Lyme disease natural history, complications and prognosis
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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]
Overview
Lyme disease may present as a red, expanding rash called erythema migrans (EM) along with flu-like symptoms such as fatigue, arthralgia, myalgias, headache, fever and/or chills, stiff neck, anorexia, and regional lymphadenopathy. EM resolves in approximately 28 days in untreated patients. Lyme disease is effectively managed by prompt treatment.
Untreated infection may spread from the site of the bite to other parts of the body, producing a range of symptoms including neurological, cardiac and dermatological manifestations. Many of these symptoms will resolve over a period of weeks to months, even without treatment. However, lack of treatment can result in additional complications. Lyme arthritis is the most frequently presented symptom in late disseminated Lyme disease.
Prognosis is mainly affected by a failure to treat in a timely manner as well as simultaneous infections with other tick-borne diseases. Sometimes, patients with Lyme disease have symptoms that last months to years after treatment with antibiotics. These symptoms includes muscle and joint pains, cognitive defects, sleep disturbance, or fatigue. The condition is referred to as post-treatment Lyme disease syndrome (PTLDS).
Natural History
Stage 1: Early Localized Lyme disease (3-30 Days Post-tick Bite)
- Patients develops red, expanding rash called erythema migrans (EM).
- Flu-like symptoms such as fatigue, arthralgia, myalgias, headache, fever and/or chills, stiff neck, anorexia, and regional lymphadenopathy may be present.
- Some people may get these flu-like symptoms in addition to an EM rash, but in some, these flu-like symptoms may be the only evidence of infection.
- Some people get a small bump or redness at the site of a tick bite that goes away in 1-2 days, like a mosquito bite. This is not a sign that one has Lyme disease. However, ticks can spread other organisms that may cause a different type of rash. For example, Southern tick-associated rash illness (STARI) causes a rash with a very similar appearance.[1]
- EM occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3-30 days (average is about 7 days).
- Early EM may be homogenously erythematous without any central clearing.
- EM gradually expands over a period of several days, and can reach up to 12 inches (30 cm) across. Parts of the rash may clear as it enlarges, resulting in a bullseye appearance.
- EM lesions may appear on any area of the body but is present the majority of the time on the axilla, inguinal region, or popliteal fossa.
- EM resolves in approximately 28 days in untreated patients.[2]
Stage 2: Early Disseminated Lyme disease (Days to Weeks Post-tick Bite)
- Untreated infection may spread from the site of the bite to other parts of the body, producing a range of symptoms including:
- Multiple EM lesions in other areas of the body. Multiple lesions are secondary to dissemination and are not to be confused with multiple tick bites[3]
- Facial or Bell's palsy
- Severe headaches and neck stiffness due to meningitis
- Pain and swelling in the large joints (such as knees)
- Shooting pains that may interfere with sleep
- Heart palpitations and dizziness due to changes in heartbeat
- Many of these symptoms will resolve over a period of weeks to months, even without treatment. However, lack of treatment can result in additional complications.
Stage 3: Late Disseminated Lyme disease (Months-to-Years Post-tick Bite)
- Lyme arthritis is the hallmark of stage 3 Lyme disease.
- Lyme arthritis is the most frequently presented symptom in late disseminated Lyme disease.
- Lyme arthritis is not necessarily preceded by erythema migrans.
- Approximately 60% of patients with untreated infection may begin to have intermittent attacks of arthritis with severe joint pain and swelling.[4]
- Intermittent attacks of Lyme arthritis range from 3 days to 11.5 months with a mean of 3 months.[5]
- 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 be months or years of complete remission between each attack of Lyme arthritis.
- The majority of the time, Lyme arthritis involves large joints. The most commonly affected joint is knee joint, but any joint can be affected including the shoulder, ankle, elbow, temporomandibular joint, and wrist.
- Lyme arthritis manifests differently than other causes of arthritis and must be distinguished from other causes of arthralgias.
- Up to 5% of untreated patients may develop chronic neurological complaints months to years after infection. These include shooting pains, numbness or tingling in the hands and/or feet, and short-term memory disturbances.
Complications
Stage 3 or late disseminated Lyme disease can cause long-term joint inflammation (Lyme arthritis) and heart rhythm problems. Brain and nervous system problems are also possible, and may include:
- Decreased concentration
- Memory disorders
- Nerve damage
- Numbness
- Pain
- Paralysis of the face muscles
- Sleep disorders
- Vision problems
Lingering Symptoms After Treatment (Post-treatment Lyme disease Syndrome)
- Approximately 10-20% of patients with Lyme disease have symptoms that last months to years even after treatment with antibiotics.
- These symptoms can include muscle and joint pains, cognitive defects, sleep disturbance, or fatigue.
- The cause of these symptoms is not known, but these symptoms are believed to be due residual damage to tissues and the immune system that occurred during the infection, similar to complications and autoimmune responses that occur in other infections including:
- In contrast, some believe that these symptoms are due to persistent B. burgdorferi infection.
- This condition is referred to as post-treatment Lyme disease syndrome (PTLDS).
- It is observed that prolonged antibiotic therapy is not helpful and can be harmful for persons with PTLDS.
- Patients with PLTDS get better with time.
Prognosis
- For early cases, prompt treatment is usually curative.[6]
- However, the severity and treatment of Lyme disease may be complicated due to:
- Late diagnosis
- Failure of antibiotic treatment
- Coinfection with other tick-borne diseases including Ehrlichiosis and Babesiosis[7]
- Immune suppression in the patient
- A meta-analysis published in 2005 found that some patients with Lyme disease have fatigue, joint and/or muscle pain, and neurocognitive symptoms persisting for years despite antibiotic treatment.[8]
- Patients with late stage Lyme disease have been shown to experience a level of physical disability equivalent to that seen in congestive heart failure.[9]
- Though rare, Lyme disease can be fatal.[10][11][12][13]
- The first CDC recognized death from Lyme disease was Amanda Schmidt, age 11.[14]
References
- ↑ Wormser GP, Masters E, Nowakowski J, McKenna D, Holmgren D, Ma K; et al. (2005). "Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions". Clin Infect Dis. 41 (7): 958–65. doi:10.1086/432935. PMID 16142659.
- ↑ 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.
- ↑ 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.
- ↑ Wormser, Gary P. (2006). "Early Lyme Disease". New England Journal of Medicine. 354 (26): 2794–2801. doi:10.1056/NEJMcp061181. ISSN 0028-4793.
- ↑ Steere AC, Schoen RT, Taylor E (1987). "The clinical evolution of Lyme arthritis". Ann Intern Med. 107 (5): 725–31. PMID 3662285.
- ↑ Krause PJ, Foley DT, Burke GS, Christianson D, Closter L, Spielman A (2006). "Reinfection and relapse in early Lyme disease". Am. J. Trop. Med. Hyg. 75 (6): 1090–4. PMID 17172372.
- ↑ Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS; et al. (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". Clin Infect Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.
- ↑ Cairns V, Godwin J (2005). "Post-Lyme borreliosis syndrome: a meta-analysis of reported symptoms". Int J Epidemiol. 34 (6): 1340–5. PMID 16040645.
- ↑ Klempner MS, Hu LT, Evans J; et al. (2001). "Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease". N Engl J Med. 345 (2): 85–92. PMID 11450676.
- ↑ Kirsch M, Ruben FL, Steere AC, Duray PH, Norden CW, Winkelstein A (1988). "Fatal adult respiratory distress syndrome in a patient with Lyme disease". JAMA. 259 (18): 2737–9. PMID 3357244.
- ↑ Oksi J, Kalimo H, Marttila RJ; et al. (1996). "Inflammatory brain changes in Lyme borreliosis. A report on three patients and review of literature". Brain. 119 (Pt 6): 2143–54. PMID 9010017.
- ↑ Waniek C, Prohovnik I, Kaufman MA, Dwork AJ (1995). "Rapidly progressive frontal-type dementia associated with Lyme disease". J Neuropsychiatry Clin Neurosci. 7 (3): 345–7. PMID 7580195.
- ↑ Cary NR, Fox B, Wright DJ, Cutler SJ, Shapiro LM, Grace AA (1990). "Fatal Lyme carditis and endodermal heterotopia of the atrioventricular node". Postgrad Med J. 66 (772): 134–6. PMID 2349186.
- ↑ "First Lyme Disease Death Told". Los Angeles Times. 1990-09-26.