Palpitations in a 19-Year-Old With a Rash

Jason S. Chang, MD; Carin M. Van Gelder, MD


May 14, 2015

The treatment of Lyme disease is managed according to the patient history or evidence of systemic involvement. First-line antibiotics used to treat Lyme disease include amoxicillin, doxycycline, and ceftriaxone. Second-line agents include cefuroxime, erythromycin, tetracycline, and azithromycin. The treatment algorithm varies according to the extent of infection. With an early localized infection (ie, a single ECM lesion), a course of a single-agent antibiotic is recommended for 10-21 days.

First-choice treatment for early localized infection should be amoxicillin (Moxatag®) or doxycycline (Oracea®).[2,5] For early disseminated infection without CNS infection or third-degree heart block, single-agent oral antibiotics are also appropriate (eg, 21-30 days of oral doxycycline or amoxicillin). A simple seventh cranial nerve palsy associated with B burgdorferi infection but without evidence of meningitis may be treated with a 14-day course of oral antibiotics[2]; however, if CNS involvement or a high-grade conduction defect is noted, parenteral therapy is indicated. The recommended first-line treatment is intravenous ceftriaxone (Rocephin®) for 14 days. Patients with high-grade heart block and hemodynamic instability should undergo transcutaneous pacing and should be monitored in the intensive care unit until they are not dependent on a pacemaker.

Latent neurologic Lyme disease requires 2-4 weeks of ceftriaxone, whereas Lyme disease arthritis can be treated with an oral antibiotic for 4 weeks.[2] Persistent arthritic symptoms may necessitate parenteral therapy and should be treated in consultation with the rheumatology department.

General precautions for avoiding tick bites in endemic areas include keeping skin covered when outdoors, using insect repellent, and examining oneself for attached ticks after outdoor activities. A tick that has been attached for less than 24 hours has a low likelihood of transmitting infection. Prophylactic treatment for a tick bite is not routinely recommended[2]; however, for patients in hyperendemic areas who present with an engorged tick that has been attached to their skin for longer than 36 hours, treatment with a single dose of doxycycline (200 mg), given within 72 hours of the tick bite, is highly effective in preventing the development of Lyme disease.[2,6]

The prognosis for treated Lyme disease is excellent. The patient in our case remained hemodynamically stable, with a normal blood pressure in the ED, and he did not require transcutaneous pacing. He received intravenous ceftriaxone and was admitted to the cardiac care unit for Lyme disease-associated third-degree heart block. The block resolved over the treatment course, and the patient was discharged to home in good condition.


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