Diagnosing Lyme Arthritis in Children

knee arthritis
knee arthritis
Children are among the most susceptible to Lyme disease, and in many, joint inflammation may be the first symptom.

Diagnosis of Lyme disease can be complicated by a number of factors, particularly in children. A recent review by Krzysztof Orczyk, from the Department of Pediatric Rheumatology, Medical University of Lodz, Poland, and colleagues,1 published in Pediatric Rheumatology, examined differences in the underlying infectious pathology that contributes to different manifestations of the disease.

Inflammation is a common symptom in Lyme disease that can occur weeks to months after the original tick bite, but in cases in which the erythematous patch characteristic of Lyme does not appear or goes unnoticed, inflammatory arthritis may be the first clinical sign.2

The authors pointed to 20 variant genospecies of the tick-borne spirochete, Borrelia burgdorferi, 9 of which are responsible for Lyme disease in humans.3,4 The majority of Lyme cases in the United States are associated with the spirochete variant B burgdorferi sensu stricto, which was found to induce arthritis in 46%.5 Arthritis was also present to a lesser degree in European cases caused by the genospecies B garinii and B afzelli (18% and 15%, respectively, as reported by Cerar et al6). Other studies have shown additional symptoms associated with these variants, including fatigue and myalgia.7

Lyme arthritis is widespread in the United States, where it is estimated to affect 33% of patients with Lyme disease,8 and in Europe, where estimates of infection range between 3% and 15%.9 Various studies pointed to swelling and inflammation primarily of large synovial joints,10 with the knee and ankle the 2 most affected sites.11 (The knee was involved in 90% of cases.)

Age was considered a risk factor for Lyme disease, and children are particularly susceptible because of the amount of time they spend outdoors in environments the ticks inhabit. The reviewers found the highest peak incidences in children 2-5 years old, and in adults older than 50 years.12 Still, not all tick bites produce Lyme disease, and as a result of transmission through tick saliva, the most significant factor determining infection was the tick remaining attached for 24 hours or more after the initial bite.13,14 Joint inflammation develops as a result of activation of Th1 lymphocytes.

Diagnosis of Lyme is challenging, and current recommendations are to conduct a 2-step laboratory evaluation using both the enzyme-linked immunosorbent assay and, if the findings are positive, to confirm using the Western blot test.15,16 Lyme arthritis in children is easily misdiagnosed as juvenile idiopathic arthritis, the reviewers found, and therefore, should be considered as part of the differential diagnosis for symptoms of joint inflammation.

Treatment still follows the guidelines provided by the Infectious Disease Society of America, which calls for a 28-day course of antibiotics such as doxycycline, cefuroxime axetil, or amoxicillin.17

The reviewers found no benefit to continuing the course of antibiotics in cases where Lyme disease is refractory to treatment, and reported that further treatment of any kind is “questionable,” as most cases will eventually resolve. 

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