a tricky diagnosis
GPs should actively follow-up uncertain rashes with their own photographs. Doxycycline can be nephrotoxic with poor renal function and reference can be made to the current BNF for alternatives.
Clockwise from main picture: Scottish moorland is the perfect habitat for ticks; a tick burrowing into human flesh; Erythema chronicum migrans
Secondary disease In secondary Lyme borreliosis the diagnosis may be challenging. A clear history may be lacking apart from presentation of new central nervous system (CNS) or joint symptoms in someone who has been engaged in outdoor activity in an infected area. Brushing through bracken, kneeling in the garden or sitting in the grass in a picnic site should raise a clinical possibility. In contrast, where walkers have kept to hard surface paths, Lyme borreliosis is less likely. New onset cranial nerve palsy including Bell’s
palsy should raise suspicion of Lyme borreliosis in Scotland or other hot spots. Swelling of the face and redness make infection more likely in facial palsy with positive serology. Te fit elderly who garden or walk in affected areas have recently been giving unusual presentations of Lyme borreliosis and unexpected toxic confusion should raise the possibility in a differential diagnosis list. Sensory and motor symptoms which suggest
multiple sclerosis should also prompt consideration of Lyme borreliosis in the history and differential diagnosis, as should new onset mono-arthritis in knees, ankles or wrists which could be attributed to Lyme arthritis. Blood tests can be
difficult to interpret as they record previous exposure. However, a rise in titre might suggest a recent infection. Cerebrospinal fluid (CSF) can be tested using PCR techniques but there is a general acceptance that we need better tests for Lyme borreliosis.
SPRING 2016 Treatment of secondary Lyme borreliosis involves
prolonged courses of IV antibiotics to eradicate the bacteria. However, profound tiredness and continued CNS symptoms seem to persist suggesting a prolonged inflammatory response in the body and CNS in particular. Tis can make patients quite challenging as they expect a cure and are typically previously healthy “outdoor people”. Tey can feel angry with medical uncertainty. Indeed, Lyme borreliosis oſten gets mixed up with
chronic fatigue syndrome. Patients with secondary Lyme borreliosis have chronic fatigue but those with other causes of chronic fatigue syndrome may attribute their symptoms to the condition, with difficult histories and uncertain investigations. Te clinical management of Lyme borreliosis
requires managing uncertainty with professional knowledge, confidence and a willingness to listen to patients and learn from them. Tere is a balance between under diagnosis and over diagnosis, and oſten with clinical and media pressure. Doctors need to facilitate the psychological healing required following secondary Lyme borreliosis. We need to shiſt our thinking and terminology from ‘Lyme disease’ to ‘Lyme borreliosis’ for the benefit of patients and doctors.
Medico-legal implications Established GPs in areas affected by Lyme borreliosis are usually familiar and confident in the diagnosis and management. However, new doctors and locums may easily miss the diagnosis. Photographs of rashes in the patient record and coding on the computer, including ‘suspected Lyme borreliosis’ (by the patient or the doctor) will help document uncertainty in regard to the diagnosis. In secondary Lyme borreliosis a diagnosis may be
obvious with hindsight and blood tests but this represents considerable risk with regard to accusations of delayed diagnosis. Patients in at-risk occupational groups and those returning to urban GPs 4-8 weeks aſter a camping weekend need continued clinical vigilance.
n Dr James Douglas is a GP in Fort William in the Scottish Highlands
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