Transcript Slide 1

Case Study Presentation:
Lyme Disease
By Ana Corona, FNP-C
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www.nurseana.com
Objectives
1. Identify at least 3 signs and
symptoms associated with Lyme
Disease.
 2. Describe at least 2 laboratory test to
screen for Lyme Disease.
 3. Understand the Pathophysiology of
the disease.
 4. Identify at least 2 preventive
measures related to Lyme Disease.
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Identifying Information
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Patient Initials: H.R.
Age: 10 year old
Race: Hispanic
Sex: Female
Three Generation Genogram:
Subjective Data
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Chief Complaint:
“My daughter has had
a painful itching rash
on her right thigh for
2 days”
 “I am not feeling
well”
History of Present Illness
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OPQRST
O= Other associated manifestations:
fever and joint pain
P= Precipitating/palliating/aggravating factors:
Upon exertion
Q= Quality/type of symptom:
Moderate
R= Region/Radiation:
None
S= Severity of symptoms:
6/10 (pain scale 1-10)
T= Time of onset:
chief complaint began 2 days ago, 10 days after hiking trip
Review of Systems
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Skin: visible rash with pain and itching present on right
anterior mid thigh
Patient applied alcohol and petroleum jelly at affected
area without relief.
Patient denies prior injuries.
Denies eye, ears, nose and throat complaints.
Denies cough, shortness of breath, or chest pain.
Upper and lower extremities: complains of tenderness
on elbows and knees. Denies history of trauma.
No edema present. Peripheral pulses: regular and
strong.
Denies numbness, tingling, twitching or paralysis.
Relevant Past History
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Allergies: no history of allergies
Habits: likes to play outdoors
Environmental exposure and pertinent travel:
Recent hiking trip 10 days ago.
Illnesses, surgeries, traumas: denies
Mental Health: alert and oriented
Lifestyle Issues: child is a girl scout
Family History: grandfather has diabetes
Immunizations are up-to-date
Relevant Psychosocial History
Family Relations:
 Impact of illness on health and integrity of family:
mother very concerned due to low income.
 Values, beliefs, stressors: value family, cultural and
religious beliefs.
 Education: child is a student, 4th grader
 Economics, financial problems: underserved
population, unable to receive public assistance,
uninsured,
 Current living environment: family of 4 in a one
bedroom home
 Perception of illness: mother thinks child has leukemia
Objective Data:
Physical Examination
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Symmetrical facial features
No bony deformities
Eyes symmetrical, pupils equal, reactive to light
Ears: non-tender mastoid process, canal walls pink and uniform with
tympanic membrane visible. Tympanic membrane intact, pearly gray
shiny and translucent.
Oropharanx: tonsillar pillars are pink and symmetrical without exudate
present.
No drooling or neck weakness present.
Neck and Axillary Lymph nodes: pea size, mild tenderness present
Lungs: bilateral clear, respirations regular in rhythm and rate.
Heart: S1 S2, no audible murmurs present
Abdomen: soft and subtle, no tenderness present, bowel sounds present
on all four quadrants.
Musculoskeletal: mild tenderness on elbows and knees upon palpation,
no heat or deformities present.
Skin warm to touch.
Rash measures 50 cm; is warm to touch with tenderness upon palpation.
Objective Data:
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Vital signs:
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Blood pressure
100/60
Pulse
92
Respirations
22
Temperature
100.8 F
What is Lyme Disease?
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Infection caused by the bacterium Borrelia
burgdorferi
 Transmitted by the bite of certain species of
ticks
 The disease often starts as a skin rash and
can progress to more serious stages involving
joint, nerve, or heart tissue.
 Lyme disease is the most common vector
borne disease in the United States.
Lyme Disease: Pathophysiology
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Lyme disease is caused
by a coiled bacterium –
a spirochete called
Borrelia burgdorferi.
The bacterium enters
the skin at the site of a
tick bite and may spread
in lymph, producing
regional adenopathy, or
disseminate in blood to
organs or other skin
sites.
Distribution of Lyme Disease
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According to the Centers
for Disease Control and
Prevention (CDC), in
1996 there were 16,461
cases of Lyme Disease
reported in the United
States.
The majority of cases
have occurred in four
endemic regions: the
Northeast, the MidAtlantic, Minnesota,
Wisconsin, California
and Oregon.
Animal Reservoirs
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Immature ticks become
infected by feeding on small
rodents such as mice and
also on other mammals: deer,
birds, horses, dogs and cats
that are infected with the
bacterium Borrelia
burgdorferi.
In later stages, these ticks
then transmit the Lyme
disease bacterium to humans
and other mammals during
the feeding process.
Lyme disease bacteria are
maintained in the blood
systems and tissues of small
rodents.
Ticks
Tick Bite
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Begins as a red macule
or papule.
Usually on the proximal
portion of an extremity
or on the trunk (thigh,
buttock, or axilla)
between 3 and 32 days
after a tick bite.
The area expands, often
with central clearing to a
diameter of up to 50 cm.
Objective Findings
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The “Bulls eye” or Erythema
Migrans (EM) rash is an early
symptom of Lyme disease.
Usually appears 7 to 10 days
after the bite of an infected
tick.
Proper treatment with
antibiotics is mandatory.
If untreated, Lyme disease
may progress to chronic
stage that can be disabling
and difficult to cure.
Secondary Lesions
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Soon after onset, nearly
½ of untreated U.S.
patients develop
multiple, lesions without
indurated centers.
Cultures of biopsies of
these secondary lesions
have been positive,
indicating dissemination
of infection.
Lyme Disease: Late Stage
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Over time the central portion
of the rash may become
necrotic or vesicular
During this stage, patients
may complain of flu-like
symptoms, such as fatigue,
chills, fever, headache,
muscle and joint pain.
Other symptoms may include
regional lymphadenopathy,
facial nerve paralysis and
irregularities of heart rhythm.
Laboratory and Radiology Findings
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Diagnosis of early Lyme disease in a patient with typical
Erythema Migrans in an endemic area does not require laboratory
confirmation.
ELISA Titers of specific antispirochetal antibodies-IgM, then IgG
are preferably determined.
Indirect immunofluorescence: is less useful before patient has
made antibodies.
Western blot: confirmation of positive titers is needed.
In Skin Biopsy: all layers of the dermis are heavily infiltrated with
mononuclear cells around blood vessels and skin appendages.
CSF: elevated titers
ESR: elevated
AST and LDH: slightly elevated
X-ray findings usually are limited to soft tissue swelling, but a few
patients have had erosion of cartilage and bone.
Hematocrit and WBC and differential counts usually are normal.
Differential Diagnosis
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Lyme disease must be distinguished from
Juvenile Rheumatoid Arthritis in children.
In adults, from Reiter’s syndrome and atypical
Rheumatoid Arthritis.
Ehrlichiosis-is an emerging infection
transmitted by the same the tick.
Spondyloarthropathies
Idiopathic Bell’s Palsy
Other CNS syndromes
Therapeutic Plan:
Antibiotic treatment for 3 – 4 weeks with
doxycycline or amoxicillin is generally effective
in early disease.
 Cefuroxime axetil or erythromycin can be used
for persons allergic to penicillin or who cannot
take tetracyclines.
 Intravenous ceftriaxone or penicillin for 4
weeks or more may be required for patients
with neurologic manifestations.
 In later disease, treatment failures may occur
and retreatment may be necessary.
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Lyme Disease: Prevention
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As of February 25, 2002 the
vaccine manufacturer
announced that the LYMErix
Lyme disease vaccine will no
longer be commercially
available.
CDC Advisory Committee on
Immunization Practices
recommendations regarding
LYMErix Vaccine:
Persons who reside, work, or
recreate in areas of high or
moderate risk.
Educative and Prevention Plan:
Personal Protection
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Avoidance of tick habitat: persons should avoid
entering areas that are likely to be infested with ticks.
Ticks favor moist, shaded environment, provided by
leaf litter and low-lying vegetation in wooded, brushy
or overgrown grassy habitat.
 Personal Protection: wear light-colored clothing so that
ticks can be spotted more easily and removed before
becoming attached.
 By wearing long-sleeved shirts and tucking pants into
socks or rubber boot tops may help keep ticks from
reaching the skin.
 Application of insect repellents containing DEET (n,ndiethylm toluamide) to clothes and exposed skin, and
permethrin which kills ticks on contact to clothes.
Prevention: Tick Check
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Prompt removal of ticks will help prevent infection,
since transmission of B burgdorferi from an infected
tick is unlikely to occur before 36 hours of tick
attachment.
 Embedded ticks should be removed using fine-tipped
tweezers.
 DO NOT use petroleum jelly, a hot match, nail polish
or other products.
 Grasp the tick firmly and as closely to the skin as
possible.
 Pull the tick’s body away from the skin with a steady
motion.
 Cleanse the area with an antiseptic.
 Seek medical attention.
Plan: Referrals and Follow-up
Internal Medicine: Joint pain present
 Neurology: CNS involvement
 Cardiology: Chest pain, heart murmur
involved
 Reported to Centers for Disease Control
and Prevention
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Questions?