Lyme Disease Case Study: A 38-Year-Old Male Had A 3-Week His ✓ Solved

Lyme Disease Case Study: A 38-year-old male had a 3-week his

Lyme Disease Case Study: A 38-year-old male had a 3-week history of fatigue and lethargy with intermittent headache, fever, chills, myalgia, and arthralgia. Symptoms began shortly after a camping vacation; he recalled a bug bite and rash on his thigh. Studies: Lyme disease test: elevated IgM antibody titers against Borrelia burgdorferi; ESR 30 mm/hr (normal ≤15); AST 32 U/L (normal 8-20); Hemoglobin 12 g/dL (normal 14-18); Hematocrit 36% (normal 42-52%); RF negative; ANA negative. Diagnostic analysis: Lyme disease suspected; early testing for IgM helpful; elevated ESR, AST, and mild anemia common; RF and ANA usually absent. Critical Thinking Questions: 1. What is the cardinal sign of Lyme disease? 2. At what stages of Lyme disease are the IgG and IgM antibodies elevated? 3. Why was the ESR elevated? 4. What is the therapeutic goal for Lyme disease and what is the recommended treatment?

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Introduction

This case presents a 38-year-old man with a three-week history of constitutional and musculoskeletal symptoms following a camping trip, with a recalled insect bite and rash, laboratory evidence of elevated IgM to Borrelia burgdorferi, a modestly elevated ESR, mild transaminase elevation, and mild anemia. These findings are most consistent with early Lyme disease (early localized or early disseminated), and the clinical picture and laboratory results guide diagnosis and management (CDC, 2023; Wormser et al., 2006).

1. Cardinal sign of Lyme disease

The cardinal sign of early Lyme disease is erythema migrans (EM), the characteristic expanding skin lesion that often begins as a red macule or papule and typically expands over days to weeks, sometimes developing central clearing (a “bull’s-eye” appearance) (Steere, 2001; Stanek et al., 2012). EM may be accompanied by systemic symptoms such as fever, fatigue, headache, myalgias, and arthralgias—the pattern seen in this patient. Importantly, EM is a clinical diagnosis: when present, it is sufficient to initiate treatment for Lyme disease without awaiting serologic confirmation, because antibodies may not yet be detectable early in infection (Wormser et al., 2006; Shapiro, 2014).

2. Timing of IgM and IgG antibody responses

Serologic testing for B. burgdorferi detects host antibody responses; the typical kinetics are an early IgM response followed by a later IgG response. IgM antibodies usually become detectable approximately 2–4 weeks after infection, peak early, and then decline. IgG antibodies generally rise later—often detectable by 4–6 weeks after infection and persist for months to years (Wormser et al., 2006; Stanek et al., 2012). Thus, in a patient with a three-week history of symptoms and elevated IgM titers, the serologic pattern is consistent with early infection. Clinicians should recognize that false-positive IgM tests can occur and that isolated IgM later in the illness is less reliable; two-tiered testing (enzyme immunoassay followed by Western blot) and clinical correlation are essential (CDC, 2023).

3. Why the ESR was elevated

Elevated erythrocyte sedimentation rate (ESR) reflects nonspecific systemic inflammation. In infectious processes such as early Lyme disease, host inflammatory responses to spirochetal infection can increase acute phase reactants and raise ESR (Steere, 2001). The patient’s ESR of 30 mm/hr (above the usual upper limit ~15 mm/hr) is consistent with an inflammatory state driven by infection. Mild elevations of liver enzymes (e.g., AST) and modest anemia are also reported in some patients with early Lyme disease and likely reflect systemic inflammation or transient effects on hepatic function and hematopoiesis (Shapiro, 2014; Stanek et al., 2012). Negative rheumatoid factor and antinuclear antibody tests help distinguish Lyme-associated inflammatory findings from autoimmune diseases that may present similarly (Wormser et al., 2006).

4. Therapeutic goal and recommended treatment

The primary therapeutic goals in Lyme disease are to eradicate B. burgdorferi, resolve acute symptoms, prevent progression or dissemination (including neurologic, cardiac, and arthritic complications), and reduce the risk of post-infectious sequelae (Wormser et al., 2006; Stanek et al., 2012). Treatment choices depend on the stage and manifestations of disease.

For early localized Lyme disease presenting with erythema migrans or early systemic symptoms without severe neurologic or cardiac involvement, recommended oral antibiotic regimens for adults include doxycycline 100 mg twice daily for 10–21 days (commonly 10–14 days in many protocols), or alternatives such as amoxicillin 500 mg three times daily for 14–21 days or cefuroxime axetil 500 mg twice daily for 14–21 days (Wormser et al., 2006; CDC, 2023). Doxycycline has the advantage of also covering certain tickborne coinfections such as Anaplasma phagocytophilum in endemic areas and penetrates tissues well, making it a preferred first-line agent for most nonpregnant adults (Shapiro, 2014).

In patients with specific complications—e.g., Lyme meningitis, cranial neuritis with progressive neurologic deficits, or carditis with high-grade atrioventricular block—parenteral therapy such as ceftriaxone 2 g IV daily (duration individualized, often 14–28 days) is indicated (Wormser et al., 2006; Stanek et al., 2012). For Lyme arthritis, oral regimens are often effective, but intravenous therapy may be required for refractory cases. Pregnant patients and young children have modified regimens: doxycycline is generally avoided in pregnancy and in children under 8, with amoxicillin favored (CDC, 2023).

Applying recommendations to this patient

Given the patient’s short history after a tick exposure, systemic symptoms, rash, and positive IgM, he most likely has early Lyme disease. If erythema migrans is still present or the clinical suspicion is high, immediate initiation of oral doxycycline 100 mg twice daily for 10–21 days (unless contraindicated) is appropriate to reduce the risk of dissemination and relieve symptoms (Wormser et al., 2006). If the patient is pregnant, breastfeeding, or allergic to doxycycline, amoxicillin or cefuroxime would be appropriate alternatives. Follow-up should assess for clinical improvement; lack of response, progressive neurologic or cardiac findings, or evolving arthritis should prompt reevaluation and consideration of intravenous therapy (Stanek et al., 2012; Shapiro, 2014).

Conclusion

This patient’s presentation is characteristic of early Lyme disease: the cardinal sign is erythema migrans, IgM antibodies are elevated early while IgG appear later, ESR is elevated due to systemic inflammation, and treatment aims to eradicate the organism and prevent complications. Empiric oral doxycycline for an appropriate duration is standard for early disease in adults, with alternative agents and intravenous therapy reserved for specific clinical situations (CDC, 2023; Wormser et al., 2006).

References

  • Centers for Disease Control and Prevention (CDC). Lyme Disease (Borrelia burgdorferi). CDC website. 2023. Available at: https://www.cdc.gov/lyme/ (accessed 2023).
  • Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2006;43(9):1089–1134.
  • Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet. 2012;379(9814):461–473.
  • Steere AC. Lyme disease. New England Journal of Medicine. 2001;345(2):115–125.
  • Shapiro ED. Clinical practice. Lyme disease. New England Journal of Medicine. 2014;370:1724–1731.
  • Aucott JN. Post-treatment Lyme disease syndrome. Infectious Disease Clinics of North America. 2015;29(2):309–323.
  • Marques A. Chronic Lyme disease: a review. Infectious Disease Clinics of North America. 2008;22(2):341–360.
  • Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott's Diagnostic Microbiology. 13th ed. Mosby; 2014. (Relevant sections on serologic testing and interpretation.)
  • UpToDate. Lyme disease: Clinical manifestations, diagnosis, and treatment. UpToDate online clinical resource. Reviewed 2023. Available at: https://www.uptodate.com/contents/lyme-disease (accessed 2023).
  • Krause PJ, Fish D, Narasimhan S. Tick-borne coinfections in the United States. Clinics in Laboratory Medicine. 2015;35(4):825–838.

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