To whom should a patient with persistent Lyme disease arthritis symptoms be referred?

Referral for Persistent Lyme Disease Arthritis Symptoms

Patients with persistent Lyme arthritis symptoms who have failed one course of oral antibiotics and one course of IV antibiotics should be referred to a rheumatologist or other trained specialist for consideration of disease-modifying antirheumatic drugs, biologic agents, intraarticular steroids, or arthroscopic synovectomy. 1

Treatment Algorithm for Lyme Arthritis

1. Initial Treatment:

   • Oral antibiotic therapy for 28 days (doxycycline, amoxicillin, or cefuroxime axetil) 1, 2

2. For Partial Response (mild residual joint swelling after first course):

   • Consider excluding other causes of joint swelling
   • Assess medication adherence and duration of arthritis prior to treatment
   • A second course of oral antibiotics for up to 1 month may be reasonable 1

3. For Minimal/No Response (moderate to severe joint swelling):

   • 2-4 week course of IV ceftriaxone 1, 2

4. For Persistent Arthritis After Above Treatments:

   • Refer to rheumatologist for non-antibiotic management 1

Rationale for Rheumatology Referral

Persistent Lyme arthritis symptoms after appropriate antibiotic therapy likely represent post-antibiotic (previously termed antibiotic-refractory) Lyme arthritis. This condition has an autoimmune component and requires specialized management:

• Antibiotic therapy beyond 8 weeks (including one course of IV therapy) provides no additional benefit 1
• Patients with certain genetic and immune markers (particularly HLA-DR4 specificity and OspA reactivity) may have persistent arthritis despite appropriate antibiotic treatment 3
• The inflammation clinically and histopathologically resembles juvenile idiopathic arthritis 4

Management Options by Rheumatologist

A rheumatologist can offer several treatment approaches:

1. Disease-modifying antirheumatic drugs (DMARDs)
2. Biologic agents
3. Intraarticular steroid injections
4. Arthroscopic synovectomy - particularly valuable for cases with marked synovial proliferation 1, 5

Important Considerations

• Avoid additional antibiotic therapy: For patients who have received appropriate treatment but have persistent symptoms without objective evidence of active infection, additional antibiotics are not recommended 1, 2

• Distinguish from post-Lyme disease syndrome: Persistent arthritis with objective joint swelling differs from subjective symptoms like fatigue or pain without objective findings 2

• Rule out reinfection or treatment failure: Look for objective signs of disease activity 1

• Consider testing for co-infections: In patients with persistent fever or characteristic laboratory abnormalities, evaluate for possible co-infection with Anaplasma phagocytophilum and/or Babesia microti in endemic regions 1, 2

Common Pitfalls to Avoid

• Misinterpreting persistent symptoms as requiring additional antibiotic therapy 2
• Failing to recognize the transition from infectious to autoimmune pathology in persistent cases
• Delaying appropriate rheumatologic care by pursuing extended antibiotic courses
• Not considering arthroscopic synovectomy for cases with marked synovial proliferation 6, 5

Proper specialist referral ensures patients receive appropriate non-antibiotic management strategies that address the autoimmune component of persistent Lyme arthritis, improving outcomes and quality of life.