Delaware Division of Public Health Bureau of Epidemiology PATIENT INFORMATION: Last Name:__________________________________________________ First Name:_________________________________________________ Telephone #:_________________________ Street Address:_____________________________________________ Zip Code:____________________________ County: (circle one) New Castle Kent Sussex Gender: (circle one) Male Female Date of birth:_______________________ Hispanic Ethnicity: (circle one) Yes No Unknown Race: (circle all that apply) American Indian or Alaskan Native Black or African American Native Hawaiian or Pacific Islander White Asian Other Unknown PHYSICIAN / PROVIDER INFORMATION: Physician:__________________________________________________ Address:____________________________________________________ Phone:_______________________________ LABORATORY RESULTS: EIA/IFA (IgM, IgG, Total) Specimen Source:(circle one) Serum CSF Synovial Fluid Other Result: (circle one) Positive Negative Equivocal Not done Titer __________ WESTERN BLOT (WB) For IgM, 2 of 3 bands must be positive For IgG, 5 of 10 bands must be positive Please circle result and all positive WB bands, if known. IgM: Positive Negative Not done 41kDa (FlaB) 39 kDa (BmpA) 21-25 kDa (OspC) IgG: Positive Negative Not done 93 kDa 66 kDa 58 kDa 45 kDa 41 kDa 39 kDa 30 kDa 28 kDa 21 kDa 18 kDa OTHER TESTS (circle all that apply): B. burgdorferi culture positive? CSF titer higher than serum titer*? Other positive result? (PCR, etc.): Specify: __________________ CLINICAL Did you diagnose the patient with LD? Yes No Date of LD diagnosis:_________________ Date of symptom onset:________________ Case definition signs and symptoms: (Indicate Yes(Y), No(N), Unknown(U)) Erythema Migrans (EM) rash ____ Arthritis (objective episodes of joint swelling) ____ Bells palsy or other cranial neuritis ____ Radiculoneuropathy ____ Lymphocytic meningitis ____ Encephalomyelitis* ____ *If encephalomyelitis is present, CSF titer must be higher than serum titer 2nd or 3rd degree atrioventricular block ____ Other signs and symptoms (circle all that apply): Arthralgias Bundle branch block Cognitive impairment Encephalopathy Fatigue Fever/Sweats/Chills Headache Myalgias Myocarditis Neck pain Other rash Palpitations Paresthesias Peripheral neuropathy Visual/auditory impairment Symptom(s) not listed ______________________________ SUPPLEMENTAL INFORMATION (Indicate Yes(Y), No(N), Unknown(U), NA) Was the patient pregnant at the time of illness? ____ Was the patient hospitalized for this illness? ____ Antibiotic(s) used for this illness: __________________________________ Antibiotic usage (days prescribed): ___________________________________ ---------------FOR PUBLIC HEALTH SURVEILLANCE USE ONLY------------------ DERSS ID#: ________________ COMMENTS: _____________________________________________________________ CASE STATUS: . Confirmed: . Unconfirmed: . Not a Case: ------------------------------------------------------------------------ LYME DISEASE SURVEILLANCE CASE DEFINITION CLINICAL DESCRIPTION: A systemic, tick-borne disease with protein manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is the initial skin lesion, erythema migrans, which occurs among 60%-80% of patients. CLINICAL CASE DEFINITION: • Erythema migrans, OR • At least one late manifestation, as defined below and laboratory confirmation of infection. Laboratory Confirmation -For the purposes of surveillance, the definition of a qualified laboratory assay is: • A positive culture for B. Burgdorferi • Single-tier IgG immunoblot seropositivity • A two-tiered approach using a sensitive enzyme immunoassay or immunofluorescence antibody followed by Western blot. Case Classification – Confirmed: a case that meets one of the clinical case definitions above. Definition of terms used in the clinical description and case definition: A. Erythema migrans (EM) • For purpose of surveillance, EM is defined as a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks to form a large round lesion, often with partial central clearing. A solitary lesion must reach at least 5cm in size. Secondary lesions may also occur. Annular Erythematous lesions occurring within several hours of tick bite represent hypersensitivity reactions and do not qualify as EM. For most patients, the expanding EM lesion is accompanied by other acute symptoms, particularly fatigue, fever, headache, mild stiff neck, arthralgia, and myalgia. These symptoms are typically intermittent. The diagnosis of EM must be made by a physician. Laboratory confirmation is recommended for persons with no known exposure. B. Late manifestations – Include any of the following when an alternate explanation is not found: • Musculoskeletal system: Recurrent, brief attacks (weeks or months) of objective joint swelling in one or few joints, sometimes followed by chronic arthritis in one or few joints. Manifestations not considered as criteria for diagnosis include chronic progressive arthritis not proceeded by brief attacks and chronic symmetrical Polyarthritis. Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement. • Nervous system: (Any one the following alone, or in combination): lymphocytic meningitis; cranial neuritis, particularly facial palsy (may be bilateral); radiculoneuropathy; or rarely encephalomyelitis, which must be confirmed by showing antibody production against B. Burgdorferi in the cerebrospinal fluid (CSF), demonstrated by a higher titer of antibody in CSF than in serum. Headache, fatigue, paresthesias, or mild stiff neck alone, are not criteria for neurologic involvement. • Cardiovascular system: Acute onset, high grade (2nd or 3rd degree) artioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular involvement. C. Laboratory confirmation – As noted above, laboratory confirmation of infection with B. Burgdorferi is established when a laboratory isolates the spirochete from tissue or sterile body fluid or detects diagnostic levels of IgM or IgG antibodies to the spirochete in serum, CSF, or other sterile body fluid (i.e., synovial fluid). States may determine the criteria for laboratory confirmation and diagnostic levels of antibody. Syphilis and other known causes of biologic false-positive serologic test results should be excluded when laboratory confirmation has been based on serologic testing alone. Note: This surveillance case definition was developed for national reporting of Lyme disease; it is not intended to be used in clinical diagnosis. Source: Centers for Disease Control and Prevention (CDC) For questions related to this form, please call the Bureau of Epidemiology at 1-888-295-5156 This form is available on our webpage: http://www.dhss.delaware.gov/dhss/dph/epi/lyme.html Reviewed: 1/2008