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Differential Case Study: Lyme Disease or Covid-19?

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Lakeith, a 35-year-old black man living in New York State, presents with a fever of 101 degrees F. He is concerned he might have contracted Covid-19. Based upon a true story, this case study highlights the need to be aware of life-threatening diseases that can masquerade as Covid-19. It also discusses health disparities that can impact outcomes for people of color.

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

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Differential Case Study: Lyme Disease or Covid-19?
If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

Chief Complaint

Fever of 101o F, fatigue and lethargy, stiff neck and jaw, chills and sweating with fever, muscle aches and pains with fever. “I feel like I have the flu. I’m worried I might have Covid-19.”

History of Present Illness

Lakeith awoke on Saturday morning feeling exhausted. As the morning progressed, he began to have aches and pains. He took an oral temperature that was 101o F. His first thought was that he had contracted Covid-19. He is a home health physical therapist who specializes in geriatric physical therapy. He sees four to five patients each day. Several of his patients have tested positive for Covid-19. When working with any of his patients, Lakeith wears an N-95 mask and gloves and practices strict hand hygiene.

Before calling his primary care provider, Lakeith went online and took the Mayo Clinic Covid-19 Self-Assessment Tool to see if his symptoms fit with those for Covid-19.

Here are the questions with his response

  • Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days? YES
  • Does the person with COVID-19 live with you? NO
  • In the last 48 hours, have you had any of the following NEW symptoms? Check all that apply.
Response Symptom
Yes Fever of 100 F (37.8 C) or above
Yes Fever symptoms like alternating chills and sweating
No Cough
No Trouble breathing, shortness of breath or severe wheezing
Yes Chills or repeated shaking with chills
Yes Muscle aches
No Sore throat
No Loss of smell or taste, or a change in taste
No Nausea, vomiting or diarrhea
Yes Headache
No None of the above
  • Do you have any of the following possible emergency symptoms? Check all that apply.
Response Emergency Symptom
No Struggling to breathe or fighting for breath even while inactive or when resting
No Feeling about to collapse every time you stand or sit up (floppiness or a lack of response in a child under age 2)
No None of the above
  • Is the person with a fever younger than 3 months old? NO
  • Have you traveled in the past 14 days to regions affected by COVID-19? NO
  • Do you live in a care facility? NO
  • Do you work in healthcare? YES

After taking the test, he called his primary care office and the triage nurse directed him to come in for a Covid-19 test.

General appearance

The patient arrived at clinic for a Covid-19 test wearing a mask, shoulders drooping, eyes heavy-lidded. Speech is slow and measured. While the nurse prepped for the test, she noticed the patient repeatedly attempting to scratch his back.

Past Medical History

Uncomplicated appendicitis at age 12

Family History

Father, age 56, and mother, age 52 both have HTN and hypercholesterolemia. Thirty-three-year-old sister with obesity and type 2 diabetes.

Social History

Occasional marijuana use, drinks alcohol 1-2 times weekly. Non-smoker. Lives alone. Patient has a girlfriend of three years. He has been socially isolating since March 15th due to his high-risk job.

Medications

Takes Tylenol or ibuprofen for aches and pains. Daily Allegra for seasonal allergies.

Allergies

NKA

This case study is different from others in that I am letting you know from the start that Lakeith has Lyme disease, Covid-19 or both.

What information do you need to determine his diagnosis? He’s had a nasal swab for Covid-19, but the results won’t be available for another three days.
What else would you check before he leaves the primary care clinic?

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

References

Merck Manual Professional Edition: Lyme Disease

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: gf.me/u/xzs5sa

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36 Comment(s)

curlnbe, BSN

Specializes in Telemetry/Step Down. Has 5 years experience.

I'd ask the primary provider if they wanted to do a blood panel. As far as my own nursing assessment, I'd ask to see the spot the patient is trying to scratch, assess severity of stiff jaw and neck, and ask about activities in the past few days related to outdoors.

Jgennett57, ASN, LPN, RN

Specializes in Telemetry, DD, Ortho, CCU, BHU. Has 45 years experience.

I would ask him about his recent activities. Does he hike, does he live in a high Lyme disease known area, did he notice a bullseye, has he had to remove a tick from his skin and does he have any areas that he would consider a bug bite? I would ask him if I could check his skin.

Report to physician my findings.

I would ensure that any orders for blood work , cultures ect were done. Find out if physician wanted him to be on doxycycline (if no allergy) until blood work came back.

LeahHona

Has 6 years experience.

I would ask about blood panel as well. There are particular values I am looking for, but I don’t want to give away any spoilers. 😊

As someone who has had Lyme disease since 1996 and unfortunately knows way too much about this and the co infections...ask if the patient has pets that go outside for bathroom purposes. Many times the pet will bring it inside and the person will deny having been hiking or even gone outside much at all. Basic blood work is important because a co infection such as erlichia will likely change blood counts (CBC). Babesia, RMSF, Anaplasmosis, mycoplamsa pneumonae, etc are careful co infection considerations when diagnosing potential tick borne infection. Also, lyme disease tests are crap (60% reliable) and especially crap when done too quickly. The western blot shows antibodies to the bacteria, borrelia burgdorferi cannot be cultured, it is an incredibly slow growing spirochete (similar to syphilis) and difficult to kill. Sometimes an antibiotic challenge is necessary to prompt the body to produce antibodies. Personally, providing prophylactic doxycycline 100 BID is the best bet to reduce the chance that the patient will endure years or chronic lyme disease which can ruin ones' quality of life.

Run blood panel. Look for elevated liver enzymes, low platelets.

scribblz, BSN, CNA, LPN

Specializes in Med Surg, Tele, Geriatrics, home infusion. Has 14 years experience.

Check a d-dimer and get a chest xray.

Agree with prev posters re: blood panel including LFTs, would also add on Fe studies. With his family hx would check a lipid panel.

Agree with the skin assessment to assess for bull's eye rash, Lyme titers and tick panel.

Given his fever starting him on doxy (and a probiotic) sounds beneficial.

We also need a set of vital signs on this gentleman to ensure he's stable and not going septic on us.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

Lab values:

Many of you are asking for lab values, and rightly so. I promise, you’ll get them (the lab is running behind these days). We did get the results of the rapid Covid test (see below). While we wait for the other blood work, I have a small amount of information and a few more questions

Review of Systems: only abnormal values presented

Skin: bullseye rash on right shoulder blade

HEENT: slightly swollen cervical lymph nodes

Neuro: occasional headache

Vital signs:

BP 118/65 sitting, RA

HR 85

RR 20

T 100oF

O2 sat 95%

HT 6’ 2”

WT 210 lbs

Covid-19 results: negative. Lakeith stated he’s been hiking several times a week in the woods behind his house. “I don’t have anything else to do, I’m sick of watching Netflix. I feel like being outside helps with my stress levels.”

Given these results, can you rule out Covid-19? Have you confirmed Lyme disease? What other information would you need to confirm or rule out Covid-19 and/or Lyme disease?

GracefullyGritty, LPN

Specializes in wound care/rehabilitative care. Has 5 years experience.

Any joint swelling in the knee, unilaterally? Would probably r/o COVID but continue self isolation until labs are back.

NewEnglandRN16

Has 3 years experience.

On 6/28/2020 at 8:27 AM, SafetyNurse1968 said:

Lab values:

Many of you are asking for lab values, and rightly so. I promise, you’ll get them (the lab is running behind these days). We did get the results of the rapid Covid test (see below). While we wait for the other blood work, I have a small amount of information and a few more questions

Review of Systems: only abnormal values presented

Skin: bullseye rash on right shoulder blade

HEENT: slightly swollen cervical lymph nodes

Neuro: occasional headache

Vital signs:

BP 118/65 sitting, RA

HR 85

RR 20

T 100oF

O2 sat 95%

HT 6’ 2”

WT 210 lbs

Covid-19 results: negative. Lakeith stated he’s been hiking several times a week in the woods behind his house. “I don’t have anything else to do, I’m sick of watching Netflix. I feel like being outside helps with my stress levels.”

Given these results, can you rule out Covid-19? Have you confirmed Lyme disease? What other information would you need to confirm or rule out Covid-19 and/or Lyme disease?

I would change your Phrase “negative” when referring to covid test. Say “not detected”. He could still have covid with a non detected result.

Also was chest X-ray or chest ct done? Any ground glass opacities?

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

From the provider point of view:

1). Ddx question in this situation is principally nil and zero, because right now every patient is basically treated like COVID19 patient until proven otherwise.

It is not written if the patient came to urgent care, ER or primary care office, but with fever and aches and direct contact with people of increased risk he will be sent to testing place at once, and so the question about COVID19 will therefore be solved. It is not necessary to think about it or follow absurd protocols and checklists (by common sense anyone who visit any place with more than himself around cannot for all honesty say that he absolutely was not near anyone who had confirmed COVID unless everyone around him was tested negative and it is known). It is just necessary to recognize one simple fact of today: not confirmed "negative" = "positive" unless proven not by DOUBLE test PCR (antibodies are optional and possibly useless at the beginning of the process).

Once we answered the question about the COVID, we can proceed with further differential, which is a little wider than just Lime. And we are not forgetting that one can have COVID19 and Lime disease at the same time.

2) from answers: some of them illustrate very common mistake, particularly characteristic for nursing providers: ordering every test and the kitchen sink, at once, basing on some bits and pieces. It illustrates the classic American nursing way of thinking of "doing something for something".

Routine tests such as lipid profile, TSH or iron profile should NEVER be ordered in the middle of acute infectious process, trauma, severe acute exacerbation of chronic disease, in immediate postop period, etc. unless there is a compelling evidence of need to test such as well-based differential. A human being in acute period of infection is different from the same human being after recovery, in metabolic point of view. Doing otherwise leads to diagnostic mistakes and, eventually, harm. Assuming you got cholesterol of 275 on this patient. He is in acute stage of infection and already has muscle pains. He might have already, or develop soon, mild transaminitis. We may have to use quite a bit of Tylenol and other hepatotoxic meds on him. Do you really want add statin on top of this mess? If not, why spend $$ for inherently useless testing which can be safely performed later?

3). Again, line of thinking characteristic for nursing providers in particular: one big thing or no thing. Bull's eye =>> Lime disease, stop at that. Without even checking the total body surface. With the patient being 35 years old male, our differential must include syphilis (at secondary stage, it can produce skin rashes looking amazingly like bull's eyes) and several other common skin conditions like erythema multiforme, by a short list.

Overall, not a good example of clinical question. Sorry. But at least an attempt.

Edited by KatieMI

Jgennett57, ASN, LPN, RN

Specializes in Telemetry, DD, Ortho, CCU, BHU. Has 45 years experience.

COVID-negative. COVID -19 is so new and there is so much more to learn. There have been people who have tested positive detection, quarantined and then show negative detection and then positive detection again. We have so much more to learn about this virus and possible mutations.
Would wait for lab results Elisa, Western Blott before saying Lyme disease is positive although there is an overwhelming evidence without blood work that indicates it is Lyme disease. VegRNmom mentioned that the Lyme disease test is not reliable. I have to agree with that. So I would treat for Lyme disease.

Prophylactic Doxycycline 100mg BID order by Physician should be started and continued for a full treatment of 2 weeks should the Lyme disease be detected or not.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

Sorry I didn't post the final results sooner, but I seem to have some kind of infection...folks, it’s getting weird over here. Over the weekend I developed the exact same symptoms I described in Lakeith (fever, aches and pains, chills, headache). I had a tick bite 2 weeks ago, though no bulls eye rash. I just got tested for Covid-19 this morning at an urgent care clinic, and I’m waiting to hear back from my primary care provider (apparently, they don’t call you back the same day anymore!) I’ll keep you posted on my case, but in the meantime:

Lakeith’s Lab values:

  • ALT 150 (normal is 7-55 U/L)
  • AST 105 (normal is 8-48 U/L)
  • Bilirubin 3.5 (normal 0.1 to 1.2 mg/dL)
  • All other blood work was normal

Elevated liver enzymes are common in both Covid-19 and Lyme disease, so this isn’t a good differential. A study I read showed 76.3% of 417 patients had abnormal LFTs and 21.5% had liver injury with Covid-19 (April 13, 2020, https://www.journal-of-hepatology.eu/article/S0168-8278(20)30218-X/fulltext). They had ALT, AST, total bilirubin and gamma-glutamyl transferase levels elevated to more than 3× the upper limit. Patients with abnormal liver tests of hepatocellular type or mixed type at admission had higher odds of progressing to severe disease

For practical and efficient screening of large populations for a viral infection like Covid-19, reports from China recommend including white blood cells (WBC) and C-reactive protein (CRP) in laboratory examinations for early monitoring of infection (Lu, L. Interpretation of 7th edition of COVID-19 diagnostic and treatment guidelines. Lifotronic webinar: Diagnosis Guidelines for COVID-19, March 19, 2020 https://onlinelibrary.wiley.com/doi/10.1002/ajh.25774)

Their analysis revealed that on admission (so this would be for patients much sicker than Lakeith), most patients had a normal CBC (normal Hb, WBC and platelet count) and lactate dehydrogenase (LDH). And, no patient presented with moderate or severe thrombocytopenia that is frequently observed in other viral illnesses such as dengue fever.

However, reports from China are showing high levels of lymphopenia (Absolute Lymphocyte Count < 1 × 109/L). Those requiring ICU care had a lower ALC and higher LDH. Lymphopenia (ALC) and lactate dehydrogenase (LDH) have both been significantly elevated in hospitalized COVID-19 patients in a small study of 96 confirmed COVID-19 cases in Singapore.

Lyme Disease

In the U.S., Lyme disease is caused by Borrelia burgdorferi and Borrelia mayonii. The most common tick-borne illness, Lyme disease is transmitted by the bite of an infected deer tick.

Lakeith’s nurse practitioner ordered an ELISA test for Lyme, though an ELISA test might not be positive during the early stage of Lyme disease. The rash is distinctive enough to make the diagnosis without further testing in people who live in areas infested with ticks that transmit Lyme disease (New York State is a hot spot for Lyme disease). In addition, the ELISA test can sometimes provide false-positive results, so it’s not the sole basis for diagnosis. Lakeith’s ELISA and subsequent Western blot both came back positive.

Signs and Symptoms of Lyme

A small, red bump, similar to the bump of a mosquito bite, may appear at the site of a tick bite or tick removal, but this may occur with or without Lyme disease. Erythema migrans (bullseye rash) is one of the hallmarks of Lyme disease, although not everyone with Lyme disease develops the rash. Other symptoms include Fever, chills, fatigue, body aches, headache, neck stiffness and swollen lymph nodes. If untreated, new signs and symptoms of Lyme infection might appear in the following weeks to months (https://www.CDC.gov/lyme/signs_symptoms/index.html). These include bouts of severe joint pain and swelling, especially likely to affect the knees, but the pain can shift from one joint to another. Weeks, months or even years after infection, meningitis can cause Bell's palsy, numbness or weakness in limbs, impaired muscle movement and problems with mentation and memory, so it is important to diagnose Lyme early. Delayed diagnosis increases the risk of Post Treatment Lyme Disease Syndrome (https://www.cureus.com/articles/24863-lyme-disease-with-erythema-migrans-and-seventh-nerve-palsy-in-an-african-american-man) and other long-term complications from Lyme disease.

Antibiotics are used to treat Lyme disease. In general, recovery will be quicker and more complete the sooner treatment begins. Many signs and symptoms of Lyme disease are often found in other conditions, so diagnosis can be difficult.

Covid-19 False Negatives

Researchers at Johns Hopkins have found that the chance of a false negative result -- when a virus is not detected in a person who actually is, or recently has been, infected -- is greater than 1 in 5 and, at times, far higher. The researchers caution that the predictive value of these tests may not always yield accurate results, and timing of the test seems to matter greatly in the accuracy. https://www.sciencedaily.com/releases/2020/05/200526173832.htm.

Lakeith requested a second Covid-19 test, which was also negative. He is currently taking a two-week course of oral Doxycycline.

Health disparities and Lyme

A recent study finds that African Americans who contract Lyme disease are 10% more likely than Caucasians to exhibit symptoms such as neurological or heart problems, and they are 30% more likely to suffer from arthritis as a result of the disease. Whites were nearly six times more likely than African Americans to have detected a bull’s-eye rash, according to the study, which may be due to darker skin color that hides the bull’s-eye rash. Because skin tone may hide this key indicator, African Americans may remain untreated longer and therefore suffer more complications from Lyme disease. This highlights the need for increased health care education on Lyme disease in African-American communities. https://minoritynurse.com/darker-skin-tones-slow-detection-of-lyme-disease/

Health disparities and Covid-19

Twenty-two percent of U.S. counties that are disproportionately black account for 52 percent of the nation’s COVID-19 cases and 58 percent of COVID-19 deaths (https://directorsblog.nih.gov/2020/05/14/covid-19-brings-health-disparities-research-to-the-forefront/)

In another study, 33% of hospitalized patients were black, compared to 18% in the community, and 8% were Hispanic, compared to 14% in the community. These data suggest an overrepresentation of blacks among hospitalized patients. Death rates among black/African American persons (92.3 deaths per 100,000 population) and Hispanic/Latino persons (74.3) that were substantially higher than that of white (45.2) or Asian (34.5) persons. (https://www.CDC.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html)

Racial disparities are a major issue with Covid-19. Evidence has emerged that doctors are less likely to refer African Americans for testing for covid-19 when they exhibit symptoms (https://www.washingtonpost.com/outlook/2020/05/18/most-medical-professionals-arent-racist-but-our-medical-system-is/). U.S. Senator Elizabeth Warren (D-MA) and Representative Ayanna Pressley (D-MA) have called for more thorough collection of racial data, faulting the government for “currently failing to collect and publicly report on the racial and ethnic demographic information of patients tested for and affected by Covid-19.” (https://www.nejm.org/doi/full/10.1056/NEJMp2012910)

Thanks for commenting and liking - I so appreciate it. I'm going to take some acetaminophen and go back to sleep. Ugh.

On 6/30/2020 at 9:23 PM, KatieMI said:

From the provider point of view:

1). Ddx question in this situation is principally nil and zero, because right now every patient is basically treated like COVID19 patient until proven otherwise.

It is not written if the patient came to urgent care, ER or primary care office, but with fever and aches and direct contact with people of increased risk he will be sent to testing place at once, and so the question about COVID19 will therefore be solved. It is not necessary to think about it or follow absurd protocols and checklists (by common sense anyone who visit any place with more than himself around cannot for all honesty say that he absolutely was not near anyone who had confirmed COVID unless everyone around him was tested negative and it is known). It is just necessary to recognize one simple fact of today: not confirmed "negative" = "positive" unless proven not by DOUBLE test PCR (antibodies are optional and possibly useless at the beginning of the process).

Once we answered the question about the COVID, we can proceed with further differential, which is a little wider than just Lime. And we are not forgetting that one can have COVID19 and Lime disease at the same time.

2) from answers: some of them illustrate very common mistake, particularly characteristic for nursing providers: ordering every test and the kitchen sink, at once, basing on some bits and pieces. It illustrates the classic American nursing way of thinking of "doing something for something".

Routine tests such as lipid profile, TSH or iron profile should NEVER be ordered in the middle of acute infectious process, trauma, severe acute exacerbation of chronic disease, in immediate postop period, etc. unless there is a compelling evidence of need to test such as well-based differential. A human being in acute period of infection is different from the same human being after recovery, in metabolic point of view. Doing otherwise leads to diagnostic mistakes and, eventually, harm. Assuming you got cholesterol of 275 on this patient. He is in acute stage of infection and already has muscle pains. He might have already, or develop soon, mild transaminitis. We may have to use quite a bit of Tylenol and other hepatotoxic meds on him. Do you really want add statin on top of this mess? If not, why spend $$ for inherently useless testing which can be safely performed later?

3). Again, line of thinking characteristic for nursing providers in particular: one big thing or no thing. Bull's eye =>> Lime disease, stop at that. Without even checking the total body surface. With the patient being 35 years old male, our differential must include syphilis (at secondary stage, it can produce skin rashes looking amazingly like bull's eyes) and several other common skin conditions like erythema multiforme, by a short list.

Overall, not a good example of clinical question. Sorry. But at least an attempt.

I thought it would make for an interesting and informative discussion. Thanks for reading and commenting.

I haven't taken care of any covid patients. I'm just here to learn something. Carry on. 🤓

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

On 7/6/2020 at 5:59 PM, SafetyNurse1968 said:

Health disparities and Lyme

A recent study finds that African Americans who contract Lyme disease are 10% more likely than Caucasians to exhibit symptoms such as neurological or heart problems, and they are 30% more likely to suffer from arthritis as a result of the disease. Whites were nearly six times more likely than African Americans to have detected a bull’s-eye rash, according to the study, which may be due to darker skin color that hides the bull’s-eye rash. Because skin tone may hide this key indicator, African Americans may remain untreated longer and therefore suffer more complications from Lyme disease. This highlights the need for increased health care education on Lyme disease in African-American communities.

https://minoritynurse.com/darker-skin-tones-slow-detection-of-lyme-disease/

The fact that African Americans have higher incidence of arthritis as complication of Lyme is interesting and it is not a "disparity". It is not "rasist" to state the fact: African Americans have genetic markup of many conditions different from that of other ethnicities. Classic b-blockers therapy for CHF can be much less effective for them than it is for Caucasians, they have mutations of ACE receptors more common, they develop HTN-related kidney injury earlier and more severe because of it, their metabolism of vitamin D is different as skin synthesis of D2 is much less effective, etc., etc.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3933289/ (one of many)

Darker skin tones conceal not only bull's eyes rash but many other rashes as well. This is why it is so important not to hold onto one symptom but develop "whole picture" systemic diagnostic vision and do not "fix" on symptomal/syndromal differentials. "Transaminitis" is a fact and a symptom, not a diagnosis.

I know it takes heck of time and decreases "productivity". But it is what have to be done. In every single case, no exclusions, whatever skin color and other variables might be.