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Clinical diagnosis of Lyme disease frequently misses the "bull's-eye"
Clinical Question
In children, how accurate is the clinical suspicion for Lyme disease in areas of high prevalence?
Bottom line
For children with suspected Lyme disease but without a classic bull's-eye lesion (erythema migrans of at least 5 cm), check serology rather than rely on your clinical impression. In this study, 12% of the children not suspected of having Lyme disease did have Lyme, and 31% of children thought to have Lyme disease did not have serologic findings either at that time or within 30 days. 1b
Reference
Study design: Cohort (prospective)
Funding: Foundation
Setting: Emergency department
Synopsis
The researchers assembled a convenience sample of children, 1 year and older, who underwent evaluation for Lyme disease at 1 of 5 hospital emergency departments in endemic areas, mostly on the east coast of the United States (one site was in Wisconsin). The children were evaluated by clinicians who had received training on the diagnosis of Lyme disease. The diagnostic criterion was a single characteristic lesion of at least 5 cm in diameter with or without central clearing, or a single smaller but enlarging lesion associated with a known or suspected tick bite with a known interval between the bite and the onset of the lesion. Lyme disease was confirmed in was 23% of the 1021 children via either a positive 2-tiered serology result within 30 days of presentation (82.4% of diagnoses) or a physician-diagnosed erythema migrans lesion at the time of presentation. Clinician suspicion in cases without clear erythema migrans was "minimally accurate" in either ruling in or ruling out Lyme disease (concordance statistic = .75; 95% CI .71 to .79). Of the 554 (54%) thought to be unlikely to have Lyme disease, 12% had a positive laboratory diagnosis, and 39 (31%) of the 127 children deemed to be very likely to have Lyme disease by clinicians did not have Lyme disease.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
good poem
I have not seen a case of Lyme disease as a first time presentation yet. The diagnostic criteria are helpful as a new season approaches.
Lyme disease
Always to be kept in mind, with those patients living on endemic areas or patients who have been in endemic areas, because early diagnosis is so important
Only confirms how confusing this area might be. The accuracy results in a known endemic area are disheartening. ONe would think more reliance on 2 phase serology would be the norm, and more readily available. One also needs to consider non-Lyme tick borne diseases to add to the complex investigations.
Marginally helpful information.
1) If you suspect Lyme in an endemic region you treat irrespective of anything else
2) There is controversy about the accuracy of Lyme serology to diagnosis this.
3) There is huge anxiety and fear of this disease and if you can't be sure you treat now with adequate relatively simple and relatively benign treatment to avoid the possibility of the dreaded "Chronic Lyme Disease"