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:
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
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Features of early localized disease includes erythema migrans and flu-like symptoms.
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Stage 2 - Early disseminate disease
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Features of early disseminated disease can be divided by organ system and include:
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- Cardiac manifestations
- Dermatological manifestations[9]
- Borrelial lymphocytoma: most common site is earlobe
- Ocular manifestations[10]
- Primary ocular symptoms occur due to inflammation of ocular tissue. These symptoms include conjunctivitis, keratitis, iridocyclitis, retinal vasculitis, chorioiditis, and optic neuropathy (and, extremely rarely, episcleritis, panuveitis, panophthalmitis).
- Secondary ocular symptoms occur due to extraocular manifestations. These symptoms includes pareses of cranial nerves and 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 include:
- Musculoskeletal manifestations:
- Lyme arthritis
- Lyme arthritis is the hallmark of stage 3 Lyme disease.
- Most frequently presented symptom in late disseminated Lyme disease.
- Commonly affects knee joint.
- Lyme arthritis
- Neurological manifestations:
- These neurological symptoms may take months to years to manifest after the infection. In addition to acute symptoms, neuroborreliosis can manifest as a wide-range of neurological disorders, either central or peripheral including:
- Encephalopathy (sub-acute): Affects memory, mood, sleep, and sometimes with subtle language disturbances
- Polyneuropathy or paresthesia
- Leukoencephalitis[11]
- Muscle twitching
- Otolaryngologic manifestations: Neck pain, odynophagia, head and neck dysesthesia, otalgia, tinnitus, hearing loss, vertigo, temporomandibular joint pain, lymphadenopathy, and dysgeusia[12][13]
- Neuropsychiatric symptoms often develop much later in the disease's progression, much like tertiary neurosyphilis[14]
- In rare cases, frank psychoses have been attributed to chronic Lyme disease effects, including misdiagnoses of schizophrenia and bipolar disorder
- Panic attack and anxiety can occur, as well as 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[15]
- These neurological symptoms may take months to years to manifest after the infection. In addition to acute symptoms, neuroborreliosis can manifest as a wide-range of neurological disorders, either central or peripheral including:
- Dermatological manifestations:[9]
- Musculoskeletal manifestations:
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| Difference in clinical features in Europe and North America[17] | ||
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| 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
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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 block to complete heart block) including lightheadedness, palpitations, shortness of breath, chest pain, and syncope.[23]
- Less commonly, patients may present with an acute picture of left ventricular dysfunction, cardiomegaly, perimyocarditis, or pancarditis without noticeable cardiac murmurs.[24]
- Lyme carditis can occur independently, but it is usually accompanied by other cutaneous, joint, or neurologic features of Lyme disease.[25]
Lyme Arthritis
- Lyme arthritis is the hallmark of stage 3 Lyme disease.
- Lyme arthritis is most frequently presented symptom in late disseminated Lyme disease.
- Lyme arthritis is not necessarily preceded by erythema migrans.
- Lyme arthritis may occur due to hematogenous spread of B. burgdorferi to multiple joints during early infection. This might explain migratory arthralgia during early stages of Lyme disease.
- It usually takes months to years for Lyme disease to progress to Lyme arthritis.
- Lyme arthritis symptoms range from intermittent attacks of monoarthritis/oligoarthritis to persistent arthritis.
- Intermittent attacks of Lyme arthritis range from 3 days to 11.5 months in duration with a mean of 3 months.[26]
- During early years of illness, attacks of Lyme arthritis are more frequent and longer in duration. Both frequency and duration of attacks subsequently decrease.
- There may months or years of complete remission between each attack of Lyme arthritis.
- Most of the time, Lyme arthritis involves large joints. The most commonly affected joint is the knee joint, but any joint can be affected including the shoulder, ankle, elbow, temporomandibular joint, and wrist.
- Tendonitis and/or bursitis may also be present in some patients. Most of the time, joints involved are the shoulder, knee, or elbow.
- Most patients have little/no joint dysfunction after remission of attack. Some patients with persistent arthritis may show erosion and permanent damage to joint.[27]
Manifestations of Lyme Disease by Stage
| System | Stage 1 (Localized Infection) | Stage 2 (Early Disseminated Infection) | Stage 3 (Late Persistent Infection) |
| Skin |
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| Musculoskeletal | — |
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| Neurologic | — |
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| Lymphatic |
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| Heart | — |
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| Eyes | — |
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| Liver | — |
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| Respiratory | — |
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| Kidney | — |
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| Genitourinary | — | — | |
| Flu-like symptoms systems |
Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.
References
- ↑ 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.
- ↑ Steere AC, Sikand VK, Schoen RT, Nowakowski J (2003). "Asymptomatic infection with Borrelia burgdorferi". Clin. Infect. Dis. 37 (4): 528–32. PMID 12905137.
- ↑ 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.
- ↑ 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.
- ↑ 5.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 9.0 9.1 Mullegger RR (2004). "Dermatological manifestations of Lyme borreliosis". Eur J Dermatol. 14 (5): 296–309. PMID 15358567.
- ↑ Stanek G, Strle F (2003). "Lyme borreliosis". Lancet. 362 (9396): 1639–47. doi:10.1016/S0140-6736(03)14798-8. PMID 14630446.
- ↑ Halperin JJ, Volkman DJ, Wu P (1991). "Central nervous system abnormalities in Lyme neuroborreliosis". Neurology. 41 (10): 1571–82. PMID 1922798.
- ↑ 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.
- ↑ 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.
- ↑ 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.)
- ↑ 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.
- ↑ 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.
- ↑ 18.0 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.
- ↑ 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.
- ↑ 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.
- ↑ Edlow JA (2002). "Erythema migrans". Med Clin North Am. 86 (2): 239–60. PMID 11982300.
- ↑ 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.
- ↑ 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.
- ↑ 24.0 24.1 Steere, Allen C. (1989). "Lyme Disease". New England Journal of Medicine. 321 (9): 586–596. doi:10.1056/NEJM198908313210906. ISSN 0028-4793.
- ↑ 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.
- ↑ Steere AC, Schoen RT, Taylor E (1987). "The clinical evolution of Lyme arthritis". Ann Intern Med. 107 (5): 725–31. PMID 3662285.
- ↑ Steere AC, Schoen RT, Taylor E (1987). "The clinical evolution of Lyme arthritis". Ann Intern Med. 107 (5): 725–31. PMID 3662285.