Lyme disease history and symptoms: Difference between revisions
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In addition to the acute symptoms, chronic Lyme disease can be manifested by a wide-range of neurological disorders, either | In addition to the acute symptoms, chronic Lyme disease can be manifested by a wide-range of neurological disorders, either | ||
[[central nervous system|central]] or [[peripheral nervous system|peripheral]], including [[encephalitis]] or [[encephalomyelitis]], [[Fasciculation|muscle twitching]], [[polyneuropathy]] or [[paresthesia]], and [[balance disorder|vestibular symptoms]] or other [[Otolaryngology|otolaryngologic]] symptoms,<ref>{{cite journal |author=Rosenhall U, Hanner P, Kaijser B |title=Borrelia infection and vertigo |journal=Acta Otolaryngol. |volume=106 |issue=1-2 |pages=111-6 |year=1988 |pmid=3421091}}</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> among others. Neuropsychiatric disturbances can occur (possibly from a low-level [[encephalitis]]), which may lead to symptoms of [[memory loss]], [[sleep disturbance]]s, or changes in [[Mood (psychology)|mood]] or [[Affect (psychology)|affect]]. In rare cases, frank [[psychosis]] have been attributed to chronic Lyme disease effects, including mis-diagnoses of [[schizophrenia]] and [[bipolar disorder]]. Panic attack and anxiety can occur, also delusional behavior, including somataform 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 |author=Fallon BA, Nields JA |title=Lyme disease: a neuropsychiatric illness |journal=The American journal of psychiatry |volume=151 |issue=11 |pages=1571-83 |year=1994 |pmid=7943444}}{{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> | [[central nervous system|central]] or [[peripheral nervous system|peripheral]], including [[encephalitis]] or [[encephalomyelitis]], [[Fasciculation|muscle twitching]], [[polyneuropathy]] or [[paresthesia]], and [[balance disorder|vestibular symptoms]] or other [[Otolaryngology|otolaryngologic]] symptoms,<ref>{{cite journal |author=Rosenhall U, Hanner P, Kaijser B |title=Borrelia infection and vertigo |journal=Acta Otolaryngol. |volume=106 |issue=1-2 |pages=111-6 |year=1988 |pmid=3421091}}</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> among others. Neuropsychiatric disturbances can occur (possibly from a low-level [[encephalitis]]), which may lead to symptoms of [[memory loss]], [[sleep disturbance]]s, or changes in [[Mood (psychology)|mood]] or [[Affect (psychology)|affect]]. In rare cases, frank [[psychosis]] have been attributed to chronic Lyme disease effects, including mis-diagnoses of [[schizophrenia]] and [[bipolar disorder]]. Panic attack and anxiety can occur, also delusional behavior, including somataform 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 |author=Fallon BA, Nields JA |title=Lyme disease: a neuropsychiatric illness |journal=The American journal of psychiatry |volume=151 |issue=11 |pages=1571-83 |year=1994 |pmid=7943444}}{{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> | ||
==Lyme Carditis== | |||
Lyme carditis (or cardiac Lyme borreliosis) is one of the extracutaneous presentations at early disseminated (stage 2) infection which typically develops within several weeks after the onset of the illness. [[Borrelia burgdorferi|Borrelial]] spirochetes have been shown to infiltrate [[epicardium]], [[myocardium]], or [[endocardium]] and cause diffuse perivascular lymphoplasmacellular or lymphohistiocytic [[inflammation]].<ref name="Steere-1980">{{Cite journal | last1 = Steere | first1 = AC. | last2 = Batsford | first2 = WP. | last3 = Weinberg | first3 = M. | last4 = Alexander | first4 = J. | last5 = Berger | first5 = HJ. | last6 = Wolfson | first6 = S. | last7 = Malawista | first7 = SE. | title = Lyme carditis: cardiac abnormalities of Lyme disease. | journal = Ann Intern Med | volume = 93 | issue = 1 | pages = 8-16 | month = Jul | year = 1980 | doi = | PMID = 6967274 }}</ref> 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>{{cite journal|doi=10.7326/0003-4819-157-3-20120807-01002}}</ref> Less commonly, patients may present with an acute picture of left ventricular dysfunction, [[cardiomegaly]], [[perimyocarditis]], or pancarditis without noticeable [[cardiac murmurs]].<ref name="Steere-1989">{{Cite journal | last1 = Steere | first1 = AC. | title = Lyme disease. | journal = N Engl J Med | volume = 321 | issue = 9 | pages = 586-96 | month = Aug | year = 1989 | doi = 10.1056/NEJM198908313210906 |PMID = 2668764 }}</ref> While Lyme carditis can occur independently, it is usually accompanied by other cutaneous, joint, or neurologic features of Lyme disease.<ref name="Fish-2008">{{Cite journal | last1 = Fish | first1 = AE. | last2 = Pride | first2 = YB. | last3 = Pinto | first3 = DS. | title = Lyme carditis. | journal = Infect Dis Clin North Am | volume = 22 | issue = 2 | pages = 275-88, vi | month = Jun | year = 2008 | doi = 10.1016/j.idc.2007.12.008 | PMID = 18452801 }}</ref> | |||
Patients with high-grade first-degree and advanced [[atrioventricular block]] should be hospitalized and closely monitored. [[Temporary cardiac pacing]] might be considered is selected cases of [[complete heart block]] and [[hemodynamic instability]]. With appropriate [[antibiotic]] therapy,<ref name="WormserDattwyler2006">{{cite journal|last1=Wormser|first1=Gary P.|last2=Dattwyler|first2=Raymond J.|last3=Shapiro|first3=Eugene D.|last4=Halperin|first4=John J.|last5=Steere|first5=Allen C.|last6=Klempner|first6=Mark S.|last7=Krause|first7=Peter J.|last8=Bakken|first8=Johan S.|last9=Strle|first9=Franc|last10=Stanek|first10=Gerold|last11=Bockenstedt|first11=Linda|last12=Fish|first12=Durland|last13=Stephen Dumler|first13=J.|last14=Nadelman|first14=Robert B.|title=The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America|journal=Clinical Infectious Diseases|volume=43|issue=9|year=2006|pages=1089–1134|issn=1058-4838|doi=10.1086/508667}}</ref> Lyme carditis has a favorable prognosis and generally resolves within 1 to 6 weeks depending on the degree of [[conduction disturbances]].<ref name="McAlister-1989">{{Cite journal | last1 = McAlister | first1 = HF. | last2 = Klementowicz | first2 = PT. | last3 = Andrews | first3 = C. | last4 = Fisher | first4 = JD. | last5 = Feld | first5 = M. | last6 = Furman | first6 = S. | title = Lyme carditis: an important cause of reversible heart block. | journal = Ann Intern Med | volume = 110 | issue = 5 | pages = 339-45 | month = Mar | year = 1989 | doi = | PMID = 2644885 }}</ref> However, a total of seven deaths from Lyme carditis have been reported until the year of 2013.<ref name="www.cdc.gov">{{Cite web | last = | first = | title = Three Sudden Cardiac Deaths Associated with Lyme Carditis — United States, November 2012–July 2013 | url = http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6249a1.htm?s_cid=mm6249a1_w | publisher = | date = | accessdate = 13 December 2013 }}</ref> | |||
==Manifestations of Lyme Disease by Stage== | ==Manifestations of Lyme Disease by Stage== | ||
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| ''Skin'' ||valign="top"| ▸ [[Erythema migrans]] ||valign="top"| ▸ Secondary annular lesions <BR> ▸ [[Malar rash]] <BR> ▸ Diffuse [[erythema]] or [[urticaria]] <BR> ▸ Evanescent lesions <BR> ▸ Lymphocytoma ||valign="top"| ▸ [[Acrodermatitis chronica atrophicans]] <BR> ▸ Localized [[scleroderma]]-like lesions | | ''Skin'' ||valign="top"| ▸ [[Erythema migrans]] ||valign="top"| ▸ Secondary annular lesions <BR> ▸ [[Malar rash]] <BR> ▸ Diffuse [[erythema]] or [[urticaria]] <BR> ▸ Evanescent lesions <BR> ▸ Lymphocytoma ||valign="top"| ▸ [[Acrodermatitis chronica atrophicans]] <BR> ▸ Localized [[scleroderma]]-like lesions | ||
|- | |- | ||
| ''Musculoskeletal'' || ||valign="top"| ▸ Migratory [[arthralgia]] <BR> ▸ Brief [[arthritis]] attacks <BR> ▸ [[Myositis]] <BR> ▸ [[Osteomyelitis]] <BR> ▸ [[Panniculitis]]||valign="top"| ▸ Prolonged [[arthritis]] attacks <BR> ▸ Chronic [[arthritis]] <BR> ▸ Peripheral [[enthesopathy]] <BR> ▸ [[Periostitis]] or joint subluxations below acrodermatitis | | ''Musculoskeletal'' || ||valign="top"| ▸ Migratory [[arthralgia]] <BR> ▸ Brief [[arthritis]] attacks <BR> ▸ [[Myositis]] <BR> ▸ [[Osteomyelitis]] <BR> ▸[[Panniculitis]]||valign="top"| ▸ Prolonged [[arthritis]] attacks <BR> ▸ Chronic [[arthritis]] <BR> ▸ Peripheral [[enthesopathy]] <BR> ▸ [[Periostitis]] or joint subluxations below acrodermatitis | ||
|- | |- | ||
| ''Neurologic'' || ||valign="top"| ▸ [[Meningitis]] <BR> ▸ Cranial [[neuritis]] or [[Bell's palsy]] <BR> ▸ Motor or sensory radiculoneuritis <BR> ▸ [[Encephalitis]] <BR> ▸[[Mononeuritis multiplex]] <BR> ▸ [[Pseudotumor cerebri]] <BR> ▸ [[Myelitis]] <BR> ▸ [[Chorea]] <BR> ▸ [[Cerebellar ataxia]] ||valign="top"| ▸ Chronic [[encephalomyelitis]] <BR> ▸ Spastic parapareses <BR> ▸ [[Ataxic gait]] <BR> ▸ Mental disorders <BR> ▸ Chronic axonal polyradiculopathy <BR> ▸ [[Dementia]] | | ''Neurologic'' || ||valign="top"| ▸ [[Meningitis]] <BR> ▸ Cranial [[neuritis]] or [[Bell's palsy]] <BR> ▸ Motor or sensory radiculoneuritis <BR> ▸ [[Encephalitis]] <BR>▸[[Mononeuritis multiplex]] <BR> ▸ [[Pseudotumor cerebri]] <BR> ▸ [[Myelitis]] <BR> ▸ [[Chorea]] <BR> ▸ [[Cerebellar ataxia]] ||valign="top"| ▸ Chronic [[encephalomyelitis]] <BR> ▸ Spastic parapareses <BR> ▸ [[Ataxic gait]] <BR> ▸ Mental disorders <BR> ▸ Chronic axonal polyradiculopathy <BR> ▸ [[Dementia]] | ||
|- | |- | ||
| ''Lymphatic'' ||valign="top"| ▸ Regional [[lymphadenopathy]] ||valign="top"| ▸ Regional or generalized [[lymphadenopathy]] <BR> ▸ [[Splenomegaly]] || | | ''Lymphatic'' ||valign="top"| ▸ Regional [[lymphadenopathy]] ||valign="top"| ▸ Regional or generalized [[lymphadenopathy]] <BR> ▸ [[Splenomegaly]] || | ||
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<SMALL><span style="align=center">''Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.''</span></SMALL> | <SMALL><span style="align=center">''Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.''</span></SMALL> | ||
==References== | ==References== | ||
Revision as of 20:26, 13 December 2013
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
History and Symptoms
The acute phase of Lyme disease infection is a characteristic reddish "bulls-eye" rash, with accompanying fever, malaise, and musculoskeletal pain (arthralgia or myalgia). The characteristic reddish "bull's-eye" rash (known as erythema chronicum migrans) may be seen in up to 80% of early stage Lyme disease patients,[1] appearing anywhere from one day to a month after a tick bite.[2] The rash does not represent an allergic reaction to the bite, but rather a skin infection with the Lyme bacteria, Borrelia burgdorferi sensu lato.
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.[3] Asymptomatic infection exists, but is uncommon.[4]
Other, less common findings in acute Lyme disease include cardiac manifestations (up to 10% of patients may have cardiac manifestations including heart block and palpitations[5]), neurologic symptoms (neuroborreliosis may occur in up to 18%), as well as simple altered mental status as the sole presenting symptom has been reported in early neuroborreliosis.[6]
Chronic Symptoms
Untreated or persistent cases may progress to a chronic form most commonly characterized by meningoencephalitis, cardiac inflammation (myocarditis), and frank arthritis. It should be noted, however, that chronic Lyme disease can have a multitude of symptoms affecting numerous physiological systems: the symptoms appear heterogeneous in the affected population, which may be due to innate immunity or variations in Borrelia bacteria. Late symptoms of Lyme disease can appear months or years after initial infection and often progress in cumulative fashion over time. Neuropsychiatric symptoms often develop much later in the disease progession, much like tertiary neurosyphilis.
In addition to the acute symptoms, chronic Lyme disease can be manifested by a wide-range of neurological disorders, either central or peripheral, including encephalitis or encephalomyelitis, muscle twitching, polyneuropathy or paresthesia, and vestibular symptoms or other otolaryngologic symptoms,[7][8] among others. Neuropsychiatric disturbances can occur (possibly from a low-level encephalitis), which may lead to symptoms of memory loss, sleep disturbances, or changes in mood or affect. In rare cases, frank psychosis have been attributed to chronic Lyme disease effects, including mis-diagnoses of schizophrenia and bipolar disorder. Panic attack and anxiety can occur, also delusional behavior, including somataform 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.[9]
Lyme Carditis
Lyme carditis (or cardiac Lyme borreliosis) is one of the extracutaneous presentations at early disseminated (stage 2) infection which typically develops within several weeks after the onset of the illness. Borrelial spirochetes have been shown to infiltrate epicardium, myocardium, or endocardium and cause diffuse perivascular lymphoplasmacellular or lymphohistiocytic inflammation.[10] 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 block to complete heart block) including lightheadedness, palpitations, shortness of breath, chest pain, and syncope.[11] Less commonly, patients may present with an acute picture of left ventricular dysfunction, cardiomegaly, perimyocarditis, or pancarditis without noticeable cardiac murmurs.[12] While Lyme carditis can occur independently, it is usually accompanied by other cutaneous, joint, or neurologic features of Lyme disease.[13]
Patients with high-grade first-degree and advanced atrioventricular block should be hospitalized and closely monitored. Temporary cardiac pacing might be considered is selected cases of complete heart block and hemodynamic instability. With appropriate antibiotic therapy,[14] Lyme carditis has a favorable prognosis and generally resolves within 1 to 6 weeks depending on the degree of conduction disturbances.[15] However, a total of seven deaths from Lyme carditis have been reported until the year of 2013.[16]
Manifestations of Lyme Disease by Stage
| System | Stage 1 (Localized Infection) | Stage 2 (Disseminated Infection) | Stage 3 (Persistent Infection) |
| Skin | ▸ Erythema migrans | ▸ Secondary annular lesions ▸ Malar rash ▸ Diffuse erythema or urticaria ▸ Evanescent lesions ▸ Lymphocytoma |
▸ Acrodermatitis chronica atrophicans ▸ Localized scleroderma-like lesions |
| Musculoskeletal | ▸ Migratory arthralgia ▸ Brief arthritis attacks ▸ Myositis ▸ Osteomyelitis ▸Panniculitis |
▸ Prolonged arthritis attacks ▸ Chronic arthritis ▸ Peripheral enthesopathy ▸ Periostitis or joint subluxations below acrodermatitis | |
| Neurologic | ▸ Meningitis ▸ Cranial neuritis or Bell's palsy ▸ Motor or sensory radiculoneuritis ▸ Encephalitis ▸Mononeuritis multiplex ▸ Pseudotumor cerebri ▸ Myelitis ▸ Chorea ▸ Cerebellar ataxia |
▸ Chronic encephalomyelitis ▸ Spastic parapareses ▸ Ataxic gait ▸ Mental disorders ▸ Chronic axonal polyradiculopathy ▸ Dementia | |
| Lymphatic | ▸ Regional lymphadenopathy | ▸ Regional or generalized lymphadenopathy ▸ Splenomegaly |
|
| Heart | ▸ Atrioventricular block ▸ Myopericarditis ▸ Pancarditis |
||
| Eyes | ▸ Conjunctivitis ▸ Iritis ▸ Choroiditis ▸ Retinal hemorrhage or retinal detachment ▸ Panophthalmitis |
▸ Keratitis | |
| Liver | ▸ Mild or recurrent hepatitis | ||
| Respiratory | ▸ Nonexudative sore throat ▸ Nonproductive cough ▸ Adult respiratory distress syndrome |
||
| Kidney | ▸ Microscopic hematuria or proteinuria | ||
| Genitourinary | ▸ Orchitis | ||
| Constitutional systems | ▸ Minor | ▸ Severe malaise and fatigue | ▸ Fatigue |
Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.
References
- ↑ CDC (2005-07-06). "Lyme Disease Erythema Migrans". Retrieved 2007-08-21.
- ↑ Donta ST (2002). "Late and chronic Lyme disease". Med Clin North Am. 86 (2): 341–9, vii. PMID 11982305.
- ↑ Edlow JA (2007-01-25). "Lyme disease". eMedicine. Retrieved 2007-08-21.
- ↑ Steere AC, Sikand VK, Schoen RT, Nowakowski J (2003). "Asymptomatic infection with Borrelia burgdorferi". Clin. Infect. Dis. 37 (4): 528–32. PMID 12905137.
- ↑ 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.
- ↑ 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.
- ↑ Rosenhall U, Hanner P, Kaijser B (1988). "Borrelia infection and vertigo". Acta Otolaryngol. 106 (1–2): 111–6. PMID 3421091.
- ↑ 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.
- ↑ 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.)
- ↑ Steere, AC.; Batsford, WP.; Weinberg, M.; Alexander, J.; Berger, HJ.; Wolfson, S.; Malawista, SE. (1980). "Lyme carditis: cardiac abnormalities of Lyme disease". Ann Intern Med. 93 (1): 8–16. PMID 6967274. Unknown parameter
|month=ignored (help) - ↑ . doi:10.7326/0003-4819-157-3-20120807-01002. Missing or empty
|title=(help) - ↑ 12.0 12.1 Steere, AC. (1989). "Lyme disease". N Engl J Med. 321 (9): 586–96. doi:10.1056/NEJM198908313210906. PMID 2668764. Unknown parameter
|month=ignored (help) - ↑ Fish, AE.; Pride, YB.; Pinto, DS. (2008). "Lyme carditis". Infect Dis Clin North Am. 22 (2): 275–88, vi. doi:10.1016/j.idc.2007.12.008. PMID 18452801. Unknown parameter
|month=ignored (help) - ↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Stephen Dumler, J.; Nadelman, Robert B. (2006). "The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1058-4838.
- ↑ McAlister, HF.; Klementowicz, PT.; Andrews, C.; Fisher, JD.; Feld, M.; Furman, S. (1989). "Lyme carditis: an important cause of reversible heart block". Ann Intern Med. 110 (5): 339–45. PMID 2644885. Unknown parameter
|month=ignored (help) - ↑ "Three Sudden Cardiac Deaths Associated with Lyme Carditis — United States, November 2012–July 2013". Retrieved 13 December 2013.
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