Sairaanhoitajien sivustolla (USA) näyttää olevan laajempi näkemys borrelioosin diagnostiikasta ja hoidosta kuin terveydenhuollon ammattilaisilla yleensä esim. Amerikan infektiotautien yhdistyksellä eli IDSA:lla.
http://rn.modernmedicine.com/rnweb/Mode ... oryId=5796
CDC:n ( =Yhdysvaltojen tartuntatautien valvonta-ja ehkäisykeskus) mukaan "Yksikään nykyinen testi ei pysty luotettavasti toteamaan sairastaako henkilö borrelioosia vai ei." Joka tapauksessa testaaminen tulee tehdä kahdella testillä; ELISA + Western Blot. Näissäkin tapauksissa vääriä negatiivisia tuloksia esiinty usein. Syynä on esim. immuunipuolustuksen heikentyminen jonka seurauksena se ei tunnista taudinaiheuttajia jne. Serologiset testit menettävät myös herkkyyttään ajan kuluessa. Lisäksi erilaiset lisäinfektiot ovat yleisiä borrelioosia sairastavilla. Usein myös latenttina olleet virukset kuten Epstein Barr -virus aktivoituvat borrelioosia sairastavilla. Nämä tekijät tulee ottaa huomioon borrelioosiin sairastuneita hoidettaessa (suom.huom. onko asiaa huomiotu todellisuudessa yhdeltäkään suomalaiselta?).
Sivuilla tunnustetaan myös borrelioosin kroonistuminen. Artikkelin lähteistä löytyy mm. Burrascanon ja Nicholsonin artikkelit.
Originally Posted December 2008
By LYNN SEBOLD, MSN, RN, LORRAINE REISER, PHD, CRNP, and ELIZABETH SCHLENK, PHD, RN
LYNN SEBOLD is a Clinical Instructor of the University of Pittsburgh Medical Center-Shadyside School of Nursing and developed a Lyme disease educational awareness plan for medical offices and school nurses in Pittsburgh. LORRAINE REISER is nurse practitioner and an Associate Professor at the Carlow University School of Nursing in Pittsburgh where she has treated individuals with Lyme disease. ELIZABETH SCHLENK is an Assistant Professor at the University of Pittsburgh, School of Nursing, Pittsburgh, and has a special interest in rheumatic and arthritic diseases such as in late Lyme disease. The authors have no financial relationship to disclose. STAFF EDITOR: MARTHA K. RAYMOND, RN, BSN, BS
Lyme disease is the most common vector-borne disease in the United States, with approximately 20,000 new cases reported each year.1 The incidence rate in 10 endemic states?Connecticut, Delaware, Maryland, Massachusetts, Minnesota, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin?is more than three times the targeted goal of the U. S. Department of Health and Human Services (HHS) Healthy People 2010 objective, which was set at 9.7 per 100,000.2 The Centers for Disease Control and Prevention (CDC) is particularly keen on tracking Lyme disease in those 10 northeastern states, where the concentration of Lyme disease was 29.2 cases for every 100,000 people from 2003 to 2005.1 The CDC suggests that reports of Lyme disease are 10 times lower than the probable actual number.1 Reasons related to underreporting include delay in or lack of the diagnosis, especially when patients live in nonendemic areas. Recognizing Lyme disease in its early stage is key because prompt treatment is imperative for optimal patient outcomes.
Ticks carrying Borrelia burgdorferi spirochetes transmit Lyme disease. The bacteria that cause the disease are transmitted to humans when an infected tick bites and stays attached for one to two days. Brief periods of attachment rarely transmit disease. At first, the bacteria multiply at the site of the tick bite. After three to 32 days, the bacteria migrate from the site of the bite into the surrounding skin, and also spread through the blood and lymphatics to other organs or sites in the skin.
There's a variety of ticks, but the ones most apt to carry Borrelia burgdorferi are the Ixodes genus, which has more than 200 potentially disease-carrying species. Typical vectors include the Ixodes scapularis or deer tick; the Ixodes pacificus, known as the West Coast tick; the Dermacentor variabilis, familiarly the American Dog tick; and the Amblyomma americanum, including the Lone Star tick.3
A tick's two-year life cycle determines the infectious process. The larva, nymph, and adult ticks vary in the ability to pass the Borrelia burgdorferi spirochete to their hosts. The life cycle starts in the spring when eggs develop into larvae toward summer. Larva can become infected with Borrelia burgdorferi if it feeds on a host carrying that specific spirochete. The larva molts in the fall and lies dormant until it becomes active in the spring in the form of a nymph, which is the size of a poppy seed. It's at the nymphal stage that ticks have the most potential to infect their hosts due to their heavily infected salivary glands. In the fall, the nymph develops into an adult tick.3
Lyme disease may be difficult to diagnose because symptoms vary from person to person. A differential diagnosis of Lyme disease should be considered even in areas not considered endemic, since every state has reported cases of Borrelia burgdorferi spirochete. The first step in diagnosis is establishing potential risk. Healthcare providers need to ask all individuals presenting with fatigue and joint pain about potential exposure to ticks. For example: Do they camp, hike, hunt, bike, or walk in grassy or wooded areas that may have ticks? Do they have pets? These simple questions are helpful in establishing risk. Once risk is established, reports of clinical symptoms along with a medical history, physical examination, and diagnostic blood test results are key in diagnosing Lyme disease.
The American College of Physicians defines three stages of Lyme disease based on patient symptoms, history, and blood test results.3 Early Lyme disease usually presents with one or more signs and symptoms, including fatigue, chills and fever, headache, muscle and joint pain, swollen lymph nodes, and/or erythema migrans (EM). The erythema migrans rash associated with early Lyme disease infection usually is round or oval with a clearing center, often called a "bull's-eye" rash.4 It may be flat or have raised bumps, and can sometimes itch. More than 50% of Lyme disease patients report having never noticed a rash or bite, perhaps because the bite may have been in an area of the body that is difficult to inspect.5 The fatigue, muscle, and joint pain may be mistakenly attributed to the influenza or cold virus. Healthcare providers should remember that the flu does not usually occur in summer months when tick season is peaking, so this could be a sign to consider a diagnosis of Lyme disease.
Early disseminated Lyme disease?middle stage?is a spirochetal infection that has spread and is affecting other body functions. At this stage, signs and symptoms include numbness and pain in the arms or legs; paralysis of facial muscles, usually on one side of the face; and meningitis with fever, stiff neck, and severe headaches. Additional neurological symptoms include numbness, tingling, and muscle twitching. The heart may exhibit conduction abnormalities that include first-degree heart block and prolonged QT intervals.
Late or chronic Lyme disease develops weeks, months, or years after infection in patients who never received antibiotic treatment for early disease or whose treatment did not eradicate the spirochetal infectious processes. Problems of late Lyme disease include chronic Lyme arthritis, which involves brief bouts of pain and swelling usually in one or more of the large joints, especially the knees. Nervous system problems include memory loss and difficulty concentrating. Patients often complain of chronic muscle pain or disturbed sleep.
Because early symptoms may seem so mild, infected individuals sometimes don't seek treatment. As the disease progresses, symptoms either get worse or lapse into remission. However, left unchecked and untreated, Lyme disease can progress to a multisystem infection. The International Lyme and Associated Diseases Society (ILADS) developed three criteria for chronic cases of late-stage Lyme disease:5 First, the illness is present for at least one year, approximately when immune breakdown attains clinically significant levels. Second, patients have persistent major neurological involvement, such as encephalitis/encephalopathy or meningitis, or present active arthritic manifestations such as active synovitis. Lastly, patients continue to be actively infected with Borrelia burgdorferi, regardless of prior antibiotic therapy.6
Is it Lyme disease?
The CDC reports that no reliable test can diagnose Lyme disease but recommends a two-step testing procedure that first uses serologic testing by an enzyme-linked immunosorbent assay (ELISA) titer.1 This test has a 65% sensitivity value in screening for Lyme disease, whereas typical screening tests have 95% sensitivity.5 blot test, is used if ELISA titer is equivocal or positive. Western blot test has a higher accuracy rate, especially the reading of bands 31 and 34, which are more specific to detecting antibody proteins for Borrelia burgdorferi. However, bands 31 and 34 are not reported in most Lyme tests because the CDC eliminated reading of bands 31 and 34 due to the fact that they were chosen for vaccine development, which is currently unavailable.5 Therefore, the patient may be infected even with a negative Western blot test. False negative results also are due to a damaged immune system, which decreases the immune response. As time passes, the serologic tests become less sensitive, further complicating diagnosis. However, ELISA serology testing with Western blot increases accuracy to 50% to 75%.7 In addition, Western blot can be used six to 12 weeks after infection and is recommended to confirm all positive or ambiguous ELISA results.3
Making matters worse, co-infections also are prevalent among those with Lyme disease.8 The ticks carrying the Borrelia burgdorfi spirochete often have other bacterial infectious agents on board that can infect the host. Some of these co-infection pathogens include Babesia, Bartonella, Ehrlichia, Mycoplasma, and Anaplasma.6 Latent viruses, such as Epstein-Barr, that an individual may already have, also can be reactivated. When co-infections are present, the clinical symptoms exhibited usually are more severe. These factors must be taken into consideration when treating infected patients.
Guidelines state that treatment early in the course of the infection improves the outcome in eradicating the Borrelia burgdorfi spirochete.4,5,6 Therefore, if a patient is positive for erythema migrans, treatment should begin immediately, and the healthcare provider should not wait for serologic testing results.9 The standard choice of antibiotics varies and may consist of single or multiple types of drugs, according to the prescribing healthcare provider. In the early stages of Lyme disease, both localized and disseminated, first-line treatment is oral doxycycline (Vibramycin, Periostat), amoxicillin (Amoxil, Trimox), or cefuroxime axetil (Ceftin) with accepted alternatives being erythromycin (E-Mycin, Ilosone), clarithromycin (Biaxin), or azithromycin (Zithromax, Zmax).8 If the disease progresses to nervous system involvement, IV medications should be used. IV ceftriaxone (Rocephin) is the drug of choice with penicillin G (Pfizerpen) and doxycycline (Vibramycin, Periostat) being acceptable alternatives. In the late, disseminated stage of the disease, oral amoxicillin (Amoxil, Trimox) and doxycycline (Vibramycin, Periostat) are considered.
In disseminated disease, the patient may develop psychological problems, such as depression, anxiety, and mood disorders. These may be related to waiting for the Lyme disease diagnosis, confusion over the diagnostic serologic tests, and slow improvement.9
Educate to prevent
A thorough treatment plan includes an educational component for disease prevention.10 An infected person can be reinfected by another tick bite.10 The HHS has included Lyme disease prevention as a priority in the Healthy People 2010 program.2 HHS also seeks to decrease the incidence of Lyme disease by 40% by 2010.10 Nurses can be a vital force in the educational process against Lyme disease.11 Patient education should include a description of the symptoms at the different stages, the treatment modalities, and any potential complications of the therapy.12
For example, a patient may develop the Herxheimer reaction, which is a result of the Borrelia burgdorferi dying off with the antimicrobial treatment. The patient's immune system responds to the toxins from the destroyed spirochete. This reaction can be mild to completely debilitating. A Herxheimer reaction can include worsening of present symptoms, recurrence of previous symptoms that may not have been attributed to Lyme disease, rashes, and flu-like symptoms. This adverse reaction can frighten patients if they aren't informed prior to antimicrobial therapy. Supportive therapies are used to ease discomfort. Aspirin, nonsteroidal anti-inflammatory drugs, pain medication, muscle relaxers, and hot baths are treatment modalities that may be prescribed by a practitioner. Other complications include gastrointestinal intolerance with some of the first-choice antibiotics, such as doxycycline (Vibramycin, Periostat), which can be a separate problem and not related to the Herxheimer reaction.
Primary prevention includes:
* Dressing appropriately for the outdoors in tick-laden environments. Light-colored clothing should be worn to make ticks more visible. Tuck pants into socks when going into areas that could harbor ticks.
* Properly using insect repellents containing DEET (N, N-diethyl-m-toluamide). Use caution with children because increased absorption and resultant toxicity is a concern. Do not apply repellents directly to children; instead an adult should apply repellent to his or hands and then put it on the child. Do not apply the repellent near eyes, nose, or mouth, and use sparingly around ears. Do not apply it to the hands of small children. There also are insect repellents that can be applied to clothing; do not apply these to a person's skin. Outdoor areas also may be treated with commercial chemical preparations to reduce the number of landscape ticks, with applications of pesticides done in the spring and early fall seasons.
* Carefully monitoring for ticks. Daily tick checks should be conducted after coming in from the outdoors.
* Properly removing ticks when found. Patient teaching of how to properly remove a tick should be demonstrated so that the entire tick is detached. Using fine-pointed tweezers, grasp the tick by the head or mouthparts, as close to the skin as possible, and pull straight out with a steady movement until the tick releases. The tick's body should not be grasped or squeezed. Apply an antiseptic, such as alcohol, to the bite area. The Lyme Disease Association offers kits for this purpose, and many outdoor recreation stores also carry tick removal kits. Prevention is the best protection.
Other populations to focus on for primary prevention of tick bites and Lyme disease are schools. The Lyme Disease Association has educational information for children in its brochure The ABC's of Lyme Disease, along with information on the schooling of children who are infected with the disease, as they may be too ill to attend regular school classes.13 Furthermore, the public needs to be aware that one can be reinfected with the Borrelia burgdorferi spirochete, even after treatment and recovery from a previous tick bite. Increased Lyme disease education in all areas of healthcare will help prevent and reduce its incidence and meet the Healthy People 2010 goals.
Research to develop better diagnostic testing is essential because of the growing prevalence of Lyme disease. Two institutions studying the disease are the NIH Rocky Mountain Laboratory14 and Columbia University15, the latter of which developed a Lyme Disease Research Center. In addition, ongoing monitoring to report the incidence, prevalence, and endemic regions of Lyme disease will heighten awareness of healthcare providers. In turn, these providers could suspect Lyme disease in differential diagnoses leading to earlier identification, which will improve treatment effectiveness. Additionally, research efforts could compare the effectiveness and outcomes of differing treatment guidelines, providing an evidence base for treating patients with Lyme disease.
Late Lyme disease can be costly for society in the form of individuals who no longer can be productive, work, or function independently. They may feel that they alone are enduring the ongoing infection process. Once a diagnosis is made, patients often perceive validation for their illness and symptoms. The patients then feel hopeful about the future and that they will regain their health. Patients with Lyme disease need support from their healthcare providers throughout the course of the disease and treatment.13
A trusting relationship with the patient is imperative. The healthcare provider also can offer information on various resources available to patients. Support groups are available in locations around the United States. The Lyme Disease Association and the CDC's Web sites have valuable information for those who have the disease or know someone who has it.
1. Centers for Disease Control and Prevention. (2007). Lyme disease?United States 2003-2005. Morbidity & Mortality Weekly Report, 56(23), 573-576.
2. U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. Washington, DC: Government Printing Office.
3. American College of Physicians. (2003). American College of Physicians: Internal Medicine. Lyme disease: A patient's guide. Retrieved Oct. 30, 2008. http://www.acponline.org/clinical_infor ... index.html.
4. National Guideline Clearinghouse. (Nov. 6, 2007). Evidence-based guidelines for the management of Lyme disease. Retrieved Oct. 30, 2008. http://www.guideline.gov/summary/summar ... tring=lyme
5. National Guideline Clearinghouse. (2007). Infectious Diseases Society of America practice guidelines for clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis. Retrieved Oct. 30, 2008. http://www.guideline.gov/summary/summar ... tring=lyme
6. Burrascano, J.J. (2005). Advanced topics in Lyme disease. Managing Lyme disease. Retrieved Oct. 30, 2008. www.ilads.org/files/burrascano_0905.pdf
7. DePietropaolo, D.L., Powers, J.H., et al. (2005). Diagnosis of Lyme disease. American Family Physician. Retrieved Oct. 30, 2008. www.aafp.org/afp/20050715/297.html
8. Nicolson, G.L. (April 2007). Diagnosis and therapy of chronic systemic co-infections in Lyme disease and other tick-borne infectious diseases. Townsend Letter, 93-98.
9. Wormser, G.P., Dattwyler, R.J., et al. (2006). The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babeosis: Clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases, 43(9), 1089-1134.
10. Hayes, E.B., & Piesman, J. (2003). How can we prevent Lyme disease? New England Journal of Medicine, 24(348), 2424-2430
11. Kinsley, J., & Johnson, M. (2004). Lyme disease: Knowledge is the best prevention. The Nurse Practitioner, 29(8 ), 34-43.
12. Lyme Disease Association. (2005). ABCs of Lyme disease. Retrieved Oct. 30, 2008. www.lymediseaseassociation.org/ABCsLYME.pdf
13. Drew, D., & Hewitt, H. (2006). A qualitative approach to understanding patients' diagnosis of Lyme disease. Public Health Nursing, 23(1), 20-26.
14. Gherardini, F. (Feb. 19, 2008). Laboratory of zoonotic pathogens, gene regulation section, Borrelia projects. National Institute of Allergy and Infectious Diseases. Retrieved Oct. 30, 2008. http://www.niaid.nih.gov/labs/aboutlabs ... ionSection
15. Lyme and Tick-Borne Diseases Research Center. (2008). Columbia University Medical Center. Retrieved Nov. 5, 2008, from www.columbia-lyme.org
About the Author
Lynn Sebold, MSN, RN
About Lynn Sebold, MSN, RN
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Lorraine Reiser, PhD, CRNP
About Lorraine Reiser, PhD, CRNP
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Elizabeth Schlenk, PhD, RN
About Elizabeth Schlenk, PhD, RN
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