Lyme disease and related tick-borne infections
Description
An in-depth report on the causes, diagnosis, treatment, and prevention of Lyme disease.
Alternative Names
Babesiosis; Human granulocytic anaplasmosis (HGA)
Symptoms
Symptoms of Lyme disease are diverse and often occur in early and late phases. They vary widely from person to person. Any one symptom may fail to appear, and symptoms may overlap in various combinations. Death from Lyme disease is very rare and occurs only in a few cases in which the heart is severely affected.
Typical Course
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Stage 1
. In the majority of cases, the first sign of early Lyme disease is the appearance of a bull's-eye skin rash. It usually develops about 1 - 2 weeks after the bite, although it may appear as soon as 3 days, and as late as 1 month. In some cases, it is never detected. Flu-like symptoms (joint aches, fever, and general fatigue) commonly develop.
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Stage 2
. Untreated, the infection spreads through the bloodstream and lymph nodes within days to weeks, involving the joints, nervous system, and possibly the heart. Multiple rashes may erupt in other places. If the infection affects the nervous system in stage 2, it most often causes weakness or paralysis in the nerves of the face (Bell's palsy) or in nerves of the spine.
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Stage 3
. If the disease remains untreated, then within a few weeks or months a late or persistent infection can occur, which leads to prolonged bouts of arthritis and neurologic problems, such as concentration problems or personality changes. Fatigue is a prominent feature of both early and late stages.
Skin Rash
Evidence suggests that up to 90% of patients with Lyme disease exhibit a rash a few days to a month after a tick bite. The rash, known as
erythema migrans
, usually first appears on the thigh, buttock, or trunk in older children and adults, and on the head or neck in young children.
The bull's eye rash, which is commonly believed to be the classic sign of Lyme disease, may take the following course:
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It can first appear as a pimple-like spot, which expands over the next few days into a purplish circle. The circle may reach up to 6 inches in diameter with a deeper red rim. In some cases the ring is incomplete, forming an arc rather than a full circle.
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The center of the rash often clears or may turn bluish. Or secondary concentric rings may develop within the original ring, creating the bull's-eye pattern. Over the next several weeks, the circular rash may grow to as large as 20 inches across.
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Patients often describe the sensation of the rash as burning rather than itching.
It is important to note that in a 2002 study, only 9% of patients diagnosed with Lyme disease exhibited this classic pattern. Nearly 60% had a rash that was more general in appearance and 32% had a circular dense red rash.
In most patients, any rash fades completely after 3 - 4 weeks, although secondary rashes may appear during the later stages of disease.
Flu-like Symptoms
A flu-like condition is the most common sign of Lyme infection and it can occur with or without a rash. Symptoms can last from 5 - 21 days and may include:
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Fatigue
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Chills and fever (100 - 103°)
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Headache (usually most prominent at the back of the head)
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Joint aches (usually in the large joints)
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Stiff neck
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Backache
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Swollen glands (in the area around the tick bite or elsewhere)
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Less often, nausea, vomiting, and sore throat occur
Some experts recommend that children in high-risk areas be tested for Lyme in the summer months if they have the most common Lyme symptoms (fever, headache, joint aches) -- even if they have no tell-tale rash. Severe and sustained flu symptoms without the rash in such patients may indicate the presence of human granulocytic anaplasmosis (HGA) or babesiosis -- the other infections carried by the
Ixodes
tick.
Arthritis
Joint pain can arise at any time after the appearance of a skin rash. In the absence of a rash, arthritic symptoms may be the first indication of Lyme disease. Or, as suggested by some studies, it can develop months after the disease has been diagnosed. Arthritic symptoms may occur as follows:
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Aches, stiffness, and swelling, sometimes massive, of large joints, such as the knee, elbow, or shoulder. One or both knees are affected most often. The ankle, wrist, jaw, and finger joints are involved less often.
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Typically, no more than three joints are affected during the course of the disease. If several joints are involved, they tend to be asymmetrically distributed.
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Joint pain flare-ups are often accompanied by muscle pain.
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Arthritis symptoms usually last for a few days or weeks and are interspersed with longer periods during which the joints feel fine.
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The severity and frequency of attacks peak within 1 - 2 years then decrease and usually resolve, even without treatment.
Neurologic Symptoms
About 15% of untreated patients develop neurologic symptoms. They can occur in all stages of the disease and can affect any part of the nervous system.
Common Early Neurologic Symptoms.
Most often, neurologic symptoms first appear while the initial skin rash is still present or within 6 weeks after its disappearance. Sometimes they are the first symptoms that the patient experiences. The most common neurologic symptoms may be headaches, sleep problems, and mood disturbance. Memory problems can also occur. Neurologic symptoms typically improve or resolve within a few weeks or months, even in untreated patients.
Bell's Palsy.
In 5 - 10% of untreated Lyme patients, the facial nerve is affected, which results in Bell's palsy. This is a sudden weakness and drooping of the facial muscles and eyelid on one side of the face. Nerves around the facial area may also cause numbness, dizziness, double vision, and hearing changes. Another common neurologic problem is pain in the lower spine. It resembles low back pain from arthritis (although in the case of Lyme disease the skin near the spine may have abnormal sensations). Of note, Lyme disease has been observed in more than half the children who develop Bell's palsy.
Symptoms of Meningitis.
In about 10 - 15% of patients, the infection takes place in the membranes that surround the brain and spinal cord (called meningitis). This can cause:
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Episodes of headache not relieved by over-the-counter medication
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Mild stiff neck
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Sensitivity to light
Symptoms of Lyme Encephalopathy.
In some cases of untreated disease, the infection causes a condition called Lyme encephalopathy or
neuroborreliosis
. This causes the following symptoms:
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Unexplained mood changes
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Depression
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Trouble concentration and remembering
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Irritability
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Feelings of "pins and needles" or numbness in the arms or legs
Other Neurologic Symptoms.
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If the infection affects the white brain matter, symptoms resemble multiple sclerosis.
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If the infection occurs in the nerves affecting the skin, some patients experience pricking, tingling, or creeping feelings.
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Children have a higher risk than adults for neurologic effects on the eye. (This is still rare, however.)
Heart Symptoms
The infection may affect electrical conduction to the heart and cause symptoms suggesting heart rhythm disturbances:
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Palpitations
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Shortness of breath
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Chest pain
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Dizziness
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Fainting can occur if the infection affects the heart
These symptoms almost never produce serious problems in people without other types of heart disease.
Eye Symptoms
Symptoms in the eyes have been reported at every stage. Conjunctivitis ("pink eye") may be a symptom in the early stages. In late, untreated Lyme disease, neurologic problems can affect the eye, causing pain and sensitivity to light.
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Review Date: 1/18/2007
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
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