What are the symptoms of Lyme disease?

Symptoms of Lyme Disease

Lyme disease presents with distinct symptoms depending on the stage of infection, beginning with the characteristic erythema migrans rash in 50-80% of cases, accompanied by flu-like symptoms, and potentially progressing to neurologic, cardiac, and arthritic manifestations if untreated.

Early Localized Disease (Days 3-30, typically 7-14 days after tick bite)

Erythema Migrans Rash

• The hallmark sign is erythema migrans, occurring in 50-80% of patients 1
• The rash must be at least 5 cm in diameter for secure diagnosis and expands outward from the tick bite site 1, 2
• Appears 7-14 days after tick detachment, not while the tick is still attached 2
• Important pitfall: A rash that clears within hours is a hypersensitivity reaction, not Lyme disease, and does not require antibiotics 2

Systemic Symptoms

• Fever, malaise, and fatigue are common 1
• Headache occurs frequently 1
• Myalgia (muscle aches) and arthralgia (joint pain) without objective swelling 1
• These symptoms resemble a "summer cold" or viral infection 3
• 20-50% of infected persons remain asymptomatic or have only nonspecific symptoms without the characteristic rash, making diagnosis challenging 1

Early Disseminated Disease (Days to ~9 months after onset)

Neurologic Manifestations (occur in ~15% of untreated patients)

• Lymphocytic meningitis 1
• Cranial neuropathy, especially facial nerve palsy (Bell's palsy), which can be bilateral 1, 4
• Radiculoneuritis (nerve root inflammation) 1
• Motor or sensory radiculoneuritis, mononeuritis multiplex, or myelitis 4

Cardiac Manifestations (occur in ~8% of untreated patients)

• Myocarditis and transient atrioventricular heart block of varying degree 1
• Acute myopericarditis, cardiomegaly, or pancarditis 4

Musculoskeletal Symptoms

• Migratory joint and muscle pains with or without objective joint swelling 1
• Pain in joints, tendons, bursae, muscle, or bone 4

Skin Manifestations

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

Late Disseminated Disease (Weeks to years after onset)

Arthritic Manifestations (occur in ~60% of untreated patients)

• Intermittent swelling and pain of one or several large, weight-bearing joints, especially the knee 1
• Large knee effusions that are disproportionate to the amount of pain 1
• Arthritis may be intermittent or chronic 4
• Approximately 10% of patients develop persistent joint swelling even after appropriate antibiotic treatment, lasting up to 4-5 years in some cases 5, 1

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

Post-Treatment Symptoms

Timing and Frequency

• Subjective symptoms persist in 35% of patients at day 20,24% at 3 months, and 17% at 12 months after treatment 5, 1
• These symptoms represent slow resolution of the inflammatory process, not persistent infection 1

Common Complaints

• Arthralgia, myalgia, and fatigue without objective findings 5
• Some patients fulfill clinical criteria for fibromyalgia with multiple tender points 5
• These post-treatment symptoms are not antibiotic-sensitive and do not warrant prolonged antibiotic therapy 3

Critical Diagnostic Considerations

• Early diagnosis and treatment are essential to prevent progression to late-stage complications 1
• The incubation period typically ranges from 3-30 days, most commonly 7-14 days 1
• Patients with erythema migrans in endemic areas can be diagnosed clinically without laboratory testing 5
• All other manifestations require serologic testing for confirmation, though sensitivity is only 30-40% during early infection 5