Lyme disease physical examination

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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

The physical examination of Lyme disease is necessary for diagnosis. Erythema migrans and fever are commonly seen on physical examination in early disease. Disseminated disease is characterized by multiple erythema migrans, neurological, musculoskeletal, and cardiac symptoms.

Physical Examination in Stage 1 - Early localized disease

Appearance of the patient Patients are usually well appearing in early stages but may appear fatigued Vital signs Fever and/or chills Skin Erythema migrans (target-like lesions): usually single, present at the site of tick bite Regional lymphadenopathy: around site of tick bite Some patients may have: Multiple annular lesions Malar rash Evanescent skin lesions Urticarial rash HEENT Headache Pain on neck flexion Some patients may have: Pharyngitis Conjunctivitis Fewer patients may have: Periorbital edema Photophobia Ear pain Neck Neck stiffness

Classic Lyme disease rash - Source: CDC.gov Lyme disease, expamding rash with central clearing - Source: CDC.gov

Cardiovascular

• A small number of patients may have:
  • Chest pain

Abdomen

• Some patients may have:
  • Hepatomegaly
  • Splenomegaly
  • Right upper quadrant pain
• Fewer patients may have:
  • Generalized abdominal pain and tenderness

Neurological

• Some patients may have:
  • Dysesthesia
  • Dizziness

Muscukoskeletal

• Migratory arthralgias
• Myalgia
• Back ache
• Some patients may have:
  • Frank arthritis
• Fewer patients may have:
  • Muscle tenderness
  • Hand stiffness

Physical Examination in Stage 2 - Early disseminated disease

Appearance of the patient

• As the disease progresses, the patient may appear ill. The patient has severe malaise and fatigue.

Vital signs

• Slow or irregular pulse

Skin Erythema migrans (target-like lesions): usually multiple lesions are secondary to dissemination, not to be confused with multiple tick bites Borrelial lymphocytoma: cutaneous B-cell pseudolymphoma Malar rash Diffuse erythema or urticaria Regional or generalized lymphadenopathy HEENT Facial deviation Dry eyes Drooling of saliva Blurred vision

Disseminated Lyme disease, multiple rash - Source: CDC.gov

Neck

• Neck stiffness
• Neck pain
• Cannon A waves in patients with complete heart block

Cardiovascular

• Tachycardia
• Palpitations
• Cardiac rub
• Dyspnea
• S3 and/or S4 may also be present

Abdomen

• Splenomegaly

Neurological

• Dizziness
• Numbness and tingling in extermities
• Ataxia
• Chorea

Muscuoskeletal

• Migratory arthralgia

Physical Examination in Stage 3 - Late disseminated disease

Appearance of the patient

• Patients appear ill and fatigued

Skin

• Acrodermatitis chronica atrophicans
• Localized scleroderma-like lesions

HEENT

• Severe headache
• Sore throat
• Vision changes
• Odynophagia
• Otalgia
• Tinnitus
• Hearing loss
• Vertigo
• Temporomandibular joint pain
• Dysgeusia

Neck

• Tender neck flexion
• Neck pain

Neurological

• Fasciculations
• Spastic paraparesis
• Ataxia
• Neuropsychiatric findings, including dementia, anxiety, depression, schizophrenia-like psychosis, bipolar disorder

Muscukoskeletal

• Arthralgias: commonly involving knee, may be migratory
• Joint tenderness
• Joint swelling
• Joint effusion
• Enthesitis
• Periostitis or joint subluxations below acrodermatitis

Image gallery

• 
  Common bullseye rash pattern associated with Lyme Disease - - Source: WIKICOMMONS
• 
  Characteristic "bulls-eye"-like rash caused by Lyme disease - - Source: WIKICOMMONS
• 
  Right posterior shoulder region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by Borrelia burgdorferi. - Source: Public Health Image Library (PHIL).
• 
  Left lateral buttock of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. - Source: Public Health Image Library (PHIL).
• 
  Right hip and waist region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. - Source: Public Health Image Library (PHIL).
• 
  Posterior knee with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by the bacterium Borrelia burgdorferi. - Source: Public Health Image Library (PHIL).
• 
  Medial aspect of the right calf of a patient who’d presented with what was diagnosed as Lyme disease. - Source: Public Health Image Library (PHIL).
• 
  Posterior right shoulder region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by Borrelia burgdorferi. - Source: Public Health Image Library (PHIL).
• 
  This Lyme disease patient presented with the signs and symptoms indicative of arthritic changes to his right knee due to a Borrelia burgdorferi bacterial infection. - Source: Public Health Image Library (PHIL).
• 
  Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. - Source: Public Health Image Library (PHIL).
• 
  Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. - Source: Public Health Image Library (PHIL).
• 
  Facial palsy caused by an infection by the bacterial spirochete Borrelia burgdorferi. Patient was subsequently diagnosed with Lyme disease. - Source: Public Health Image Library (PHIL).
• 
  Erythema chronicum migrans. - Source: Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

References

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