What is the treatment plan for a patient with a history of Lyme disease diagnosed in 2015, presenting with symptoms requiring immediate intervention to prevent digit amputation?

Treatment Plan for a Patient with History of Lyme Disease Requiring Immediate Intervention to Prevent Digit Amputation

Intravenous iloprost is strongly recommended for this patient with a history of Lyme disease who is presenting with symptoms requiring immediate intervention to prevent digit amputation. 1

Initial Assessment and Management

• Perform immediate clinical assessment to determine the severity of ischemia, focusing on neurological function (sensory loss and motor function) and pain level 2
• Evaluate for signs of limb threat including neurological deficits (sensory loss or motor deficit) which require emergency imaging and revascularization 2
• Initiate analgesia, anticoagulation with intravenous unfractionated heparin (bolus 5000 IU or 70-100 IU per kg body weight, followed by continuous infusion) or subcutaneous low molecular weight heparin (e.g., enoxaparin 1 mg per kg twice daily), and intravenous fluids 2

Specific Treatment for Digit Salvage

• Administer intravenous iloprost for 6 hours daily for up to 8 days to reduce the risk of digit amputation 1
• Consider concurrent administration of aspirin 250 mg IV daily for up to 8 days to enhance treatment efficacy 1
• Perform rapid rewarming of affected areas if frostbite is present 1

Diagnostic Imaging

• Obtain appropriate imaging without delaying treatment, using one or more of the following based on availability: duplex ultrasound (DUS), computed tomography angiography (CTA), digital subtraction angiography (DSA), or magnetic resonance angiography (MRA) 2
• Consider technetium 99m bone scintigraphy on day 7 to assess for anomalies that predict amputation risk 1

Management of Underlying Lyme Disease

• Assess for any persistent symptoms related to the patient's 2015 Lyme disease diagnosis 2
• If evidence of persistent or recurrent Lyme disease manifestations exists, consider appropriate antibiotic therapy based on clinical presentation:
  • For persistent arthritis: oral doxycycline (100 mg twice daily), amoxicillin (500 mg three times daily), or cefuroxime axetil (500 mg twice daily) for 28 days 2
  • For late neurologic disease: intravenous ceftriaxone (2 g once daily) for 2-4 weeks 2

Important Considerations and Pitfalls

• Do not delay treatment with iloprost while waiting for diagnostic confirmation, as timely intervention is critical for digit salvage 2, 1
• Avoid prolonged or multiple repeated courses of antibiotics for Lyme disease beyond recommended durations, as there is no evidence supporting their efficacy 2, 3
• Do not use treatments listed as "not recommended" for Lyme disease, including hyperbaric oxygen therapy, intravenous hydrogen peroxide, or combination antimicrobial therapy 2
• Be aware that persistent symptoms following appropriate Lyme disease treatment may not represent active infection and may not respond to additional antibiotic therapy 2, 3

Follow-up Care

• Monitor for response to iloprost therapy through clinical assessment of perfusion and sensation 1
• For patients with persistent joint swelling despite appropriate antibiotic therapy, consider consultation with a rheumatologist for symptomatic treatment with NSAIDs or other appropriate medications 2
• If digit salvage is successful, implement a rehabilitation plan to maximize functional recovery 2