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Case History Document

Logan, et al V Empire Blue Cross and Blue Shield
Entered By: Ira M Maurer/LymeNetDate Created: 2-15-98
Document Type: Other
Empire Blue Cross And Blue Shield Managed Care Medical Guideline: Treatment of Lyme Disease dated 10-1-90

The following document was obtained during a recent pre-trial deposition of an in-house doctor employed by Empire Blue Cross and Blue Shield. The document reveals a far more reasonable and fairer approach to Lyme Disease back in 1990.
TOPIC: Lyme disease, Lyme borreliosis or borreliosis, is a recently recognized sphirochetal infection. It is transmitted to humans by Ixodid ticks. Evidence indicates that the disease may have been present in this country for many years; it is also found worldwide. There has been discussion as to the need for hospitalization of patients who require IV therapy. An alternative procedure has been promoted for home IVtreatment. The present guideline addresses this issue.

BACKGROUND: As with syphilis, findings of Lyme borreliosis have been divided into 3 stages. Stage I (acute) is manifested by a spreading skin lesion (erythema migrans), a flu-like illness, regional lymphadenopathy or absence of these signs. Stage II (subacute) includes more extensive skin involvement, musculoskeletal/joint pain, and neuropathic entities, such as meningitis, encephalitis, mono-or polyradiculapathy (Bell's palsy bilateral), cardiac involvement (A-V nodal block), pancarditis, panophthalimitis, ARDS, hepatitis, and orchitis. Constitutional symptoms of malaise and fatigue are prominent. Stage III (chronic) disease includes chronic prolonged arthritis, keratitis, indolent acrodermatitis with or without periostitis or joint subluxation, chronic neurological syndromes (ataxic gait, paraparesis, psychological disturbances, dementia, encaphalomylitis, polyradiculopathy).

The diagnosis of Lyme borreliosis is established by symptomatology, clinical findings and measurement of serum IgG and IgM antibodies, the latter indicating recent onset. However, spirochetes can persist in body tissues even with negative serum titres.

Treatment of Stage I illness calls for oral antibiotics such as doxycycline, tetracycline, amoxicillin (or erythromycin if the patient is penicillin-allergic). These are given for 10-30 days. Hospitalization is not warranted. Similarly, oral therapy is indicated for mild Stage II entities, i.e., headaches, (without meningeal signs), musculoskeletal pain, mild to moderate arthritis, radiculopathy such as Bell's palsy, first degree A-V block as long as P-R interval is <0.3 seconds.

For Stage II and III, particularly with involvement of vital organs (CNS, heart), hospitalization with IV antibiotics is indicated: Ceftriaxone (2 gms/day IV x10-21 days) Cefotaxime (2x3g/day IV x10 days) or Penicillin (20-40 million units/day IV x10-21 days). In less clinically urgent cases, office or home IV administration has been recommended. However, a number of patients experience Jarish-Herxheimer reactions; still others demonstrate allergy to their antibiotics. It is warranted to admit patients with serious Stage II and III disease for at least 4-5 days for initiation of IV therapy. Thereafter, if no complications ensue and depending on their disease status, outpatient IVtherapy can follow. Treatment failures have occurred with all regimens, and retreatment may be necessary. Slow recovery from subacute or chronic Borreliosis can take years, even after treatment. This may be due to the natural history of the disease or treatment failure. It is known that autoimmune mechanisms in the later phases of the infection prevent full response to antibiotics. As the present state of knowledge expands, changes in diagnostic methodology and therapy will occur.

SUBMITTED BY: Edward Weissman, M.D.


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