LYME DISEASE CASE REPORT FORM
DHA:
ANDS Case ID:
Classification:
Confirmed
Probable
Date Investigation Opened
Does not meet
(yyyy/mm/dd):
/
/
CASE DEMOGRAPHICS
Last Name:
DOB
First Name:
(yyyy/mm/dd):
/
Age:
/
Middle Name:
Sex:
Male
Female
HCN:
Phone Number:
Street Address:
City:
Transgender
Postal Code:
MEDICAL HISTORY
Date of Onset (yyyy/mm/dd):
/
Re-infection:
Physician’s Name:
Yes
/
No
Unknown
No
Date of initial diagnosis
/
Hospitalized:
Yes
(yyyy/mm/dd):
/
Location:
If yes,
Duration:
Erythema Migrans :
1
Erythema Migrans (EM)1:
Yes
No
Unknown
EM diagnosed by a health care
provider:
Yes
No
Unknown
Date EM diagnosed:
Central Clearing:
No
(yyyy/mm/dd):
/
Yes
/
Unknown
EM - Date of Onset
/
(yyyy/mm/dd):
/
Site(s)
Specify:
Lesion:
Size (diameter):
cm
Other Symptoms:
Other skin rashes:
Yes
Influenza-Like Illness:
Yes
No
No
Unknown
Date of Onset
/
Unknown
If yes, description:
(yyyy/mm/dd):
Late Manifestation(s) – see sections below
Yes
/
No
Unknown
If no, continue with the ‘Exposure Information’ section.
Notes:
Musculoskeletal System:
Yes
No
Unknown
(If yes, please specify below)
Description:
Yes
No
Unk
Date of Onset
(yyyy/mm/dd)
Recurrent, brief attacks (lasting weeks or months) of large joint swelling.
Number of Joints involved:
/
/
Other (specify):
/
/
Notes:
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Cardiovascular System:
Yes
No
Unknown
(If yes, please specify below)
Description:
Yes
No
Unk
Date of Onset
(yyyy/mm/dd)
AV Heart Block
/
/
Myocarditis
/
/
Other (specify)
/
/
Notes:
Nervous System:
Yes
No
Unknown
(If yes, please specify below)
Description:
Yes
No
Unk
Date of Onset
(yyyy/mm/dd)
Peripheral Nervous System:
Mononeuropathy – cranial or peripheral nerve (e.g. Bell’s Palsy), pain,
numbness, tingling or weakness in distribution of single peripheral nerve
/
/
Mononeuropathy multiplex – pain, numbness, tingling or weakness in
distribution of a few or several peripheral nerves
/
/
Peripheral polyneuropathy – pain, numbness, tingling or weakness in a
symmetrical, diffuse fashion not corresponding to the distribution of specific
peripheral nerves
/
/
Lymphocytic Meningitis
/
/
Encephalopathy
/
/
Encephalomyelitis
/
/
Other (specify)
/
/
Central Nervous System:
Notes:
EXPOSURE INFORMATION
History of tick exposure (bite):
Definite
Possible (exposed to wood or brushy areas)
No
Geographic location of tick exposure – please specify as much as possible:
Unknown
Date of Tick Exposure
(yyyy/mm/dd)
/
/
If exposure outside of Nova Scotia or Canada, please specify as much as possible:
History of residence in, or visit to, an endemic2 area?
Yes
No
Unknown - If yes, specify:
Received a donation of blood, blood products,
tissue/organs?
Yes
No
Document1
Donated blood, blood products, tissue/organs?
Yes
No
2
TREATMENT
Did case receive treatment?
Yes
No
If yes, start date (yyyy/mm/dd):
If yes, antibiotic:
/
/
Dose:
Duration of treatment:
Have symptoms resolved?
Yes
No
Notes:
LABORATORY EVIDENCE3
Was laboratory testing ordered?
Yes
Test
No
If yes, specify in table below:
Result
Collection Date
Lab Report Date
(yyyy/mm/dd)
(yyyy/mm/dd)
EIA
/
/
/
/
lgM WB
/
/
/
/
lgG WB
/
/
/
/
Other
/
/
/
/
Was client referred to infectious disease?
Follow-up completed with:
Client
Yes
No
Parent/Guardian
Unknown
Physician
Other
MOH/PHN Comments:
CASE DEFINITION ASSESSMENT
1. Clinical Illness:
Yes
No
2. Clinician-observed EM:
Yes
No
3. Positive serologic test using two-tier ELISA and Western blot criteria:
4. History of residence in, or visit to an endemic area?
Confirmed Case:
i.
ii.
1+3+4
OR
2+3+4
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Probable 1 Case:
i.
ii.
1+3
OR
2+3
Yes
Yes
No
No
Probable 2 Case:
2+4
3
STATUS OF INVESTIGATION
Open – pending further information
Closed – incomplete
Reason:
Lost to follow-up
Deceased
Transferred
Other (specify:
Closed – completed
Not a case (please comment):
Date investigation closed
(yyyy/mm/dd):
/
/
LYME DISEASE CASE DEFINITION:
Confirmed case: Clinical evidence of illness with laboratory conformation:

Isolation of Borrelia burgdorferi from an appropriate clinical specimen, OR

Detection of B. burgdorferi DNA by PCR
OR
Clinical evidence of illness with a history of residence in, or visit to, an endemic2 area and with laboratory evidence of infection: i.e.
Positive serologic test using the two-tier ELISA and Western Blot criteria
Probable case: Clinical evidence of illness without a history of residence in, or visit to, an endemic2 area and with laboratory
evidence of infection: i.e. Positive serologic test using the two-tier ELISA and Western Blot criteria
OR
Clinician-observed EM1 without laboratory evidence but with history of residence in, or visit to, an endemic2 area.
NOTES:
1. Erythema migrans (EM)
A round or oval expanding erythematous area of the skin greater than 5 cm in diameter and enlarging slowly over a period
of several days to weeks. It appears 1-2 weeks (range 3-30 days) after infection & persists for up to 8 weeks. Some lesions
are homogeneously erythematous, whereas others have prominent central clearing or a distinctive target-like appearance.
On the lower extremities, the lesion may be partially purpuric. Signs of acute or chronic inflammation are not prominent.
There is usually little pain, itching, swelling, scaling, exudation or crusting, erosion or ulceration, except that some
inflammation may be associated with the tick bite itself, which may be present at the very centre of the lesion. Note: an
erythematous skin lesion present while a tick vector is still attached or that has developed within 48 hours of a tick bite is
most likely a tick bite hypersensitivity reaction (i.e. a non-infectious process), rather than EM. Tick bite hypersensitivity
reactions are usually <5cm in largest diameter, sometimes have an urticarial appearance & typically begin to disappear
within 24-48 hours.
2. Endemic area
An endemic area is defined as a locality in which a reproducing population of Ixodes scapularis or Ixodes pacificus tick
vectors is known to exist, as demonstrated by molecular methods, to support transmission of B. burgdorferi at that site.
Endemic areas in NS:
http://www.gov.ns.ca/hpp/cdpc/lyme.asp
Endemic areas in Canada:
http://www.phac-aspc.gc.ca/id-mi/tickinfo-eng.php
Endemic areas in the USA:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5623a1.htm
3. Lyme Serology (Positive)
Criteria for serologic testing are described by the guidelines of the Canadian Public Health Laboratory Network. Serologic
evidence is confirmatory only in patients with EM or objective clinical evidence of disseminated Lyme disease, and a history
of residence in, or visit to, an endemic area.
Reporter’s
Name/Signature:
Document1
Collection Date (yyyy/mm/dd):
/
/
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