Form assigned Lyme Disease

LYME D ISEASE C ASE R EPORT

Patient's Name:

Phone No.: (

First Name:

)

City:

Address:
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DEPARTMENT OF
HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention

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LYME D ISEASE C ASE R EPORT
Approved OMB No. 0920-0004

State:

County:

Sex:

Age:

Zip:

Patient Race: (select all that apply)

Patient Ethnicity: (select one)

■ Male ■ Female
■ Unspecified

■ Hispanic/Latino ■ Unk
■ Not Hispanic/Latino

Indian or
■ American
■ Black or African American ■ White ■
Alaska Native
Native Hawaiian
■ Asian
■ or Pacific Islander
■ Other

Unk

– SYMPTOMS AND SIGNS OF CURRENT EPISODE – (PLEASE MARK EACH QUESTION )
DERMATOLOGIC:
Erythema migrans (physician diagnosed EM at least 5 cm in diameter) . . . . . .

■ Yes

■ No

■ Unk

RHEUMATOLOGIC:
Arthritis characterized by brief attacks of joint swelling . . . . . . . . . . . . . . . . . . . . . .

■ Yes

■ No

■ Unk

NEUROLOGIC:
Bell’s palsy or other cranial neuritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Radiculoneuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lymphocytic meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Encephalitis/Encephalomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CSF tested for antibodies to B. burgdorferi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antibody to B. burgdorferi higher in CSF than serum . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes
■ Yes
■ Yes
■ Yes
■ Yes
■ Yes

■ No
■ No
■ No
■ No
■ No
■ No

■ Unk
■ Unk
■ Unk
■ Unk
■ Unk
■ Unk

CARDIOLOGIC:
2nd or 3rd degree atrloventricular block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes

■ No

■ Unk

Other clinical:
Date of onset of first symptoms:
Mo.

Day

Date of diagnosis:

Year

Mo.

Date of report to health agency

Day

Year

Mo.

Day

Year

– OTHER HISTORY –
Was the patient hospitalized for the current episode . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes

■ No

■ Unk

Name of antibiotic(s) used this episode___________________________________ Use in days __________
Was the patient pregnant at the time of illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes

■ No

■ Unk

Where was the patient most likely exposed: County ________________________ State: ___________________________
– LABORATORY RESULTS –
Positive
Serologic test results: . . . . . . . . . . . . . . . . . . . . . . . . . .
Culture results: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other (specify) ________________________________
Phone No.

Physician’s name:

(

■
■
■

Negative

■
■
■

Equivocal

■
■
■

Not done/Unk

■
■
■

Phone No.

Person completing form:

)

(

Address:

)

Address:

– FOR INTERNAL USE ONLY –
CDC ID No.

State ID No.

Date reported to CDC
Mo.

Day

Year

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS E-71, Atlanta, GA 30333, ATTN: PRA (0920-0004). Do not send the completed form to this address.
LYME D ISEASE C ASE R EPORT

CDC 52.60 Rev. 05-2004

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LYME DISEASE NATIONAL SURVEILLANCE CASE DEFINITION
Lyme disease is a systemic, tick-borne disease with protean manifestations, including dermatologic,
rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is the initial skin
lesion. erythema migrans (EM), that occurs in 60% to 80% of patients.
A case of Lyme disease is defined as follows:
1.
A person with erythema migrans; or
2.
A person with at least one late manifestation and laboratory confirmation of infection.
NOTE: It should be emphasized that is an epidemiologic case definition intended for surveillance purposes only.

General clinical epidemiologic definitions:
1.

Erythema migrans (EM):
For purposes of surveillance, EM is a skin lesion that typically begins as a red macule or papule and expands
over a period of days or weeks to form a large round lesion, often with partial central clearing. A solitary lesion
must reach at least 5 cm in size. Secondary lesions may also occur. Annular erythematous lesions occuring within
several hours of a tick bite represent hypersensitivity reactions and do not qualify as EM. In most patients, the
expanding EM lesion is accompanied by other acute symptoms, particularly fatigue, fever, headache, mild stiff
neck, arthralgias, or myalgias. 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.

2.

Late manifestations:
These include any of the following when an alternate explanation is not found.
a.

Musculoskeletal system:
Recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints sometimes followed
by chronic arthritis in one or a few joints. Manifestations not considered as criteria for diagnosis include
chronic progressive arthritis not preceeded by brief attacks and chronic symmetrical polyarthritis.
Additionally, arthralgias, myalgias, or fibromyalgia syndromes alone are not accepted as criteria for
musculoskeletal involvement.

b.

Nervous system:
Lymphocytic meningitis, cranial neuritis, particularly facial palsy (may be bilateral), radiculoneuropathy or
rarely, encephalomyelitis alone or combination. Encephalomyelitis 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 accepted as criteria
for neurologic involvement.

c.

Cardiovascular system:
Acute onset, high grade (2nd or 3rd degree) atrioventricular conduction defects that resolve in days to
weeks and are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or
myocarditis alone are not accepted as criteria for cardiovascular involvement.

3.

Exposure:
Exposure is defined as having been in wooded, brushy, or grassy areas (potential tick habitats) in an endemic
county no more than 30 days prior to the onset of EM. A history of tick bite is not required.

4.

Endemic county:
An endemic county is one in which at least 2 definite cases have been previously acquired or a county in which a
tick vector has been shown to be infected with B. burgdorferi.

5.

Laboratory confirmation:
Laboratory confirmation of infection with B. burgdorferi is established when a laboratory isolates the spirochete
from tissue or body fluid, detects diagnostic levels of IgM or IgG antibodies to the spirochete in serum or CSF, or
detects a significant change in antibody levels in paired acute and convalescent serum samples. 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, as appropriate, when laboratory confirmation has
been based on serologic testing alone.

CDC 52.60 Rev. 05-2004

LYME D ISEASE C ASE R EPORT

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