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 80% of patients, typically appearing 7-14 days after a tick bite, accompanied by flu-like symptoms including fever, malaise, fatigue, headache, myalgia, and arthralgia. 1

Early Localized Stage (Days to Weeks After Tick Bite)

Erythema Migrans (EM) - The Hallmark Sign:

• Occurs in 80% of infected patients, though only 25% recall the actual tick bite 1, 2
• Appears typically 7-14 days post-exposure (range: within one month) 1, 2
• Begins as a red macule or papule that expands gradually over days to weeks, potentially reaching up to 20 cm in diameter 2
• May develop central clearing creating a "bull's-eye" appearance after several days, though initial coloration is often uniform 2
• Common locations include axilla, groin, cubital area, and waist 2
• Usually not painful but may be warm to touch or pruritic 2

Associated Constitutional Symptoms:

• Fever (present in approximately 20% of patients) 2
• Malaise and fatigue 1, 3
• Headache 3, 2
• Myalgia (muscle pain) 1, 3
• Arthralgia (joint pain) 1, 3
• Loss of appetite 2
• Regional lymphadenopathy 2

Important Clinical Pitfall: Multiple EM lesions indicate spirochetemia (bloodstream dissemination), not multiple tick bites, and signal early disseminated disease 2

Early Disseminated Stage (Weeks to Months After Infection)

Neurologic Manifestations:

• Lymphocytic meningitis 1
• Cranial neuropathy (most commonly facial nerve palsy/Bell's palsy, which can be bilateral) 1, 2
• Radiculoneuritis (motor or sensory nerve root inflammation) 1, 2
• The classic triad is meningitis, cranial neuropathy, and radiculopathy (Bannwarth syndrome) 2
• These can occur individually or in combination 2

Cardiac Manifestations:

• Atrioventricular heart block 1
• Myopericarditis 1
• Historically reported in 4-10% of untreated patients, though relatively rare 1

Musculoskeletal Symptoms:

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

Key Point: Some patients progress to this stage without recognizing or experiencing the early localized stage 2

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, 2
• Affects 45-60% of untreated patients 4
• Episodes persist for weeks to months 1
• Approximately 10% develop persistent joint swelling even after appropriate antibiotic treatment 1
• Can be the first manifestation without prior early-stage symptoms 2

Late Neurologic Manifestations:

• Chronic axonal polyneuropathy 1
• Encephalopathy (subtle cognitive dysfunction) 1
• These are relatively rare due to early treatment 2

Dermatologic (European Strains):

• Acrodermatitis chronica atrophicans (ACA) - chronic skin changes on extensor surfaces of hands and feet 2
• Most common in women over 40 years of age 2
• Comprises 1-10% of European LB cases depending on region 2

Post-Treatment Symptoms

Common Subjective Symptoms After Treatment:

• Present in 35% of patients at day 20, declining to 24% at 3 months and 17% at 12 months after treatment 5
• Include arthralgia, myalgia, fatigue, and other subjective complaints 5
• Most often represent slow resolution of inflammatory processes, not persistent infection 5

Post-Lyme Disease Syndrome Criteria:

• Widespread musculoskeletal pain, cognitive complaints, radicular pain, paresthesias, or dysesthesias 5
• Symptoms must interfere with function 5
• Must begin within 6 months of initial diagnosis and persist for at least 6 months 5
• Fatigue reported in 90% of these patients 5

Critical Distinction: Objective clinical manifestations (measurable physical findings) are uncommon after appropriate treatment; persistent symptoms are typically subjective without objective abnormalities on examination 5, 6

Laboratory and Diagnostic Considerations

Non-Specific Laboratory Findings in Early Disease:

• Erythrocyte sedimentation rate may be slightly elevated 2
• Leukocyte counts typically normal 2
• Anemia and thrombocytopenia rare 2

Serologic Testing Caveats:

• Antibodies persist for months to years after successful treatment 6
• Positive serology alone does not indicate active infection 6
• Repeated infection can occur despite prior infection and positive antibodies 6

Asymptomatic Infection

Important Note: Some patients may have asymptomatic infection with no recognized illness, making diagnosis challenging 1