What is Lyme Disease?
Lyme disease, also known as Lyme borreliosis, is the most common tick-borne infection in the United States and one of the most frequent globally. It progresses in three phases: early localized, early spread out, and late. During the early localized stage, symptoms like a reddish, ring-shaped rash that grows bigger near the area of a recent tick bite become visible. At this stage, individuals may also experience flu-like symptoms such as tiredness, headaches, fever, muscle ache, and joint pain. Most patients only experience these early localized symptoms.
About 20% of patients progress to the early spread-out stage of the disease, characterized by multiple similar rashes. Other symptoms at this stage include flu-like symptoms, swelling of the lymph nodes, joint pain, muscle ache, paralysis of facial nerves, eye conditions, and inflammation of the protective membranes covering the brain and spinal cord (lymphocytic meningitis). Heart-related issues such as abnormal heart rhythms, inflammation of the heart muscle, or inflammation of the tissue surrounding the heart may also occur. The most common symptom in the late stage of Lyme disease is arthritis that typically affects larger joints, mainly the knees.
Diagnosing Lyme disease can be challenging, as many people do not remember getting bitten by a tick. However, in regions where Lyme disease is common, patients who display typical rash can be started on treatment even before blood test results are available.
What Causes Lyme Disease?
In the United States, Lyme disease is caused by a specific bacteria called Borrelia burgdorferi. This bacteria gets into our bodies through the bite of a tick, specifically the Ixodes genus tick, and most commonly, the Ixodes scapularis tick. In Europe and Asia, the main culprits behind Lyme disease are the same Borrelia burgdorferi, as well as Borrelia afzelii and Borrelia garinii.
Each of these bacteria has a preference for certain parts of the body. For example, Borrelia burgdorferi likes to settle in the joints. Borrelia garinii, which is only found in Europe, is known to cause a condition known as white matter encephalitis, targeting the brain. Borrelia afzelii mainly targets the skin and can often be found at the site of the infection. It’s important to know that different types of Ixodes ticks can carry and transmit these Borrelia bacteria.
Risk Factors and Frequency for Lyme Disease
Lyme disease is often reported in the Northeastern and upper Midwestern United States, particularly in states like Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin. There are also occasional instances of this disease in northern parts of California, Oregon, and Washington.
In the regions where Lyme disease is prevalent, about 40 in 100,000 people are affected by it. The disease often surfaces in late spring, summer, and early fall.
- Furthermore, for unknown reasons, Lyme disease is frequently noted in Caucasians, but it can affect people of all races.
- In darker-skinned individuals, it might be harder to detect the skin lesions associated with the disease.
- People of all age groups can contract Lyme disease, but it appears to be slightly more common in females.
Signs and Symptoms of Lyme Disease
Localized Lyme disease typically shows up 1-2 weeks after a person has been bit by a tick in an area where Lyme disease is commonly found. The main sign is a skin condition called erythema migrans. However, this could also be confused with other skin problems like tinea and nummular eczema. Without proper treatment, the disease can spread or develop into late-stage Lyme disease. Early neurological symptoms of Lyme disease can range from facial nerve paralysis, lymphocytic meningitis, to radiculopathy. It could also affect the heart, causing myopericarditis and presenting as heart block. Lyme arthritis is another symptom and it usually affects one or few large joints, most commonly the knee, several months after the initial tick bite.
Seeing as the symptoms are not specific to Lyme disease, coinfections, such as those with Babesia microti and Ehrlichia, should also be considered. Coinfections have been found in about 10% of patients.
Like syphilis, Lyme disease can be divided into three stages: localized, disseminated, and persistent. The first two stages represent early infection while the third stage represents persistent or chronic disease. The third stage usually sets in within 12 months of the infection.
- Stage 1: Early localized disease. This may be marked by erythema migrans and a low-fever, typically showing up 1-28 days after the tick bite. Itchiness or burning sensation, flu-like symptoms, eye redness, and tearing might occur.
- Stage 2: Sets in 3-12 weeks after infection. Common manifestations can include general discomfort, fever, neurological symptoms, muscle pain, and cardiac symptoms. Joints such as the knee, ankle, and wrist are often affected. In some cases, conditions such as encephalopathy, meningitis, Bell’s palsy may occur
- Stage 3: Late Lyme disease. This stage can set in months or years after the initial infection and is usually marked by neurological and rheumatological problems. Patients might present with aseptic meningitis, Bell’s palsy, arthritis, cognitive deficits or dysesthesias. Cardiac involvement in stage 3 could result in arrhythmias or transient heart block.
It’s important to note that Lyme disease can also present differently based on regions. For example, in Europe, a rare presentation of early Lyme disease is Borrelia lymphocytoma, which appears as a red-bluish swelling on the ear lobe or areola of the nipple. The neurological and psychiatric symptoms are similar to those experienced in fibromyalgia. The rare condition of Borrelia encephalomyelitis could cause issues such as ataxia, seizures, hemiparesis, autonomic dysfunction, and hearing loss. Acrodermatitis chronica atrophicans, another symptom, is usually seen in older women and tends to affect the backs of the hands and feet.
Testing for Lyme Disease
In areas where Lyme disease is common, if you have the characteristic rash and recent tick exposure, you can start treatment without waiting for test results. However, often the symptoms are nonspecific, and most people don’t remember a tick bite or didn’t develop the rash, which means testing is necessary.
Blood tests for Lyme disease aren’t too sensitive during the first weeks of infection, so when you have the telltale rash alongside a history of living in or visiting an area known for Lyme disease, you might be treated based on these clinical signs.
But, when it comes to late-stage Lyme disease, a two-step diagnostic approach is recommended. The first step involves an enzyme immunoassay (EIA) or immunofluorescent antibody assay (IFA) to screen for antibodies to B burgdorferi – the bacteria causing Lyme disease. If results are positive or unclear, a follow-up Western blot test is performed. If patients show neurological or heart symptoms, this blood-based diagnosis is usually correct more than 80% of the time.
However, it’s not advisable to perform serial blood tests early on because the related antibody levels often remain high for an extended period. Testing the tick itself or doing a skin biopsy isn’t generally recommended.
You may get other blood work done, which could show an increased ESR (erythrocyte sedimentation rate) – a sign of inflammation, a decreased white blood cell count, or a decreased platelet count. A joint fluid test is suggested only if there’s a suspicion of infectious arthritis.
In children, the chance of contracting Lyme meningitis—a type of brain inflammation—is low given the following conditions: headache has lasted less than a week, there are less than 70% mononuclear cells in the cerebrospinal fluid (CSF), and there’s no facial or other cranial nerve weakness.
An ECG might show a heart block, and brain scans may reveal abnormalities in about 20% of patients with CNS symptoms. Most common abnormalities are small lesions in the brain’s white matter. Borrelia species, the bacteria causing Lyme Disease, are tough to grow in the lab and are usually not tested routinely.
Treatment Options for Lyme Disease
The treatment for Lyme disease varies based on the patient’s age and how advanced the disease is. If a patient over the age of 8 has early-stage Lyme disease which hasn’t spread, doctors will typically recommend a 10-day course of the antibiotic doxycycline. However, in children under the age of 8, the treatment is different due to the risk of tooth staining caused by doxycycline. Instead, these children are given a 14-day course of amoxicillin or cefuroxime.
For more severe cases of Lyme Disease that involve complications like arthritis, heart block, inflammation of the heart, meningitis, or encephalitis, the treatment may involve longer use of antibiotics and potentially an intravenous administration. Yet, some newer research suggests that in certain cases, oral antibiotic treatments or transitioning to oral antibiotics at the time of leaving the hospital could be sufficient.
Doxycycline is commonly prescribed for most patients except for children and pregnant individuals due to safety concerns. Children are generally treated with amoxicillin, while pregnant women usually respond well to the antibiotic cefuroxime.
If a patient presents with Lyme carditis, which is a heart complication of Lyme disease, they should be admitted to the hospital for monitoring until their electrocardiogram (ECG), which shows the electrical activity of the heart, returns to normal. Joint inflammation from Lyme disease, called Lyme arthritis, usually clears up in about 6-8 weeks. Infections of the central nervous system from Lyme disease generally respond well to the antibiotic cefuroxime.
When a patient starts therapy for Lyme disease, they may experience something called the Jarisch-Herxheimer reaction. This is a temporary reaction to antibiotic treatment, as the antibiotics destroy Lyme disease-causing bacteria in the body, leading to inflammatory symptoms. This reaction occurs in around 5-15% of Lyme disease patients and usually resolves on its own within a day.
Eye-related symptoms from Lyme disease can be treated with topical steroids and intravenous antibiotics like ceftriaxone or penicillin. However, some patients may experience lingering, nonspecific symptoms even after treatment, known as posttreatment Lyme disease syndrome, which does not respond to further antibiotics.
What else can Lyme Disease be?
When diagnosing Lyme disease, doctors mainly rely on the patient’s medical history and a thorough physical examination. In particular, they look for a common skin rash known as erythema migrans. However, diagnosing this disease can be difficult because not all patients develop this rash or might not have noticed it. Additionally, it is possible that a doctor might not correctly identify the rash.
Lyme disease may also be mistaken for other health conditions, such as:
- Short-term memory issues
- Ankylosing spondylitis (a type of arthritis that affects the spine) and rheumatoid arthritis
- Atype of heart problem known as an atrioventricular block
- Skin infection known as cellulitis
- Reaction to direct contact with certain substances, known as contact dermatitis
- Gout and pseudogout, which are types of arthritis caused by crystal buildup in the joints
- A skin condition known as granuloma annulare
- Diseases related to prions, which are abnormal proteins that can cause brain damage
What to expect with Lyme Disease
For early detected cases, the treatment is typically successful. However, the situation could become complicated if the diagnosis is delayed, if antibiotics fail, or if there are simultaneous infections with other tick-borne diseases such as ehrlichiosis and babesiosis. Add the presence of a weakened immune system, and the treatment gets more complex.
About 5% of patients continue experiencing symptoms like fatigue, pain, or aches in muscles and joints even after treatment. These symptoms may persist for 6 months or more. This condition is referred to as post-treatment Lyme disease syndrome. Chronic Lyme disease is usually managed in a similar way to other conditions like fibromyalgia or chronic fatigue syndrome. Still, there is debate if a chronic disorder truly exists.
The problem lies in the fact that many diagnostic tests available on the market often yield incorrect positive results. Moreover, there’s a public scare over chronic Lyme disease, with patients calling for treatments that might not fit their medical needs. Frequently diagnostic tests for suspected chronic Lyme disease turn out to be negative. Furthermore, there are no concrete findings suggesting that long-term antibiotic therapies provide any benefits. In the end, most of these patients recover without any lasting health consequences.
Possible Complications When Diagnosed with Lyme Disease
Lyme disease can cause various complications, such as:
- Arthritis
- Heart inflammation (Carditis)
- Problems with nervous system (Neurological deficits)
- Eye problems (Ocular manifestations)
- A rare skin condition that causes skin to become thin and wrinkled (Acrodermatitis chronica atrophicans)
