Lyme disease history and symptoms

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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], Ilan Dock, B.S.

Overview

Lyme disease is divided into 3 stages and symptoms are stage specific. Initial symptoms include "bulls-eye" rash, with accompanying constitutional symptoms. It can progress to cardiovascular or neurological complications.

History

  • The incubation period from infection to the onset of symptoms is usually 1–2 weeks, but can be much shorter (days), or much longer (months to years). Symptoms most often occur from May through September because the nymphal stage of the tick is responsible for most cases. [1]Asymptomatic infection exists, but is uncommon.[2]
  • The specific areas of focus when obtaining the history, are outlined below:
    • Tick bite
    • Vacation, living, or working environment in endemic areas
    • Spending time outdoor (especially in woody or grassy area).

Symptoms

Lyme disease is divided into 3 stages and symptoms are stage specific.

  1. Stage 1 - Early localized disease
  2. Stage 2 - Early disseminated disease
  3. Stage 3 - Late disseminated disease

Stage 1 - Early localized disease

Features of early localized disease includes erythema migrans and constitutional symptoms.

Classic Lyme disease rash
Lyme disease, expamding rash with central clearing

Stage 2 - Early disseminate disease

Features of early disseminated disease can be divided system wise and includes:

Disseminated Lyme disease, Multiple rash

Stage 3 - Late disseminated disease

Symptoms differentiated on the basis of frequency

[16]

Common symptoms Less common symptoms
  • Arthritis
  • Neurological manifestation
  • Cardiac manifestations
  • Ocular manifestations
  • Hepatitis
Frequency of Lyme disease symptoms, 2001-2015
Difference in clinical features in Europe and North America[17]
Features Europe North America
Erythema migrans Single lesion more frequently Multiple lesions occurs more freuqently
Heterogenous dissemination Less common More common
Borrelial lymphocytoma Present Absent
Acrodermatitis chronica atrophicans Present Absent
Meningoradiculoneuritis More common Less common
Lyme arthritis Rarely preceded by Erythema migrans Commonly preceded by Erythema migrans

Erythema migrans

  • Erythema migrans (EM) also known as Erythema chronicum migrans, "bull’s-eye" rash, or Lyme rash develops in around 70% - 80% of patients.[3]
    • EM is the the pathognomonic rash of Lyme disease. Majority of patients with the rash do not recall tick bite.
    • EM begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days).
    • EM is classically 5 to 6.8 cm in diameter appearing as an annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%).[18]
    • EM gradually expands over a period of days reaching up to 12 inches(30 cm)or more across.
    • EM may feel warm to touch but is rarely itchy or painful.
    • EM clears as it enlarges, resulting in a target or “bull’s-eye” appearance.
    • EM may appear on any area of the body but majority of times present in areas including axilla, inguinal region, or popliteal fossa.
    • The rash does not represent an allergic reaction to the bite, but rather a skin infection with the Lyme bacteria, Borrelia burgdorferi sensu lato.
    • EM resolves in approximately 28 days in untreated patients.[19]
    • The characteristic "bull's-eye" rash with central clearing is present in about 20% of endemic cases in the United States; whereas in Europe and the non-endemic United States 80% of rashes have central clearing. In endemic areas of the United States homogeneously red rashes are more frequent.[20][21]
    • Serologic testing is not recommended in patients with EM. Initially, majority of patients are seronegative.[18]
    • Multiple Erythema migrans are present in disseminated disease.[5]
    • Mini erythema migrans - Sometimes , erythema migrans may be less than 5 cm in diameter. It is an important and atypical sign of early localized Lyme disease.[22]

Lyme Carditis

Lyme arthritis

  • Lyme arthritis is the hallmark of stage 3 Lyme disease.
  • Lyme arthritis is most frequently presented symptom in late disseminated Lyme disease.
  • Lyme arthritis is not necessarily preceded by erythema migrans.
  • Lyme arthritis may occur due to hematogenous spread of B. burgdorferi to multiple joints during early infection. This might explain migratory arthralgia during early stage of Lyme disease.
  • It usually takes months to years for Lyme disease to progress to Lyme arthritis.
  • Lyme arthritis symptoms ranges from intermittent attack of monoarthritis/oligoarthritis to persistent arthritis.
  • Intermittent attack of Lyme arthritis ranges from 3 days to 11.5 months with a mean of 3 months.[27]
  • Majotiry of times Lyme arthritis involves large joints. Most commonly affected joint is knee joint, but any joint can be affected including shoulder, ankle, elbow, temporomandibular joint, and wrist.
  • Tendonitis and/or bursitis may also be present in few patients.
  • Majority of patients have little/no joint dysfunction after remission of attack. Few patients with persistent arthritis may show erosion and permanent damage to joint.[28]

Manifestations of Lyme Disease by Stage

Manifestations of Lyme Disease by Stage[25]
System Stage 1 (Localized Infection) Stage 2 (Early Disseminated Infection) Stage 3 (Late Persistent Infection)
Skin
Musculoskeletal
Neurologic
Lymphatic
Heart
Eyes
Liver
Respiratory
Kidney
Genitourinary
Constitutional systems

Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.

References

  1. Falco RC, McKenna DF, Daniels TJ, Nadelman RB, Nowakowski J, Fish D; et al. (1999). "Temporal relation between Ixodes scapularis abundance and risk for Lyme disease associated with erythema migrans". Am J Epidemiol. 149 (8): 771–6. PMID 10206627.
  2. Steere AC, Sikand VK, Schoen RT, Nowakowski J (2003). "Asymptomatic infection with Borrelia burgdorferi". Clin. Infect. Dis. 37 (4): 528–32. PMID 12905137.
  3. 3.0 3.1 Steere AC, Sikand VK (2003). "The presenting manifestations of Lyme disease and the outcomes of treatment". N Engl J Med. 348 (24): 2472–4. doi:10.1056/NEJM200306123482423. PMID 12802042.
  4. Nadelman RB, Nowakowski J, Forseter G, Goldberg NS, Bittker S, Cooper D; et al. (1996). "The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans". Am J Med. 100 (5): 502–8. PMID 8644761.
  5. 5.0 5.1 Wormser GP, McKenna D, Carlin J, Nadelman RB, Cavaliere LF, Holmgren D; et al. (2005). "Brief communication: hematogenous dissemination in early Lyme disease". Ann Intern Med. 142 (9): 751–5. PMID 15867407.
  6. Halperin JJ (2008). "Nervous system Lyme disease". Infect Dis Clin North Am. 22 (2): 261–74, vi. doi:10.1016/j.idc.2007.12.009. PMID 18452800.
  7. England JD, Bohm RP, Roberts ED, Philipp MT (1997). "Mononeuropathy multiplex in rhesus monkeys with chronic Lyme disease". Ann Neurol. 41 (3): 375–84. doi:10.1002/ana.410410313. PMID 9066359.
  8. Chabria SB, Lawrason J (2007). "Altered mental status, an unusual manifestation of early disseminated Lyme disease: A case report". 1 (1): 62. doi:10.1186/1752-1947-1-62. PMID 17688693.
  9. 9.0 9.1 Mullegger RR (2004). "Dermatological manifestations of Lyme borreliosis". Eur J Dermatol. 14 (5): 296–309. PMID 15358567.
  10. Stanek G, Strle F (2003). "Lyme borreliosis". Lancet. 362 (9396): 1639–47. doi:10.1016/S0140-6736(03)14798-8. PMID 14630446.
  11. Halperin JJ, Volkman DJ, Wu P (1991). "Central nervous system abnormalities in Lyme neuroborreliosis". Neurology. 41 (10): 1571–82. PMID 1922798.
  12. Rosenhall U, Hanner P, Kaijser B (1988). "Borrelia infection and vertigo". Acta Otolaryngol. 106 (1–2): 111–6. PMID 3421091.
  13. Moscatello AL, Worden DL, Nadelman RB, Wormser G, Lucente F (1991). "Otolaryngologic aspects of Lyme disease". Laryngoscope. 101 (6 Pt 1): 592–5. PMID 2041438.
  14. Logigian, Eric L.; Kaplan, Richard F.; Steere, Allen C. (1990). "Chronic Neurologic Manifestations of Lyme Disease". New England Journal of Medicine. 323 (21): 1438–1444. doi:10.1056/NEJM199011223232102. ISSN 0028-4793.
  15. Fallon BA, Nields JA (1994). "Lyme disease: a neuropsychiatric illness". The American journal of psychiatry. 151 (11): 1571–83. PMID 7943444.Hess A, Buchmann J, Zettl UK; et al. (1999). "Borrelia burgdorferi central nervous system infection presenting as an organic schizophrenialike disorder". Biol. Psychiatry. 45 (6): 795. PMID 10188012.)
  16. Ciesielski CA, Markowitz LE, Horsley R, Hightower AW, Russell H, Broome CV (1989). "Lyme disease surveillance in the United States, 1983-1986". Rev. Infect. Dis. 11 Suppl 6: S1435–41. PMID 2682955.
  17. Stanek G, Strle F (2008). "Lyme disease: European perspective". Infect Dis Clin North Am. 22 (2): 327–39, vii. doi:10.1016/j.idc.2008.01.001. PMID 18452805.
  18. 18.0 18.1 Feder HM, Abeles M, Bernstein M, Whitaker-Worth D, Grant-Kels JM (2006). "Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis". Clin Dermatol. 24 (6): 509–20. doi:10.1016/j.clindermatol.2006.07.012. PMID 17113969.
  19. Steere AC, Bartenhagen NH, Craft JE, Hutchinson GJ, Newman JH, Rahn DW; et al. (1983). "The early clinical manifestations of Lyme disease". Ann Intern Med. 99 (1): 76–82. PMID 6859726.
  20. Smith RP, Schoen RT, Rahn DW, Sikand VK, Nowakowski J, Parenti DL; et al. (2002). "Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans". Ann Intern Med. 136 (6): 421–8. PMID 11900494.
  21. Edlow JA (2002). "Erythema migrans". Med Clin North Am. 86 (2): 239–60. PMID 11982300.
  22. Weber K, Wilske B (2006). "Mini erythema migrans--a sign of early Lyme borreliosis". Dermatology. 212 (2): 113–6. doi:10.1159/000090650. PMID 16484816.
  23. "Dermatology Atlas".
  24. Hu LT (2012). "In the clinic. Lyme disease". Ann Intern Med. 157 (3): ITC2-2–ITC2-16. doi:10.7326/0003-4819-157-3-20120807-01002. PMID 22868858.
  25. 25.0 25.1 Steere, Allen C. (1989). "Lyme Disease". New England Journal of Medicine. 321 (9): 586–596. doi:10.1056/NEJM198908313210906. ISSN 0028-4793.
  26. Fish, Airley E.; Pride, Yuri B.; Pinto, Duane S. (2008). "Lyme Carditis". Infectious Disease Clinics of North America. 22 (2): 275–288. doi:10.1016/j.idc.2007.12.008. ISSN 0891-5520.
  27. Steere AC, Schoen RT, Taylor E (1987). "The clinical evolution of Lyme arthritis". Ann Intern Med. 107 (5): 725–31. PMID 3662285.
  28. Steere AC, Schoen RT, Taylor E (1987). "The clinical evolution of Lyme arthritis". Ann Intern Med. 107 (5): 725–31. PMID 3662285.


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