EMERGENCY DEPARTMENT PRESENTATIONS OF LYME-DISEASE IN CHILDREN

Objective: To review the clinical characteristics and diagnostic evalu ation of children with Lyme disease evaluated in an emergency departme nt (ED) in an endemic area. Design: A retrospective review of the demo graphic, historical, clinical, and laboratory data of pediatric patien ts with a final diagnosis of Lyme disease. Setting: The pediatric ED o f an urban university hospital. Participants: Children with Lyme disea se evaluated during the three-year period from 1992 to 1994. Results: Twenty-nine children ranging in age from three to 19 years who were di agnosed with Lyme disease subsequent to a visit to a pediatric ED were identified. Four patients had early localized disease with erythema m igrans and varying degrees of systemic symptoms. Ten had early dissemi nated Lyme disease, with multiple erythema migrans, neurologic involve ment (including three patients with pseudotumor cerebri), or carditis, Fifteen cases of late Lyme disease with arthritis were identified. Re cognition of Lyme arthritis proved particularly difficult; seven child ren were initially diagnosed as having septic arthritis, six of whom u nderwent arthrotomy, Marked elevations of the erythrocyte sedimentatio n rate and synovial fluid white blood cell counts were observed in the se patients, making it difficult to distinguish Lyme disease from sept ic arthritis on the basis of laboratory findings. Conclusion: Lyme dis ease is an infrequent, often difficult, diagnosis in children who pres ent to an ED. Early disseminated and late disease predominate; classic erythema migrans is uncommon in the ED in comparison with other ambul atory venues. Diagnosis of Lyme arthritis may be difficult; exposure i n an endemic area and clinical findings may help distinguish it from s eptic arthritis. Overall, underdiagnosis of Lyme disease may actually be more of a problem than overdiagnosis in the ED setting. Recognition of Lyme disease by emergency medicine practitioners requires familiar ity with its epidemiology and its multiple manifestations.