Delayed diagnosis of Lyme disease in North Carolina

In their case report, “Delayed Diagnosis of Locally Acquired Lyme Disease, Central North Carolina, USA,” Boyce and colleagues highlight the need for greater awareness and education on the prevalence of Lyme disease in Southeastern states, such as North Carolina. [1]

Although North Carolina reportedly has some of the highest incidence rates of spotted fever rickettsiosis and ehrlichiosis, there have been fewer cases of Lyme disease reported – until recently. However, “many clinicians have limited experience with Lyme disease, and diagnostic errors are common,” Boyce et al. states.

Cases of Lyme disease on the rise in North Carolina

A woman in her late 60’s went bike riding in the suburbs north of Raleigh, North Carolina. “After the ride, she felt dehydrated, lightheaded, and excessively fatigued for the level of exertion,” the authors state. Four days later, a large erythematous rash appeared on the right side of her neck and she developed a fever.

Five days after the rash appeared, her fever had subsided but the rash remained. She also developed additional symptoms including a severe frontal headache and bilateral ear pain.

Her primary care doctor diagnosed her with cellulitis and prescribed a 10-day course of cephalexin. “After starting antibiotics, the patient felt subjectively better,” the authors state. “However, the headache returned 2 days later.”

Although she was prescribed a different antibiotic, her headaches persisted.

“… she had visits with multiple clinicians and underwent a wide range of testing but never had specific testing or treatment for Lyme disease.”

Ten days later, the woman still reported pain in her ears, along with shortness of breath.

She was referred to a cardiologist. “After that visit, the patient became increasingly forgetful, withdrawn, and unable to perform basic cognitive tasks,” the authors state.

Two weeks later, the woman developed a left-sided facial droop and was diagnosed with Bell’s palsy and prescribed a 1-week course of prednisone and valacyclovir.

She continued to exhibit new onset of symptoms including back pain with spasms that radiated into the cervical spine and neck, anorexia, and unintentional 10-pound weight loss.

“Other than the bike rides, her only risk factor for tick or mosquito exposure was working in the flower garden in her yard.”

A consult with an infectious disease doctor was requested, which led to testing for tick-borne illnesses.

The woman tested positive for Lyme disease on the Western blot with 6 of 10 IgG bands reactive and was prescribed a 28-day course of doxycycline.

“Substantial improvement in her mood, cognitive function, and energy levels were noted within 3 days,” the authors state.

The authors conclude:

• “Although the patient did not have obvious exposures to ticks, her clinical manifestations were highly suggestive of Lyme disease.”
• “In addition to the nonspecific constitutional symptoms, such as malaise, she also had a large erythema migrans rash that appeared within 1 week of the likely exposure, followed by Bell’s palsy approximately 1 month later. During that period, she had visits with multiple clinicians and underwent a wide range of testing but never had specific testing or treatment for Lyme disease.”
• “Those delays … highlight the need for greater awareness and professional education among healthcare providers in North Carolina.”