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ILADS LD Conference 2012 Boston: Ann Corson, MD - Pregnant and Pediatric Lyme Treatment - Part 2

The Treatment of TBD in the Pregnant and Pediatric Patient - Ann F. Corson, MD
ILADS Lyme Disease Conference 2012 Boston Notes
Pediatric Antibiotic Dosing
1.       Amoxicillin 50-100 mg/kg BID eg: 400 mg for 2-3 year old
2.       Bicillin 1.2 million units IM weekly in over 7-8 year old up to twice weekly, depending on size of buttocks (limiting factor in using Bicillin is size of buttock muscles) using ¾” needles
3.       Omnicef 125-250 mg BID up to 100 lbs
4.       Cedax under 8 yo 90 mg BID, over 8 yo up to 180 mg BID
5.       Ceftin 125-250 mg BID up to 100 lbs
6.       Ketek 400 mg 6 yo and up (Dr Jones: I’ve given it as young as 4 yo with excellent results). Get EKG before and 3-4 days after starting treatment check PR interval
7.       Zithromax 100 mg to 250 mg BID
8.       Biaxin 125-250 mg BID Careful: Biaxin can cause psychosis
9.       Tinidazole can be given as young as 1-2 yo at 125 mg BID, older 250 mg BID (2 consecutive days/wk)
10.   Flagyl 125 mg BID 1-3 yo, older 250 mg BID
11.   Rifampin, ask pharmacist to make suspension 30 mg/ml. Dose at 10-20 mg/kg up to 600 mg daily
12.   Plaquenil 100-200 mg BID, especially if 31 or 39 kDa bands present as these often associated with high degree of autoimmunity. (Dr. Jones: I also use Plaquenil if a lot of joint pain is present due to its anti-inflammatory as well as anti-Borrelia effects)
13.   Mepron, use highest dose tolerated 1/2 – 1 tsp BID
14.   Minocin or doxycycline over 8 yo use 50-100 BID (Dr. Jones: I have pushed Minocin to 300 mg/day in 9-12 yo) Minocin can cause increased ICP with papilledema (PTC, especially in peri-pubescent girls
15.   Ciprofloxacin 250-500 mg BID. Ciprofloxacin often tolerated as young as 12 yo (Dr Jones: I have used it as young as 8 yo successfully)
16.   Cannot use Levaquin or Avalox in children as they have more tendon/muscle problems than adults
17.   Cholestyramine resin dosing in under 100 lbs or under 12 yo give 60 mg/kg per dose
18.   “Sleepers” to use in kids: Benadryl, chloral hydrate, Sonata (over 6 yo), benzodiazepines, melatonin cream or spray
19.   IV Rocephin 75 mg/kg up to 2 grams QD
20.   IV Zithromax 200-400 mg QD in over 12 yo
21.   IV doxycycline rarely used by Dr. Jones in kids
22.   IV Claforan 100 m/kg up to 2 gm/dose BID (can suppress bone marrow causing decrease in WBC and RBC)
23.   IV Primaxin OK in kids, crosses BBB better than PCN
24.   For Ehrlichia: in kids under 8yo use 1-4 weeks of doxycycline 1/2 tsp BID
25.   For Bartonella: in children under 8 yo use rifampin and Bactrim together for 1 week to 3 months. Also use Bactrim and Zithromax or Rifampin and Zithromax
26.   For Borrelia: Zithromax and rifampin often good in combination, eg for 85 lb 10 yo dose would be rifampin 150 mg BID and Zithromax 250 mg BID
27.   For Borrelia: Zithromax (intracellular) and cephalosporin or Penicillin (CWAbx) in combination
28.   For Mycoplasma fermentans: Rifampin and Zithromax or Bactrim and Zithromax
29.   For autism symptoms: Flagyl and Zithromax often good in combo
30.   For neurological tics: Clonidine 0.1 mg QD
31.   For unrelenting HA and paresthesias think Babesia co-infection
32.   Safe in pregnancy: Penicillins, cophalosporins, Zithromax, Mepron
33.   Not safe in pregnancy: Quinolones, Biaxin, Tetracyclines, Flagyl, Bactrim
Dr. Charles Ray Jones notes:
34.   Dr. Jones has treated children anywhere from 3 months to 10 years of continuous antibiotics.
a.        He does not pulse treatment, but always uses continuous antibiotic therapy.
b.      Duration of treatment is based on the child’s symptoms. Continue antibiotics for a full 2 months after all symptoms have resolved, and until there is no recurrence of Lyme symptoms with concurrent infections, injury/trauma, surgery, emotional trauma, or menses.
c.        Also treat until the child him/herself feels that the “Lyme bugs” are gone. ALWAYS as the CHILD what he/she thinks!
35.   Any child who becomes ill after a tick bite needs a full evaluation for the presence of co-infections
36.   Any child who becomes ill after a tick bite who was treated with 3 to 4 weeks of oral antibiotics has most likely been inadequately treated
37.   Initial inadequate treatment makes future treatment more difficult
38.   Neurological and/or neuropsychiatric signs and symptoms are often the first and only presenting sign of infection
39.   Neurological and/or neuropsychiatric signs and symptoms are often the most common indication of persistence infection after inadequate treatment
40.   Identifying TBD children
41.   Lyme is truly the “Great Imitator” of our times just as syphilis was for prior generations
42.   Onset of the illness can be abrupt or indolent
43.   All organ systems of the body can be affected
44.   Symptoms are often vague and shifting from day to day therefore many children are through to be malingerers or be emotionally disturbed
45.   Children often don’t understand what is happening to their bodies and have a hard time explaining often unusual or bizarre symptoms
How does Lyme disease present?
a.       Flu-like illness at any time of the year
b.      Fatigue, often unrelieved by rest
c.       Unexplained fevers, often cyclical
d.      Headaches of all kinds
e.      Frequent infections, viral, bacterial, and/or fungal
f.        Recurrent swollen lymph nodes
g.       Recurrent sore throats
h.      Chest pains, shortness of breath, dry cough
i.         Abdominal pain of all kinds
j.        Changes in appetite
k.       Irritable bowel symptoms with changes in stooling patterns
l.         Joint pains, migratory and intermittent
m.    Deep bone pains
n.      Myalgias, muscle spasms and twitches
o.      Urinary urgency and frequency, dysuria, incontinence
p.      Rashes of all kinds come and go
q.      New onset neurological and/or psychiatric symptoms
r.        Sleep disturbances
s.       New onset aerobic exercise intolerance
t.        Dark circles under the eyes
u.      Intermittent red, hot pinnae
v.       Increased allergies and chemical sensitivities
46.   Less than 50% of children with Lyme Disease remember a tick bite
47.   Even less remember an EM rash
48.   EM rash has highly variable appearance
Neurological symptoms
a.       90% of children have deterioration in school performance due to cognitive dysfunction
b.      Difficulty with concentration and attention
c.       Easy distractibility, often labeled as ADD
d.      Word and name retrieval problems
e.      Short term memory difficulties
f.        Decreased reading comprehension
g.       Impaired speech fluency
h.      Dyslexic-like errors
i.         Loss of mathematical skills
j.        Children with TBD demonstrate defects in auditory and visual sequential processing
k.       Encephalopahty, confusional states
l.         Headaches of all kinds
m.    Sensory hypersensitivity to noise, light, odors, touch
n.      Poor balance and coordination
o.      Gait abnormalities
p.      Loss of previously acquired motor skills
q.      Movement disorders: spasticity, ataxia
r.        Motor or vocal tics
s.       Convergence and visual tracking problems
t.        Spinal cord myelopathies
u.      Radiculopathies: Bannwarth’s syndrome
v.       Peripheral neuropathies: paresthesias, subtle, weakness, mild to severely painful
w.     Cranial neuropathies: Bell’s Palsy, optic neuritis, hearing or swallowing difficulties
x.       Autonomic dysfunction: Pots syndrome
y.       Partial complex seizures, grand mal seizures
z.       Pseudo tumor cerebri
Psychiatric Symptoms
aa.   Uncharacteristic behavior outburst, mood swings, irritability, emotional lability
bb.  Social withdrawal, decreased participation in activities
cc.    Depression
dd.  Suicidal thoughts in over 40%
ee.  Rage and anger management disorders
ff.     Anxiety disorders, panic attacks
gg.   Depersonalization
hh.  Oppositional behaviors
ii.       Frustration intolerance
jj.      Obsessive compulsive disorders
kk.   Hallucinations of all kinds
ll.       Psychosis
mm.                      Personality changes
nn.  Self-mutilating behaviors
oo.  Parents and teachers may think any unusual behaviors are just “normal” adolescence or problems such as illicit drug use or new onset psychiatric disorder
pp.  Mood swings, oppositional behaviors, anxiety, depression
qq.  Self-mutilating behaviors
rr.     Teenagers often do not report to or show parents problems with their bodies
ss.    Teens can also turn to alcohol and illicit drugs as self medication
tt.     Teenage girls may have pelvic pain or menstrual problems, ovarian cysts, boys may have testicular pain
uu.  Teens need to be aware that Boreelia may be sexually transmitted and that a fetus can acquire the infection from the mother during pregnancy
Pre-schoolers and toddlers
vv.   Mood swings, sudden emotional outbursts
ww.                       Irritability
xx.   Personality changes
yy.   Return of separation anxiety
zz.    New phobias
aaa.                        Regression of motor and social skills (loss of developmental milestones)
bbb.                      Changes in play behavior, tire easily, less active
ccc. Trouble falling asleep, frequent awakenings
ddd.                      Nightmares, night terrors, sleep walking
eee.                      Diaper rash, unresponsive to normal treatment
fff.   Return to bedwetting or loss daytime bladder control after being dry
ggg.                        Frequent URIs, ear and throat infections, bronchitis, pneumonia
Signs and Symptoms of co-infections
49.   Co-infections are the rule, not the exception
a.       80% of pediatric patients are co-infected
b.      Co-infections often best diagnosed clinically
c.       Co-infected patients are:
                                                               i.      Sicker
                                                             ii.      More likely to have failed prior treatment
                                                            iii.      Require longer treatement with multiple agents
50.   Co-infections must be eradicated or Borrelpia infection will persist
51.   Babesia species
a.       High fevers with initial infection, later cyclical fevers
b.      Night sweats or chills (come in clusters 1-2 week cycles)
c.       Profound fatigue
d.      Headache
e.      Myalgias
f.        Deep bone pains (especially of the distal extremities)
g.       SOB, dry cough, chest pain
h.      Painful soles of feet
i.         Poor balance
j.        Severe brain fog/encephalitis
k.       Anxiety, panic attacks
l.         Chronic low grade anemia, elevated ferritin
52.   Bartonella henselae
a.       Fatigue
b.      Insomnia
c.       Headache
d.      Abdominal pain
e.      Lymph node enlargement
f.        Transient soreness of soles of feet upon standing first thing in the morning
g.       Neurological symptoms
                                                               i.      Resistant radiculopathies
                                                             ii.      New onset seizure disorder
                                                            iii.      Acute encephalitis, disorientation, memory loss
                                                           iv.      Ataxia, tremors
h.      Psychiatric disorders of all kinds
                                                               i.      Rage attacks, anger
                                                             ii.      Cutting Behavior
i.         Subcutaneous nodules (shins, thighs)
j.        Rashes
                                                               i.      “stretch marks”
                                                             ii.      Acne like eruptions
Needs of sick children
53.   Social impact
a.       Symptoms fluctuate so friends, family and teachers often don’t believe the sick child
b.      Isolation
c.       Loss of peer group and normal socialization
d.      Loss of academic work
e.      Loss of self-esteem
54.   Physical impact
a.       Children feel sick, they hurt, their brains don’t work
b.      Inability to participate in sports or other extracurricular activities
55.   Family impact
a.       Interruption of normal family life, stress on working parents and siblings
What can schools do?
56.   Children with persistent neuro-borreliosis need
a.       Appropriate medical, psychological, and educational assistance
57.   Allow for individual educations plans
a.       Late arrival, early dismissal
b.      Flexibility in assignment due dates
c.       Removing time limits from test taking
d.      Allowing course auditing or changes
e.      Tutor support at school or home (online)
What can parents do?
58.   Make sure schools are abiding by the two Federal laws that protect students with Lyme Disease and supercede state code regulations:
a.       IDEA: Individuals with Disabilities Education Act
b.      Section 504 of the 1973 Rehabilitation Act
59.   Avoid exposure to tick habitats
a.       Damp, shade, edges, wood, rocks, tall grass
60.   Clear away underbrush, cut back shrubbery
a.       Wood chip boundary, play set location
61.   Get the deer out of your yard
a.       Fences, repellants
62.   Spray with natural or synthetic insecticides
a.       Timed spring and fall
63.   Damminix or Maxforce for mice
a.       Kill larval and nymphal ticks
64.   Wear protective clothing
a.       Shirts and pants tucked in, hats, permethrin-impregnated
65.   Use appropriate insecticides while outdoors
a.       DEET
66.   Treat tick exposed domestic animals with topical insecticides regularly
67.   Lobby local government regarding tick and deer control and elimination

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