Single dose of doxycycline for Lyme disease leads to poor outcome for 61-year-old man

Ever wonder what the outcome might be if a patient were prescribed a single dose of oral doxycycline for Lyme disease? Not so good, according to a case report by Ebner and colleagues from the Mayo Clinic in Rochester, Minnesota. [1]

 

by Daniel J. Cameron, MD, MPH

In the January 2018 issue of the British Medical Journal, the authors describe the case of a 61-year-old man who complained to his primary care physician and multiple emergency room personnel that he was having severe shooting pain over his scalp, neck and back.

“The degree of discomfort from his hair moving was so extreme he elected to shave his head to provide some relief,” writes Ebner. The man also presented with non-radiating back pain and bilateral dorsal arm paresthesias.

He reported having “three distinct large circular red lesions, one with a central clearing,” writes Ebner. However, his serologic and spinal tap results were normal.

The man had been exposed to ticks, “working outside optimizing the landscape for white tailed deer,” states Ebner. He had also been exposed to at least 30 ticks in 1 day, but did not recall a tick bite.

The initial doctors did not prescribe the treatment regime of at least 3 weeks of antibiotics, as recommended by both the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS).

Instead, the man was prescribed a single dose of doxycycline 200 mg. And physicians attempted to manage his symptoms with pain medications. “He had been up-titrated on gabapentin with minimal response and started on a narcotic for pain control,” the authors explain.

For the next 6 weeks, the man continued suffering with severe pain, worsening paresthesias, and right-sided cranial nerve VII palsy.

His repeat spinal tap was abnormal for lymphocytosis, elevation of protein, 6 oligoclonal bands, and a positive ELISA and IgG and IgM immunoblot. Physicians then diagnosed him with early Lyme neuroborreliosis and prescribed a 28-day course of intravenous ceftriaxone.

“After completion of antibiotic therapy, the patient reported feeling significantly improved,” explains Ebner. He did, however, continue to have some weakness on the right side of his face, along with intermittent back pain that was managed with gabapentin.

The 61-year-old man might have avoided 6 weeks of pain and suffering, narcotics, a repeat spinal tap, intravenous antibiotics, weakness of his face in the lower motor neuron pattern and back pain if he had been treated with at least 3 weeks of antibiotics, instead of a single dose of doxycycline.

Related Articles:

Single dose of prophylactic treatment of a tick bite only prevents a Lyme rash

Case report: persistent pain and fatigue after treatment for Lyme disease

At least 50% of patients with Lyme neuroborreliosis remain ill years after treatment

References:

  1. Ebner D, Smith K, DeSimone D, Sohail MR. Cranial neuropathy and severe pain due to early disseminated Borrelia burgdorferi infection. BMJ Case Rep. 2018;2018.


10 Replies to "Single dose of doxycycline for Lyme disease leads to poor outcome for 61-year-old man"

  • TC
    02/05/2018 (2:56 am)
    Reply

    Way to go Dr. C! If anyone wants to see the current treatment protocols for a tick bite you can go to http://www.TreatTheBite.com There you’ll find a one page hand out to take with you to your doctors office- one for adults and one for children. Also there is a link to Dr. Cameron’s Lyme Treatment Guidelines there.

  • mark
    02/05/2018 (4:44 pm)
    Reply

    Nothing at all said in the online pubmed article abstract about the failed one dose of doxycycline treatment at first, and that is what most people will be seeing. Why is Mayo publishing in a British journal? Can’t find an American journal that will publish any failure report of an inadequate treatment? Will this man continue to have symptoms for which no further treatment will be provided, or will they go back to pain meds?

    • Dr. Daniel Cameron
      02/06/2018 (12:22 am)
      Reply

      The man was treated successfully at 6 weeks. The authors offered insight into the consequences of treating Lyme disease with a single dose of doxycycline. The blog suggests that timely treatment might have avoided “The 61-year-old man might have avoided 6 weeks of pain and suffering, narcotics, a repeat spinal tap, intravenous antibiotics, weakness of his face in the lower motor neuron pattern and back pain if he had been treated with at least 3 weeks of antibiotics, instead of a single dose of doxycycline.”

      It is not clear why the BMJ published the paper.

  • William Pals, DVM
    07/08/2018 (9:57 pm)
    Reply

    I agree with Dr C!! Please don’t undertreat, or wait to treat. If you are unsure, just interview a few people that have had to live with chronic Lyme disease. Many people have told me their stories of how they were finally personally diagnosed with Lyme, Ehrlichia, or Rocky Mountain spotted fever, etc. I’m a veterinarian in the Franklin/Nashville area of middle TN. We blood test family dogs annually for antigen for Anaplasma, Lyme, and Ehrlichia. We have had almost 100 positives in just over 2 years. We are alarmed at these results and tell moms and dads to watch out for their kids and dogs regarding tick bites.

  • Linda Smith
    06/19/2019 (9:44 pm)
    Reply

    On January 10, 2018 my husband was given doxycycline 100 mg twice a day for 10 days by his primary health provider. He had been deer hunting in North Eastern North Carolina and found a blacklegged deer tick on his right side under his armpit.
    He also had a bullseye rash. I took a picture to show him. I removed the tick, but couldn’t remove the head. After doing a bit of research, he decided to see his doctor and get antibiotics. She told him she didn’t think it was lyme because it was the wrong time of the year but since it looked infected she prescribed the antibiotic. No lyme test was done. No follow up was done even when he went back because his blood pressure was elevated. On May 9th, four months later, he died suddenly of “unknown causes”. The death certificate states the cause of death acute myocardial infarction. An autopsy was not done. Months later I remembered the tick bite. After researching lyme disease, I believe my husband had lyme carditis. My husband may be alive today if his doctor had been more conscientious and better educated.

    • Dr. Daniel Cameron
      06/21/2019 (5:49 pm)
      Reply

      You may never know. Acute myocardial infarctions are common. Tick can bite during warms spells in the North. Ticks are also active in the South in the winter.

  • Drew
    07/10/2019 (10:46 pm)
    Reply

    There is such a lack of information or belief by doctors that Lyme actually exists in Missouri, I could use your dosage duration advice or recommendation if you have time. The short: Starting at 7 weeks post bite, is 100 mg of Doxy for 10 days sufficient?

    The long: I was bitten by a tick 7 weeks ago and had no initial rash, zero symptoms, etc. I went and got tested at 3 weeks post bite because my niece was also bitten a week later and had the rash and they prescribed antibiotics. My test came back negative at 4 weeks so I moved on. 5 weeks post bite I had minor chills, bad headache, stiff neck and lower back pain for 4 days but wrote it off as the flu as symptoms subsided, sans the headaches. I was outdoors again this past weekend and came back with bug bites (no ticks that I saw) and started to see two (2) circular rashes around my mosquito bites in an area that was not my initial tick bite location. In addition, headaches were getting worse and was feeling minor joint pain and dizziness. I went to urgent care and was prescribed 100 mg of Doxy for 10 days at 7 weeks post bite. I am now 3 days in and am even more dizzy and the joints feel swollen (assuming this is herxing). Do you believe the 100 mg for 10 days is sufficient time for a 7 week lingering Lyme infection to be eradicated? Thank you very much in advance!

    • Dr. Daniel Cameron
      07/11/2019 (12:38 am)
      Reply

      I often do not find 10 days of antibiotics enough.

  • Dave Gill
    07/27/2019 (1:36 pm)
    Reply

    I was prescribed 2 doses of 100 mg a day for 21 days, would it be ok to take both doses at once, as in 200mg instead doing 100 mg twice a day.

    • Dr. Daniel Cameron
      07/27/2019 (9:45 pm)
      Reply

      NO


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