Lyme disease natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]


Lyme disease may present as a red, expanding rash called erythema migrans (EM) along with flu-like symptoms such as fatigue, arthralgia, myalgias, headache, fever and/or chills, stiff neck, anorexia, and regional lymphadenopathy. EM resolves in approximately 28 days in untreated patients. Lyme disease is effectively managed by prompt treatment.

Untreated infection may spread from the site of the bite to other parts of the body, producing a range of symptoms including neurological, cardiac and dermatological manifestations. Many of these symptoms will resolve over a period of weeks to months, even without treatment. However, lack of treatment can result in additional complications. Lyme arthritis is the most frequently presented symptom in late disseminated Lyme disease.

Prognosis is mainly affected by a failure to treat in a timely manner as well as simultaneous infections with other tick-borne diseases. Sometimes, patients with Lyme disease have symptoms that last months to years after treatment with antibiotics. These symptoms includes muscle and joint pains, cognitive defects, sleep disturbance, or fatigue. The condition is referred to as post-treatment Lyme disease syndrome (PTLDS).

Natural History

Stage 1: Early Localized Lyme disease (3-30 Days Post-tick Bite)

  • Some people may get these flu-like symptoms in addition to an EM rash, but in some, these flu-like symptoms may be the only evidence of infection.
  • EM occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3-30 days (average is about 7 days).
  • Early EM may be homogenously erythematous without any central clearing.
  • EM gradually expands over a period of several days, and can reach up to 12 inches (30 cm) across. Parts of the rash may clear as it enlarges, resulting in a bullseye appearance.

Stage 2: Early Disseminated Lyme disease (Days to Weeks Post-tick Bite)

  • Many of these symptoms will resolve over a period of weeks to months, even without treatment. However, lack of treatment can result in additional complications.

Stage 3: Late Disseminated Lyme disease (Months-to-Years Post-tick Bite)


Stage 3 or late disseminated Lyme disease can cause long-term joint inflammation (Lyme arthritis) and heart rhythm problems. Brain and nervous system problems are also possible, and may include:

Lingering Symptoms After Treatment (Post-treatment Lyme disease Syndrome)



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