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Differential Case Study: Lyme Disease or Covid-19?

Nurses Article CSI   (1,789 Views | 16 Replies | 896 Words)

SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 63 Articles; 20,396 Profile Views; 396 Posts

How Good of an Investigator Are You?

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.

Differential Case Study: Lyme Disease or Covid-19?
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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 https://www.merckmanuals.com/professional/infectious-diseases/spirochetes/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

12 Followers; 63 Articles; 20,396 Profile Views; 396 Posts

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curlnbe has 4 years experience as a BSN and specializes in Telemetry/Step Down.

6 Posts; 56 Profile Views

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.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 63 Articles; 396 Posts; 20,396 Profile Views

Great ideas- more to come soon!

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3 Posts; 64 Profile Views

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.

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LeahHona has 6 years experience.

5 Posts; 81 Profile Views

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. 😊

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4 Posts; 588 Profile Views

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. 

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1 Post; 29 Profile Views

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

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scribblz has 13 years experience as a BSN, CNA, LPN and specializes in Med Surg, Tele, Geriatrics, home infusion.

112 Posts; 1,911 Profile Views

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.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 63 Articles; 396 Posts; 20,396 Profile Views

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?

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GracefullyGritty has 4 years experience as a LPN and specializes in wound care/rehabilitative care.

4 Posts; 242 Profile Views

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

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1 Follower; 6,992 Posts; 33,151 Profile Views

PO  is low for age, would not rule out either

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NewEnglandRN16 has 3 years experience.

43 Posts; 804 Profile Views

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? 

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