Herxheimer Reaction in a 13-Year-Old Boy With Lyme Arthritis
A recently published case report describes a Herxheimer reaction in a child treated for Lyme arthritis. Nykytyuk and colleagues reported the case of a 13-year-old boy who developed worsening symptoms after starting doxycycline for Lyme disease. [1]
“A 13-year-old boy was admitted to the regional hospital with complaints of left knee swelling, hip, ankle and cervical spine pain,” the authors write.
The first signs of left knee arthritis began six months before hospitalization.
Initially, physicians believed the patient had post-traumatic arthritis and prescribed non-steroidal anti-inflammatory drugs (NSAIDs), which provided only minimal relief.
Diagnosis of Lyme Arthritis
Six months later, a rheumatologist diagnosed Lyme disease, in part because the patient reported a tick bite that occurred three months before the onset of knee arthritis.
The patient did not develop the typical erythema migrans (EM) rash.
Laboratory testing supported the diagnosis of Lyme arthritis, and physicians prescribed doxycycline.
Herxheimer Reaction After Starting Doxycycline
On the seventh day of antibiotic therapy, the boy developed symptoms consistent with a Jarisch-Herxheimer reaction.
“On the seventh day of doxycycline treatment the patient’s condition deteriorated: a low-grade fever occurred, and severe arthralgias with intense hip, ankle and cervical spine pain and myalgias developed,” the authors explain.
The boy also had elevated inflammatory markers including CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate). Physicians prescribed steroids.
There was no evidence of neurologic involvement, and a spinal tap was normal. However, the patient was treated with four weeks of intravenous ceftriaxone.
The treatment led to resolution of the knee swelling and improvement of the joint pain.
Herxheimer Reactions in Lyme Disease
Jarisch-Herxheimer reactions have been described in Lyme disease patients receiving antibiotic therapy. Symptoms may include fever, severe polyarthralgia, and myalgia.
Other reported symptoms include chills, high fever, hypotension, tachycardia, nausea, headache, and worsening of existing symptoms of the underlying infection.
Some studies suggest that Herxheimer reactions tend to be milder in Lyme disease than in other spirochetal infections and rarely require hospitalization.
However, Haney and colleagues described a more severe Herxheimer reaction in a patient treated with doxycycline for chronic Lyme disease. The patient developed fever, sore throat, sinus congestion, watery diarrhea, headache, muscle pain, fasciculations, and fatigue. [2]
Physician Education Needed
The exact cause of Jarisch-Herxheimer reactions remains unclear.
Early theories suggested that endotoxins triggered the reaction. However, later research demonstrated that spirochetes such as Borrelia burgdorferi do not produce biologically active endotoxins.
Nykytyuk and colleagues emphasized that physician awareness of the Herxheimer reaction remains limited.
“JHR is often mistaken for an allergic reaction,” the authors wrote.
Clinical Insight
In my clinical practice, Lyme disease patients sometimes experience worsening symptoms shortly after beginning treatment. These reactions are often referred to by patients as “Herxing.”
The underlying mechanisms are not fully understood. I generally avoid prescribing steroids to manage these reactions because I do not want to suppress a patient’s immune response.
Related Articles:
Diagnosing Lyme arthritis of the hip in children
Successful treatment for Lyme arthritis after knee surgery
Will steroid injections help children with Lyme arthritis of the knee?
References:
- Nykytyuk S, Boyarchuk O, Klymnyuk S, Levenets S. The Jarisch-Herxheimer reaction associated with doxycycline in a patient with Lyme arthritis. Reumatologia. 2020.
- Haney C, Nahata MC. Unique expression of chronic Lyme disease and Jarisch-Herxheimer reaction to doxycycline therapy in a young adult. BMJ Case Rep. 2016.
I have had LYME since Oct 1984. It was originally diagnosed Epstein Barr Virus & Chronic Fatigue Syndrome. I have had a few major stressful events and I am bedridden again like in the early stages. It is severely active. I have never been treated with antibiotics for it. Ironically last week I had bilateral itching near both thumbs to the point of drawing blood. Now I am having severe joint pain in both thumbs which I was told years ago was arthritis. I am assuming I have significantly elevated EBV again as I feel as bad as I did 38 years ago.
Hi Paula, how are you doing now? Did you ever take antibiotics or seek herbal remedies?
Great article. I was unaware that a Herxheimer reaction was not caused by the release of toxins as the bacteria were killed. I also was not aware the cause remains unknown. An incredibly complex disease (s) that in Canada is not recognized at all. As a result little research is being done. Thanks
I was interested to read that the boy was given additional antibiotic treatment, which was effective. It is good news that the spinal tap was negative. I am glad to hear that you typically avoid prescribing steroids, to avoid suppressing the immune system.
Besides low awareness, I think sometimes doctors are nervous about prescribing antibiotics beyond 30 days, unless there is a positive spinal tap.
I think I read of a slightly longer course being recommended for lyme arthritis.
If you find an attached tick, going to urgent care to have it removed professionally is a safer option – they may also prescribe a prophylactic antibiotic starting the same day.
You can get Lyme more than once.
I think probiotic drinks can be helpful to maintain immunity – even between antibiotic doses, as well as once the course of antibiotics has ended.
Thoughts?
Only 2 of 27 patients with neurologic Lyme disease had an abnormal spinal tap according to Logigian and Steere 1990 NEJM. That means up to 9 out of 10 patients with neurologic Lyme have a negative spinal tap. I am not a fan of a single dose doxycycline for a tick bite. I encourage probiotics during and after antibiotic treatment.
Tiny ticks got all over me delivering mail to a house with an overgrown lawn in the country, only two got beneath my clothing and attached.. 2 weeks later i was hurting somewhat but it went away. I thought no more of the tick bites. a couple of weeks later I thought i had a circular area of veins becoming varicose and I wish I had looked better as it has went away and I believe it to have been the bullseye rash. 2 years later I have neurological symptoms muscular vasciculations, weakness and fatigue and am currently thinking about going on antibiotics. I do have enough medications to get me through 4 weeks of doxycycline as my dr’s are slow to respond or do anything at all no testing no nothing I am tempted to treat myself with 4 weeks of antibiotic. Is there a reason I shouldn’t go ahead and do this. I don’t want to be sick anymore
I advise my patients to work with a doctor experienced in treating chronic manifestations of Lyme disease and work to rule out other causes of their illness.
I’m sorry, but they do not work with you. They think it’s all in your head and when you try to suggest something to them they ask what doctorate I got my degree from that’s terrible.
I experienced acute knee swelling and tendinitis when taking azithromycin and 4.5 months later same thing when taking doxycycline. I just tested positive for Lyme and wondering if that’s why I had this reaction to antibiotics. If so I don’t know how to treat it without making it worse.
I have patients with Lyme disease who present with a Herxheimer reaction. I have sene this flare up in patients with a persistent infection.
I have received 2x doxycycline 100mg on day one, followed by 30 days of 100mg a day of doxycycline, followed by 12 days of 200mg of doxycycline a day, is this enough to eradicate Lymes disease????
I suspect I had Lymes for nearly 5 months before diagnosis and treatment starting as I had no bullseye rash, however I had a large fixed, hard and painful lymph node come up suddenly under my jaw bone and had felt unwell for a couple of days, before diagnosis and treatment I experienced severe neurological pain, especially in my head and torso joint pain, among other issues
I ask my patient to return after a month to determine whether additional treatment might be warranted. Some are well. Some are not. Some patients have a co-infection ie Babesia that is not treated with doxycycline