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 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.

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 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)

Symptoms

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: CDC.gov
Lyme disease, expanding rash with central clearing - Source: CDC.gov

Stage 2 - Early disseminate disease

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

Disseminated Lyme disease, multiple rash - Source: CDC.gov

Stage 3 - Late disseminated disease

Symptoms differentiated on the basis of frequency

[16]

Common symptoms Less common symptoms
Frequency of Lyme disease symptoms, 2001-2015 - Source: CDC.gov/
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)
Skin
Musculoskeletal
Neurologic
Lymphatic
Heart
Eyes
Liver
Respiratory
Kidney
Genitourinary
Flu-like symptoms 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. 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.
  26. Steere AC, Schoen RT, Taylor E (1987). "The clinical evolution of Lyme arthritis". Ann Intern Med. 107 (5): 725–31. PMID 3662285.
  27. 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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