When to Suspect Lyme Disease in Children by odq14517

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       When to Suspect Lyme
         Disease in Children:
      Learn to See the “Red Flags”


              Ginger Savely, RN, FNP-C
              San Francisco, CA
              April 17, 2008

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        Session Objectives

• Name at least 2 reasons a Lyme
  diagnosis may not be considered
• List 3 possible red flags for Lyme
  disease in children
• Tell which diagnostic test is best to
  use for Lyme disease
• Name 2 possible antibiotics for the
  treatment of Lyme in children
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    Lyme Disease is Caused
     by Borrelia burdorferi
      (Bb), a Spirochete




          HISTORY
• Named “Lyme disease” in 1975 for
  town of New Lyme, CN where an
  unusual outbreak of pediatric
  arthritis occurred

• 1982, Dr. Willy Burgdorfer
  discovered the causative agent of
  Lyme – a spirochete - and it was
  named Borrelia burgdorferi




      The Deer Tick
Nymphal Ticks are Tiny!




 DEMOGRAPHICS
  Deer Population
     in the US
1900: 500,000
2000: 35-40 Million




   Risky Behaviors
                   RISK FOR NYMPH EXPOSURE
                         BY BEHAVIOR
                        Lane RS, Steinlein DB, Mun J. J Med Entomol
                                      2004;41:239-48.
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90
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         (30)
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      Sitting on logs   Gathering Wood   Sitting against   Stirring/sitting in   Sitting in litter
                                              trees               litter




          Protecting Kids from Tick Bites

• Bug spray with permethrin on boots and
  clothes.
• Sprays with DEET on skin (not too much!)
• Light-colored clothes so it is easier to see
  any ticks.
• Pant legs tucked into socks to keep ticks
  from getting under clothes.
• Most important: avoid areas with tall
  grasses and behaviors from previous
  slide!
       HOW TO REMOVE A TICK

• NEVER try to “smother” the tick with
  things like vaseline , mineral oil, liquid
  soap, or alcohol
• Don’t burn the tick
• Don’t grab the tick by the BODY or twist
  it to pull out
• ALL OF THE ABOVE ENCOURAGE THE
  TICK TO REGURGITATE PATHOGENS
  INTO THE WOUND




         DO: Gently remove tick by placing
         tweezers right next to the skin and
         pulling steadily until the tick lets go




           Lyme Disease Staging

• ACUTE – <1 month since infection
  • AKA early localized, early disseminated
    Lyme

• CHRONIC – >3 mos since infection
  • AKA Late localized, late disseminated
    Lyme
      Early Signs & Symptoms

• Erythema Migrans (bull’s eye rash)
   • diagnostic but only 60% get this
   • varied in appearance

• Early symptoms can be confused with a
  virus – headache, body aches, low grade
  fever, dizziness, diffuse joint pain




            Examples of EMs




        Lyme Disease in Children
            is Often Missed


• Tick bite not noticed half the time
• No tell-tale bull’s eye rash half the time
• Clinicians aren’t experienced in how to
  recognize the subtle and varied signs
• Clinicians aren’t aware that it can occur
  in any State in any month
• Symptoms can be subtle
       Lyme Symptoms in Children
        Often Confused with other
                Illnesses
•   Juvenile Rheumatoid Arthritis (JRA)
•   Hypercholesterolemia
•   Migraines
•   Crohn’s disease
•   Gastritis
•   Maturation delay
•   ADD or ADHD
•   Learning disabilities




          PNPs: Uniquely Suited
NPs spend more time with children and
 their parents than doctors do and so
 have the opportunity to pick up on the
 subtle clues to Lyme disease.

Pediatric NPs who learn the “red flags” for
  the disease can encourage their
  pediatrician colleagues to consider Lyme
  disease as a possible diagnosis

NPs are more open to “thinking outside the
 box”!j




         Consider the Possibility of Lyme
            Disease When a Child…..


……is a frequent visitor to the office
……has many and varied complaints
……has consulted numerous specialists
    who are not able to diagnose their
    symptoms
……catches everything that goes around
…… has many school absences and
    visits to the school nurse
        “Red Flags” :
     Symptoms that Don’t Fit
        Standard Diagnoses
• Low energy without anemia
• Frequent urination without UTI
• Visual problems with normal eye
  exam
• Insomnia unresponsive to typical
  treatments




      More red flags…..

 • Clumsiness, poor balance
 • Frequent “growing pains”
 • Hypersensitivity to light
 • Hypersensitivity to noise
 • Hypersensitivity to touch
 • New onset of cardiac murmur




     Other Symptoms ….

• New onset of anxiety, panic
  attacks
• Trouble sleeping
• Dizziness, light-headedness
• Rashes that come and go
• Itching all over without rash
           GI Problems in Children
             with Chronic Lyme

• Irritable bowel syndrome
• Sharp abdominal pains, especially lower
  quadrants
• Nausea, sometimes severe
• Abdominal tenderness
• Bloating, gas
• Loose stools




       Other Symptoms by System
• Urologic – frequent urination, bladder
  pain
• Ophthalmic – transient blurry vision,
  photophobia, drooping eyelid (eye exams
  are normal)
• Endocrine – insulin resistance, clinical
  hypothyroidism, temperature
  dysregulation, fluid balance dysregulation
  (constant thirst, urination), high
  triglycerides
• Psychiatric – depression, anxiety, OCD
  tendencies, bi-polar, sometimes
  hallucinations




        Behavioral & Cognitive Symptoms
                   Are Striking

Change in child’s normal behavior –

  • Active child becomes quiet and withdrawn
  • Quiet child becomes loud, hyper and
    aggressive
  • Calm child starts throwing fits and tantrums
  • Happy child becomes weepy and sad
  • Moodiness, inconsistent behavior
  • Notes from school for poor behavior
  • Distractible
         Cognitive issues:
 New onset of…

   • Difficulty with school work; lower
     grades
   • Attention deficit
   • Learning disabilities
   • Poor memory, speech difficulties
   • Maturation delay




         Laboratory Testing

• Lyme ELISA - Screening Test
   • Doctors learn to do this test first
   • Very poor screening test! (<50% sens)
   • Large variation in lab proficiency
   • Almost never + in acute cases

• Lyme Western Blot
   • Higher sensitivity, very high specificity
   • Better to go straight to this test
   • In acute Lyme, WB will be +
       Western Blot
• Very difficult to read a WB for
  Lyme

• Very few clinicians, even ID docs
  know how

• Don’t look at “bottom line” – this
  just shows positivity for
  epidemiology purpses
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     PICK THE RIGHT LAB!!!

• Use a specialty lab that reports all
  the bands of the blot

• Email me when you have results –
  I will help you interpret

• I use IGeneX Laboratories in CA
  Call 1-800-832-3200 for lab tests

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           TREATMENT
EARLY TREATMENT
 • Treatment successful if disease caught
   early
 • Treat with one month of Doxycycline (if
   age 8 or older) or Amoxicillin or Ceftin
 • Treating early can avoid disseminated
   illness which leads to years of needless
   suffering
        CHRONIC LYME TREATMENT

• Two standards of care – IDSA vs ILADS
• IDSA (Infectious Disease Society of America)
   • “Rare and easy to treat”
   • Treat one month, no more
   • No such thing as chronic Lyme – “Post Lyme
     Syndrome”
• ILADS (Int Lyme & Associated Disease Society)
   • “Prevalent and hard to treat”
   • Treat until better, even if it takes years
   • Evidence shows Bb is very difficult to
     eradicate




        Co-Infections Complicate
               Treatment
OTHER TICK-BORNE DISEASES:

•   Babesia (Piroplasma)
•   Bartonella
•   Anaplasma (aka granulocytic ehrlichia)
•   Ehrlichia
•   WA-1, MO-1, EU-1 (Babesias)
•   Rickettsia/Coxiella
•   Tularemia




               ILADS Treatment of
                  Chronic Lyme
 • Use Doxy or a combination of a
   beta-lactam and a macrolide
     • Eg. Amox + Azithromycin, or a
       cephalosporin + Clarithromycin
 • Treat as long as it takes to see
   improvement
 • Rotate antibiotics every 3-6
   months due to adaptation of the
   spirochete

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      The Herxheimer Reaction

• Important to understand!
• Intensification of existing symptoms
• May include Lyme symptoms that are
  typical but new to the child
• Due to “die-off” and inflammatory
  cytokine flares
• Starts about day 4 of treatment,
  cycles q 3-4 wks
• May be confused with allergic reaction!




                    Summary
  Session Take-Away Points…..
  1. Half the children who get Lyme
    disease don’t recall a tick bite and
    didn’t get a bull’s eye rash
  2. Lyme disease in children most
    often presents with behavioral and
    cognitive changes
  3. Lyme disease in children is often
    missed and can have devastating
    consequences

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          A Quote to Think About….


   "We know that there are known unknowns;
   that is to say, we know that there are some
   things we do not know. But there are also
   unknown unknowns - the ones that we don't
   know we don't know.” (Donald Rumsfeld)


   DON’T LET LYME DISEASE BE YOUR
   “UNKNOWN UNKNOWN”!
                      Questions
                       (last 5 minutes of session)




                       ?
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          Thank You for Your Interest in
            Lyme Disease in Children!

  • For more information please go to:
      www.ilads.org
  • Feel free to contact me if you have
    questions:
      Ginger Savely, RN, FNP-C
      450 Sutter Street Suite 1504
      San Francisco, CA 94108
      415-399-1035
      lymesf@gmail.com




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