Rosen & Barkin's 5-Minute Emergency Medicine Consult (428 page)

• 20 mL/kg of 0.9% NS IV fluid bolus for dehydration
  
• IV access for neurologic and cardiac involvement
  
• Cardiac monitoring
  
• Temporary pacemaker for heart block
  

• Remove tick:
  
  • Disinfect site.
    
  • With blunt instrument, grasp tick close to skin and pull upward with gentle pressure.
    
• Medications:
  
  • Aspirin as adjunctive therapy for cardiac involvement
    
  • NSAIDs for arthritis or arthralgias
    
• Vaccine (Lymerix) for prevention of disease:
  
  • A recombinant surface protein
    
  • For persons in high/moderate risk areas
    
  • For travelers to endemic areas
    
  • 3 doses (0–1 mo–2 mo)
    
• Stage I:
  
  • Amoxicillin, doxycycline (for those ≥8 yr of age), or cefuroxime (21 days)
    
  • Azithromycin (14–21 days)
    
  • Parenteral therapy in pregnant patients
    
• Stage II:
  
  • Oral therapy for isolated Bell palsy and mild involvement:
    
    • Amoxicillin with probenecid (30 days) or doxycycline (avoid if pregnant or ≥8 yr old; 10–21 days)
      
  • Parenteral therapy for more severe involvement (meningitis, carditis, severe arthritis):
    
    • Ceftriaxone, cefotaxime (14–21 days), or penicillin G (14–28 days)
      
• Stage III:
  
  • Parenteral therapy:
    
    • Penicillin G, cefotaxime (14–21 days), or ceftriaxone (14–28 days)
      

• Amoxicillin: 500 mg (peds: 50 mg/kg/24 h) PO TID for those <8 yr of age or unable to tolerate doxycycline.
  
• Aspirin: 80–100 mg/kg/d (peds: 50–100 mg/kg/d in 6 div. doses) PO; do not exceed 4 g/24 h (peds: Do not exceed 120 mg/kg/24 h or 4 g/24 h)
  
• Doxycycline: 100 mg PO BID for 14–21 days for children ≥8 yr and adults (except if pregnant)
  
• Ceftriaxone: 2 g (peds: 100 mg/kg/24 h) IV daily (1st line for late-term disease)
  

• Azithromycin: 500 mg PO daily
  
• Cefuroxime axetil, 500 mg BID (all ages)
  
• Cefotaxime: 2 g (peds: 100–150 mg/kg/24 h) IV q8h
  
• Penicillin G: 20–24 million U IV q4–6h
  
• Probenecid: 500 mg PO TID
  

FOLLOW-UP

• Meningoencephalitis
  
• Telemetry/ICU admission for carditis
  

Patients treated with oral therapy

• Duration of treatment for later organ involvement will be ≥30 days.
  
• Be aware of coinfections with
  Anaplasmosis
  and
  Babesiosis.
  

• American Academy of Pediatrics: Report of the Committee on Infectious Diseases
  . 29th ed. Elk Grove, CA: Ill; 2012.
  
• Kowalski TJ, Tata S, Berth W, et al. Antibiotic treatment duration and long-term outcomes of patients with early lyme disease from a lyme disease-hyperendemic area.
  Clin Infect Dis.
  2010;50:512–520.
  
• Marques AR. Lyme disease: A review.
  Curr Allergy Asthma Rep.
  2010;10:13–20.
  
• Steere AC, Coburn J, Glickstein L. The emergence of Lyme disease.
  J Clin Invest
  . 2004;113(8):1093–1101.
  

CODES

• 088.81 Lyme Disease
  
• 320.7 Meningitis in other bacterial diseases classified elsewhere
  
• 711.80 Arthropathy associated with other infectious and parasitic diseases, site unspecified
  

BASICS

• Lymph nodes may be swollen and tender as part of the systemic response to infection:
  
  • Become engorged with lymphocytes and macrophages
    
  • May be primarily infected
    
  • Infection in distal extremity may result in painful tender adenopathy proximally
    
• Acute suppurative lymphadenitis may occur after pharyngeal or skin infection
  

• Most frequently caused by bacterial infection
  
• Most common organisms in pyogenic lymphadenitis:
  
  • Staphylococcus aureus
    —including resistant strains such as community-associated methicillin-resistant
    S. aureus
    (CA-MRSA):
    
    • CA-MRSA risk factors include prior MRSA infection, household contact of CA-MRSA patient, military personnel, incarcerated persons, athletes in contact sports, IV drug users, men who have sex with men
      
    • Different antibiotic susceptibility than nosocomial MRSA
      
    • CA-MRSA now sufficiently prevalent to warrant coverage in empiric treatment
      
    • Suspect CA-MRSA in unresponsive infections
      
  • Group A β-hemolytic
    Streptococcus
    
• Cervical lymphadenitis:
  
  • Usually pharyngeal or periodontal process
    
  • Streptococcus and anaerobes
    
• Axillary lymphadenitis:
  
  • Streptococcus pyogenes (group A β-hemolytic Streptococcus)
    
• Nosocomial MRSA
  :
  
  • Risk factors: Recent hospital or long-term care admission, surgery, injection drug use, vascular catheter, dialysis, recent antibiotic use, unresponsive infection
    
  • Resistant to most antibiotics (see “Treatment”)
    

• Acute unilateral cervical suppurative lymphadenitis:
  
  • Most common at age <6 yr
    
  • Group A
    Streptococcus
    ,
    S. aureus
    , and anaerobes are most common causes
    

DIAGNOSIS

• Painful swelling, inflammation/infection of lymph nodes
  
• Commonly presents simultaneously with acute cellulitis or abscess if pyogenic cause
  
• Axillary lymphadenitis:
  
  • Fever, axillary pain, and acute lymphedema of arms and chest, without features of cellulitis or lymphangitis; ipsilateral pleural effusion may be present
    

• Occupation
  
• Exposure to pets
  
• Sexual behavior
  
• Drug use
  
• Travel history
  
• Associated symptoms:
  
  • Sore throat
    
  • Cough
    
  • Fever
    
  • Night sweats
    
  • Fatigue
    
  • Weight loss
    
  • Pain in nodes
    
• Duration of lymphadenopathy
  

• Extent of lymphadenopathy (localized or generalized)
  
• Size of nodes:
  
  • Abnormal size by site:
    
    • General: >1 cm
      
    • Epitrochlear: >0.5 cm
      
    • Inguinal: >1.5 cm
      
• Presence or absence of nodal tenderness
  
• Signs of inflammation over node
  
• Skin lesions
  
• Splenomegaly
  
• Enlargement of supraclavicular or scalene nodes is always abnormal
  

• Acute regional lymphadenitis is clinical diagnosis
  ,
  often part of larger syndrome (cellulitis)
  
• History and physical exam to reveal infectious source
  

• WBC is not essential:
  
  • Possible leukocytosis with left shift or normal
    
• CBC, Epstein–Barr virus (EBV), cytomegalovirus (CMV), HIV, and other serologies based on clinical findings
  

US or CT in patients who do not improve or progress to suppuration

Consider percutaneous needle aspiration or surgical drainage in patients who do not improve or progress to suppuration

• Common infections:
  
  • Adenovirus
    
  • Scarlet fever
    
  • Cat scratch disease
    
  • Fungal
    
  • Herpes zoster
    
• Unusual infections:
  
  • Sporotrichosis (rose thorns)
    
  • Diphtheria
    
  • West Nile fever
    
  • Plague
    
  • Anthrax
    
  • Typhoid
    
  • Rubella
    
• Venereal infections:
  
  • Syphilis
    
  • Genital herpes
    
  • Chancroid
    
  • Lymphogranuloma venereum
    
• Other systematic infections causing generalized lymphadenitis:
  
  • HIV
    
  • Infectious mononucleosis (EBV or CMV)
    
  • Toxoplasmosis
    
  • Tuberculosis
    
  • Infectious hepatitis
    
  • Dengue
    
• Drug reaction:
  
  • Phenytoin
    
  • Allopurinol
    
• Silicone implants
  
• Malignancy
  
• Rheumatologic disorders
  
• Systemic lupus erythematosus
  
• Sarcoidosis
  
• Amyloidosis
  
• Serum sickness