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.


Lyme disease is divided into 3 stages and the symptoms are stage specific. Initial symptoms include bullseye rash called erythema migrans, with accompanying flu-like symptoms. Lyme disease can progress to cardiovascular, neurological, dermatological and/or musculoskeletal manifestations. Multiple erythema migrans develops as disease disseminates throughout the body. Most common neurological manifestation includes lymphocytic meningitis and cranial nerve palsies (usually facial nerve palsy). Dermatological manifestation includes borrelial lymphocytoma and acrodermatitis chronica atrophicans appearing in stage 2 and stage 3 Lyme disease respectively. Cardiac manifestation include Lyme carditis. Musculoskeletal manifestation include Lyme arthritis. There is a difference in clinical features of Lyme disease in patients living in different geographical regions depending on the genospecies of Borrelia burgdorferi sensu lato complex causing it.


  • 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 can happen, but is uncommon.[2]
  • The specific areas of focus when obtaining patient history are outlined below:
    • Tick bite
    • Vacation, living, or working environment in endemic areas
    • Spending time outdoors (especially in woody or grassy areas)


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

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

Stage 1 - Early localized disease

Features of early localized disease includes erythema migrans and flu-like symptoms.

Classic Lyme disease rash - Source:
Lyme disease, expanding rash with central clearing - Source:

Stage 2 - Early disseminate disease

Features of early disseminated disease can be divided by organ system and include:

Disseminated Lyme disease, multiple rash - Source:

Stage 3 - Late disseminated disease

Symptoms differentiated on the basis of frequency


Common symptoms Less common symptoms
Frequency of Lyme disease symptoms, 2001-2015 - Source:
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

Lyme Carditis

Lyme Arthritis

Manifestations of Lyme Disease by Stage

Manifestations of Lyme Disease by Stage[24]
System Stage 1 (Localized Infection) Stage 2 (Early Disseminated Infection) Stage 3 (Late Persistent Infection)
Flu-like symptoms systems

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


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  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.
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  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.
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  23. 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.
  24. 24.0 24.1 Steere, Allen C. (1989). "Lyme Disease". New England Journal of Medicine. 321 (9): 586–596. doi:10.1056/NEJM198908313210906. ISSN 0028-4793.
  25. 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.
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