What is the treatment for brachial plexitis in the setting of Lyme disease?

Treatment of Brachial Plexitis in the Setting of Lyme Disease

For brachial plexitis in the setting of Lyme disease, intravenous ceftriaxone 2g daily for 14-21 days is the recommended first-line treatment, as this neurological manifestation represents a form of early Lyme neuroborreliosis requiring aggressive therapy. 1

Antibiotic Treatment Regimen

First-line Treatment:

• Intravenous ceftriaxone: 2g daily for 14-21 days 1, 2
  • Demonstrated efficacy in a case report with complete recovery of muscle strength and sensation 2

Alternative Parenteral Options (if ceftriaxone cannot be used):

• Cefotaxime: 150-200 mg/kg per day divided into 3-4 doses (maximum 6g daily) 3
• Penicillin G: 200,000-400,000 units/kg per day divided every 4 hours (maximum 18-24 million units daily) 3

For Adults Unable to Tolerate Cephalosporins:

• Oral doxycycline: 200-400mg daily in divided doses may be considered for less severe cases 1
  • Note: This is only appropriate if the patient can tolerate oral medication and has milder neurological symptoms

For Pregnant Patients:

• Avoid doxycycline
• Use ceftriaxone at standard dosing 1

For Children:

• Ceftriaxone: 50-75 mg/kg per day as a single daily dose (maximum 2g) 3
• Children ≥8 years may be treated with oral doxycycline at 4-8 mg/kg per day in 2 divided doses (maximum 100-200 mg per dose) for milder cases 3

Treatment Duration and Monitoring

1. Initial Treatment Phase:

   • Begin with intravenous therapy for 14-21 days 1
   • Hospitalization may be necessary during initial treatment, especially if significant neurological deficits are present

2. Follow-up Assessment:

   • Evaluate clinical response after 2 weeks
   • Motor deficits may require 7-8 weeks for complete recovery even with appropriate therapy 4

3. Extended Treatment Considerations:

   • For severe or persistent symptoms, treatment duration may be extended to a maximum of 28 days 1
   • No evidence supports treatment beyond recommended durations 5

Clinical Pearls and Pitfalls

Important Considerations:

• Brachial plexitis in Lyme disease represents a form of peripheral neuropathy/radiculopathy that requires aggressive treatment to prevent long-term neurological sequelae 1, 2
• Pain typically subsides during therapy, but motor deficits may take several weeks to resolve completely 4

Common Pitfalls to Avoid:

1. Delayed Treatment: Early recognition and treatment are crucial for preventing long-term neurological complications
2. Inadequate Treatment Duration: Premature discontinuation of antibiotics may lead to treatment failure
3. Overtreatment: Extended antibiotic courses beyond recommended durations, combination antibiotic therapy, or pulsed dosing are not recommended and may cause harm 1
4. Misdiagnosis: Brachial plexitis can be confused with other conditions causing acute pain and weakness in the shoulder and arm 6, 7

Diagnostic Considerations:

• Confirm Lyme disease diagnosis with appropriate serological testing (enzyme immunoassay and Western blot) 2
• Consider MRI neurography to visualize inflammation of the brachial plexus if diagnosis is uncertain 7
• Evaluate for possible CSF abnormalities, as these may indicate more extensive neurological involvement requiring more aggressive treatment 3

Post-Treatment Management

• Monitor for resolution of neurological symptoms
• Patients may experience slower improvement of pain compared to motor function 2
• If symptoms persist after appropriate antibiotic therapy, consider:
  1. Evaluation for other causes of symptoms
  2. Symptomatic treatment for residual pain or weakness
  3. Physical therapy for rehabilitation of affected limb

Remember that complete recovery may take weeks to months even with appropriate treatment, and patients should be counseled accordingly.