What are the symptoms of Lyme disease?

Lyme Disease Symptoms

Lyme disease most commonly presents with erythema migrans (a characteristic expanding rash) accompanied by nonspecific flu-like symptoms including fever, malaise, fatigue, headache, muscle aches, and joint pain, typically appearing 7-14 days after a tick bite. 1

Early Localized Disease (Days to Weeks After Tick Bite)

Dermatologic Manifestations:

• Erythema migrans rash occurs in 50-80% of patients and is the hallmark of early Lyme disease 1, 2
• The rash typically appears 7-14 days after infection but can occur as early as 3 days or as late as 30 days 1
• Early erythema migrans commonly presents with homogeneous or central redness rather than the classic "bull's-eye" appearance with peripheral erythema and central clearing 2
• The rash expands outward from the tick bite site 1

Systemic Symptoms:

• Low-grade fever is common 2
• Headache 1, 2
• Fatigue and malaise 1, 2
• Myalgia (muscle aches) 1, 2
• Arthralgia (joint pain) 1, 2
• Neck stiffness 2
• These symptoms resemble a "summer cold" or viral infection 3

Important Clinical Pitfall: Some infected persons remain asymptomatic or manifest only nonspecific symptoms without the characteristic rash, making diagnosis more challenging 1

Early Disseminated Disease (Days to Weeks After Initial Symptoms)

Neurologic Manifestations:

• Lymphocytic meningitis 1
• Cranial neuropathy, especially facial nerve palsy (Bell's palsy) 1
• Radiculoneuritis (nerve root inflammation) 1

Musculoskeletal Manifestations:

• Migratory joint and muscle pains with or without objective joint swelling 1
• Pain can move from joint to joint 1

Cardiac Manifestations (Rare):

• Myocarditis 1
• Transient atrioventricular heart block of varying degree 1

Dermatologic:

• Multiple or secondary erythema migrans lesions can appear at sites distant from the original tick bite 1

Late Disseminated Disease (Weeks to Months After Infection)

Musculoskeletal:

• Intermittent swelling and pain of one or several large, weight-bearing joints (especially the knee) is the most common late manifestation 1, 4
• Large knee effusions that are disproportionate to the amount of pain are typical 4
• Baker's cysts may develop 4
• Approximately 10% of patients develop persistent joint swelling even after appropriate antibiotic treatment 4

Neurologic:

• Chronic axonal polyneuropathy presenting as mild, diffuse "stocking-glove" neuropathy with intermittent limb paresthesias and reduced vibratory sensation in distal lower extremities 4
• Encephalopathy manifested by cognitive disorders, sleep disturbance, fatigue, and personality changes 1, 4
• Encephalomyelitis (rare, unifocal or multifocal inflammatory CNS disease, primarily diagnosed in Europe) 4

Critical Clinical Consideration: Lyme disease morbidity can be severe, chronic, and disabling in some cases, though the disease is rarely, if ever, fatal 1

Post-Treatment Symptoms

• Subjective symptoms may persist for weeks to months after appropriate treatment due to slow resolution of the inflammatory process, not persistent infection 4
• Approximately 35% of patients have subjective symptoms at day 20,24% at 3 months, and 17% at 12 months after treatment 4
• An ill-defined post-Lyme disease syndrome occurs in some persons after treatment 1

Key Diagnostic Considerations

The incubation period is typically 7-14 days but ranges from 3-30 days 1, so symptom timing relative to potential tick exposure is crucial for diagnosis. The diagnosis is based primarily on clinical findings and known exposure history, particularly in endemic areas (northeastern, mid-Atlantic, and upper north-central United States) 1, 5. Early diagnosis and treatment are essential to prevent progression to late-stage complications that require more intensive therapy 1.