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Steven, a 17-year-old male, visited his primary care physician with a complaint of facial droop. He first noticed the droop earlier that day while looking in the mirror and brushing his teeth. A thorough history revealed Steven experienced a fever, flu-like symptoms, and joint pains a few days prior. One week ago, he returned from a two-week trip to Connecticut to visit a few friends. Steven and his friends had walked through a densely wooded area to get to a lake where they could swim and rope swing into the lake. He denied known animal or tick exposure during the trip.

The primary care physician prescribed oral steroids for treatment of suspected Bell’s palsy and performed no further testing.

Facial Paralysis Score

Facial Nerve Dysfunction Score

The following day, Steven experienced neck stiffness and a headache. After discussing these new symptoms with his primary care physician, Steven was urgently referred to a local emergency department for further evaluation. Serologic testing for Lyme disease tick bite testing was performed and results were sent to the lab. An MRI was performed to evaluate his neurologic symptoms. While prepping for the MRI and putting on the hospital gown, a nurse noticed a light bulls-eye appearing rash on his inner thigh. MRI was normal. A lumbar puncture was performed as well, which showed marked pleocytosis (increased WBC count in CSF). CSF was also sent for immunologic testing.

At this point, Steven was admitted to the hospital and started on IV ceftriaxone therapy. Test results returned over the next few days and revealed positive serology for Lyme disease with three IgM bands and five IgG bands, as well as IgM positive in the CSF .

Steven was discharged home to complete 28 days of treatment via PICC line.

Western Blot Testing in Diagnosis of Lyme Disease

Clinical Score for Diagnosis of Pediatric Lyme Disease Arthritis

Approximately two weeks into his ceftriaxone treatment, Steven’s facial droop resolved, but he started experiencing severe abdominal pain and watery diarrhea. A few stools were noted to be bloody as well.  Steven was seen in the local emergency room where the attending physician ordered a complete work-up. Complete blood count, complete metabolic profile, and the CT scan were without significant findings.  Stool testing for clostridium difficile was sent and the patient was started empirically on metronidazole. C. Diff testing via polymerase chain reaction was noted to be positive. The patient completed treatment for C. Diff and made a full recovery.

Risk Factors for Clostridium Difficile Diarrhea

Clostridium Difficile Disease Evaluation Score

Clostridium Difficile Colitis Symptom Score

Diagnoses:

Bell’s palsy, Lyme Disease, Clostridium Difficile Infection

  1. Facial Paralysis Score
  2. Facial Nerve Dysfunction Score
  3. Western Blot Testing in Diagnosis of Lyme Disease
  4. Clinical Score for Diagnosis of Pediatric Lyme Disease Arthritis
  5. Risk Factors for Clostridium Difficile Diarrhea
  6. Clostridium Difficile Disease Evaluation Score
  7. Clostridium Difficile Colitis Symptom Score

Take Home Points

  • Use of evidence-based medical algorithms to screen patients with classic signs of Lyme disease and C. Diff not only reduces missed diagnoses, but also reduces patient morbidity and cost through prompt detection and treatment.
  • Medical algorithms, if used strategically and appropriately, can be instrumental in diagnosis, assessment and disease management

The medical algorithms highlighted in this case study are available at The Medical Algorithms Company and also on the Apervita health analytics platform.

About the Authors

Umang Jain is the Health Innovations Fellow at Apervita. He is passionate about medicine, research, and business. He is a fourth year medical student at Northwestern University’s Feinberg School of Medicine and will pursue Emergency Medicine residency. Umang’s scholarly interests include surgical outcomes research, in which he is published in the fields of ENT, orthopedic, plastic, cardiac, and urologic surgery. He has also participated in research in neurodegenerative disease at MIT and Boston University. Umang’s business experience stems from his work at the Institute of Healthcare Improvement (IHI) in Boston, MA. He worked closely with Dr. Donald Berwick, Administrator of Medicare and Medicaid Services (CMS) and Sir Nigel Crisp, the former Chief Executive of UK’s National Health Service, on engaging in evidence-based healthcare improvement interventions on a global scale. Umang was also an intern at Senticare Inc. and Personica, where he evaluated EHRs and in-home health monitoring equipment.

Dr. Chad Rudnick, MD, FAAP is a board-certified pediatrician in Boca Raton, FL. He is the Medical Director of The Medical Algorithms Company. A proponent of incorporating medical technology into his practice, Dr. Rudnick uses telemedicine and medical algorithms from The Medical Algorithms Company in his daily practice to better serve his patients and their families. An accomplished medical writer, he maintains a popular pediatric blog, All Things Pediatric, and has written for numerous online and print publications including KevinMD.com.

John Svirbely, MD is a founder and Chief Medical Officer of The Medical Algorithms Company and the primary author of its medical algorithms. John is a co-founder of the Medical Algorithms Project and has developed its medical content for nearly 20 years. He has a BA degree from the Johns Hopkins University and his MD from the University of Maryland. He is a board-certified pathologist with a fellowship in medical microbiology and biomedical computing at Ohio State University. Currently he is in private practice in Cincinnati, Ohio. He has authored multiple books and articles on medical algorithms.

 


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