A 42-year-old man comes to the physician with muscle aches and joint pain. He reports fatigue, headaches, diffuse muscle aches, and occasional spine stiffness for the past 4-6 weeks. He has no fevers, chills, night sweats, dizziness, or vision changes. The patient was diagnosed with Lyme disease 2 months ago after a skin rash and was treated with doxycycline for 21 days. He denies non-compliance with doxycycline. He takes no other medications and does not use tobacco, alcohol, or illicit drugs.
His temperature is 36.7 C (98 F), blood pressure is 134/82 mm Hg, and pulse is 80/min and regular. There are no skin rashes. The neck is supple without lymphadenopathy. Cardiac examination shows no murmurs. There is no joint swelling or peripheral edema. Range of motion is normal. The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the next best step in managing this patient?

Question

A 42-year-old man comes to the physician with muscle aches and joint pain.  He reports fatigue, headaches, diffuse muscle aches, and occasional spine stiffness for the past 4-6 weeks.  He has no fevers, chills, night sweats, dizziness, or vision changes.  The patient was diagnosed with Lyme disease 2 months ago after a skin rash and was treated with doxycycline for 21 days.  He denies non-compliance with doxycycline.  He takes no other medications and does not use tobacco, alcohol, or illicit drugs.
His temperature is 36.7 C (98 F), blood pressure is 134/82 mm Hg, and pulse is 80/min and regular.  There are no skin rashes.  The neck is supple without lymphadenopathy.  Cardiac examination shows no murmurs.  There is no joint swelling or peripheral edema.  Range of motion is normal.  The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the next best step in managing this patient?

Quizplus · Accepted Answer

This patient was appropriately treated for early Lyme disease with doxycycline. Most patients have complete resolution of symptoms within 2-3 weeks, and treatment failure is extremely rare. However, several patients have had subjective symptoms of headaches, arthralgias, myalgias, fatigue, and cognitive complaints weeks to months after treatment. This is not due to treatment failure or persistent infection with Borrelia Burgdorferi. Extending antibiotic treatment may temporarily improve fatigue but does not affect the other symptoms, which usually resolve within 6 months of initial treatment (Choice C). Patients without physical or objective findings of Lyme disease (eg, CSF or synovial fluid analysis, leukocytosis, elevated ESR) should be treated with supportive care. (Choice A) Blood cultures are not routinely ordered in a patient with no fever, leukocytosis, or new heart murmurs. (Choice B) IgM ELISA is an appropriate initial work-up for suspected Lyme disease. Positive ELISA results must be confirmed by Western blot. However, this patient was recently diagnosed with Lyme disease and reordering the test would yield no new information as IgM and IgG antibodies remain positive for several months to years after the infection. (Choice D) Lumbar puncture would be indicated if this patient had signs of meningitis, encephalitis, or cranial nerve palsies. However, CSF negative for Lyme antibodies but positive for serum antibodies does not exclude CNS Lyme disease. This patient's fatigue is nonspecific and does not indicate CNS Lyme disease. As a result, he does not require lumbar puncture. Educational objective: Post-Lyme disease syndrome usually presents with myalgias, arthralgias, headaches, and cognitive complaints weeks to months after initial successful treatment. Antibiotics are not indicated for these symptoms, and spontaneous resolution is seen within 6 months of initial treatment. __________ References: Chronic Lyme disease: a review. (http://www.ncbi.nlm.nih.gov/pubmed/18452806) Post-Lyme borreliosis syndrome: a meta-analysis of reported symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/16040645)

A 42-Year-Old Man Comes to the Physician with Muscle Aches