What are the symptoms of Lyme disease?

Symptoms of Lyme Disease

Lyme disease typically presents with erythema migrans (EM), an expanding rash that occurs in 50-80% of patients, accompanied by nonspecific flu-like symptoms including fever, fatigue, headache, muscle aches, and joint pain, usually appearing 7-14 days after a tick bite. 1

Early Localized Disease (Days to Weeks After Tick Bite)

Dermatologic Manifestations

• Erythema migrans is the hallmark of early Lyme disease, appearing as a characteristic expanding rash that develops outward from the tick bite site 1
• The rash must be at least 5 cm in diameter for secure diagnosis and typically appears 7-14 days after tick detachment 2
• Only 50-80% of infected patients develop the characteristic EM rash 1
• Some patients may develop multiple annular secondary lesions, evanescent red blotches or circles, malar or urticarial rash, conjunctivitis, periorbital edema, or diffuse erythema 3

Systemic Symptoms

• Fatigue, fever, headache, mildly stiff neck, arthralgia (joint pain), and myalgia (muscle aches) are the most common accompanying symptoms 4
• These symptoms are typically intermittent and changing over several weeks 4, 3
• Malaise, generalized achiness, and regional lymphadenopathy frequently occur 3
• Some patients experience evidence of meningeal irritation, mild encephalopathy, hepatitis, generalized lymphadenopathy and splenomegaly, sore throat, nonproductive cough, or testicular swelling 3

Important Caveat

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

Early Disseminated Disease (Days to Months After Infection)

Neurologic Manifestations

• Lymphocytic meningitis, cranial neuropathy (especially facial nerve palsy/Bell's palsy), and radiculoneuritis are the classic neurologic triad 4, 1
• Facial palsy may be bilateral 4
• Encephalomyelitis occurs rarely and must be confirmed by demonstration of antibody production against B. burgdorferi in CSF 4

Musculoskeletal Manifestations

• Migratory joint and muscle pains with or without objective joint swelling occur 1
• Symptoms are intermittent rather than constant 4

Cardiac Manifestations

• Acute onset of high-grade (2nd-degree or 3rd-degree) atrioventricular conduction defects that resolve in days to weeks 4
• Myocarditis and transient atrioventricular heart block are rare cardiac manifestations 1

Dermatologic Progression

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

Late Disseminated Disease (Weeks to Years After Infection)

Musculoskeletal Manifestations

• Intermittent swelling and pain of one or several large, weight-bearing joints (especially the knee) is the most common late manifestation 1
• Recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis 4
• Large knee effusions that are disproportionate to the amount of pain are typical 1
• Approximately 10% of patients develop persistent joint swelling even after appropriate antibiotic treatment 1
• Arthritis occurs in 45-60% of untreated patients 5

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
• Encephalopathy manifested by cognitive disorders, sleep disturbance, fatigue, and personality changes 1

Dermatologic Manifestations (European Cases)

• Acrodermatitis chronica atrophicans (ACA) is a late-stage skin manifestation seen primarily in Europe, typically localized to the extensor surfaces of the hands and feet 6

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 1
• Approximately 35% of patients have subjective symptoms at day 20,24% at 3 months, and 17% at 12 months after treatment 1
• An ill-defined post-Lyme disease syndrome occurs in some persons after treatment 1

Key Diagnostic Pitfalls to Avoid

• Do not confuse tick bite hypersensitivity reactions with erythema migrans: hypersensitivity reactions appear within 48 hours of tick removal, are less than 5 cm in diameter, and clear within 24-48 hours 2
• Headache, fatigue, paresthesia, or mildly stiff neck alone are not criteria for neurologic involvement 4
• Arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement 4
• Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular involvement 4
• The incubation period typically ranges from 3-30 days, with most cases appearing 7-14 days after tick bite 1