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Generalized septicemia (30%): usually multiple abscesses; seen in pulmo- nary infections generic 250mg disulfiram with amex symptoms before period, bacterial endocarditis iii buy 250mg disulfiram otc symptoms stiff neck. Common organisms: aerobic and anaerobic streptococci generic disulfiram 500mg visa medications affected by grapefruit, staphylococci purchase disulfiram 250 mg medications for rheumatoid arthritis, Bacte- roides, Enterobacteriaceae, and anaerobic organisms c. Initial cerebritis followed by central necrosis with surrounding vasogenic edema followed by capsule formation 2. Immunocompromised patients and patients with congenital heart disease more susceptible 3. Antibiotics: third-generation cephalosporin with metronidazole and vancomy- cin if Staphylococcus suspected b. Source of infection: local spread from cranial infection or after trauma or surgery 2. Source of infection: local spread from cranial infection or after trauma or surgery 2. Caused by the neurotoxins of gram-positive spore-forming anaerobes Clos- tridium botulinum and, in rare cases, Clostridium butyricum and Clostridium baratii b. Eight distinct type of botulism toxins; neurotoxins types A, B, and E are most frequently responsible for disease in humans, whereas types F and G have been reported only occasionally. Irreversible binding to the presynaptic membrane of cholinergic nerve end- ings in the neuromuscular junction, parasympathetic and sympathetic ganglia ii. Symptoms 12 to 38 hours after ingestion of food due to ingestion of pre- formed toxin ii. Descending weakness from cranial nerves (ptosis, diplopia, blurred vision, dysphagia, and dysarthria) to proximal muscles, including respiratory muscles iii. Autonomic symptoms: dilated pupils, dry mouth, urinary retention, ileus, vomiting, abdominal cramping, constipation b. Constipation, lethargy, hypotonia, poor sucking, weak cry, poorly reactive pupils, respiratory distress iii. Antitoxin: human-derived botulinum immunoglobulin for infants and equine serum botulism antitoxin for children older than 1 year and adults c. Systemic: primary involvement of lymph nodes, spleen, and bone marrow, but almost every organ may be involved. Neuropathology: granulomas, demyelination, thickening of leptomeninges, an- giitis, mycotic aneurysms, and degeneration of anterior horn cells 3. Systemic: chills, fever, headache, generalized weakness, muscle pain, and ar- thralgias with lymphadenopathy b. Prevention: avoid consumption of undercooked meat and unpasteurized dairy products. Treatment: doxycycline (200 mg/day) plus rifampin (600–900 mg/day); longer du- ration for neurological involvement C. Transmitted byskin-to-skin contact or through nasal secretions of infected individuals c. Clinical: differences in the host’s susceptibility to infection result in marked differ- ences in the severity of disease. Intense cell-mediated immune reaction at the portal of entry reduces or- ganism proliferation but causes circumscribed acute peripheral nerve and skin damage. Skin lesions: well demarcated hypopigmented anesthetic lesions on face, arm, chest iii. Thickened nerves and asymmetric neuropathy: ulnar = claw-hand, radial = wristdrop, peroneal = footdrop, and/or facial nerves b. Borderline forms: borderline tuberculoid, borderline intermediate and border- line lepromatous c. Thickened nerves and peripheral neuropathy with symmetric loss of pain and temperature sensations in the distal portions of the extremities and relative preservation of deep sensation iv. Anesthetic hands are prone to repeated trauma and infection, leading to ulcerated skin lesions, bone destruction, finger loss, and deformities. Trigeminal nerve involvement leads to facial hypoalgesia with associated corneal ulcerations and blindness. Multibacillary: clofazimine (50–300 mg/day), rifampin (600 mg/day), and dap- sone (100 mg/day) for 2 years D. Usually basilar meningitis causing fever, headache, neck stiffness, cranial neuropathies, and altered mentation; seizures can also occur. Complications: hydrocephalus and strokes due to vascular involvement of leptomeningeal inflammation. Tuberculoma (central caseating necrosis with collagenous capsule of mononuclear inflammatory cells) or tuberculoid abscess (liquefactive ne- crosis with neutrophilic infiltrate) ii. Very rarely causes tuberculous encephalopathy with diffuse edema and extensive demyelination c. Tuberculous infection of lower thoracic and lumbar vertebral bodies and intervertebral discs, causing collapse of vertebrae ii. Involvement of paravertebral tissues can cause abscess; retropharyngeal abscess in cervical spine involvement. Radiculomyelitis: meningeal enhancement; clumping and enhancement of nerve roots iv. Pott’s disease: hypointense marrow on T1 with hyperintensity on T2, en- hancement of dura, discs; epidural or paraspinal fluid collection; may have evidence of cord compression 4. Intensive phase for 2 months with isoniazid, rifampin, pyrazinamide, and either fluoroquinolone or injectable aminoglycoside ii. Surgical resection of tuberculoma if diagnosis uncertain or if poor re- sponse to medical management iii. Spine surgery if progressive symptoms, instability, or poor response to medical management E. Systemic: 1 to 5 weeks after an acute episode of streptococcal pharyngitis; acute migratory polyarthritis, subacute/chronic carditis, subcutaneous nodules and erythema marginatum, congestive heart failure, and valvular heart disease b. Pathology: infiltration of tissues with foamy macrophages containing periodic acid–Schiff-positive bacilli in the cytoplasm (rectal or jejunal biopsy) 2. Triad (A) Slowly progressive dementia (B) Supranuclear vertical-gaze palsy (C) Myoclonic jerks ii. Antibiotics: penicillin G (12–24 million u/day) and ceftriaxone (50–100 mg/ kg/day) for 2 to 4 weeks in the initial phase followed by trimethoprim (320 mg) and sulfamethoxazole (1,600 mg) for 1 year in the maintenance phase b. Primary stage (within 4 weeks of tick bite): erythema chronicum migrans, con- stitutional symptoms b. Secondary stage (weeks after rash): systemic with cardiac arrhythmias, arthral- gia, lymphadenopathy; neurological manifestations: i. Systemic dissemination with constitutional symptoms, lymphadenopathy, and rash iii. Tertiary syphilis: cardiovascular and delayed neurological complications of tabes dorsalis or dementia 3. Meningeal invasion with endarteritis obliterans and vasculitis, causing strokes ii.

It may provide clues to the cause of the about what information they are meant to be getting from neurological disorder or uncover risk factors order disulfiram 250mg with amex medications names. Students often dive into the active part of fnding a breast mass in a woman with a progressive the neurological examination and miss important physical hemiparesis suggests there are cerebral metastases; raised signs that can be seen if looked for discount 500 mg disulfiram fast delivery medications prednisone, for example the relative blood pressure and hypertensive retinopathy indicate facial immobility in Parkinson’s disease cheap disulfiram 250mg with amex medicine x xtreme pastillas. General examination may reveal conditions associated test and as an investigative tool disulfiram 500 mg without a prescription treatment models. In patients in whom with the neurological problem, for example fnding you anticipate a normal examination (e. The examination is used to investigate the unrelated important diseases that may affect the hypotheses generated by the history and to clarify and management of the neurological condition: for example, a understand any abnormalities found on the screening patient with diffculty walking and lumbar canal stenosis examination. For example, sensory examination of the hand who was also found to have signifcant osteoarthritis of the will need to be done carefully in a patient with sensory hip may beneft more from a hip replacement than from symptoms affecting the hand; this would not be done in the lumbar canal decompression. For most patients with neurological disease the general When considering the examination as a whole you examination is simply a screening examination. There are should try to answer the following questions: exceptions, for example: ¦ Are there any abnormalities? The following sections will explore how to examine the nervous system and highlight some of the patterns of Box 1 Screening neurological examination abnormality that can be found. These brief descriptions ¦ Gait should only be regarded as an outline to be augmented by ¦ Pupils – direct and consensual reactions bedside teaching. Various areas of importance will be ¦ Test felds to hand movements further highlighted in a later section, which deals with ¦ Fundoscopy particular problems. Any description of divisions of the trigeminal nerve neurological examination technique will inevitably include ¦ Facial movement – ‘screw up your eyes, show me your teeth’ brief excursions into blind alleys that are only occasionally ¦ Mouth – ‘open your mouth (look at tongue) and say ‘arrh’ important. Please put out your tongue’ ¦ Test neck fexion ¦ Arms Basic screening neurological examination – look for wasting – test tone at wrist and elbow – observe outstretched arms with eyes closed – test power (shoulder abduction, elbow fexion and Investigative examination of symptomatic extension, fnger extension and abduction and abductor or abnormal parts of the nervous system pollicis brevis) – refexes (biceps, triceps arid supinator) ¦ Legs – look for wasting – test tone at hip Test hypothesis: – test power (hip fexion and extension, knee fexion and • predicted findings extension, foot dorsifexion and plantarfexion) Synthesis of examination: – refexes (knee and ankle and plantar response) • associated findings • normal ¦ Sensation • syndrome – test joint position sense in toes and fngers • single lesion – test vibration sense on toes and fngers – test light touch and pinprick distally in hands and feet • multiple lesions ¦ Coordination K2 – test fnger–nose and heel–shin Fig. Examination: introduction 11 Temporal artery Table 1 Framework for mental state testing (temporal arteritis) heading Consider Comment Appearance Does he or she seem anxious or Ask relatives and make your Rash and behaviour depressed? Patients with psychiatric illness can be distinguished from illusions, where to mind as soon as you see the patient present with physical symptoms. For there is a misinterpretation of a physical – if they don’t come to mind then they example, fatigue, headaches and sensation (the dressing gown on the can be diffcult to fnd. Olfactory, visual and tactile the mental state examination is hallucinations are more commonly conducted along with the history. Auditory Organization of the examination useful to have a mental framework for hallucinations are usually associated Neurological examination fndings are areas to consider in a patient with an with psychiatric disease. In can be described as being elementary This has developed because it is easier patients in whom the changes result (e. Simple hallucinations large amount of information if it is important to obtain independent are more commonly organic. While corroboration of any change in Delusions are fxed beliefs not most neurologists will examine patients personality, delusions and so on. One I know starts his practice are neuroses, depression and psychiatric disease, though when they examination at the feet! Patients with psychoses, illness occur in organic disease there are usually develop (and practise) your own order characterized by delusions and other signifcant higher function defcits. In general Mental state examination underlying neurological disease, the neurological practice it is important the mental state examination is an organic psychoses. Patients with organic not to miss the opportunity to treat assessment of the patient’s mood and psychoses (e. This is not undertaken states) have an altered mental state presentation of anxiety or depression formally on every neurological examination. However, it is important to be abnormalities in higher function, which to their neurological problems. Personality changes usually result Abnormalities of mental state can from frontal disease. This can result in Examination: introduction occur for three reasons: two extremes of behaviour, either 1. Patients with neurological disease apathy, loss of interest in appearance ¦ General examination can provide may develop delusions or and mental slowness or disinhibition, information about the aetiology of, or personality change, for example in and overfamiliar and at times risk factors for, neurological disease. This should be undertaken in patients who report diffculties or if an abnormality is suggested by the history. Abnormalities in these areas can explain diffculties in obtaining a clear history. The processes in language and terms used to describe X 7 abnormalities are summarized in Figure 1. The process of understanding occurs in Wernicke’s area in the supramarginal gyrus of the parietal lobe and the upper temporal lobe. This is linked by the arcuate fasciculus to Tongue Broca’s area in the inferior frontal gyrus where speech Ear output is generated. This then requires motor output Larynx involving corticospinal tracts, the basal ganglia and cerebellar inputs. The larynx is innervated by the vagus Site Function Abnormality nerve to produce the voice, and then the tongue and lips, innervated by the hypoglossal and facial nerves, produce 1 Ear and auditory nerve Hearing Deafness articulated speech. Fluent aphasia = Wernicke’s aphasia = receptive Corticospinal tracts aphasia = sensory aphasia. Patients have impaired 6 Motor output pathways, Articulation Dysarthria understanding and do not answer questions appropriately peripheral: facial, of speech and do not obey commands. The speech output is fuent hypoglossal, vagus but is often meaningless because they cannot edit their own nerves, face and tongue output. Patients with a milder fuent aphasia may 7 Larynx Voice Dysphonia production seem normal superfcially, especially on social pleasantries. In milder defcits this dominant occipitoparietal lesions, reading can be lost particularly affects less commonly used words. This results without losing the ability to write (alexia without agraphia) from lesions in Broca’s area. These patterns of aphasia can occur in isolation but there is often a mixed picture affecting comprehension and higher function speech production, which, if severe, is referred to as global Higher function is the term used to include all the aphasia. Smaller lesions can produce more subtle speech processes of thought, memory, interpretation and problems: for example, lesions of the arcuate fasciculus comprehension of visual, auditory and sensory information. Assessment Assessment of aphasias follows the pathway of language Factors affecting assessment of higher function processing given above. If these are Give instructions of increasing complexity to determine the affected, testing has to be more limited and interpretation degree of comprehension. Non-verbal communication can (patients may need to be asked to describe something, for sometimes be used to a limited extent with abnormal example their work) – is it fuent? The level of premorbid intelligence needs to be K2 name objects (watch, strap, buckle), to list animals considered, and some estimation made of expected level (normally >18 in 1 min) or words beginning with F or S of function. Formal assessment of higher function needs to be undertaken after conducting a full Limbic system Things I have Storing new Temporal neurological examination. The mental state of a patient will affect higher function thalamus) (episodic testing. Temporal Things I have Storing new Temporal Patients with frontal lesions have marked behaviour neocortex learnt about information lobe changes, with altered personality, apathy or disinhibition (semantic and perseveration, but may have relatively modest memory) abnormalities of higher function.

All the steps require reasoning with a great deal of experience in a specific area skills order 500 mg disulfiram otc symptoms 3 days past ovulation. This concept of a five-step process discount 250 mg disulfiram overnight delivery symptoms anxiety, consist- (domain expertise) reasoned during a problem- ing of assessment buy disulfiram 500 mg without a prescription medicine tramadol, diagnosis discount disulfiram 500mg fast delivery symptoms kidney failure, planning, implemen- solving task. In between an information processing system (the what has become a classic treatise, Henderson human problem solver) and a task environment (1982) cautioned that the nursing process should (the context in which problem solving occurs). A not be confused with the process of clinical postulate of this theory is that there are limits to reasoning. Individuals with a great deal of knowl- tree made better decisions about diagnosis and edge and experience in a particular domain can treatment choices for both acute and chronic con- more easily chunk information pertaining to that ditions. The found that conflict and ambiguity significantly theory proposes that information gained from increased task complexity. The intent of studies of nurses’ clinical experience (Glaser & Chi 1988, Joseph & reasoning guided by this method is to understand Patel 1990). Their findings medicine over 20 years ago as a method of solving indicated that nurses at different levels of exper- difficult clinical problems. Findings from a later application involves the use of mathematical for- study by the same authors (1996) indicate that this mulas, tabular techniques, nomograms, and com- clinical world is shaped by experience that teaches puter programs to determine the likelihood of nurses to make qualitative distinctions in practice. They also found that beginner nurses were more Several nursing studies have demonstrated the task-oriented, while those with more experience applicability of decision theory to nurses’ decision focused on understanding their patients and their making. Lipman & Deatrick (1997) found that tributed to the understanding of nurses’ clinical nurse practitioner students who used a decision reasoning. De la Cruz study, described characteristics of clinical judge- (1994) studied the problem-solving skills of home ment exhibited by critical care nurses with varying health nurses and identified three types of thinking levels of practice experience when they reasoned style: ‘skimming’, ‘surveying’ and ‘sleuthing’. Characteristics of clinical judge- la Cruz defined skimming as a decision-making ment identified in the most experienced subjects style that is used by experienced nurses who draw included: (a) the ability to recognize patterns in clin- upon their previous knowledge and experience to ical situations that fit with patterns they had seen in quickly assess a clinical situation to expedite a pre- other similar clinical cases; (b) a sense of urgency determined and well-defined task. Surveying is a related to predicting what lies ahead; (c) the ability decision-making style that focuses on addressing to concentrate simultaneously on multiple, complex distinct and specific patient problems which can patient cues and patient management therapies; be resolved using standardized nursing interven- and (d) an aptitude for realistically assessing patient tions. Benner & Tanner’s subsequent work strategies, including hypothetico-deductive, intui- with Chesla (Benner et al 1996) helps further the the- tive and pattern recognition. These studies have oretical understanding of nurses’ judgement that is emphasized the importance of consultation with needed to improve educators’ ability to teach their experienced colleagues (Manias et al 2004) and students to reason better, and to provide nurses in the use of clinical supervision to facilitate review practice with knowledge that will help them to and feedback (Riley 2003). Thus, Stern (1983) to explore the reasoning of a group of research into nurses’ problem solving and decision critical care nurses with varying levels of expertise. Fonteyn enced by the more seasoned nurse subjects, which & Fisher (1995) examined nurses’ decision making they believed was as important to nurses’ when monitoring unstable clients immediately reasoning as their formal knowledge about patient after major surgery. Subjects said they used these gut feelings to of reasoning in this situation: predictive reasoning temper information from specific clinical cues; (anticipating patient responses and outcomes they also emphasized the importance of previous based on the current status of a client and on previ- clinical experience in developing intuitive skills. Subjects described their intuitive Clinical reasoning in nursing 239 experiences as strong feelings or perceptions about further exploration. Beyond research conducted their patients, about themselves and responding to outside the clinical arena, using simulation, ques- their patients, or about anticipated outcomes, that tionnaires or interviews, there is a need for more they sensed without going through an analytical studies situated in the clinical arena to achieve the reasoning process. Rather, nurses reason to distinguish aloud technique, the investigators collected data between relevant and irrelevant patient data, to from a group of expert critical care nurses while determine the significance of patient data, and they were providing postoperative care to critically to make decisions that assist in accomplishing the ill patients. Their study a tremendous amount of rich, relevant data about also provided a description of nurses’ reasoning– nurses’ reasoning can be obtained using this thinking strategies (heuristics). Moreover, studying nurses’ reasoning in Heuristics are mental rules of thumb that assist the clinical setting does not appear to compromise in reasoning and are acquired over time through patient care or to disrupt either subject or unit multiple experiences with similar patient cases functioning. In demonstrated the feasibility of this methodological a later study, Fonteyn (1998) provided a more com- approach in a study examining how nurses with plete description of the heuristics nurses use when varying levels of expertise use knowledge to make reasoning about clinical dilemmas. Additional, less common thin- ine the relationship between nurses’ clinical king strategies were pondering, posing a question, reasoning and other variables, such as level of making assumptions and qualifying and making expertise, domain knowledge, the climate in which generalizations. This evidence strengthens and the reasoning and decision making take place, expands previous clinical reasoning studies of patient stability and patient outcomes. Cioffi & Markham (1997) important questions are: found that advanced practice nurses relied on How is nurses’ reasoning related to their sense heuristics in clinical decision making when uncer- of autonomy and job satisfaction? Affective dispositions that characterize Can nurses be taught strategies that will good critical thinkers include inquisitiveness, con- improve their reasoning? Does improvement in nurses’ reasoning result Facione & Facione (1996) contended that the in improved patient outcomes? In their text Developing Clinical Problem-solving include carefully examining and delineating key Skills, Barrows & Pickell (1991, p. This is equally true in ships, hypotheses and theories, while formulating nursing, where dealing with complex patient pro- alternatives for justifying procedures and stating blems with uncertain and unpredictable outcomes findings. Since responses and actions are formulated for antici- then various authors have constructed definitions pated and unanticipated situations. The need to make effective practice decisions, utilizing expert panel worked toward development of a good judgement, in the context of uncertainty. Secondly, they found that one must have of the nursing process as an identified problem, Clinical reasoning in nursing 241 goal and desired outcome. The use of faculty-developed instru- been adopted that are designed to improve stu- ments to assess student outcomes is strongly dents’ reasoning skills and furnish them with a recommended. Course-specific measures such as repertoire of creative approaches to care (Norman clinical performance criteria or written assign- & Schmidt 1993). Page et al (1995) advocated them to identify potential patient problems, sug- the use of key feature problem (case scenario) gest nursing actions and describe outcome vari- examinations to assess clinical decision-making ables that would allow them to evaluate the skills. Case studies provide In the future, educators must strive to devise the advantage of allowing nurse educators to give additional methods to develop and improve continuous feedback in the safe environment of nurses’ clinical reasoning. Further changes will be simulation and to provide reality-based learning required in the structure and function of nursing (Manning et al 1995, Neill et al 1997, Ryan-Wenger curricula. Lipman & Deatrick (1997) found ways in which they identify significant clinical that beginning nurse practitioner students tended data and determine the meaning of data in regard to formulate diagnoses too early in the data- to patient problems. They also need to learn how gathering phase, thus precluding consideration to reason about patient problems in ways that facil- of all diagnostic options. Paul & Heaslip (1995) advo- provide information in chronological segments cated that students need to reason their way criti- that more closely reflect real-life cases, in which cally through nursing principles, concepts and clinical events and outcomes evolve over time theories frequently, so that accurate application (Fonteyn 1991). Technolog- simulations, clinical logs, collaboration, decision ical advances such as the internet, with access analysis, discussion, email dialogue, patient simu- to online video conferencing, journals, websites, lations, portfolios, reflection, role modelling, role interactive programs and distance learning, hold playing and writing position papers (Baker 1996, rich promise for promoting creative and effective Fonteyn & Cahill 1998, Kuiper & Pesut 2004, teaching environments (Fetterman 1996). Once students tems and expert systems are currently being devel- have developed their reasoning skills in this man- oped to assist nurses in practice to reason more ner, they can then apply them while caring for real efficiently and to make better clinical decisions. Fonteyn & Flaig Expert system development began in research (1994) suggested teaching students to reason and laboratories in the mid-1970s and was first imple- plan care in the same manner as practising nurses. Fonteyn & Grobe ally obtained in report form and confirmed by (1994) suggested that an expert system could be patient assessment) the most important patient designed to represent the knowledge and rea- problems on which to focus during their nursing soning processes of experienced nurses, and could shift. Information from the patient, the family then be used to assist less experienced nurses and other members of the healthcare team should to improve their reasoning skills and strategies. As the shift ing programme, which has been shown by Lange progresses, nurses continuously evaluate and et al (1997) to be effective in improving nurse prac- refine their plan of care based on additional data titioner students’ diagnostic abilities. Expert sys- obtained from further patient assessment, tem shells, coupled with a focus on the concise additional clinical data and information from nursing problems encountered within a specific all individuals involved in carrying out the area of nursing practice and a common taxonomy, plan of care. Nursing literature suggests that nurses’ the relationship between nurses’ reasoning and reasoning and interventions have a significant patient outcomes should receive greater attention effect on patient outcome (Fowler 1994).

Listeriosis occurs most frequently among pregnant women and their fetuses or newborns generic 500 mg disulfiram with visa treatment nerve damage, people of advanced age discount disulfiram 250mg otc symptoms 3 days before period, or immunocompromised people generic disulfiram 250mg symptoms 9 days after iui. Courtesy of Centers for Disease Control and Prevention/Dr Balasubr Swaminathan; Peggy Hayes cheap disulfiram 250mg free shipping symptoms ruptured spleen. Carditis, Clinical manifestations of Lyme disease are which usually manifests as various degrees of divided into 3 stages: early localized, early dis- heart block, can occur in children but is rela- seminated, and late disease. Occasionally, people with ease is characterized by a distinctive lesion, early Lyme disease have concurrent human erythema migrans, at the site of a recent tick granulocytic anaplasmosis or babesiosis, which bite. Coinfection common manifestation of Lyme disease in can present as more severe disease than Lyme children. Erythema migrans begins as a red monoinfection, and the presence of a high macule or papule that usually expands over fever with Lyme disease or inadequate response days to weeks to form a large, annular, ery- to treatment should raise suspicion of concur- thematous lesion that typically increases in size rent anaplasmosis or babesiosis. Certain labo- to 5 cm or more in diameter, sometimes with ratory abnormalities, such as leukopenia, partial central clearing. The lesion is usually thrombocytopenia, anemia, or abnormal but not always painless, and it is not pruritic. A treated at an earlier stage of illness and most classic bull’s-eye appearance with concentric commonly manifests as Lyme arthritis in chil- rings appears in a minority of cases. Factors dren, which is characterized by infammatory that distinguish erythema migrans from local arthritis that is usually pauciarticular and allergic reaction to a tick bite include larger afects large joints, particularly knees. Constitutional symp- stage of Lyme disease, Lyme arthritis has toms, such as malaise, headache, mild neck objective evidence of joint swelling. Arthritis stifness, myalgia, and arthralgia, ofen accom- can occur without a history of earlier stages of pany the rash of early localized disease. Com- can be present but is not universal and is pared with pyogenic arthritis, Lyme arthritis generally mild. Poly- an infective tick bite and consist of secondary neuropathy, encephalopathy, and encephalitis annular, erythematous lesions similar to, but are extremely rare manifestations of late dis- usually smaller than, the primary lesion. Children who are treated with antimicro- manifestations of early disseminated illness bial agents in the early stage of disease almost (which may occur with or without rash) are never develop late disease. No evidence suggests Lyme junctivitis, optic neuritis, keratitis, uveitis) can disease can be transmitted via human milk. Although the cause between April and October; more than 50% is unknown, ongoing infection with Borrelia of cases occur during June and July. People burgdorferi has not been demonstrated, and of all ages can be afected, but incidence in long-term antibiotics have not been shown the United States is highest among children to be benefcial. Patients with posttreatment 5 through 9 years of age and adults 55 through Lyme disease syndrome usually respond to 59 years of age. A lesion similar to erythema migrans known “Chronic Lyme disease” is a nonspecifc term as “southern tick-associated rash illness” or that lacks a clinical defnition. The etiology and plained syndromes usually characterized by appropriate treatment of this condition pain and fatigue. Southern tick-associated be responsible for symptoms and should be rash illness results from the bite of the lone considered. In none of these situations is there star tick, Amblyomma americanum, which is credible evidence that persistent infection abundant in southern states and is biologically with B burgdorferi is demonstrable. Clinical manifestations of Lyme disease in Epidemiology eastern Canada, Europe, states of the former Lyme disease primarily occurs in 2 distinct Soviet Union, China, and Japan vary some- geographic regions of the United States. More what from manifestations seen in the United than 90% of cases occur in New England and States. In particular, European Lyme disease in the eastern Mid-Atlantic States, as far south may cause borrelial lymphocytoma and acro- as Virginia. The disease also occurs, but with dermatitis chronica atrophicans and is more lower frequency, in the upper Midwest, espe- likely to produce neurologic disease, whereas cially Wisconsin and Minnesota. Tese diferences are also occurs at a low level on the West Coast, attributable to the diferent genospecies of especially northern California. The occurrence Borrelia responsible for European Lyme dis- of cases in the United States correlates with ease. The primary tick vector in Europe is the distribution and frequency of infected tick Ixodes ricinus, and the primary tick vector in vectors—Ixodes scapularis in the east and Asia is Ixodes persulcatus. In Incubation Period Southern states, I scapularis ticks are rare From tick bite to appearance of single or mul- compared with the northeast. Ticks that are tiple erythema migrans lesions is 1 to 32 days present in Southern states do not commonly (median 11 days). Late manifestations can feed on competent reservoir mammals and are occur months afer the tick bite. Reported cases from states Diagnostic Tests without known enzootic risks may have been The diagnosis of Lyme disease rests frst and acquired in states with endemic infection or foremost on the recognition of a consistent may be misdiagnoses resulting from false- clinical illness in people who have had plau- positive serologic test results or results that sible geographic exposure. Although sensi- a small lesion (<5-cm diameter) that resembles tive, the frst-tier test is not specifc and has a erythema migrans, the patient can be followed rate of false-positive results that may exceed 5% over several days to see if the lesion expands in clinically compatible cases and far higher in to greater than 5 cm; this will improve the clinically nonsuggestive cases. In areas because the test is not well standardized and endemic for Lyme disease during the warm because there are antigenic components of months of the year, it is expected that the vast B burgdorferi that are not specifc to this spe- majority of erythema migrans is attributable cies. In particular, other spirochetal infections, to B burgdorferi infection, and early initiation normal spirochetes from our oral fora, other of treatment is appropriate. This assay tests for the presence of anti- who have multiple lesions of erythema migrans bodies to specifc B burgdorferi antigens. Tree are also diagnosed clinically, although the like- IgM antibodies (to the 23/24, 39, and 41 kDa lihood of seropositivity is higher. Diagnosis of polypeptides) and 10 IgG antibodies (to the 18, disseminated Lyme disease requires a typical 23/24, 28, 30, 39, 41, 45, 60, 66, and 93 kDa poly- clinical illness, plausible geographic exposure, peptides) are tested. Laboratory report- The standard testing method for Lyme disease ing practices can produce some confusion is a 2-tier serologic assay. It is a quantitative screening for antibodies common for clinical laboratories to report the to a whole-cell sonicate or C6 antigen of titers of all 13 bands and describe them as posi- B burgdorferi. It misinterpretation of the overall result as posi- should be noted that clinical laboratories vary tive despite the fact that 4 or fewer IgG bands somewhat in their description of this test. This is the most foolproof way of ordering the appro- The IgM assay is only useful for patients in priate 2-tier test for Lyme disease. They are interdependent parts of an positive serologic test results in these patients overall testing method. In areas with endemic A licensed, commercially available serologic infection, previous subclinical infection with test (C6) that detects antibody to a peptide seroconversion may occur, and the patient’s of the immunodominant conserved region symptoms may be merely coincidental. Patients of the variable surface antigen (VlsE) of with active Lyme disease almost always have B burgdorferi appears to have improved objective signs of infection (eg, erythema sensitivity for patients with early Lyme disease migrans, facial nerve palsy, arthritis). How- specifc symptoms commonly accompany ever, when used alone, its specifcity is lower these specifc signs but almost never are the than that of standard 2-tier testing. This test, however, is not in patients treated for early Lyme disease does necessary for the diagnosis of Lyme arthritis, not indicate lack of cure or presence of per- a late disseminated manifestation in which sistent infection. Most standard course of therapy, polymerase chain patients with early disseminated disease and reaction testing of synovial fuid or tissue may virtually all patients with late disease have help discriminate ongoing infection from antibodies against B burgdorferi. Polymerase antibodies develop, they persist for many chain reaction testing can also detect B burg­ years.

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