What are the symptoms and treatment options for Lyme disease?

Lyme Disease Symptoms

Lyme disease presents with a characteristic expanding rash called erythema migrans in approximately 80% of patients, typically appearing 7-14 days after a tick bite, accompanied by flu-like symptoms including fever, fatigue, headache, myalgia, and arthralgia. 1

Early Localized Stage (Days to Weeks After Tick Bite)

Erythema Migrans (EM)

• Occurs in 80% of patients, appearing 7-14 days after tick bite (range: days to 1 month) 1, 2
• Gradually expands over days to weeks, can reach up to 20 cm in diameter 3
• Central clearing may be absent in >50% of patients 2
• Usually not painful but may be warm to touch or pruritic 3
• Common locations: axilla, groin, cubital area, or around the waist 3
• Only 25% of patients recall the tick bite 3
• Multiple EM lesions indicate spirochetemia and occur in approximately 20% of current U.S. cases 2

Associated Systemic Symptoms

• Fatigue (54%), myalgia (44%), arthralgia (44%), headache (42%), fever/chills (39%) 2
• Symptoms may begin before, during, or after the rash appears 2
• Fever present in approximately 20% of patients 3
• Regional lymphadenopathy may occur 3

Laboratory Findings

• Antibodies may be absent in up to 50% of patients at initial presentation, particularly with shorter duration of EM 2
• Erythrocyte sedimentation rate may be slightly elevated 3
• Leukocyte counts usually normal; anemia and thrombocytopenia rare 3

Early Disseminated Stage (Weeks to Months After Infection)

Neurologic Manifestations

• Classic triad: lymphocytic meningitis, cranial neuropathy (especially facial nerve palsy), and radiculoneuritis (Bannwarth syndrome) 1, 3
• Cranial nerve neuropathies can be bilateral 3
• Each manifestation can occur independently 3

Cardiac Manifestations

• Atrioventricular heart block and myopericarditis 1
• Historically reported in 4-10% of untreated patients 1
• Relatively rare complication 1

Musculoskeletal Symptoms

• Migratory joint and muscle pains with or without objective joint swelling 1

Late Disseminated Stage (Months to Years After Infection)

Lyme Arthritis

• Intermittent swelling and pain of one or several large joints, most commonly the knees 1, 3
• Can persist for weeks to months 1
• Approximately 10% of patients develop persistent joint swelling despite appropriate antibiotic treatment 4, 1
• In these antibiotic-refractory cases, joint swelling eventually resolves but may last up to 4-5 years 4
• Can be the first manifestation without earlier stages 3

Late Neurologic Manifestations

• Chronic axonal polyneuropathy 1
• Encephalopathy with discrete cognitive dysfunction 1
• Seventh nerve palsy may result in mild residual facial muscle weakness in a small proportion of patients 4

Dermatologic Manifestations (Europe)

• Acrodermatitis chronica atrophicans (ACA): chronic skin changes on extensor surfaces of hands and feet 3
• Most common in women >40 years of age 3
• Comprises 1-10% of European LB cases depending on region 3
• Can be misdiagnosed as vascular insufficiency, chronic venous insufficiency, livedo reticularis, or lymphedema 3

Post-Treatment Symptoms

Common Subjective Symptoms After Treatment

• Subjective symptoms present in 35% at day 20,24% at 3 months, and 17% at 12 months after treatment 4
• Most often due to slow resolution of inflammatory process, not persistent infection 4
• Include arthralgia, myalgia, fatigue, and cognitive complaints 4

Post-Lyme Disease Syndrome

• Defined as widespread musculoskeletal pain, cognitive complaints, radicular pain, paresthesias, or dysesthesias that interfere with function 4
• Symptoms must begin within 6 months of initial diagnosis and persist for at least 6 months 4
• Approximately 90% also complain of fatigue 4
• Some patients fulfill criteria for fibromyalgia 4
• Objective clinical manifestations are uncommon after appropriate treatment 4

Critical Diagnostic Pitfalls

• Antibodies persist for months to years after successful treatment and should not be used as markers of active infection 5
• Respiratory and gastrointestinal complaints are infrequent in Lyme disease 2
• Late-stage disease can occur without any signs of earlier stages 3
• Atypical skin presentations may mimic vascular or other dermatologic conditions 3