incredible care of John. I love Dr. Theiss! He took very good care of my son and did a tap of the knee: withdrew 50cc of fluid and called me immediately with the results. It was not an infected or septic joint but I should see Rheumatology.
I just called his Pediatrician’s office. The Lyme Western Blot is Positive for Lyme.
Moral to the story: if your child has a swollen joint and you live in any location where there is LYME disease, treat with Doxycycline 2mg/kg/ day (maximum for kids is 100mg po bid) until the Lyme titer comes back. If it is positive, continue Doxycycline 100mg po bid for 28 days (at least: assuming no neurological signs develop: I pray my son does not have any
Controversy exists on how best to treat Lyme.
Here is the research so far.
Lyme disease is due to a bacteria Borrelia burgdorferi causes Lyme disease.Deer ticks can carry this bacterium. When a person gets bitten by a deer tick it can transfer the bacteria to your body, which is a total bummer!
The patient may experience symptoms in the
1. joints: any swollen knee in a child in a Lyme disease area needs a Lyme test & start treatment until Lyme titers come back.
2. skin: bullseye rash is classic.
4. nervous system (peripheral nerves (nerves outside the brain and spinal cord), the brain, and the spinal cord).
Without antibiotic treatment, neurological Lyme disease either may resolve or cause long-term problems.
Neurological Lyme disease differs between Europe and the United States, probably because of differences in B. burgdorferi between the continents.
Limited information exists about which antibiotics are better for the treatment of neurological Lyme disease which is frustrating.
Lyme neuroborreliosis (LNB) is a group of many diseases that can affect the central nervous system (CNS) and the peripheral nervous system (PNS), or both, as a result of infection with or the postinfectious consequences of different species of the spirochete bacterium Borrelia burgdorferi.
These organisms are transmitted by particular Deer Ticks called Ixodid ticks. They are endemic areas in the United States and Europe. Although a multitude of clinical manifestations of LNB have been reported, the most common are:
1. radicular pains,
2. facial paralysis, and
3. meningitis, referred to as Bannwarth’s syndrome in Europe (Bannwarth 1941; Bannwarth 1944). It was not until 1981 that entomologist Willy Burgdorfer and colleagues in the USA suspected that the cause of Lyme disease was a tick-borne spirochete (Burgdorfer 1982).
LNB is one of the most common and important complications of Lyme disease. The diagnosis of LNB requires confirmation of infection with B. burgdorferi plus evidence of involvement of the CNS, the PNS, or both. According to the Centers for Disease Control and Prevention, from the 154,405 cases of Lyme disease reported during 2001 to 2010 in the United States, 14% were identified with facial palsy, radiculoneuropathy, meningitis, or encephalitis (CDC 2011a).
5% of individuals with an untreated erythema migrans will develop LNB (Hansen 2013): so get treated fast!
For LNB and Brain involvement of Lyme:
In Ljostad 2008, investigators obtained CSF at inclusion and at 13 days and 4 months after the start of antibiotic treatment. No significant difference was found between oral doxycycline and intravenous ceftriaxone for reduction in CSF cell count at 13 days (P = 0.89) or 4 months (P = 0.56) after the start of treatment (data not provided; low-quality evidence).
The safety population included 113 participants with available data. The RR of adverse event between the two groups favored doxycycline, but the data were very imprecise and allowed for the possibility of no difference (RR 0.79, 95% CI 0.51 to 1.23; N = 113; moderate-quality evidence; Analysis 2.3). Three participants discontinued ceftriaxone treatment due to adverse events: one with cholecystitis, one with stomatitis and proctitis, and one with allergy. There were no other serious adverse events. There was one serious adverse event but no withdrawals in the doxycycline group. Results for adverse events leading to discontinuation (RR 0.14, 95% CI 0.01 to 2.71; N = 118; Analysis 2.4) and serious adverse events (RR 0.33, 95% CI 0.04 to 3.05; N = 113; Analysis 2.5) also favored doxycycline but with serious imprecision. Diarrhea, nausea, and urticaria were reported for 19, 15, and 3 participants, respectively; all were generally mild. Emergence of new symptoms compatible with LNB or intensification of symptoms during treatment was not reported.
Karlsson 1994 compared a 14-day treatment with penicillin G to 14 days of oral doxycycline in 54 participants with LNB. The study included only participants with objective findings and a positive serology or evidence of abnormal CSF. Investigators used a rating of subjective and objective findings on a Likert scale from 0 to 3 (no symptoms, mild symptoms, moderate or severe symptoms) for primary efficacy. The RRs for improvement and resolution with penicillin G versus oral doxycycline at 12 months were 1.0 (95% CI 0.92 to 1.08) and 0.95 (95% CI 0.77 to 1.18), respectively (N = 51; low-quality evidence; Analysis 3.1; Analysis 3.2). Participants were followed for 12 months, with no difference found between the two treatment arms except for the fact that more participants treated with doxycycline reported vertigo at the end of treatment but not at one month. One participant in each treatment group was retreated because of residual symptoms. Subjective symptoms were completely absent at 12 months except for 1 penicillin G participant with neuromuscular pain and hypoesthesia and 1 doxycycline participant with arthralgia. Selection bias is a concern in this study due to a considerable imbalance in the number of participants randomized to each treatment arm. The report provided few statistics and did not allow a distinction to be made between participant- and physician-based judgements. Objective judgement of findings at the end of follow-up was implied but not well documented, thus this study did not use a well-characterized objective measure of efficacy by a physician.
Kohlhepp 1989 randomized a clinically well-defined cohort of 75 participants with predominantly acute (n = 67) but also chronic (n = 8) LNB to a 10-day course of intravenous doxycycline or intravenous penicillin G. Follow-up was 12 months, but for cases with residual symptoms the follow-up was three years. The primary outcome was the treating physicians’ categorical grading of the clinical status as “no remission,” “partial remission,” or “full remission,” based on objective and subjective signs and symptoms with no specification given. At the end of treatment, over 80% of participants had responded to some degree in both groups. Early responders were usually asymptomatic after six months. Pain, meningitic symptoms, and acute cranial neuritis began to remit within days. A slower improvement was observed in symptoms of radiculitis, myelitis, encephalitis, and peripheral neuropathy. According to data in Figure 2 of the study report, at six months the RR for “partial remission” (improvement) showed no clear difference between interventions (RR 1.10, 95% CI 0.95 to 1.28), whereas the RR for “full remission” (resolution) favored doxycycline, but with the possibility of no effect (RR 1.42, 95% CI 0.83 to 2.42; low-quality evidence; Analysis 4.1 and Analysis 4.2). At 12 months, the RRs for “partial remission” and “full remission” were 0.98, 95% CI 0.80 to 1.21 and 0.96, 95% CI 0.70 to 1.31, respectively (low-quality evidence; Analysis 4.1 and Analysis 4.2). Of the 22 participants with only partial remission after 6 months, 10 chose to receive retreatment with penicillin G, 6 from the penicillin arm and 4 from the doxycycline arm. Three years after randomization, the recovery rate was 94% in the doxycycline and 91% in the penicillin G group if the retreatment group was excluded. In the “partial remission” group, 7/10 participants who chose retreatment recovered completely, compared to 7/12 of those who did not choose retreatment (no significant difference). Participants with partial remission had central nervous system involvement, a disseminated clinical picture, and/or a longer disease duration. The authors concluded that there was no clinically relevant difference between doxycycline and penicillin G. The number of participants with chronic LNB was too low for any subgroup analysis. In addition, the majority of these chronic LNB cases were also treated with immunosuppressants.
Implications for practice
More info from WebMD:
- An expanding red rash with a pale center. This is sometimes called a “bull’s-eye” rash.
- Extreme tiredness.
- Headache and stiff neck.
- Muscle and joint pain.