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Emergency department presentations of Lyme disease in children
1Pediatric Emergency Services, Maine Medical Center, Portland, USA.
Insights
Lyme disease in children presenting to the emergency department (ED) is often difficult to diagnose, with disseminated and late-stage Lyme arthritis being most common. Familiarity with its varied symptoms is key for emergency medicine practitioners.
Area of Science:
- Pediatric Infectious Diseases
- Emergency Medicine
- Epidemiology
Background:
- Lyme disease is a tick-borne illness with diverse clinical presentations.
- Diagnosis in the emergency department (ED) setting can be challenging, particularly in pediatric populations.
- Understanding the specific manifestations in children presenting to the ED is crucial for timely diagnosis and treatment.
Purpose of the Study:
- To review the clinical characteristics of pediatric Lyme disease cases evaluated in an emergency department.
- To assess the diagnostic evaluation process for children with Lyme disease in an ED setting.
- To identify challenges in diagnosing Lyme disease, especially Lyme arthritis, in the ED.
Main Methods:
- Retrospective review of demographic, historical, clinical, and laboratory data.
- Inclusion of pediatric patients with a confirmed Lyme disease diagnosis.
- Study conducted at a pediatric emergency department in an urban university hospital.
Main Results:
- Twenty-nine pediatric cases of Lyme disease were identified over a three-year period.
- Early disseminated disease (including neurologic and cardiac involvement) and late Lyme arthritis predominated.
- Lyme arthritis was frequently misdiagnosed as septic arthritis, leading to unnecessary procedures.
Conclusions:
- Lyme disease is an infrequent but challenging diagnosis in pediatric EDs.
- Early disseminated and late Lyme disease are more common than early localized disease in this setting.
- Distinguishing Lyme arthritis from septic arthritis requires clinical suspicion and awareness of endemic exposure, as laboratory findings can be similar.
Objective:
To review the clinical characteristics and diagnostic evaluation of children with Lyme disease evaluated in an emergency department (ED) in an endemic area.
Design:
A retrospective review of the demographic, historical, clinical, and laboratory data of pediatric patients with a final diagnosis of Lyme disease.
Setting:
The pediatric ED of an urban university hospital.
Participants:
Children with Lyme disease evaluated during the three-year period from 1992 to 1994.
Results:
Twenty-nine children ranging in age from three to 19 years who were diagnosed with Lyme disease subsequent to a visit to a pediatric ED were identified. Four patients had early localized disease with erythema migrans and varying degrees of systemic symptoms. Ten had early disseminated Lyme disease, with multiple erythema migrans, neurologic involvement (including three patients with pseudotumor cerebri), or carditis. Fifteen cases of late Lyme disease with arthritis were identified. Recognition of Lyme arthritis proved particularly difficult; seven children were initially diagnosed as having septic arthritis, six of whom underwent arthrotomy. Marked elevations of the erythrocyte sedimentation rate and synovial fluid white blood cell counts were observed in these patients, making it difficult to distinguish Lyme disease from septic arthritis on the basis of laboratory findings.
Conclusion:
Lyme disease is an infrequent, often difficult, diagnosis in children who present to an ED. Early disseminated and late disease predominate; classic erythema migrans is uncommon in the ED in comparison with other ambulatory venues. Diagnosis of Lyme arthritis may be difficult; exposure in an endemic area and clinical findings may help distinguish it from septic arthritis. Overall, underdiagnosis of Lyme disease may actually be more of a problem than overdiagnosis in the ED setting. Recognition of Lyme disease by emergency medicine practitioners requires familiarity with its epidemiology and its multiple manifestations.