Diagnosing Pediatric Lyme Arthritis

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Arthritis may be the first sign of Lyme disease in children after the tick bite.
Arthritis may be the first sign of Lyme disease in children after the tick bite.

Diagnosis of Lyme disease can be complicated by a number of factors, particularly in children. A recent review by Krzysztof Orczyk, from the Department of Pediatric Rheumatology, Medical University of Lodz, Poland, and colleagues,1 published in Pediatric Rheumatology, examined differences in the underlying infectious pathology that contributes to different manifestations of the disease.

Inflammation is a common symptom in Lyme disease that can occur weeks to months after the original tick bite, but in cases in which the erythematous patch characteristic of Lyme does not appear or goes unnoticed, inflammatory arthritis may be the first clinical sign.2

The authors pointed to 20 variant genospecies of the tick-borne spirochete, Borrelia burgdorferi, 9 of which are responsible for Lyme disease in humans.3,4 The majority of Lyme cases in the United States are associated with the spirochete variant B burgdorferi sensu stricto, which was found to induce arthritis in 46%.5 Arthritis was also present to a lesser degree in European cases caused by the genospecies B garinii and B afzelli (18% and 15%, respectively, as reported by Cerar et al6). Other studies have shown additional symptoms associated with these variants, including fatigue and myalgia.7

Lyme arthritis is widespread in the United States, where it is estimated to affect 33% of patients with Lyme disease,8 and in Europe, where estimates of infection range between 3% and 15%.9 Various studies pointed to swelling and inflammation primarily of large synovial joints,10 with the knee and ankle the 2 most affected sites.11 (The knee was involved in 90% of cases.)

Age was considered a risk factor for Lyme disease, and children are particularly susceptible because of the amount of time they spend outdoors in environments the ticks inhabit. The reviewers found the highest peak incidences in children 2-5 years old, and in adults older than 50 years.12 Still, not all tick bites produce Lyme disease, and as a result of transmission through tick saliva, the most significant factor determining infection was the tick remaining attached for 24 hours or more after the initial bite.13,14 Joint inflammation develops as a result of activation of Th1 lymphocytes.

Diagnosis of Lyme is challenging, and current recommendations are to conduct a 2-step laboratory evaluation using both the enzyme-linked immunosorbent assay and, if the findings are positive, to confirm using the Western blot test.15,16 Lyme arthritis in children is easily misdiagnosed as juvenile idiopathic arthritis, the reviewers found, and therefore, should be considered as part of the differential diagnosis for symptoms of joint inflammation.

Treatment still follows the guidelines provided by the Infectious Disease Society of America, which calls for a 28-day course of antibiotics such as doxycycline, cefuroxime axetil, or amoxicillin.17

The reviewers found no benefit to continuing the course of antibiotics in cases where Lyme disease is refractory to treatment, and reported that further treatment of any kind is "questionable," as most cases will eventually resolve. 

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References

  1. Orczyk K, Świdrowska-Jaros J, Smolewska E. When a patient suspected with juvenile idiopathic arthritis turns out to be diagnosed with an infectious disease – a review of Lyme arthritis in children. Pediatr Rheumatol Online J. 2017;15:35. doi: 10.1186/s12969-017-0166-0
  2. Arvikar SL, Steere AC. Diagnosis and treatment of Lyme arthritis. Infect Dis Clin North Am. 2015;29:269-280. doi: 10.1016/j.idc.2015.02.004
  3. Gryczyńska A, Welc-Falęciak R. Long-term study of the prevalence of Borreliaburgdorferi s.l. infection in ticks (Ixodes ricinus) feeding on blackbirds (Turdus merula) in NE Poland. Exp Appl Acarol. 2016;70:381-394. doi: 10.1007/s10493-016-0082-x
  4. Kmieciak W, Ciszewski M, Szewczyk EM. Tick-borne diseases in Poland: Prevalence and difficulties in diagnostics [in Polish]. Med Pr. 2016;67:73-87. doi: 10.13075/mp.5893.00264
  5. van Dam AP, Kuiper H, Vos K, et al. Different genospecies of Borrelia burgdorferi are associated with distinct clinical manifestations of Lyme borreliosis. Clin Infect Dis. 1993;17:708-717.
  6. Cerar T, Strle F, Stupica D, et al. Differences in genotype, clinical features, and inflammatory potential of borrelia burgdorferi sensu stricto strains from Europe and the United States. Emerg Infect Dis. 2016;22:818-827.
  7. Kocbach PP, Kocbach BP. Prevalence of Lyme disease among forestry workers [in Polish]. Med Pr. 2014;65:335-341.
  8. Centers for Disease Control and Prevention (CDC). Lyme disease–United States, 2001-2002. MMWR Morb Mortal Wkly Rep. 2004;53:365-369.
  9. Pancewicz SA, Rutkowski R, Rutkowski K, Zajkowska J, Kondrusik M. Immunopathology of lyme arthritis [in Polish]. Pol Merk Lekarski. 2007;134:141-144.
  10. Miller JR, Dunn KW, Braccia D, et al. Lyme disease manifestations in the foot and ankle: a retrospective case series. J Foot Ankle Surg. 2016;55:1241-1244. doi: 10.1053/j.jfas.2015.06.006
  11. Aiyer A, Hennrikus W, Walrath J, Groh B, Ostrov B. Lyme arthritis of the pediatric lower extremity in the setting of polyarticular disease. J Child Orthop. 2014;8:359-365. doi: 10.1007/s11832-014-0602-3
  12. Borchers AT, Keen CL, Huntley AC, Gershwin ME. Lyme disease: a rigorous review of diagnostic criteria and treatment. J Autoimmun. 2015;57:82-115. doi: 10.1016/j.jaut.2014.09.004
  13. Hodzic E, Feng S, Freet KJ, Borjesson DL, Barthold SW. Borrelia burgdorferi population kinetics and selected gene expression at the host-vector interface. Infect Immun. 2002;70:3382-3388. doi: 10.1128/IAI.70.7.3382-3388.2002
  14. Aenishaenslin C, Bouchard C, Koffi JK, Ogden NH. Exposure and preventive behaviours toward ticks and Lyme disease in Canada: Results from a first national survey. Ticks Tick Borne Dis. 2017;8:112-118. doi: 10.1016/j.ttbdis.2016.10.006
  15. Lipsett SC, Nigrovic LE. Diagnosis of Lyme disease in the pediatric acute care setting. Curr Opin Pediatr. 2016;28:287-293. doi: 10.1097/MOP.0000000000000339
  16. Hu LT. Lyme disease. Ann Intern Med. 2016;165:677. doi: 10.7326/L16-0409
  17. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43:1089-1134. doi: 10.1086/508667

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