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{{Lyme disease}}
{{CMG}} {{AE}}{{Anmol}}, {{IMD}}
==Overview==
[[Lyme disease]] is divided into 3 stages and symptoms are stage specific. Symptoms include "bulls-eye" [[rash]], with accompanying [[fever]], [[malaise]], and [[musculoskeletal pain]] ([[arthralgia]] or [[myalgia]]). It can progress to [[cardiovascular]] or [[neurological]] complications.


==History==
{{CMG}}; {{AE}} {{Anmol}}
*The [[incubation period]] from [[infection]] to the onset of symptoms is usually 1&ndash;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. <ref name="pmid10206627">{{cite journal| author=Falco RC, McKenna DF, Daniels TJ, Nadelman RB, Nowakowski J, Fish D et al.| title=Temporal relation between Ixodes scapularis abundance and risk for Lyme disease associated with erythema migrans. | journal=Am J Epidemiol | year= 1999 | volume= 149 | issue= 8 | pages= 771-6 | pmid=10206627 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10206627  }}</ref>[[Asymptomatic]] [[infection]] exists, but is uncommon.<ref name="pmid12905137">{{cite journal |author=Steere AC, Sikand VK, Schoen RT, Nowakowski J |title=Asymptomatic infection with Borrelia burgdorferi |journal=Clin. Infect. Dis. |volume=37 |issue=4 |pages=528-32 |year=2003 |pmid=12905137}}</ref>
*The specific areas of focus when obtaining the history, are outlined below:
** [[Tick]] bite
** Vacation,living, or working environment in endemic areas
**Spending time outdoor (especially in woody or grassy area).
 
==Symptoms==
[[Lyme disease]] is divided into 3 stages and symptoms are stage specific.
#Early localized disease
#Early disseminated disease
#Late disseminated disease
 
===Early localized disease===
Features of early localized disease includes erythema migrans and constitutional symptoms.
*'''Erythema migrans (EM)''' also known as Erythema chronicum migrans, "bull’s-eye" rash, or Lyme rash develops in around 70% - 80% of patients.<ref name="pmid12802042">{{cite journal| author=Steere AC, Sikand VK| title=The presenting manifestations of Lyme disease and the outcomes of treatment. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 24 | pages= 2472-4 | pmid=12802042 | doi=10.1056/NEJM200306123482423 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12802042  }} </ref>
**EM egins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days).
**EM gradually expands over a period of days reaching up to 12 inches(30 cm)or more across.
**EM may feel warm to touch but is rarely itchy or painful.
**EM clears as it enlarges, resulting in a target or “bull’s-eye” appearance.
**EM may appear on any area of the body but majority of times present in areas including axilla, inguinal region, popliteal fossa, or along belt line.
**The [[rash]] does not represent an [[allergic reaction]] to the bite, but rather a [[skin infection]] with the [[Borrelia burgdorferi|Lyme bacteria]], [[Lyme disease microbiology|''Borrelia burgdorferi'' sensu lato]].
**An [[infection]] resulting from a [[Borrelia mayonii|B. mayonii]] [[infection]] may cause a diffuse [[rash]], erupting in "red spots," spanning the entire [[body]].
*Constitutional symptoms includes:<ref name="pmid8644761">{{cite journal| author=Nadelman RB, Nowakowski J, Forseter G, Goldberg NS, Bittker S, Cooper D et al.| title=The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. | journal=Am J Med | year= 1996 | volume= 100 | issue= 5 | pages= 502-8 | pmid=8644761 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8644761  }} </ref>
**[[Fatigue]]
**[[Arthralgia]]
**[[Myalgia]]
**[[Headache]]
**[[Fever]] and/or [[chills]]
**[[Stiff neck]]
**[[Anorexia]]
 
===Early disseminate disease===
Features of early disseminated disease can be divided system wise and includes:
*Neurological symptoms:<ref name="pmid18452800">{{cite journal| author=Halperin JJ| title=Nervous system Lyme disease. | journal=Infect Dis Clin North Am | year= 2008 | volume= 22 | issue= 2 | pages= 261-74, vi | pmid=18452800 | doi=10.1016/j.idc.2007.12.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18452800  }} </ref>
**Lymphocytic meningitis (most common neurological symptom)
**Cranial neuropathies(particularly facial nerve palsy)
**Painful radiculitis
**Mononeuritis multiplex<ref name="pmid9066359">{{cite journal| author=England JD, Bohm RP, Roberts ED, Philipp MT| title=Mononeuropathy multiplex in rhesus monkeys with chronic Lyme disease. | journal=Ann Neurol | year= 1997 | volume= 41 | issue= 3 | pages= 375-84 | pmid=9066359 | doi=10.1002/ana.410410313 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9066359  }} </ref>
**Pseudotumor cerebri
**Myelitis
**Chorea
**Cerebellar ataxia
**The triad of neurologic manifestation of Lyme disease includes meningitis, cranial neuritis, and radiculoneuritis.
*Cardiac manifestations
**Atrio-ventricular block
**Myopericarditis
**Sudden cardiac death
**Chronic cardiomyopathy
*Dermatological manifestations<ref name="pmid15358567">{{cite journal| author=Mullegger RR| title=Dermatological manifestations of Lyme borreliosis. | journal=Eur J Dermatol | year= 2004 | volume= 14 | issue= 5 | pages= 296-309 | pmid=15358567 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15358567  }} </ref>
**Borrelial lymphocytoma
*Ocular manifestations
 
===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 includes:
**Arthritis
***Commonly affects knee joint
 
**Neurological: These neurological symptoms may take months to years to manifest after the infection. [[Neuropsychiatric]] symptoms often develop much later in the disease progression, much like tertiary [[neurosyphilis]].<ref name="LogigianKaplan1990">{{cite journal|last1=Logigian|first1=Eric L.|last2=Kaplan|first2=Richard F.|last3=Steere|first3=Allen C.|title=Chronic Neurologic Manifestations of Lyme Disease|journal=New England Journal of Medicine|volume=323|issue=21|year=1990|pages=1438–1444|issn=0028-4793|doi=10.1056/NEJM199011223232102}}</ref>
***Sub-acute encephalopathy: Affects  memory, mood, sleep, and sometimes with subtle language disturbances.
***Polyneuropathy
***Leukoencephalitis<ref name="pmid1922798">{{cite journal| author=Halperin JJ, Volkman DJ, Wu P| title=Central nervous system abnormalities in Lyme neuroborreliosis. | journal=Neurology | year= 1991 | volume= 41 | issue= 10 | pages= 1571-82 | pmid=1922798 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1922798  }} </ref>
**Dermatological manifestation<ref name="pmid15358567">{{cite journal| author=Mullegger RR| title=Dermatological manifestations of Lyme borreliosis. | journal=Eur J Dermatol | year= 2004 | volume= 14 | issue= 5 | pages= 296-309 | pmid=15358567 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15358567  }} </ref>
*Acrodermatitis chronica atrophicans


==Tables==
{| class="wikitable"
{| class="wikitable"
! colspan="3" |Difference in clinical features in Europe and North America<ref name="pmid18452805">{{cite journal| author=Stanek G, Strle F| title=Lyme disease: European perspective. | journal=Infect Dis Clin North Am | year= 2008 | volume= 22 | issue= 2 | pages= 327-39, vii | pmid=18452805 | doi=10.1016/j.idc.2008.01.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18452805  }}</ref>
|+
!Diagnosis
!Lab findings
!
!
|-
|-
|'''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
|
|-
|
|ACA
|Present
|Absent
|-
|Meningoradiculoneuritis
|More common
|Less common
|-
|Lyme arthritis
|Rarely preceded by Erythema migrans
|Commonly preceded by Erythema migrans
|}
|}
{| class="wikitable"
! colspan="2" |Symptoms differentiated on the basis of frequency
|-
|'''Common symptoms'''
|'''Less common symptoms'''
|-
|Erythema migrans(Erythema chronicum migrans)
Constitutional symptoms
Arthritis
|Cardiac manifestations
Neurological manifestations
|}
===Less Common===
*[[Cardiac]] manifestations (up to 10% of patients may have [[cardiac]] manifestations including  [[heart block]] and [[palpitations]])<ref name="Ciesielski_19892">{{cite journal|author=Ciesielski CA, Markowitz LE, Horsley R, Hightower AW, Russell H, Broome CV|title=Lyme disease surveillance in the United States, 1983-1986|journal=Rev. Infect. Dis.|volume=11 Suppl 6|issue=|pages=S1435-41|year=1989|pmid=2682955}}</ref>
*[[Neurology|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.<ref>{{cite journal |author=Chabria SB, Lawrason J |title=Altered mental status, an unusual manifestation of early disseminated Lyme disease: A case report |journal= |volume=1 |issue=1 |pages=62 |year=2007 |pmid=17688693 |doi=10.1186/1752-1947-1-62}}</ref>
==Chronic Disease==
*Untreated or persistent cases may progress to a chronic form most commonly characterized by [[meningoencephalitis]]
*[[Cardiac]] [[inflammation]] ([[myocarditis]])
*Frank [[arthritis]]
*It should be noted, however, that chronic [[Lyme disease]] can have a multitude of symptoms affecting numerous [[Physiology|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 progression, much like tertiary [[neurosyphilis]].
===Chronic neurological disorders===
*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]]
**[[Balance disorder|Vestibular symptoms]]
**[[Otolaryngology|Otolaryngologic]]<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>
*[[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 misdiagnoses 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==
*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>
*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>
==Manifestations of Lyme Disease by Stage==
{| align="center" style="font-size:85%;" border="1" cellspacing="0" cellpadding="4"
|+ '''Manifestations of Lyme Disease by Stage<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>'''
|-
| style="background:LightSlateGray; width:15%;" | '''System''' || style="background: #efefef; width:25%;" | '''Stage 1 (Localized Infection)''' || style="background: #efefef; width:25%;" | '''Stage 2 (Early Disseminated Infection)''' || style="background: #ffdead; width:35%" | '''Stage 3 (Late Persistent Infection)'''
|-
| ''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
|-
| ''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]] || —
|-
| ''Heart'' || — || valign="top" | ▸ [[Atrioventricular block]] <BR> ▸ [[Myopericarditis]] <BR> ▸ Pancarditis || —
|-
| ''Eyes'' || — || valign="top" | ▸ [[Conjunctivitis]] <BR> ▸ [[Iritis]] <BR> ▸ [[Choroiditis]] <BR> ▸ Retinal hemorrhage or [[retinal detachment]] <BR> ▸ Panophthalmitis|| valign="top" | ▸ [[Keratitis]]
|-
| ''Liver'' || — || ▸ Mild or recurrent [[hepatitis]] || —
|-
| ''Respiratory'' || — || valign="top" | ▸ Nonexudative [[sore throat]] <BR> ▸ Nonproductive [[cough]] <BR> ▸ [[Adult respiratory distress syndrome]] || —
|-
| ''Kidney'' || — || valign="top" | ▸ Microscopic [[hematuria]] or [[proteinuria]] || —
|-
| ''Genitourinary'' || — || ▸ [[Orchitis]] || —
|-
| ''Constitutional systems'' || ▸ Minor || ▸ Severe [[malaise]] and [[fatigue]] || ▸ [[Fatigue]]
|}
<SMALL><span style="align=center">''Adapted from Steere AC. Lyme disease. N Engl J Med. 1989;321:586.''</span></SMALL>


==References==
==References==
{{Reflist|2}}
{{reflist|2}}
 
[[Category:Bacterial diseases]]
[[Category:Insect-borne diseases]]
[[Category:Lyme disease]]
[[Category:Zoonoses]]
[[Category:Spirochaetes]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Dermatology]]
 
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Latest revision as of 17:32, 14 January 2019


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]

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