What are the symptoms of Lyme disease?

Symptoms of Lyme Disease

Lyme disease presents with a characteristic expanding rash called erythema migrans in 50-80% of patients, accompanied by flu-like symptoms including fever, fatigue, headache, muscle aches, and joint pain, typically appearing 7-14 days after a tick bite. The hallmark early symptom is erythema migrans, which expands outward from the tick bite site and should prompt immediate evaluation and treatment. 1

Early Localized Disease (Days to Weeks After Tick Bite)

Skin Manifestations:

• Erythema migrans rash occurs in 50-80% of patients and is the pathognomonic feature of early Lyme disease 1
• The rash expands outward from the tick bite site, often developing a "bull's-eye" appearance 1
• 20-50% of infected persons remain asymptomatic or have only nonspecific symptoms without the characteristic rash, making diagnosis challenging 1

Systemic Symptoms:

• Fever, malaise, and fatigue resembling a viral or "summer cold" illness 1
• Headache with possible meningeal irritation 1
• Myalgia (muscle aches) and arthralgia (joint pain) 1
• Generalized lymphadenopathy and splenomegaly may occur 2
• Less common manifestations include sore throat, non-productive cough, conjunctivitis, periorbital edema, or testicular swelling 2

Early Disseminated Disease (Weeks to Months After Infection)

Neurologic Manifestations (occur in approximately 15% of patients):

• Lymphocytic meningitis 1
• Cranial neuropathy, especially facial nerve palsy (Bell's palsy), which can be bilateral 1, 2
• Radiculoneuritis (nerve root inflammation) 1
• Motor or sensory radiculoneuritis, mononeuritis multiplex, or myelitis 2

Cardiac Manifestations (occur in approximately 8% of patients):

• Myocarditis and transient atrioventricular heart block of varying degree 1
• Acute myopericarditis, cardiomegaly, or pancarditis 2

Musculoskeletal Manifestations:

• Migratory joint and muscle pains with or without objective joint swelling 1
• Multiple or secondary erythema migrans lesions appearing at sites distant from the original tick bite 1

Late Disseminated Disease (Months to Years After Infection)

Lyme Arthritis (occurs in approximately 60% of untreated patients):

• Intermittent swelling and pain of one or several large, weight-bearing joints, especially the knee 1, 3
• Large knee effusions that are disproportionate to the amount of pain are typical 1, 3
• Baker's cysts may develop 3
• Approximately 10% of patients develop persistent joint swelling even after appropriate antibiotic treatment 1, 3

Late Neurologic Manifestations:

• Chronic axonal polyneuropathy presenting as mild, diffuse "stocking-glove" neuropathy with intermittent limb paresthesias and reduced vibratory sensation in distal lower extremities 1, 3
• Encephalopathy manifested by cognitive disorders, sleep disturbance, fatigue, and personality changes 1, 3
• Encephalomyelitis (rare, unifocal or multifocal inflammatory CNS disease, primarily diagnosed in Europe) 3

Chronic Skin Manifestations (primarily in Europe):

• Acrodermatitis chronica atrophicans, typically localized to the extensor surfaces of the hands and feet 4
• Borrelial lymphocytoma 4

Post-Treatment Symptoms

Important Caveat:

• Subjective symptoms may persist for weeks to months after appropriate treatment due to slow resolution of the inflammatory process, not persistent infection 1, 3
• Approximately 35% of patients have subjective symptoms at day 20,24% at 3 months, and 17% at 12 months after treatment 1, 3
• An ill-defined post-Lyme disease syndrome occurs in some persons after treatment 1
• These persistent symptoms do not indicate ongoing infection and do not warrant prolonged or repeated antibiotic courses 5

Key Clinical Pearls

Timing:

• The incubation period is typically 7-14 days but ranges from 3-30 days 1
• Peak onset occurs in June and July for patients with erythema migrans 6

Diagnostic Challenges:

• Only 25% of patients can recall the tick bite 4
• Some patients progress directly to late-stage disease without manifesting early symptoms 4
• Atypical skin changes can mimic vascular insufficiency, livedo reticularis, or other dermatologic conditions 4

Critical Action Point:

• Early diagnosis and treatment are essential to prevent progression to late-stage complications that require more intensive therapy 1