What are the stages of Lyme disease and their respective treatments?

Stages of Lyme Disease and Their Respective Treatments

Lyme disease progresses through three distinct stages: early localized, early disseminated, and late disseminated, each requiring specific antibiotic treatments based on clinical manifestations and disease severity.

Stage I: Early Localized Infection (Days to Weeks)

Clinical Manifestations:

• Erythema migrans (EM): Pathognomonic gradually expanding annular lesion >5 cm in diameter at the tick bite site 1
• Associated symptoms: Fever, lymphadenopathy, myalgias, arthralgias 1
• Occurs in approximately 70-80% of infected persons 1

Diagnosis:

• Clinical diagnosis based on EM rash in endemic areas (no laboratory testing needed) 1
• Serologic testing has low sensitivity (30-40%) during this early stage 1

Treatment:

• Oral antibiotics for 10-14 days 2:
  • Doxycycline: 100 mg twice daily (first-line for adults and children ≥8 years)
  • Amoxicillin: 500 mg three times daily (preferred for children <8 years, pregnant women)
  • Cefuroxime axetil: 500 mg twice daily (alternative)
  • Azithromycin (second-line option)

Stage II: Early Disseminated Infection (Weeks to Months)

Clinical Manifestations:

• Multiple EM lesions (hematogenous spread) 1
• Borrelial lymphocytoma (bluish-red tumor-like skin infiltrate, often on ear lobe or nipple) 1
• Neurologic involvement:
  • Facial nerve palsy (Bell's palsy)
  • Meningitis
  • Meningoradiculitis 1
• Cardiac involvement (5% of cases):
  • Atrioventricular block
  • Myocarditis
  • Conduction disorders 1, 2

Diagnosis:

• Two-tiered serologic testing: ELISA/IFA followed by Western immunoblot 1, 2
• Sensitivity of 70-100% during this stage 1
• Specificity >95% 1

Treatment:

• For neurologic manifestations:

  • Facial nerve palsy without CSF abnormalities: Oral antibiotics for 14 days 2
  • Meningitis or radiculopathy: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 2

• For cardiac manifestations:

  • Parenteral antibiotics (IV ceftriaxone) 2
  • Hospitalization for symptomatic patients or those with advanced heart block 2
  • Temporary pacemaker for symptomatic bradycardia or high-grade AV block not responding to antibiotics 2

Stage III: Late Disseminated Infection (Months to Years)

Clinical Manifestations:

• Arthritis: Recurrent large-joint arthritis, especially knee 1
• Acrodermatitis chronica atrophicans (ACA): Bluish-red discoloration progressing to skin atrophy, associated with B. afzelii 1
• Late neurologic manifestations (uncommon in US):
  • Peripheral neuropathy
  • Encephalopathy
  • Encephalomyelitis 1

Diagnosis:

• Strong serologic reactivity with expanded Western blot IgG banding patterns 1
• Synovial fluid analysis in arthritis cases shows mild-to-moderate inflammation 1
• PCR of synovial fluid may provide additional diagnostic certainty in seropositive patients 1

Treatment:

• For arthritis:

  • Initial treatment with oral antibiotics
  • For arthritis that has failed to improve or worsened: IV ceftriaxone 2g daily for 2-4 weeks 2
  • Refractory cases may require anti-inflammatory agents or surgical synovectomy 1

• For late neurologic manifestations:

  • IV antibiotics (ceftriaxone, cefotaxime, or penicillin G) for 14-21 days 2

Important Clinical Considerations:

• Antibody persistence: Antibodies often persist for months or years after successfully treated infection, so seroreactivity alone cannot be used as a marker of active disease 1
• Post-Lyme disease syndrome: Some patients experience persistent symptoms after appropriate treatment that are not responsive to additional antibiotics 1, 2
• The IDSA, AAN, and ACR do not recognize "chronic Lyme disease" as a valid diagnosis and recommend against prolonged antibiotic therapy 2
• Geographic variations: B. burgdorferi sensu stricto predominates in the US, while B. afzelii and B. garinii are more common in Europe and Asia, affecting clinical manifestations 1, 3

Prophylaxis:

For high-risk tick bites meeting all criteria:

• Identified Ixodes tick attached for ≥36 hours
• Prophylaxis started within 72 hours of tick removal
• Local infection rate of ticks with B. burgdorferi ≥20%
• Single dose of doxycycline: 200 mg for adults, 4.4 mg/kg (max 200 mg) for children ≥8 years 2

Proper early diagnosis and appropriate antibiotic treatment are essential to prevent progression to later stages of Lyme disease and their associated complications.