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Lyme Disease Referral Guidelines
Lyme disease, caused by the spirochete Borrelia burgdorferi sensu lato complex, is transmitted to humans usually from infected mice or white-tailed deer via the bite of the Ixodes species tick. In the United States Lyme disease is found mainly in the northeastern states, the upper Midwest, and northern California. However, climate change is affecting tick distribution and it is likely that Lyme disease will become more common in other geographic regions as well.
Clinical Lyme disease most commonly presents as early localized infection manifest by the rash termed erythema migrans; neurologic disease (Lyme neuroborreliosis) comprising both peripheral (cranial neuritis, radiculoneuritis, plexopathies, and mononeuropathies) and central (meningitis, pseudotumor cerebri, encephalitis, and meningitis) nervous system involvement; carditis (usually heart block, rarely pericarditis or myocarditis); and arthritis (usually marked swelling of one or a few large joints).
- Initial Evaluation:
- As with all conditions, careful history and physical examination is the most important aspect of evaluation for Lyme disease.
- Ask about tick exposure, rashes, and activities likely to have placed the patient in proximity to mice, deer, or ticks in general.
- On physical examination, do a careful look for skin lesions, cranial nerve abnormalities (especially peripheral 7th nerve palsy), general neurologic exam, irregular pulse by palpation for at least 60 seconds, and joint swelling, tenderness, and range of motion.
- Children with more nonspecific complaints such as prolonged fever or fatigue would not ordinarily warrant evaluation for Lyme disease if the more specific clinical features above have not been present.
- Initial Management:
- Diagnostic testing is not necessary if classic erythema migrans is present, especially because serologic testing may be negative early in infection which is the time that erythema migrans appears.
- If serologic testing is performed, this should be limited to serum sent for a 2-stage (reflex) test. The first stage is a highly sensitive screening test with expected false positives and if positive or indeterminate is followed by a confirmatory test, usually Western blot. Note that Western blot tests also have false positives and should not be performed without the initial screening test. Also note that IgM Western blot testing results for individuals with > 1 month of symptoms should not be used for any clinical determination.
- Treatment regimens vary by age and clinical features. Consult a current reference such as the American Academy of Pediatrics Red Book for details.
Providers may refer a patient with possible Lyme Disease any time there is question of diagnostic or treatment choices.
Children with possible Lyme Disease and emergent conditions, such as question of encephalitis, meningitis, or arrhythmia, may be more effectively managed in the Emergency Department or as an inpatient. Infectious Diseases physicians are available to advise on best options for emergency conditions.
Infectious Diseases outpatient referral is strongly recommended for:
- All children with possible Lyme arthritis, as soon as the diagnosis is entertained or made. Early referral helps ensure appropriate response to therapy and need for adjunct therapy and can lessen risk of long-term sequelae
- All children with presumed Lyme meningitis being treated with oral antibiotic
For urgent or emergent situations, providers can contact the outpatient Infectious Diseases physician on call by calling the Infectious Diseases office during weekday working hours or the hospital page operator nights, weekends, and holidays.
For outpatient referrals, physicians may contact the Infectious Diseases office at 202-476-6151.
- As with all referrals to Infectious Diseases clinicians, we request copies of pertinent office notes and laboratory reports prior to the visit. These can be faxed to 202-476-3850.
Infectious Diseases providers will perform a detailed history and physical examination, determine need for further testing and/or treatment, and discuss all options with the child and family. Subsequent follow up may be indicated, especially for children with arthritis or neurologic concerns.
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