What are the arthritic manifestations in Lyme disease (Lyme borreliosis)?

From the Guidelines

Lyme arthritis, a late manifestation of Lyme disease, typically presents as intermittent episodes of joint swelling and pain, predominantly affecting large joints, especially the knee, with significant swelling, moderate pain, warmth, and limited range of motion in the affected joint. Patients often experience episodes that last weeks to months and can recur without treatment. The knee is involved in about 90% of cases, and episodes may be monoarticular or oligoarticular. Laboratory findings typically include elevated inflammatory markers, synovial fluid with high white blood cell counts (predominantly neutrophils), and positive serologic tests for Borrelia burgdorferi antibodies 1. Some key characteristics of Lyme arthritis include:

• Intermittent episodes of joint swelling and pain
• Predominantly affects large joints, especially the knee
• Significant swelling with moderate pain, warmth, and limited range of motion
• Episodes may last weeks to months and can recur without treatment
• Knee is involved in about 90% of cases
• Episodes may be monoarticular or oligoarticular
• Laboratory findings include elevated inflammatory markers, synovial fluid with high white blood cell counts, and positive serologic tests for Borrelia burgdorferi antibodies Treatment involves antibiotics such as doxycycline (100mg twice daily for 28 days), amoxicillin (500mg three times daily for 28 days), or cefuroxime (500mg twice daily for 28 days) 1. Some patients may develop antibiotic-refractory Lyme arthritis, where joint inflammation persists despite appropriate antibiotic therapy, potentially requiring anti-inflammatory treatments. This persistent arthritis is thought to result from an autoimmune response triggered by the initial infection rather than ongoing bacterial presence. For patients with Lyme arthritis, we recommend using oral antibiotic therapy for 28 days (strong recommendation, moderate-quality evidence) 1. In patients with Lyme arthritis with no or minimal response to an initial course of oral antibiotic, we suggest a 2–4-week course of IV ceftriaxone over a second course of oral antibiotics (weak recommendation, low-quality evidence) 1.

From the Research

Clinical Presentation of Arthritis in Lyme Disease

• Arthritis is the most common late manifestation of Borrelia burgdorferi infection in the United States, usually beginning months after the tick bite 2, 3, 4.
• Patients with Lyme arthritis (LA) typically present with swelling and pain in one or a few large joints, especially the knee 2, 5, 3, 4.
• The arthritis can be intermittent or persistent, and may cause severe joint pain and swelling, especially confined to one or a few joints 5.

Diagnosis and Treatment

• Serologic testing is the mainstay of diagnosis for Lyme arthritis 2, 3, 4.
• Synovial fluid polymerase chain reaction for B burgdorferi DNA is often positive before treatment, but is not a reliable marker of spirochetal eradication after therapy 3.
• Antibiotic therapy is very effective in treating Lyme arthritis in the majority of cases, with responses to antibiotic treatment generally excellent 2, 5, 6.
• A small percentage of patients may develop persistent, postinfectious synovitis after 2 to 3 months of oral and IV antibiotics, which respond to anti-inflammatory therapies 2, 5.

Persistent Arthritis

• A small proportion of individuals may develop persistent chronic arthritis, which is likely mediated through immunologic mechanisms 5.
• In these patients, treatment strategies should include anti-inflammatory medications and possibly immunosuppressive treatments, and arthroscopic synovectomy may be helpful in some cases 5.
• Certain genetic and immune markers, such as HLA-DR4 specificity and OspA reactivity, may be associated with a lack of response to treatment 6.