Children With Lyme Disease May Be Missed in the Emergency Department
Some children initially thought unlikely to have Lyme disease were later diagnosed.
Clinical judgment and Lyme testing both have limitations.
Follow-up remains important when symptoms persist or evolve.
The study included more than 1,000 children, with an average age of 9, who underwent evaluation for Lyme disease at 1 of 5 participating emergency departments.
The authors found that some children initially believed unlikely to have Lyme disease were later diagnosed with the illness.
“Of the 554 children who the treating clinicians thought were unlikely to have Lyme disease (score 1–3), 65 (12%) had Lyme disease,” according to Nigrovic and colleagues from Boston Children’s Hospital.
The study also found that some children considered highly likely to have Lyme disease did not meet the study’s diagnostic criteria.
“Of the 127 children who the treating clinicians thought were very likely to have Lyme disease (score 8–10), 39 (31%) did not have Lyme disease,” wrote Nigrovic.
At the same time, the study relied heavily on the presence of an erythema migrans rash or positive 2-tier Lyme disease testing.
In clinical practice, however, some patients with Lyme disease may not develop a classic erythema migrans rash or initially test positive with standard 2-tier serologic testing.
Follow-Up Remains Important in Children With Persistent Symptoms
The findings highlight the importance of follow-up evaluations when symptoms persist, evolve, or remain unexplained.
Children with Lyme disease may initially present with non-specific symptoms including fever, fatigue, headaches, joint pain, dizziness, or neurologic complaints that overlap with many other pediatric illnesses.
Because early Lyme disease testing may be negative, clinicians often rely on evolving symptoms, exposure history, physical findings, and follow-up assessments.
In some cases, antibiotics prescribed early in the illness could potentially interfere with the later appearance of an erythema migrans rash or positive serologic testing.
Clinical Judgment and Lyme Testing Both Have Limitations
The study reminds us that diagnosing Lyme disease is not always straightforward.
Clinical judgment may occasionally underestimate the possibility of Lyme disease, while laboratory testing and strict diagnostic criteria also have important limitations.
It remains reasonable to evaluate children for alternative diagnoses when Lyme disease is suspected. At the same time, Lyme disease should not necessarily be excluded simply because early testing is negative or symptoms appear atypical.
For additional discussion, see Lyme disease symptoms guide.
FAQ: Pediatric Lyme Disease Diagnosis
Can Lyme disease be missed in children?
Yes. Early Lyme disease symptoms in children may overlap with viral illnesses or other conditions, and testing may be negative early in the course of infection.
Why can Lyme disease be difficult to diagnose?
Some children do not develop a classic erythema migrans rash, and standard Lyme disease testing may not become positive until later in the illness.
Related Articles:
Doctors agree Lyme disease patients at-risk for suicide are under-recognized group
Doctors favor personalized care over IDSA guidelines
CDC advises doctors to consider Lyme disease in emerging states
References:
- Nigrovic LE, Bennett JE, Balamuth F, et al. Accuracy of Clinician Suspicion of Lyme Disease in the Emergency Department. Pediatrics. 2017;140(6).
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
It’s worth noting that the 31% of children reportedly over-diagnosed may have been an exaggerated figure since they were required to present with an EM rash or a positive 2-tier test.
After 6 weeks, 2-tier testing is 85-90% sensitive. Stop spreading the ridiculous myth that serological testing misses Lyme disease in the late stage.
Also, the title of your article is misleading.
The discussion about antibiotic therapy terminating the antibody production in the early phase of Lyme disease was already been held between David J. Volkman and other IDSA members and Volkman was proven wrong.
Stop recycling old outdated views on this disease and start accepting that Lyme disease isn’t the disease you ILADS quacks think it is on the basis of believes.
If I had the “bulls eye” rash, what are the odds for having Lyme? Have had several blood tests turn up negative in the past. Rash was 20 plus years ago.
The risk of Lyme disease is typically 80 to 90% for a physician observed rash. It is harder to know the risk from that rash in high sight without an evaluation