Q9: March 2020 PLAB 1 Exam Style Question
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A 25-year-old woman who is currently 22 weeks pregnant presents to her GP with complaints of a rash, malaise, and mild arthralgias. She recently returned from a camping trip in a wooded area in the United States two weeks ago. She mentions feeling "off" and fatigued for about a week now. On physical examination, you notice a distinct erythematous rash with central clearing and more intense erythema at the periphery, localized on her upper arm. The rash is non-pruritic, warm to the touch, and painless. The patient denies any other focal neurological symptoms or headaches. Given the likely diagnosis, what is the most appropriate initial treatment?
A. Oral Doxycycline
B. Oral Amoxicillin
C. IV Ceftriaxone
D. Oral Prednisone
E. Reassurance and Watchful Waiting
Explanation
Correct Answer: B. Oral Amoxicillin
Diagnosis:
The patient's symptoms and clinical presentation are highly suggestive of Lyme disease, especially given her recent exposure to a tick-prone environment in the United States. The characteristic "bulls-eye" rash, known as erythema migrans, occurs in about 50-75% of individuals with Lyme disease and is a strong diagnostic clue.
A. Oral Doxycycline: Typically, doxycycline would be the treatment of choice for Lyme disease in non-pregnant adults. However, its use is contraindicated during the second and third trimesters of pregnancy due to the risk of dental staining and bone growth abnormalities in the fetus.
B. Oral Amoxicillin: This is the correct answer. Amoxicillin is the recommended antibiotic for treating Lyme disease in pregnant women and is generally considered safe during pregnancy.
C. IV Ceftriaxone: This would be considered in cases where Lyme disease has disseminated and is causing focal symptoms, or if there is central nervous system involvement. In this case, the patient does not have such symptoms; thus, IV Ceftriaxone is not warranted.
D. Oral Prednisone: Corticosteroids like prednisone are not recommended in the treatment of Lyme disease unless there are specific indications such as Lyme arthritis not responding to antibiotic treatment.
E. Reassurance and Watchful Waiting: Given the high likelihood of Lyme disease and the risk of complications, including potential harm to the fetus, treatment should not be delayed.
Clinical Takeaways:
1. Diagnosis: A high index of suspicion is essential for diagnosing Lyme disease, especially in patients with relevant exposure history and classic signs such as erythema migrans.
2. Pregnancy Considerations: Amoxicillin is the preferred treatment for Lyme disease in pregnancy, given that doxycycline is contraindicated.
3. Severity Assessment: Treatment regimens should be tailored to the patient's symptoms and disease severity, with IV antibiotics reserved for disseminated or complicated cases.
4. Follow-up: Monitoring for treatment efficacy and possible complications is critical, especially in pregnant women, where the disease may have implications for both the mother and fetus.
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Reference:
The NICE guideline NG95 provides an overview of the diagnosis and management of Lyme disease, including recommendations on testing, treatment, and prevention. It also includes a visual summary of the recommendations, a summary of the evidence, and tools and resources to support implementation.
The UK Health Security Agency (UKHSA) provides several resources about tick awareness and how to reduce the risk of Lyme disease, such as a leaflet on Lyme disease signs and symptoms1, a poster on tick bite prevention2, and a video on how to remove a tick safely3.