HPI: A six-year-old male patient was brought into the clinic accompanied by both parents (mother and father). They said there son was feverish over the last few days reporting the highest fever of a 100. 1. Parents noticed him recently touching his right ear as if he had an ear infection. The mother treated her son with Children’s Tylenol that temporarily decreased his temperature and provided a slight improvement. Parents have noticed their son lying around a little more than usual and more “sleepy”. Patient denies having a headache and loss of appetite. Patient denies urinary frequency, urgency or excessive thirst.
Patient denies N/V/D. Patient denies joint pain, or muscle pain. Upon further questioning and based on my subsequent physical exam (see below), parents said they had removed a tick from his head over two weeks ago. They did not “notice” a rash. They were outdoors having a picnic in the park during one of the last sunny days of fall and think he may have gotten the tick that day. Note: Clinician/patient exchange may have been slightly compromised as a result of a language barrier. Their primary language is Spanish and clinician have intermediate Spanish speaking level.
PMH/PSH: ? Mother removed a tick with a tweezers two weeks ago. ? The tick was above the ear auricle, near the hairline and below the temporal bone. ? No other past medical history or past surgical procedures. Allergies: NKDA Health Maintenance: ? Patient’s parents report that the States recommended immunizations (for persons ages 1-6) are up to date. ? 2011-2012 Seasonal Influenza vaccine administered prior to this visit. Medications: None Reported Social History: ? Patient not exposed to household smoke. ? Patient is the youngest of 4 children. ? Patient is in Kindergarten.
? Patient lives with Parents and three other siblings: ? Brother 7 years ? Sister 9 years ? Brother 10 years Family Medical History: • Mother age 28 with no medical problems. • Father age 32 with no medical problems. • Patient’s three siblings report no medical problems. • Grandparents have no known medical problems. OBJECTIVE: Physical Exam: General: 5-year-old Mexican American male, properly groomed, dressed appropriately for the weather, with a quiet and friendly demeanor. Patient politely follows commands. Vitals include: BP 100/60 HR 82 Resp 18 SpO2 97% Temp 100.
1 oral. Ht 46 inches/3 ft 10’ Wt 80lbs/36. 25kg BMI 26. 58 HEENT: Head: “Bull’s-eye” rash (see integument) observed between right temporal bone and right ear auricle. This area is tender based on palpation. No scars, lumps, lesions or hair loss noted. No facial asymmetry, involuntary movements or deformities. No flaking, dryness, scaling or lice noticed. Eyes: Pupils are equal, round, reactive to light and accommodation. Extra ocular movements in tact. Vision is grossly in tact. 20/20 OD, 20/30 OU. Orbits, eyelids, conjunctiva and sclera normal and clear with no discharge.
Ears: Right and left tympanic membranes clear and in tact. No erythema, no discharge. Canals are clear. Hearing in tact with whisper test. Nose: No evidence of trauma, infection or inflammation. Moist and pink mucous membranes. Throat: The oral cavity is clear. The tongue is clear with no lesions noted. Neck: Neck is supple with no palpable masses. Bilateral Anterior lymphadenopathy. The thyroid gland is not palpable. The trachea is in midline. Integument: Erythema Migrans (EM) rash presenting above right ear near the temporal lobe receding into the hairline.
The rash is 5cm in diameter, circular with a central red spot, surrounded by clear skin that is ringed by an expanding red rash. The rash area is warm to touch and non-tender to palpation. Chest and Lungs: Respirations are even and unlabored. No accessory muscle use noted. Breath sounds clear to auscultation in all lobes bilaterally, no adventitious sounds noted. Heart: Regular Rate and Rhythm. S1, S2 heart sounds present, no S3 or S4 audible, no murmur audible. Neuorological: DTR 2+. Steady Coordinated Gait. Walks on toes and heels with little effort. Rapid, alternating movements normal.
Cranial nerves in tact. Musculoskeletal: Neck range of motion with normal flexion, extension, right rotation, and left rotation. No evidence of spinal deformity/scoliosis. ROM in tact. No signs of inflammation, swelling, or redness. Abdomen: Soft and non-tender upon palpation. BS audible in all quadrants. Femoral Pulse 2+. ASSESSMENT: Early Localized Stage One Lyme Disease. Note: According to our clinic policy, we are required to refer this case out. Therefore, I am hypothetically treating this patient based on my own research and experience. PLAN: Diagnostic:
? Diagnostic modality is by visual inspection as three criteria have been met: Patient resides in endemic area of Ixodes ticks, patient presents with erythema migrans (“bull’s eye rash”) and mother removed a tick in this location two weeks ago. Treatment: ? Amoxicillin 500 mg bid for 14 days for early stage Lyme Disease (doxycycline should be avoided in children because it stains their teeth and is photosensitive). ? Take Ibuprofen junior strength 3/100mg tablets or 6/ 50mg chewable tablets every 6-8 hours (6 months to 11 years: 10 mg/kg orally every 6 to 8 hours as needed.
?The recommended maximum daily dose is 40 mg/kg). ? Fever reduction methods: Sponging is a natural fever reducer for children that works well on its own or as a complement to other treatment methods. ? Drink plenty of cool fluids as they will rehydrate and may cool you. Education and Prevention: ? Educate parents on the endemic region they live in and the risks of Lyme disease. Children 5-14 and adults age 55-70 are most affected by Lyme disease. 93% f all Lyme disease cases come from CT, DE, MD, MA, NJ, PA, RI, MN, and WI.
? Educate Parents on Proper Tick removal technique as this may reduce the risk of Lyme disease. ? Provide Multilingual pamphlets (on CDC website) on the guidelines to prevention of Lyme disease. Instructions and follow up: ? Early-stage Lyme disease responds very well to treatment. In most cases, 14 to 30 days of treatment with an antibiotic kills the bacteria. ? It’s important for you to take all the medicine prescribed to prevent the spread of Lyme disease to your joints, nervous system or heart. ? If you have problems with the medicine, do not quit taking it.
Call my office to discuss any side effects. ? Follow up in one week. Monitor your son’s fever and if fever does not improve or worsens within 2 days, call my office immediately. RATIONALE: Lyme disease is a zoonotic infection transmitted by certain Ixodes tick species and caused by a group of related spirochetes referred to as Borrelia burgdorferi. The majority of cases in New York and the nearby states of Connecticut, Pennsylvania, and New Jersey are affected by the Ixodes scapularis (also known as the deer tick or black-legged tick).
Lyme disease is the most common vector-borne infection in the United States with more than 25,000 cases reported annually (CDC, 2011). The most common clinical manifestation is a characteristic skin lesion called erythema migrans (“bull’s eye rash”). It can be seen in the early stage of Lyme disease and can appear anywhere from one day to one month after a tick bite. This lesion is a result of inflammation associated with the central spread of the spirochete within the skin from the site where the tick deposited the microorganism (Buttaro, 2008).
Except for erythema migrans, the clinical manifestations of Lyme disease are nonspecific. Erythema migrans can be confused with a number of other skin lesions (ringworm, nummular eczema, cellulitis, granuloma annulare, and insect bites), but its rapid and continuing expansion is distinctive. Routine laboratory tests rarely aid diagnosis of Lyme disease, because most laboratory abnormalities also are nonspecific (Bratton 208). Consequently, laboratory diagnosis of Lyme disease usually rests on detection of antibodies to B. burgdorferi.
Enzyme immunoassay (EIA) is the most widely used procedure for the detection of antibodies against B. burgdorferi. The immunoblot test (Western blot) is used to detect serum antibodies against specific proteins of B. burgdorferi. Currently, a two-tier approach to diagnose Lyme disease is recommended, beginning with a sensitive EIA and, if that result is either positive or equivocal, then a Western immunoblot to validate the result (Goldman 2011). However, in this specific case, a clinician’s diagnosis of classic erythema migrans in an endemic region of Lyme disease is sufficient to make a definitive diagnosis (Goldman 2011).
Furthermore, patients who have been sick with Lyme disease for less than a month (in this case) often don’t yet have antibodies to the disease. This means they won’t have a positive blood test. Also, if a person with early Lyme disease takes antibiotics, he or she may never have a positive Lyme disease test. However, the blood test is almost always positive in people who have been sick for over 4 weeks and haven’t taken antibiotics (Goldman 2011).
References Bickley, L. S. (2009). Bates’ Guide to Physical Examination and History Taking (10th ed. ).
Philadelphia, PA: Lippincott Williams & Wilkins. Bratton. RL, et al. Mayo Clinic Proceedings. (2008). Diagnosis and Treatment of Lyme Disease. 83(5):566-571. Buttaro, T. M. , et al. (2008). Primary Care: a Collaborative Practice (3rd ed). Philadelphia, PA: Mosby Elsevier. Centers for Disease Control and Prevention. (2011). Lyme Disease. Atlanta, GA. Retrieved from http://www. cdc. gov/lyme/. Goldman, L. ,Schafer, A. (2011). Goldman’s Cecil Medicine. 24th ed. Chapter 329-Lyme Disease. Retrieved from http://www. mdconsult. com. libproxy2. umdnj. edu/php/290531072-6/homepage.