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Richtlijn Lymeziekte Def 18 Juli 2013 Richtlijn Lymeziekte Juli 2013 INITIATIEF: Richtlijnconsortium Nederland ORGANISATIE: CBO MANDATERENDE VERENIGINGEN/INSTANTIES:1 - Nederlandse Internisten Vereniging - Nederlandse Vereniging van Revalidatieartsen - Nederlandse Vereniging van Spoedeisende Hulp Artsen - Nederlandse Vereniging van Ziekenhuisapothekers - Nederlandse Vereniging voor Arbeids- en Bedrijfsgeneeskunde - Nederlandse Vereniging voor Cardiologie - Nederlandse Vereniging voor Dermatologie en Venereologie - Nederlandse Vereniging voor Kindergeneeskunde - Nederlandse Vereniging voor Klinische Chemie en Laboratoriumgeneeskunde - Nederlandse Vereniging voor Medische Microbiologie - Nederlandse Vereniging voor Neurologie - Nederlandse Vereniging voor Psychiatrie - Nederlandse Vereniging voor Reumatologie - Nederlandse Vereniging voor Verzekeringsgeneeskunde - Vereniging voor Infectieziekten, Sectie Infectieziektebestrijding IN SAMENWERKING MET: - Centrum Infectieziektebestrijding/RIVM - Nederlands Huisartsen Genootschap FINANCIERING: Deze richtlijn is tot stand gekomen met financiële steun van ZonMw in het kader van het programma ‘Kennisbeleid Kwaliteit Curatieve Zorg’ (KKCZ). 1 De Nederlandse Vereniging voor Lymepatiënten (NVLP) heeft zich teruggetrokken als mandaterende vereniging. Mevr. M. Mud, Mevr. G.M. Pekel en drs. A.W.B. Klusman hebben de NVLP vertegenwoordigd bij de ontwikkeling van de richtlijn. Na vier jaar intensief overleg lag er een concepttekst waar zij achter konden staan. Zij vonden het resultaat van dit concept nog net acceptabel omdat deze aan de behandelend arts voldoende speelruimte bood om op genuanceerde wijze tot maatwerk te komen. In de laatste fase zijn naar aanleiding van de commentaren op voor de NVLP essentiële punten de nuanceringen weer uit de tekst/aanbevelingen verwijderd. Zij kunnen zich daarom niet meer vinden in de inhoud van de uiteindelijke richtlijn. Met name wat betreft de benadering van patiënten met persisterende klachten na behandeling en patiënten die niet eerder behandeld zijn voor lymeziekte maar bij wie diagnostisch laboratoriumonderzoek de diagnose lymeziekte niet bevestigt. Ook voldoet de gevolgde procedure naar hun mening niet aan de afgesproken doelstellingen en werkwijze. Naar de mening van de patiëntenvereniging wordt de zorg aan lymepatiënten met deze richtlijn niet optimaal vormgegeven. Colofon: Richtlijn Lymeziekte © Copyright CBO CBO Postbus 20064 3502 LB UTRECHT Tel.: 030 – 284 39 20 e-mail: [email protected] Alle rechten voorbehouden. De tekst uit deze publicatie mag worden verveelvoudigd, opgeslagen in een geauto- matiseerd gegevensbestand, of openbaar gemaakt in enige vorm of op enige wijze, hetzij elektronisch, mechanisch door fotokopieën of enige andere manier, echter uitsluitend na voorafgaande toestemming van de uitgever. Toestemming voor gebruik van tekst(gedeelten) kunt u schriftelijk of per e-mail en uitsluitend bij de uitgever aanvragen. Adres en e-mailadres: zie boven. Het CBO, gevestigd in Utrecht, heeft tot doel individuele beroepsbeoefenaren, hun beroeps- verenigingen en zorginstellingen te ondersteunen bij het verbeteren van de patiëntenzorg. Het CBO biedt via programma’s en projecten ondersteuning en begeleiding bij systematisch en gestructureerd meten, verbeteren en borgen van kwaliteit van de patiëntenzorg. INHOUDSOPGAVE SAMENSTELLING VAN DE WERKGROEP .......................................................................... 1 OVERZICHT AANBEVELINGEN ........................................................................................... 2 ALGEMENE INLEIDING ...................................................................................................... 14 HOOFDSTUK 1: EPIDEMIOLOGIE ..................................................................................... 20 1.1 Het voorkomen van tekenbeten en klinische manifestaties van lymeziekte in ............ 20 Nederland ........................................................................................................................ 20 1.2 Kans op lymeziekte na een tekenbeet ........................................................................ 21 1.3 Voorkomen van verschillende Borrelia-species .......................................................... 24 1.4 Andere tekenoverdraagbare infecties in Nederland en Europa .................................. 25 1.5 Co-infecties met Borrelia burgdorferi s.l. en andere tekenoverdraagbare infecties in Nederland en Europa ...................................................................................................... 26 HOOFDSTUK 2: ZIEKTEBEELDEN .................................................................................... 30 2.1 Inleiding ..................................................................................................................... 30 2.2 Dermatologische manifestaties .................................................................................. 31 2.2.1 Erythema migrans (EM) ................................................................................. 31 2.2.2 Gedissemineerde erythema migrans ............................................................. 34 2.2.3 Atypische vormen van EM en differentiaaldiagnose ....................................... 35 2.2.4 Borrelia-lymfocytoom ...................................................................................... 36 2.2.5 Acrodermatitis chronica atroficans (ACA) ....................................................... 38 2.2.6 Huidmanifestaties waarbij associatie met lymeziekte controversieel is ........... 43 2.3 Reumatische manifestaties ........................................................................................ 48 2.3.1 Artritis ............................................................................................................. 48 2.3.2 Gegeneraliseerde spier- en gewrichtsklachten ............................................... 50 2.4 Cardiale manifestaties................................................................................................ 53 2.4.1 Klinische uitingen ........................................................................................... 54 2.4.2 Diagnostiek lymecarditis ................................................................................. 56 2.4.3 Behandeling lymecarditis ............................................................................... 56 2.5 Neurologische manifestaties bij volwassenen ............................................................ 58 2.5.1 Vroege neuroborreliose .................................................................................. 58 2.5.2 Chronische neuroborreliose ............................................................................ 59 2.5.3 Encefalopathie ................................................................................................ 59 2.5.4 Aanvullende diagnostiek ................................................................................. 59 2.6 Psychiatrische manifestaties ...................................................................................... 64 2.6.1 Depressieve stoornis ...................................................................................... 65 2.6.2 Psychotische stoornis……………………………………………………………….56 2.6.3. Aandachtsconcentratie- en geheugenstoornissen .......................................... 66 2.7 Oculaire manifestaties................................................................................................ 70 2.8 Interne manifestaties .................................................................................................. 72 2.8.1 Systemische symptomen geassocieerd met vroege Borrelia-infectie .............. 72 2.8.2 Weinig voorkomende manifestaties geassocieerd met lymeziekte ................... 72 2.9 Lymeziekte bij kinderen .............................................................................................. 74 2.9.1 Erythema Migrans .......................................................................................... 74 2.9.2 Neuroborreliose .............................................................................................. 75 2.9.3 Lyme-artritis ................................................................................................... 77 2.10 Lymeziekte tijdens zwangerschap en congenitale lymeziekte .................................. 78 HOOFDSTUK 3: LABORATORIUMDIAGNOSTIEK ............................................................ 82 3.1 Serologie.................................................................................................................... 82 3.1.1 Antistofvorming in relatie tot ziekteduur ............................................................ 82 3.1.2 Relatie antistoffen en ziekte .............................................................................. 85 3.1.3 EIA’s en IFA’s ................................................................................................... 88 3.1.4 Confirmatieserologie met immunoblot ............................................................... 94 3.1.5 Vervolgserologie ............................................................................................... 97 3.1.6 Ontstekingsparameters in liquor en intrathecale antistofproduktie .................... 98 3.2 Kweek ...................................................................................................................... 101 3.3 ‘Polymerase chain reaction’ (PCR)........................................................................... 102 3.3.1 Huidbiopten ...................................................................................................
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