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 is effectively managed by prompt treatment. Prognosis is affected by failure to treat in a timely manner as well as simultaneous infections with other tick-borne diseases. Lyme disease can cause neurological complications such as facial paralysis and carditis.
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 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 you have 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 “bull's-eye” appearance.
- EM lesions may appear on any area of the body but majority of times present in areas including 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 lesion are secondary to dissemination; not to be confused with multiple tick bite.[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 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 attack of Lyme arthritis ranges 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 decreases subsequently.
- There may month or years of complete remission between each attack of Lyme arthritis.
- Majority of times Lyme arthritis involves large joints. Most commonly affected joint is knee joint, but any joint can be affected including 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, short-term memory disturbances.
Lingering Symptoms After Treatment (Post-treatment Lyme disease Syndrome)
- Approximately 10-20% of patients with Lyme disease have symptoms that last months to years 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 auto-immune responses that occur in other infections including:
- Campylobacter (Guillain-Barre syndrome)
- Chlamydia (Reiter’s syndrome)
- Strep throat (rheumatic heart disease).
- 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 gets better with time.
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
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.