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LYME DISEASE LYME DISEASE Epidemiology Epidemiology Clinical Manifestations Clinical Manifestations Differential Diagnosis Differential Diagnosis Diagnosis Diagnosis Treatment Treatment Prevention Prevention

LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

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Page 1: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

LYME DISEASELYME DISEASE

EpidemiologyEpidemiology Clinical ManifestationsClinical Manifestations Differential DiagnosisDifferential Diagnosis DiagnosisDiagnosis TreatmentTreatment PreventionPrevention

Page 2: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

EPIDEMIOLOGYEPIDEMIOLOGY

Caused by spirochete Caused by spirochete Borrelia Borrelia burgdorferiburgdorferi

Transmitted by Transmitted by IxodesIxodes ticks ticks Nymph-stage ticks feed on humans May Nymph-stage ticks feed on humans May

through July - transmit spirochetethrough July - transmit spirochete Endemic areasEndemic areas

– Northeastern coastal statesNortheastern coastal states– Wisconsin & MinnesotaWisconsin & Minnesota– Coast of Oregon & northern CaliforniaCoast of Oregon & northern California

Page 3: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

Ixodes scapularis ticks

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Larva, nymph, and adult female and male Ixodes dammini ticks

Page 5: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

EPIDEMIOLOGY (cont)EPIDEMIOLOGY (cont)

> > of dear ticks carry spirochete of dear ticks carry spirochete Rising frequency attributed to Rising frequency attributed to

enlarging deer population & enlarging deer population & concurrent suburbanizationconcurrent suburbanization

High risk areas - wooded or brushy, High risk areas - wooded or brushy, unkempt grassy areas & fringe of unkempt grassy areas & fringe of these areasthese areas

Lower risk on lawns that are mowedLower risk on lawns that are mowed

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MAJOR RISK FACTORSMAJOR RISK FACTORS

GeographicalGeographical– Northeast, north-central (Wisconsin, Northeast, north-central (Wisconsin,

Minnesota) coastal regions of Minnesota) coastal regions of California & OregonCalifornia & Oregon

OccupationalOccupational– Landscaper, forester, outdoor Landscaper, forester, outdoor

RecreationalRecreational– hiking, camping, fishing, huntinghiking, camping, fishing, hunting

Page 7: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

CLINICAL CLINICAL MANIFESTATIONSMANIFESTATIONS

Stage 1 - Acute, localized diseaseStage 1 - Acute, localized disease

Stage 2 - Subacute, disseminated Stage 2 - Subacute, disseminated diseasedisease

Stage 3 - Chronic or late persistent Stage 3 - Chronic or late persistent infectioninfection

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ACUTE INFECTIONACUTE INFECTION

Tick must have been feeding for at Tick must have been feeding for at least 24-48 hrsleast 24-48 hrs

Erythema migrans develops 1 to 4 Erythema migrans develops 1 to 4 weeks after biteweeks after bite

Without treatment rash clears within Without treatment rash clears within 3 to 4 weeks3 to 4 weeks

About 50% of pts will also c/o flulike About 50% of pts will also c/o flulike illness - fever, H/A, chills, myalgiaillness - fever, H/A, chills, myalgia

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DISSEMINATED DISEASEDISSEMINATED DISEASE

May develop in wks to mos in May develop in wks to mos in untreated ptsuntreated pts

Symptoms usually involve skin, CNS, Symptoms usually involve skin, CNS, musculoskeletal system, & cardiacmusculoskeletal system, & cardiac

Dermatological manifestationsDermatological manifestations– new skin lesions, smaller and less new skin lesions, smaller and less

migratory than initialmigratory than initial– Erythema and urticaria have been notedErythema and urticaria have been noted

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DISSEMINATED (cont)DISSEMINATED (cont)

Neurologic complicationsNeurologic complications Occurs wks to mos later in about Occurs wks to mos later in about

15% to 20% of untreated15% to 20% of untreated SymptomsSymptoms

– Lyme meningitisLyme meningitis– mild encephalopathymild encephalopathy– unilateral or bilateral Bell’s palsyunilateral or bilateral Bell’s palsy– peripheral neuritisperipheral neuritis

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Left facial palsy (Bell's palsy) in early Lyme disease

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DISSEMINATED (cont)DISSEMINATED (cont)

Musculoskeletal symptomsMusculoskeletal symptoms Symptoms evolve into frank arthritis in Symptoms evolve into frank arthritis in

up to 60% of untreated ptsup to 60% of untreated pts Onset averages 6 mos from initial Onset averages 6 mos from initial

infectioninfection SymptomsSymptoms

– migratory joint, muscle, & tendon painmigratory joint, muscle, & tendon pain– knee most common siteknee most common site– no more than 3 joints involved during courseno more than 3 joints involved during course– lasts several days to few weeks then joint returns to normallasts several days to few weeks then joint returns to normal

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DISSEMINATED (cont)DISSEMINATED (cont)

Cardiac involvementCardiac involvement Noted in about 5% to 10% beginning Noted in about 5% to 10% beginning

several wks after infectionseveral wks after infection Transient heart block may be Transient heart block may be

consequenceconsequence Range from asymptomatic to first-Range from asymptomatic to first-

degree heart block to completedegree heart block to complete Cardiac phase lasts from 3 to 6 wksCardiac phase lasts from 3 to 6 wks

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CHRONIC - LATE CHRONIC - LATE PERSISTENTPERSISTENT

Follows latent period of several mos Follows latent period of several mos to a yr after initial infectionto a yr after initial infection

60% to 80% will have 60% to 80% will have musculoskeletal complaintsmusculoskeletal complaints

Most common; arthritis of knee - Most common; arthritis of knee - may also occur in ankle, elbow, hip, may also occur in ankle, elbow, hip, shouldershoulder

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CHRONIC (cont)CHRONIC (cont)

Neurologic impairmentNeurologic impairment– distal paresthesiasdistal paresthesias– radicular painradicular pain– memory lossmemory loss– fatiguefatigue

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NATURAL HISTORYNATURAL HISTORY

Without treatment will see Without treatment will see disseminated disease in about 80% disseminated disease in about 80% of ptsof pts

Oligoarthritis - 60% to 80%Oligoarthritis - 60% to 80% Chronic neurologic & persistent Chronic neurologic & persistent

joint symptoms - 5% to 10%joint symptoms - 5% to 10%

Page 17: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

Clinical stages of Lyme disease

Page 18: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

CONCURRENT INFECTIONSCONCURRENT INFECTIONS

Human Human babesiosisbabesiosis– fever, chills, sweats, arthralgias, fever, chills, sweats, arthralgias,

headache, lassitudeheadache, lassitude– pts with both appear to have more pts with both appear to have more

severe Lyme diseasesevere Lyme disease EhrlichiosisEhrlichiosis

– described as “rashless Lyme disease”described as “rashless Lyme disease”– high fever & chills & may become high fever & chills & may become

prostrate in day or twoprostrate in day or two

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DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Acute & early disseminated stagesAcute & early disseminated stages– Rocky Mountain spotted feverRocky Mountain spotted fever– human babiosishuman babiosis– summertime viral illnessessummertime viral illnesses– viral encephalitisviral encephalitis– bacterial meningitisbacterial meningitis

Page 20: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

DIFFERENTIAL (cont)DIFFERENTIAL (cont)

Late disseminated & chronic stagesLate disseminated & chronic stages– goutgout– pseudogoutpseudogout– Reiter’s syndrome, psoriatic arthritis, Reiter’s syndrome, psoriatic arthritis,

ankylosing spondylitisankylosing spondylitis– rheumatoid arthritisrheumatoid arthritis– depressiondepression– fibromyalgiafibromyalgia– chronic fatigue syndromechronic fatigue syndrome

Page 21: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

DIAGNOSISDIAGNOSIS

Clues to early diseaseClues to early disease– EPIDEMIOLOGICEPIDEMIOLOGIC

travel or residence in endemic area travel or residence in endemic area within past monthwithin past month

h/o tick bite (especially within past 2 h/o tick bite (especially within past 2 weeks)weeks)

late spring or early summer (June, July, late spring or early summer (June, July, August)August)

Page 22: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

EARLY DISEASE (cont)EARLY DISEASE (cont)

– RASHRASH expanding lesion over days (rather than hours expanding lesion over days (rather than hours

or stable over months)or stable over months) central clearing or target appearancecentral clearing or target appearance minimal pruritis or tendernessminimal pruritis or tenderness central papular erythema, pigmentation, or central papular erythema, pigmentation, or

scaling at sit of tick bitescaling at sit of tick bite lack of scalinglack of scaling location at sites unusual for bacterial cellulitis location at sites unusual for bacterial cellulitis

(usually axillae, popliteal fossae, groin, waist(usually axillae, popliteal fossae, groin, waist

Page 23: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

Erythema (chronicum) migrans

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Single erythema migrans

Page 25: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

EARLY DISEASE (cont)EARLY DISEASE (cont)

– ASSOCIATED SYMPTOMSASSOCIATED SYMPTOMS fatiguefatigue myalgia/arthralgiamyalgia/arthralgia headacheheadache fever and/or chillsfever and/or chills stiff neckstiff neck respiratory & GI complaints are respiratory & GI complaints are

infrequentinfrequent

Page 26: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

EARLY DISEASE (cont)EARLY DISEASE (cont)

– PHYSICAL EXAMPHYSICAL EXAM

Regional lymphadenopathyRegional lymphadenopathy

Multiple erythema migrans lesionMultiple erythema migrans lesion

FeverFever

Page 27: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

DISSEMINATED DISEASEDISSEMINATED DISEASE

Clinical presentation can make Clinical presentation can make diagnosisdiagnosis– epidemiological inquiryepidemiological inquiry– review of key historic featuresreview of key historic features– physical findingsphysical findings– serum for antibody testingserum for antibody testing– spinal tapspinal tap

Page 28: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

LATE DISEASELATE DISEASE

Careful attention to musculoskeletal & Careful attention to musculoskeletal & neurologic symptomsneurologic symptoms

Differentiating Lyme from fibromyalgia Differentiating Lyme from fibromyalgia & CFS& CFS– oligoarticular musculoskeletal complaints that oligoarticular musculoskeletal complaints that

include signs of joint inflammationinclude signs of joint inflammation– limited & specific neuro deficitslimited & specific neuro deficits– abnormalities of CFSabnormalities of CFS– absence of disturbed sleep, chronic H/A, absence of disturbed sleep, chronic H/A,

depression, tender pointsdepression, tender points

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ANTIBODY TESTINGANTIBODY TESTING

Testing with ELISA is not required to Testing with ELISA is not required to confirm diagnosisconfirm diagnosis

Pts with objective clinical signs have Pts with objective clinical signs have high pretest probability of diseasehigh pretest probability of disease

Tests are not sensitive in very early Tests are not sensitive in very early diseasedisease

Should not use is pt without Should not use is pt without subjective symptoms of Lymesubjective symptoms of Lyme

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TESTING(cont)TESTING(cont)

A + test in person with low A + test in person with low probability of disease risks false + probability of disease risks false + rather than true +rather than true +

Test when pts fall between these two Test when pts fall between these two extremesextremes– pt with lesion or symptoms without pt with lesion or symptoms without

known endemic exposure (new area)known endemic exposure (new area)– pretest probability now has high pretest probability now has high

sensitivity & specificitysensitivity & specificity

Page 31: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

TESTING (cont)TESTING (cont)

For a positive or equivocal ELISA or For a positive or equivocal ELISA or IFA CDC recommends Western blotIFA CDC recommends Western blot

Testing cannot determine cure as Testing cannot determine cure as pt remains antibody +pt remains antibody +

PCR is being developed - still PCR is being developed - still considered investigationalconsidered investigational

Page 32: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

TREATMENTTREATMENT

Early Lyme diseaseEarly Lyme disease– doxycycline, 100 mg BID for 21 to 18 doxycycline, 100 mg BID for 21 to 18

daysdays– amoxicillin, 500 mg TID for 21 to 28 amoxicillin, 500 mg TID for 21 to 28

daysdays– cefuroxime, 500 mg BID for 21 dayscefuroxime, 500 mg BID for 21 days

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PREVENTIONPREVENTION

Wear light-colored clothes - easier to Wear light-colored clothes - easier to spot tickspot tick

Wear long pants, long sleevesWear long pants, long sleeves Use tick repellent, such as Use tick repellent, such as

permethrin, on clothespermethrin, on clothes Use DEET on skinUse DEET on skin Check for ticks after being outsideCheck for ticks after being outside Remove ticks immediately by headRemove ticks immediately by head

Page 34: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

VACCINATIONVACCINATION

NO LONGER AVAILABLENO LONGER AVAILABLE

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WEST NILE VIRUSWEST NILE VIRUS

Summer 1999 - first detected in Summer 1999 - first detected in NYC & Western hemisphereNYC & Western hemisphere

59 hospitalized - epicenter Queens - 59 hospitalized - epicenter Queens - 7 died7 died

Summer 2000 - epicenter Staten Summer 2000 - epicenter Staten Island - 19 hospitalized - 2 diedIsland - 19 hospitalized - 2 died

For 2002 - 39 states, 3737 For 2002 - 39 states, 3737 confirmed cases, 214 deathsconfirmed cases, 214 deaths

Page 36: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

INFECTIOUS AGENTINFECTIOUS AGENT

Member of family FilaviviridaeMember of family Filaviviridae Belongs to Japanese encephalitis Belongs to Japanese encephalitis

complexcomplex Before 1999 outbreaks seen only in Before 1999 outbreaks seen only in

Africa, Asia, Middle East, rarely EuropeAfrica, Asia, Middle East, rarely Europe Reservoir & Mode of transmissionReservoir & Mode of transmission

– wild birds primary reservoir & wild birds primary reservoir & CulexCulex spp. spp. major mosquito vectormajor mosquito vector

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INCUBATION INCUBATION PERIOD/SYMPTOMSPERIOD/SYMPTOMS

Incubation usually 6 days (range 3-15)Incubation usually 6 days (range 3-15) SymptomsSymptoms

– milder: fever, headache, myalgias, milder: fever, headache, myalgias, arthralgias, lymphadenopathy, arthralgias, lymphadenopathy, maculopapular or roseolar rash affecting maculopapular or roseolar rash affecting trunk & extremitiestrunk & extremities

– occasionally reported: pancreatitis, occasionally reported: pancreatitis, hepatitis, myocarditishepatitis, myocarditis

– CNS involvement rare & usually in elderlyCNS involvement rare & usually in elderly

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TREATMENTTREATMENT

No known effective antiviral No known effective antiviral therapy or vaccinetherapy or vaccine

Intensive supportive in more Intensive supportive in more severe casessevere cases

Page 39: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

EnterovirusesEnteroviruses Herpes simplex virusHerpes simplex virus VaricellaVaricella

Page 40: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

TESTINGTESTING

Lab conformation based on following Lab conformation based on following criteria:criteria:– isolating West Nile virus from or demonstrating viral isolating West Nile virus from or demonstrating viral

antigen or genomic sequences in tissue, blood, CSF, or antigen or genomic sequences in tissue, blood, CSF, or other body fluidother body fluid

– demonstrating IgM antibody to West Nile virus in CSF by demonstrating IgM antibody to West Nile virus in CSF by ELISAELISA

– demonstrating 4-fold serial change in plaque reduction demonstrating 4-fold serial change in plaque reduction neutralization test (PRNT) antibody to West Nile virus in neutralization test (PRNT) antibody to West Nile virus in paired, acute & convalescent serum samplespaired, acute & convalescent serum samples

– demonstrating both West Nile virus-specific IgM & IgG demonstrating both West Nile virus-specific IgM & IgG antibody in single serum specimen using ELISA & PRNTantibody in single serum specimen using ELISA & PRNT

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Must report suspected cases of West Must report suspected cases of West Nile to the NYC Department of Nile to the NYC Department of HealthHealth

During business hours call During business hours call Communicable Disease Program Communicable Disease Program (212) 788-9830(212) 788-9830

At all other times call Poison Control At all other times call Poison Control Center - (212) 764-7667Center - (212) 764-7667

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INFECTIOUS INFECTIOUS MONONUCLEOSISMONONUCLEOSIS

Infectious mononucleosis - designates Infectious mononucleosis - designates the clinical syndrome of prolonged the clinical syndrome of prolonged fever, pharyngitis, lymphadenopathyfever, pharyngitis, lymphadenopathy

Epstein-Barr virus-associated Epstein-Barr virus-associated infectious mononucleosis (EBV-IM)infectious mononucleosis (EBV-IM)

non Epstein-Barr virus-associated non Epstein-Barr virus-associated infectious mononucleosis (non-EBV-IM)infectious mononucleosis (non-EBV-IM)– approximately 10-20% haveapproximately 10-20% have

Page 43: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

EPIDEMIOLOGYEPIDEMIOLOGY

>90% of adults have serologic evidence >90% of adults have serologic evidence of prior EBV infectionof prior EBV infection

Mean age of infection variesMean age of infection varies In US 50% of 5-year-old children & 50-In US 50% of 5-year-old children & 50-

70% of first-year college students have 70% of first-year college students have evidence of prior infectionevidence of prior infection

Infection in children most prevalent Infection in children most prevalent amongst lower socioeconomicamongst lower socioeconomic

15-19 - peak rate of EBV-IM15-19 - peak rate of EBV-IM

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Chance of acute EBV infection Chance of acute EBV infection leading to IM leading to IM with age with age

Good sanitation & uncrowded Good sanitation & uncrowded living conditions living conditions risk of EBV-IM risk of EBV-IM

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OTHER CAUSES OF IMOTHER CAUSES OF IM

CMVCMV Human herpesvirus 6Human herpesvirus 6 HIVHIV AdenovirusAdenovirus ToxoToxo Corynebacterium diptheriaeCorynebacterium diptheriae Hep AHep A RubellaRubella Coxiella burnetiiCoxiella burnetii

Page 46: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

CLINICAL MANIFESTIONSCLINICAL MANIFESTIONS

Classic triad - fever, pharyngitis, Classic triad - fever, pharyngitis, lymphadenopathylymphadenopathy

Prodrome- malaise, anorexia, Prodrome- malaise, anorexia, fatigue, headache, feverfatigue, headache, fever

Symptoms usually peak 7 days Symptoms usually peak 7 days after onset & after onset & over next 1-3 wks over next 1-3 wks

Splenic enlargement - 41-100%Splenic enlargement - 41-100%

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Less common clinical featuresLess common clinical features– upper airway compromiseupper airway compromise– abdominal painabdominal pain– rash (ampicillin rash (ampicillin risk of) risk of)– hepatomegalyhepatomegaly– jaundicejaundice– eyelid edemaeyelid edema

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DIAGNOSTIC TESTINGDIAGNOSTIC TESTING

Serologic test for heterophil Serologic test for heterophil antibodiesantibodies

Percentage with antibodies higher Percentage with antibodies higher > 4yrs old> 4yrs old

% of persons who are + at 1 week % of persons who are + at 1 week varies with test (1 study - 69% + at varies with test (1 study - 69% + at 1 wk; 80% + by 3 wks)1 wk; 80% + by 3 wks)

False +s rareFalse +s rare

Page 49: LYME DISEASE n Epidemiology n Clinical Manifestations n Differential Diagnosis n Diagnosis n Treatment n Prevention

If heterophil antibody continues If heterophil antibody continues neg & still suspect;neg & still suspect;– serum for viral capsis antigen (VCA) serum for viral capsis antigen (VCA)

IgG & IgM & for EBV nuclear antigen IgG & IgM & for EBV nuclear antigen (EBNA) IgG(EBNA) IgG

– VCA antibodies + in many at onsetVCA antibodies + in many at onset

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LABORATORY LABORATORY ABNORMALITIESABNORMALITIES

Total leukocyte count Total leukocyte count usually > 50% of total leukocytes usually > 50% of total leukocytes

consist of lymphocytesconsist of lymphocytes possible mild thrombocytopeniapossible mild thrombocytopenia LFTs - 2-3-foldLFTs - 2-3-fold abnormalities on UAabnormalities on UA

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IM IN OLDER ADULTSIM IN OLDER ADULTS

3-10% of persons >40 are susceptible3-10% of persons >40 are susceptible Presenting S & S differentPresenting S & S different Fever present but few have Fever present but few have

pharyngitis & lymphadenopathypharyngitis & lymphadenopathy Jaundice in >20%Jaundice in >20% R/O; hepatobiliary disease, R/O; hepatobiliary disease,

neoplasms, collagen vascular neoplasms, collagen vascular diseases, bacterial infectionsdiseases, bacterial infections

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MANAGEMENTMANAGEMENT

SupportiveSupportive NSAIDs or tylenol - no ASANSAIDs or tylenol - no ASA Bedrest during febrile stageBedrest during febrile stage If have splenomegaly avoid If have splenomegaly avoid

vigorous activity for 3-4 wksvigorous activity for 3-4 wks No evidence that steroids or No evidence that steroids or

antivirals are of benefitantivirals are of benefit

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CHRONIC FATIGUE CHRONIC FATIGUE SYNDROMESYNDROME

Has been called: chronic EBV syndrome, Has been called: chronic EBV syndrome, postviral fatigue syndrome, “yuppie flu”postviral fatigue syndrome, “yuppie flu”

1988 CDC convened researchers & clinicians 1988 CDC convened researchers & clinicians to define & classify CFSto define & classify CFS

1994 international group proposed 1994 international group proposed guidelines for CFSguidelines for CFS

CDC reported prevalence of 4-11 CDC reported prevalence of 4-11 cases/100,000 populationcases/100,000 population

In US most cases occur in young to middle-In US most cases occur in young to middle-aged white womenaged white women

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ETIOLOGYETIOLOGY

No cause identifiedNo cause identified PostulatedPostulated

– infectiveinfective– neuromuscularneuromuscular– immunologicimmunologic– neurologicneurologic– psychiatricpsychiatric

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DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA (PER CDC)(PER CDC)

Fatigue criteriaFatigue criteria Must not be lifelongMust not be lifelong Must be persistent, relapsing & Must be persistent, relapsing &

unexplainedunexplained Must not be result of ongoing Must not be result of ongoing

exertion & cannot be relieved by exertion & cannot be relieved by restrest

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Symptom CriteriaSymptom Criteria Sore throatSore throat Short-term memory or concentration impairmentShort-term memory or concentration impairment Tender cervical or axillary lymph nodesTender cervical or axillary lymph nodes Headaches of a new type, pattern, or severityHeadaches of a new type, pattern, or severity Unrefreshing sleepUnrefreshing sleep Postexertional malaise lasting > 24 hrsPostexertional malaise lasting > 24 hrs Multijoint pain without joint swelling or Multijoint pain without joint swelling or

inflammationinflammation Muscle painMuscle pain

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Exclusion CriteriaExclusion Criteria Past or current diagnosis of major depression with Past or current diagnosis of major depression with

psychotic or melancholic features, bipolar disorder, psychotic or melancholic features, bipolar disorder, schizophrenia, delusional disorders, dementia, schizophrenia, delusional disorders, dementia, bulimia nervosa, anorexia nervosabulimia nervosa, anorexia nervosa

Active medical conditionsActive medical conditions Previously diagnosed conditions with unclear Previously diagnosed conditions with unclear

resolution (malignancies, hepatitis B or C)resolution (malignancies, hepatitis B or C) Alcohol or substance abuse within 2 yrs of onset of Alcohol or substance abuse within 2 yrs of onset of

fatiguefatigue Severe obesity (BMI Severe obesity (BMI 45) 45)

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Detailed medical historyDetailed medical history Complete physicalComplete physical LabsLabs

– CBCCBC– ESRESR– TSHTSH– UAUA– Serum chem for electrolytes, BUN, cr, glucose, Serum chem for electrolytes, BUN, cr, glucose,

calcium, phosphorus, alk phos, total protein, calcium, phosphorus, alk phos, total protein, albumen, globulin, LFTsalbumen, globulin, LFTs

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MANAGEMENTMANAGEMENT

Goal: Restore pts occupational & social Goal: Restore pts occupational & social functioning & prevent further functioning & prevent further disability.disability.

GuidelinesGuidelines– Establish diagnosisEstablish diagnosis– Prevent further disabilityPrevent further disability– If indicated, start medication ASAPIf indicated, start medication ASAP– Warn about unproven therapiesWarn about unproven therapies– Initiate psychological interventionInitiate psychological intervention

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PHARMACOTHERAPYPHARMACOTHERAPY

AntiviralsAntivirals ImmunomodulatorsImmunomodulators Psychotropic agentsPsychotropic agents Pain medicationsPain medications Antiallergy medicationsAntiallergy medications Acetylcholinesterase inhibitorsAcetylcholinesterase inhibitors Agents used in alternative medicineAgents used in alternative medicine

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NONPHARMACOLOGIC NONPHARMACOLOGIC TREATMENTTREATMENT

ExerciseExercise Cognitive behavior therapyCognitive behavior therapy Self-help groupsSelf-help groups Work as therapeutic modalityWork as therapeutic modality

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DIFFERENTIALDIFFERENTIAL

FibromyalgiaFibromyalgia EndocrineEndocrine Chronic viral infectionsChronic viral infections MalignancyMalignancy Sleep disorders causing fatigueSleep disorders causing fatigue Connective tissue diseasesConnective tissue diseases Body weight changesBody weight changes Side effects of medicationsSide effects of medications Other illnessesOther illnesses

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PSYCHIATRIC CONDITIONS PSYCHIATRIC CONDITIONS EXCLUDING CFS EXCLUDING CFS

DIAGNOSISDIAGNOSIS

Major depressive episodesMajor depressive episodes Anxiety disordersAnxiety disorders Delusional disordersDelusional disorders Bipolar disorderBipolar disorder SchizophreniaSchizophrenia Eating disordersEating disorders DementiasDementias Sleep disordersSleep disorders Substance use disordersSubstance use disorders

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HERPES ZOSTERHERPES ZOSTER

Represents reactivation of varicell-Represents reactivation of varicell-zoster viruszoster virus

Latently resides in a dorsal root or Latently resides in a dorsal root or cranial nervie gangliacranial nervie ganglia

Multiple erythematous plaques with Multiple erythematous plaques with clustered vesiclesclustered vesicles

Vesicles begin to dry & crust in 7-10 Vesicles begin to dry & crust in 7-10 days, clear within 2-3 wks, new may days, clear within 2-3 wks, new may continue to appear for up to 1 wkcontinue to appear for up to 1 wk

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COMMON DISTRIBUTIONCOMMON DISTRIBUTION

Thoracic dermatome Thoracic dermatome 50%50% Cervical dermatomeCervical dermatome 20%20% Trigeminal dermatomeTrigeminal dermatome

15%15% Lumbosacral dermatomeLumbosacral dermatome 10%10%

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PRESENTATION/PRESENTATION/DIAGNOSISDIAGNOSIS

ProdromeProdrome Vesicular rashVesicular rash Diagnosis - presentationDiagnosis - presentation

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Herpes zoster

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Acute herpes zoster ophthalmicus

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POTENTIAL POTENTIAL COMPLICATIONSCOMPLICATIONS

Trigeminal dermatomeTrigeminal dermatome– may affect second branch associated with may affect second branch associated with

involvement of eyeinvolvement of eye keratitis, uveitis, secondary glaucoma, keratitis, uveitis, secondary glaucoma,

iridocyclitisiridocyclitis

Ramsay-Hunt syndromeRamsay-Hunt syndrome– affects facial & auditory nervesaffects facial & auditory nerves– facial palsy with cutaneous zoster of facial palsy with cutaneous zoster of

external ear or TM, with associated external ear or TM, with associated tinnitus, vertigo, &/or hearing losstinnitus, vertigo, &/or hearing loss

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TREATMENTTREATMENT

Early treatmentEarly treatment– within 48-72 hrswithin 48-72 hrs

Acyclovir (Zovirax)Acyclovir (Zovirax)– 800mg 3x/day800mg 3x/day

Valacyclovir (Valtrex)Valacyclovir (Valtrex)– 1,000mg 3x/day1,000mg 3x/day

Famciclovir (Famvir)Famciclovir (Famvir)– 500mg 3x/day500mg 3x/day

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POSTHERPETIC POSTHERPETIC NEURALGIANEURALGIA

Famvir and Valtrex Famvir and Valtrex incidence incidence Capsaicin cream (Zostrix 0.025% & Capsaicin cream (Zostrix 0.025% &

Zostrix HP 0.075%) 4x/dayZostrix HP 0.075%) 4x/day AmitriptylineAmitriptyline GabapentinGabapentin Often remits spontaneously after 6 Often remits spontaneously after 6

monthsmonths Pain referralPain referral