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{{Lyme disease}}
{{CMG}} {{AE}}{{Anmol}}, {{IMD}}
==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==
{{CMG}}; {{AE}} {{Anmol}}
*The [[incubation period]] from [[infection]] to the onset of symptoms is usually 1&ndash;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. <ref name="pmid10206627">{{cite journal| author=Falco RC, McKenna DF, Daniels TJ, Nadelman RB, Nowakowski J, Fish D et al.| title=Temporal relation between Ixodes scapularis abundance and risk for Lyme disease associated with erythema migrans. | journal=Am J Epidemiol | year= 1999 | volume= 149 | issue= 8 | pages= 771-6 | pmid=10206627 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10206627  }}</ref>[[Asymptomatic]] [[infection]] exists, but is uncommon.<ref name="pmid12905137">{{cite journal |author=Steere AC, Sikand VK, Schoen RT, Nowakowski J |title=Asymptomatic infection with Borrelia burgdorferi |journal=Clin. Infect. Dis. |volume=37 |issue=4 |pages=528-32 |year=2003 |pmid=12905137}}</ref>
*The specific areas of focus when obtaining the history, are outlined below:
** [[Tick]] bite
** Vacation, living, or working environment in [[Endemic (epidemiology)|endemic]] areas
**Spending time outdoor (especially in woody or grassy area).


==Symptoms==
==Tables==
[[Lyme disease]] is divided into 3 stages and symptoms are stage specific.
{| class="wikitable"
#Stage 1 - Early localized disease
|+
#Stage 2 - Early disseminated disease
!Diagnosis
#Stage 3 - Late disseminated disease
!Lab findings
 
!
===Stage 1 - Early localized disease===
!
{|
|-
!
!
!
!
|-
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Features of early localized disease includes erythema migrans and constitutional symptoms.
*'''Erythema migrans (EM)''' also known as Erythema chronicum migrans, "bull’s-eye" rash, or Lyme rash develops in around 70% - 80% of patients.<ref name="pmid12802042">{{cite journal| author=Steere AC, Sikand VK| title=The presenting manifestations of Lyme disease and the outcomes of treatment. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 24 | pages= 2472-4 | pmid=12802042 | doi=10.1056/NEJM200306123482423 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12802042  }} </ref>
**EM begins at the site of a [[tick]] bite after a delay of 3 to 30 days (average is about 7 days).
**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 [[Itch|itchy]] or [[Pain|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]], [[popliteal fossa]], or along belt line.
**The [[rash]] does not represent an [[allergic reaction]] to the bite, but rather a [[skin infection]] with the [[Borrelia burgdorferi|Lyme bacteria]], [[Lyme disease microbiology|''Borrelia burgdorferi'' sensu lato]].
**An [[infection]] resulting from a [[Borrelia mayonii|B. mayonii]] [[infection]] may cause a diffuse [[rash]], erupting in "red spots," spanning the entire [[body]].
*Constitutional symptoms includes:<ref name="pmid8644761">{{cite journal| author=Nadelman RB, Nowakowski J, Forseter G, Goldberg NS, Bittker S, Cooper D et al.| title=The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. | journal=Am J Med | year= 1996 | volume= 100 | issue= 5 | pages= 502-8 | pmid=8644761 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8644761  }} </ref>
**[[Fatigue]]
**[[Arthralgia]]
**[[Myalgia]]
**[[Headache]]
**[[Fever]] and/or [[chills]]
**[[Stiff neck]]
**[[Anorexia]]
|
|
[[Image:Classic Lyme disease rash.jpg|thumb|250px|center|Classic [[Lyme disease]] rash]]
[[Image:Lyme disease Expanding rash with central crust.jpg|thumb|250px|center|[[Lyme disease]], expamding rash with central clearing]]
|}
===Stage 2 - Early disseminate disease===
Features of early disseminated disease can be divided system wise and includes:
*Neurological symptoms: The triad of neurologic manifestation of [[Lyme disease]] includes [[meningitis]], [[cranial]] [[neuritis]], and radiculoneuritis.<ref name="pmid184528002">{{cite journal|author=Halperin JJ|title=Nervous system Lyme disease.|journal=Infect Dis Clin North Am|year=2008|volume=22|issue=2|pages=261-74, vi|pmid=18452800|doi=10.1016/j.idc.2007.12.009|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18452800}}</ref>
**[[Lymphocyte|Lymphocytic]] [[meningitis]] (most common neurological symptom)
**[[Cranial nerve palsies|Cranial neuropathies]] (particularly facial nerve palsy)
**Painful [[radiculitis]]
**[[Mononeuritis multiplex]]<ref name="pmid9066359">{{cite journal| author=England JD, Bohm RP, Roberts ED, Philipp MT| title=Mononeuropathy multiplex in rhesus monkeys with chronic Lyme disease. | journal=Ann Neurol | year= 1997 | volume= 41 | issue= 3 | pages= 375-84 | pmid=9066359 | doi=10.1002/ana.410410313 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9066359  }} </ref>
**[[Altered mental status]]<ref>{{cite journal|author=Chabria SB, Lawrason J|title=Altered mental status, an unusual manifestation of early disseminated Lyme disease: A case report|journal=|volume=1|issue=1|pages=62|year=2007|pmid=17688693|doi=10.1186/1752-1947-1-62}}</ref>
**[[Pseudotumor cerebri]]
**[[Myelitis]]
**[[Chorea]]
**[[Cerebellar ataxia]]
*[[Cardiac]] manifestations
**[[Palpitation|Palpitations]]
**[[Atrioventricular block|Atrio-ventricular block]]
**[[Myopericarditis]]
**[[Sudden cardiac death]]
**Chronic [[cardiomyopathy]]
*[[Dermatological]] manifestations<ref name="pmid15358567">{{cite journal| author=Mullegger RR| title=Dermatological manifestations of Lyme borreliosis. | journal=Eur J Dermatol | year= 2004 | volume= 14 | issue= 5 | pages= 296-309 | pmid=15358567 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15358567  }} </ref>
**Borrelial lymphocytoma: Most common site is [[earlobe]].
*[[Ocular]] manifestations<ref name="pmid14630446">{{cite journal| author=Stanek G, Strle F| title=Lyme borreliosis. | journal=Lancet | year= 2003 | volume= 362 | issue= 9396 | pages= 1639-47 | pmid=14630446 | doi=10.1016/S0140-6736(03)14798-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14630446  }}</ref>
**Primary [[ocular]] symptoms occurs due to [[inflammation]] of [[ocular]] tissue. These symptoms includes [[conjunctivitis]], [[keratitis]], [[iridocyclitis]], [[retinal]] [[vasculitis]], chorioiditis, and [[optic neuropathy]] (extremely rarely [[episcleritis]], panuveitis, panophthalmitis)
*Secondary [[ocular]] symptoms occurs due to extraocular manifestations. These symptoms includes [[Cranial nerve palsies|pareses of cranial nerves]] and [[Orbit (anatomy)|orbital]] [[myositis]].
===Stage 3 - Late disseminated disease===
*Features of late disseminated disease can take months to years to manifest after the onset of [[infection]].
*Lyme arthritis is dominant months later but chronic neurologic involvement becomes more obvious years later.
* The symptoms of late disseminated lyme disease includes:
**[[Musculoskeletal]] manifestation:
***Lyme arthritis
****Lyme arthritis is the hallmark of stage 3 [[Lyme disease]].
****Most frequently presented symptom in late disseminated [[Lyme disease]].
****Commonly affects [[Knee|knee joint]].
**[[Neurology|Neurological]] manifestations:
***These [[neurological]] symptoms may take months to years to manifest after the [[infection]]. In addition to acute symptoms, Neuroborrerliosis can be manifested by a wide-range of [[Neurology|neurological]] disorders, either [[Central nervous system|central]] or [[Peripheral nervous system|peripheral]] including:
**** [[Encephalopathy]] (sub-acute): Affects  [[memory]], [[Mood (psychology)|mood]], [[sleep]], and sometimes with subtle [[language]] disturbances.
**** [[Polyneuropathy]] or  [[Paresthesia]]
**** Leukoencephalitis<ref name="pmid192279822">{{cite journal|year=1991|title=Central nervous system abnormalities in Lyme neuroborreliosis.|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1922798|journal=Neurology|volume=41|issue=10|pages=1571-82|doi=|pmc=|pmid=1922798|author=Halperin JJ, Volkman DJ, Wu P}}</ref>
**** [[Fasciculation|Muscle twitching]]
**** [[Otolaryngology|Otolaryngologic]] manifestations: [[Neck pain]], [[odynophagia]], head and neck [[dysesthesia]], [[otalgia]], [[tinnitus]], [[hearing loss]], [[vertigo]], [[temporomandibular joint pain]], [[lymphadenopathy]], [[dysgeusia]].<ref>{{cite journal|year=1988|title=Borrelia infection and vertigo|journal=Acta Otolaryngol.|volume=106|issue=1-2|pages=111-6|pmid=3421091|author=Rosenhall U, Hanner P, Kaijser B}}</ref><ref>{{cite journal|author=Moscatello AL, Worden DL, Nadelman RB, Wormser G, Lucente F|title=Otolaryngologic aspects of Lyme disease|journal=Laryngoscope|volume=101|issue=6 Pt 1|pages=592-5|year=1991|pmid=2041438}}</ref>
***[[Neuropsychiatric]] symptoms often develop much later in the disease progression, much like tertiary [[neurosyphilis]].<ref name="LogigianKaplan1990">{{cite journal|last1=Logigian|first1=Eric L.|last2=Kaplan|first2=Richard F.|last3=Steere|first3=Allen C.|title=Chronic Neurologic Manifestations of Lyme Disease|journal=New England Journal of Medicine|volume=323|issue=21|year=1990|pages=1438–1444|issn=0028-4793|doi=10.1056/NEJM199011223232102}}</ref>
*** In rare cases, frank [[psychosis]] have been attributed to chronic [[Lyme disease]] effects, including misdiagnoses of [[schizophrenia]] and [[bipolar disorder]].
*** [[Panic attack]] and [[anxiety]] can occur, also [[delusional]] [[behavior]], including somatoform [[delusions]], sometimes accompanied by a [[depersonalization]] or [[derealization]] syndrome similar to what was seen in the past in the prodromal or early stages of general paresis.<ref>{{cite journal|year=1994|title=Lyme disease: a neuropsychiatric illness|journal=The American journal of psychiatry|volume=151|issue=11|pages=1571-83|pmid=7943444|author=Fallon BA, Nields JA}}{{cite journal|author=Hess A, Buchmann J, Zettl UK, ''et al''|title=Borrelia burgdorferi central nervous system infection presenting as an organic schizophrenialike disorder|journal=Biol. Psychiatry|volume=45|issue=6|pages=795|year=1999|pmid=10188012}})</ref>
**Dermatological manifestation<ref name="pmid15358567">{{cite journal| author=Mullegger RR| title=Dermatological manifestations of Lyme borreliosis. | journal=Eur J Dermatol | year= 2004 | volume= 14 | issue= 5 | pages= 296-309 | pmid=15358567 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15358567  }} </ref>
***Acrodermatitis chronica atrophicans
{|
|
|
{|
! style="width: 80px; background: #4479BA; text-align: center;" colspan="2" |{{fontcolor|#FFF||Symptoms differentiated on the basis of frequency}}
<ref name="Ciesielski_198922">{{cite journal|year=1989|title=Lyme disease surveillance in the United States, 1983-1986|journal=Rev. Infect. Dis.|volume=11 Suppl 6|issue=|pages=S1435-41|pmid=2682955|author=Ciesielski CA, Markowitz LE, Horsley R, Hightower AW, Russell H, Broome CV}}</ref>
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Common symptoms'''
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Less common symptoms'''
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |
*Erythema migrans(Erythema chronicum migrans)
*Constitutional symptoms
*Arthritis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |
*Cardiac manifestations
*Neurological manifestations
|}
{|
! style="width: 80px; background: #4479BA; text-align: center;" colspan="3" |{{fontcolor|#FFF||Difference in clinical features in Europe and North America}}<ref name="pmid18452805">{{cite journal| author=Stanek G, Strle F| title=Lyme disease: European perspective. | journal=Infect Dis Clin North Am | year= 2008 | volume= 22 | issue= 2 | pages= 327-39, vii | pmid=18452805 | doi=10.1016/j.idc.2008.01.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18452805  }}</ref>
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Features'''
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Europe'''
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''North America'''
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | Erythema migrans
|Single lesion more frequently
|Multiple lesions occurs more freuqently
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | Heterogenous dissemination
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Less common
| style="background: #DCDCDC; padding: 5px; text-align: center;" | More common
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | Borrelial lymphocytoma
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Present
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Absent
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | Acrodermatitis chronica atrophicans
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Present
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Absent
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | Meningoradiculoneuritis
| style="background: #DCDCDC; padding: 5px; text-align: center;" | More common
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Less common
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | Lyme arthritis
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Rarely preceded by Erythema migrans
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Commonly preceded by Erythema migrans
|}
|
|
[[image:Symptoms of lyme disease 2001-2015.jpg|center|700px|thumb|Frequency of Lyme disease symptoms, 2001-2015]]
|}
==Lyme Carditis==
*[[Cardiac]] involvement occurs in about 5—10% of untreated [[Lyme disease]] and patients usually have symptoms related to fluctuating degrees of [[atrioventricular block]] ([[First degree AV block|first-degree block]] to [[complete heart block]]) including [[lightheadedness]], [[palpitations]], [[shortness of breath]], [[chest pain]], and [[syncope]].<ref name="pmid22868858">{{cite journal| author=Hu LT| title=In the clinic. Lyme disease. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 3 | pages= ITC2-2 - ITC2-16 | pmid=22868858 | doi=10.7326/0003-4819-157-3-20120807-01002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22868858  }} </ref>
*Less commonly, patients may present with an acute picture of [[left ventricular dysfunction]], [[cardiomegaly]], [[perimyocarditis]], or pancarditis without noticeable [[cardiac murmurs]].<ref name="Steere1989">{{cite journal|last1=Steere|first1=Allen C.|title=Lyme Disease|journal=New England Journal of Medicine|volume=321|issue=9|year=1989|pages=586–596|issn=0028-4793|doi=10.1056/NEJM198908313210906}}</ref>
*Lyme [[carditis]] can occur independently, it is usually accompanied by other [[cutaneous]], [[joint]], or [[Neurology|neurologic]] features of [[Lyme disease]].<ref name="FishPride2008">{{cite journal|last1=Fish|first1=Airley E.|last2=Pride|first2=Yuri B.|last3=Pinto|first3=Duane S.|title=Lyme Carditis|journal=Infectious Disease Clinics of North America|volume=22|issue=2|year=2008|pages=275–288|issn=08915520|doi=10.1016/j.idc.2007.12.008}}</ref>
==Manifestations of Lyme Disease by Stage==
{| align="center" style="font-size:85%;" border="1" cellspacing="0" cellpadding="4"
|+ '''Manifestations of Lyme Disease by Stage'''<ref name="pmid 2668764">{{cite journal| author=Steere AC| title=Lyme disease. | journal=N Engl J Med | year= 1989 | volume= 321 | issue= 9 | pages= 586-96 | pmid= 2668764 | doi=10.1056/NEJM198908313210906 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2668764  }}</ref>
|-
| style="background:LightSlateGray; width:15%;" | '''System''' || style="background: #efefef; width:25%;" | '''Stage 1 (Localized Infection)''' || style="background: #efefef; width:25%;" | '''Stage 2 (Early Disseminated Infection)''' || style="background: #ffdead; width:35%" | '''Stage 3 (Late Persistent Infection)'''
|-
| ''Skin'' || valign="top" |
* [[Erythema migrans]]
| valign="top" |
* Secondary annular lesions
* [[Malar rash]]
* Diffuse [[erythema]] or [[urticaria]]
* Evanescent lesions
* Lymphocytoma
| valign="top" |
* [[Acrodermatitis chronica atrophicans]]
* Localized [[scleroderma]]-like lesions
|-
|
|
* ''Musculoskeletal''
|
|
* —
|
| valign="top" |
* Migratory [[arthralgia]]
* Brief [[arthritis]] attacks
* [[Myositis]]
* [[Osteomyelitis]]
* [[Panniculitis]]
| valign="top" |
* Prolonged [[arthritis]] attacks
* Chronic [[arthritis]]
* Peripheral [[enthesopathy]]
* [[Periostitis]] or joint subluxations below acrodermatitis
|-
| ''Neurologic'' || — || valign="top" |
* [[Meningitis]]
* Cranial [[neuritis]] or [[Bell's palsy]]
* Motor or sensory radiculoneuritis
* [[Encephalitis]]
* [[Mononeuritis multiplex]]
* [[Pseudotumor cerebri]]
* [[Myelitis]]
* [[Chorea]]
* [[Cerebellar ataxia]]
| valign="top" |
* Chronic [[encephalomyelitis]]
* Spastic parapareses
* [[Ataxic gait]]
* Mental disorders
* Chronic axonal polyradiculopathy
* [[Dementia]]
|-
| ''Lymphatic'' || valign="top" |
* Regional [[lymphadenopathy]]
| valign="top" |
* Regional or generalized [[lymphadenopathy]]
* [[Splenomegaly]]
| —
|-
| ''Heart'' || — || valign="top" |
* [[Atrioventricular block]]
* [[Myopericarditis]]
* Pancarditis
| —
|-
| ''Eyes'' || — || valign="top" |
* [[Conjunctivitis]]
 
* [[Iritis]]
* [[Choroiditis]]
* Retinal hemorrhage or [[retinal detachment]]
* Panophthalmitis
| valign="top" |
* [[Keratitis]]
|-
|-
|
|
* ''Liver''
|
|
* —
|
* Mild or recurrent [[hepatitis]]
| —
|-
| ''Respiratory'' || — || valign="top" |
* Nonexudative [[sore throat]]
* Nonproductive [[cough]]
* [[Adult respiratory distress syndrome]]
| —
|-
| ''Kidney'' || — || valign="top" |
* Microscopic [[hematuria]] or [[proteinuria]]
| —
|-
| ''Genitourinary'' || — ||
* [[Orchitis]]
| —
|-
| ''Constitutional systems'' ||
* [[Fatigue]]
* [[Arthralgia]]
* [[Myalgia]]
* [[Headache]]
* [[Fever]] and/or [[chills]]
* [[Stiff neck]]
* [[Anorexia]]
|
|
* Severe [[malaise]] and [[fatigue]]
|
|
* [[Fatigue]]
|}
|}
<SMALL><span style="align=center">''Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.''</span></SMALL>


==References==
==References==
{{Reflist|2}}
{{reflist|2}}
 
[[Category:Bacterial diseases]]
[[Category:Insect-borne diseases]]
[[Category:Lyme disease]]
[[Category:Zoonoses]]
[[Category:Spirochaetes]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Dermatology]]
 
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Latest revision as of 17:32, 14 January 2019


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]

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