Lyme Disease Differential Diagnosis

Mr. Robinson is a 46-year-old man presenting with a four-day history of right ear pain. He described the pain as a constant, dull, burning pain radiating to the neck and face, associated with a feeling of congestion. The patient also stated that the right side of his face had felt numb for about one day. Three days earlier, Mr. Robinson was seen by PCP, who told him that his ear looked normal and free of infection.

The day before his current presentation, however, he noticed what he described as an "acne-like" rash on his ear lobe. Shortly before coming to the ED, the patient also developed numbness over his right upper lip, which he likened to the effects of procaine during a dental visit. He reported drooling from the right side of his mouth while drinking water and difficulty blinking his right eye. He denied any tinnitus, fever, headache, or change in hearing.

A review of symptoms was positive only for mild dizziness during the previous two to three days. The patient was a well-appearing white man. He was alert and oriented to identity, time, and place. His skin was warm, dry, and intact. The examiner noticed a small area of erythematous rash with vesicles on the man's right ear lobe. The external auditory canals appeared within normal limits, with no erythema or edema, and were nontender bilaterally. The tympanic membranes were normal bilaterally, without bulging or discernible fluid levels.

The ocular exam was normal with no visual acuity changes and no fluorescein uptake; external ocular movements were intact. A slight droop was noted in the right eyelid, but there was no droop on the contralateral side of his face. When asked to puff up his cheeks, the patient found it difficult to do so on the right side of his mouth without releasing air from his lips. The remainder of the cranial nerves were intact. Muscle strength was 5/5 in all extremities and equal bilaterally.

The man's gait was within normal limits, and the remaining findings in the physical exam were normal. Differential Diagnosis and Rationale 1. Sinusitis (Blahd, 2015): a swelling of the sinuses that blocks the sinuses from draining normally. It is often caused by a bacterial, viral, or fungal infection. Sometimes sinusitis is caused by allergies or a blockage in the nose. Sinusitis can cause a stuffy nose, bad breath, cough, fatigue, fever, and headache. You have chronic sinusitis when your symptoms last longer than 12 weeks.

If the problem lies in the blood vessels then it could be related to Vasculitis, which may also be referred to as angiitis and arteritis refers to a large group of diseases involving inflammation of the blood vessels. The specific blood vessels affected include arteries, veins and capillaries (tiny veins). The plural of vasculitis is vasculitides. Vasculitis causes alterations in the walls of blood vessels, which may include scarring, weakening, narrowing and thickening (Nordqvist, 2016). 2.

Localized otitis externa (Kucherov, 2016): Otitis externa, "a condition that causes inflammation (redness and swelling) of the external ear canal, which is the tube between the outer ear and eardrum" often caused by a bacterial infection (sometimes allergies, irritation or fungal infection), when localized can cause pimple in ear canal. Localized otitis externa happens when a hair follicle in the ear canal gets infected and will be characterized by a number of symptoms that include pain as well as "A small red pimple located in the ear canal.

This pimple may eventually become white, and have yellow pus in the middle." Localized otitis externa usually goes away on its own. Painkillers, placing a warm towel on the affected ear or prescribed antibiotics might at times be recommended. 3. Ear Canal Infection (Robinson, 2015): The ear canal is a place where bacteria can easily grow, especially if water is in the ear canal. Children and teenagers who spend a lot of time at the pool in the summer are especially prone to infection. But anyone can get it.

The most common cause is bacteria called pseudomonas. Other types of bacteria and fungi can also cause it. An acute infection lasts less than four weeks. Chronic infections may last for more than four weeks or occur four or more times in a year. Ear canal infections usually clear up when treated with antibacterial drops or antibiotics. But people with diabetes or a weakened immune system are at risk for a more severe infection called malignant otitis externa.

Malignant otitis externa can spread to other tissue, including bone at the base of the skull, and it can be life-threatening. 4. Lyme Disease (CDC, 2015): Lyme disease is caused by the bacterium Borrelia burgdorferi and is transmitted to humans through the bite of infected blacklegged ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. If left untreated, infection can spread to joints, the heart, and the nervous system.

Lyme disease is diagnosed based on symptoms, physical findings (e.g., rash), and the possibility of exposure to infected ticks. Laboratory testing is helpful if used correctly and performed with validated methods. Most cases of Lyme disease can be treated successfully with a few weeks of antibiotics. Steps to prevent Lyme disease include using insect repellent, removing ticks promptly, applying pesticides, and reducing tick habitat. The ticks that transmit Lyme disease can occasionally transmit other tickborne diseases as well. 5.

Ramsay Hunt Syndrome (Mayo Clinic Staff, 2014): Ramsay Hunt syndrome (herpes zoster oticus) occurs when a shingles infection affects the facial nerve near one of your ears. In addition to the painful shingles rash, Ramsay Hunt syndrome can cause facial paralysis and hearing loss in the affected ear.

The two main signs of Ramsay Hunt syndrome are: A painful red rash with fluid-filled blisters on, in and around one ear Facial weakness or paralysis on the same side as the affected ear Diagnosis The patient's symptoms seem to most closely resemble those of Ramsay Hunt Syndrome; however, further testing and monitoring should be done to further evaluate the symptoms. Patient Management Patients treated with appropriate medication in the early stages of Ramsay Hunt syndrome usually recover rapidly and completely; medications may include (Mayo Clinic Staff, 2014): Antiviral drugs.

Medications such as acyclovir (Zovirax), famciclovir (Famvir) or valacyclovir (Valtrex) often help combat the chickenpox virus. Corticosteroids. A short regimen of high-dose prednisone appears to.