Lyme Disease
One of the fastest growing infectious diseases in the United States, Lyme disease is caused by a tick-borne spirochete, borrelia burgdorferi. While estimates of Lyme disease are relatively low, about one in 2,179, or 100,000 people each year, cases are up significantly from the 16,000 noted in 1999 by the Center for Disease Control (CDC).
Lyme disease passes through three stages and during these the microbe is hard to find, so doctors look for the antibodies reacting to it. During the earliest stage, a patient may present an erythema migrans (bullseye) rash and in the second stage, multiple skin lesions may occur with flu-like symptoms, followed by nonspecific musculoskeletal, arthritic, neuralgic, psychiatric and even cardiac symptoms. If it’s identified during the first two stages, doctors easily treat patients with a two to four week course of oral antibiotics. Most doctors prescribe either doxycycline for adults and children over eight years old or amoxicillin or cefuroxime axetil for adults and less than eight years old. This cures the disease about 90 percent of the time.
To confirm the clinical picture, a doctor should run serologic tests, including enzyme linked immunoassay (ELISA) and Lyme Western Blot test. A diagnosis of Lyme disease should never be made on the basis of blood tests alone.
Without antibiotic treatment, ten to 15 percent of patients may enter the third, or chronic, stage of the disease with evidence of arthritis or specific neurological complaints. Patients may display nonspecific symptoms perhaps not related to the disease. Early misdiagnosis and inadequate or delayed treatment of patients also may lead to these chronic symptoms. Doctors unfamiliar with Lyme disease have frequently misdiagnosed it as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome (CFS), or other autoimmune and neurological diseases.
Late stage patients desperately seek help, and usually antibiotic treatment is indicated for up to 30 days. There is little research to suggest that extended, longer term courses of antibiotics provide any benefit.
In October 2006, the Infectious Diseases Society of America (IDSA) released new guidelines that are more restrictive about the use of antibiotics. These recommendations require either a bullseye rash or positive laboratory tests for diagnosis. The guidelines only recognize seronegative (false negative) Lyme disease during the early stage of the disease. They also suggest that post-Lyme disease syndromes do not respond to the prolonged use of antibiotics.
As a case manager, you should first look at patient’s file to see whether the patient comes from the geographies affected by Lyme disease, usually the coastal northeast, mid-Atlantic region, Wisconsin, Minnesota and northern California. Also you should look for two to four week courses of antibiotics during any stage of Lyme disease. Current literature shows scant evidence for longer courses of antibiotics. In the patient’s documentation, see if the patient received a Lyme Western Blot test or a sample of the patient’s spinal fluid shows antibodies present. Finally should also look at how well the patient’s case is documented to decide whether the cases follows the current CDC and IDSA guidelines and if the doctor considered other diagnostic possibilities.