Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA)–April 22, 2010

Lyme disease continues to be the most common vector borne illness in the United States. The Albany County Department of Health, in conjunction with the New York State Department of Health, reminds physicians and other healthcare providers of the importance of enhanced clinical surveillance for early diagnosis of Lyme disease, the need for medical reporting to the health department of clinical or laboratory diagnosed cases of Lyme disease, and the important control measure of patient education on the prevention of Lyme disease.

When Should a Healthcare Provider Report Lyme Disease?

• The presence of an Erythema Migrans rash is diagnostic of Lyme disease, and should be reported to the County health department. This characteristic rash presents as an area of erythema greater that 5 cm in diameter and is usually located near the site of tick attachment. It can infrequently present as several lesions, at sites remote from the tick bite. [photos can be viewed online by clicking the link in the navigation bar]
• Any patient with laboratory confirmed Lyme disease and either erythema migrans or at least one late clinical manifestation. Laboratory diagnosis currently includes demonstration of diagnostic levels of IgM or IgG antibodies to the spirochete in serum or CSF, or a two test approach using a sensitive enzyme immunoassay or immunofluorescence antibody followed by Western blot. Late clinical manifestations may include any of the following when an alternate explanation is not found:
  
  1. Musculoskeletal system: recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. Manifestations not considered as criteria for diagnosis include chronic progressive arthritis not proceeded by brief attacks and chronic symmetrical polyarthritis. Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement.
  2. Nervous system: Lymphocytic meningitis; cranial neuritis, particularly facial palsy (may be bilateral); radiculoneuropathy; or rarely, encephalomyelitis. Encephalomyelitis must be confirmed by showing antibody production against B. burgdorferi in the CSF, demonstrated by a higher titer of antibody in CSF than in serum. Headache, fatigue, parasthesia, or mild stiff neck alone are not criteria for neurological involvement.
  3. Cardiovascular system: Acute onset, high grade (2nd or 3rd degree) atrioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular involvement. [Comment: This surveillance case definition was developed by the CDC for national reporting of Lyme disease; it is NOT appropriate for clinical diagnosis.]

Traditional laboratory diagnostic methods for Lyme disease, consisting of a screening ELISA for antibodies to B. burgdorferi, followed by IgM and IgG Western-blot assay on screen positive specimens, continue to have several shortcomings. These include the fact that testing is often negative in early Lyme disease as IgM antibodies do not peak until 3 to 6 weeks after infection, the problem that once elevated, IgM and IgG can remain elevated for indeterminate amounts of time, and false positive tests can occur due to cross reactivity with other antigens, including those found in autoimmune conditions. These methods of testing also can fail to differentiate individuals vaccinated for Lyme disease from those having Lyme disease.

The newer is a widely available test that has several advantages over traditional testing. These include greater sensitivity in early disease, high specificity in that patients with autoimmune diseases do not yield false positive results, and the ability to differentiate between individuals vaccinated for vs. those infected with Lyme disease. References on this test are included at the conclusion of this letter.

Patient education remains important in the prevention of Lyme disease. The Arthropod- Borne Disease Program of the New York State Department of Health is offering educational materials free of charge in limited quantities to New York State residents and organizations. Please refer to the “Material Order Form.”

For further information on clinical spectrum/stages of Lyme disease and other tick borne illnesses, including treatment information, healthcare providers are encouraged to review guidelines from the Infectious Disease Society of America. Questions can also be directed to the Albany County Department of Health at (518) 447-4640. The New York State Department of Health also has information for providers available online here.

Your efforts in enhanced surveillance and reporting aid the local and state health department. The cooperative engagement of clinicians, public health, and residents of affected communities will make it possible to reduce the incidence of Lyme disease. Thank you for your assistance in this matter.