So what are the manifestations?
Well, Lyme disease like some other really unpleasant types of infections occurs in several stages
and the first stage or primary stage, is highly associated with a rash
known as erythema chronicum migrans, this is also the known as the target rash
or I guess we’ll see a couple of examples of that.
There’s certainly a slide coming up on which we can see a picture
which is worth a thousand more of my words than me stumbling about this.
So erythema chronicum migrans develops to nearly all patients
and it typically occurs up to a month after that primary inoculation
occurs as the immune reaction is getting going.
Along with that, about 2/3 of patients will develop systemic symptoms
but the systemic symptoms in primary lyme disease are very nonspecific -
headache, low grade fever, maybe they’ll have rigors,
maybe they’ll have myalgia’s, muscle aches; maybe they’ll have regional lymphadenopathy.
And whatever they have, will sort of smolder along for a couple of weeks
and be completely resolved after four weeks.
So it is entirely possible for primary lyme disease to go unrecognized if the rash,
the erythema chronicum migrans lesion is in a spot which the patient does not discover.
If untreated, then the next stage will be early disseminated Lyme disease
or what some people call stage two, and in this stage there has been dissemination of Borrelia burgdorferi,
throughout the human body and one can get pretty much any type of disease
which you can imagine. Certainly, these patients will have severe fatigue and malaise;
certainly they’ll have migratory polymyalgias, polyarthralgias; they may have primary arthritis typically of the knee.
They may develop a neuroborreliosis or neurologic disease from the Lyme disease -
all these can take anywhere from one to nine to ten months to develop.
And as you can see there, the patients affected with the overall systemic signs are at least half,
but if you look over the time period of stage two Lyme disease,
nearly all patients up to a 100% at some point in their disease course would developed
at least one or two of those systemic signs: the malaise, the myalgias, the arthralgias.
Fortunately, the neuroborreliosis, the neurologic disorders
with second stage Lyme disease occur in far fewer patients, only up to 15%
but, those patients have significant disease - peripheral neuropathy, cranial nerve palsies,
meningeal encephalitis - you name it, this is a very big deal.
Also, eight to even ten percent of the patients may develop cardiac findings
along with their secondary or second stage Lyme disease.
The most often diagnosed cardiac dysfunction is atrioventricular blockade,
so patients may have dysrhythmias or tachyarrhythmias from a AV block
due to the immune reaction to the Borrelia burgdorferi.
Some actually develop inflammation of the myopericardium
leading to congestive heart failure and these findings may slowly progress over six weeks or so.
Finally, there is a late disseminated stage or a third stage for Lyme disease
in which, again, any part of the human body can be affected.
Almost all patients here, seen about 2/3 of patients will develop migratory polyarthritis
of their large joints and certainly, polyarthralgias. But, they may also have long term neurologic complications
such as ataxia, migraines, fatigue, confusion - some people likened this to an atypical form of encephalopathy.
All of these can take place, none of these are specific to Lyme disease
and unfortunately, therefore, many patients may feel they have “chronic Lyme disease,”
when in fact they may have neurologic manifestations of a conversion disorder or a psychiatric disturbance,
that also could be that they have active Lyme disease, too.
So, all patient deserve an appropriate and full evaluation in that setting
but again, one has to have a high index to suspension to evaluate for and exclude Lyme disease.
Here, as promised is the thousand words condensed into a picture, erythema chronicum migrans rash,
a targetiod or a very prominent rash with a central erythema,
a surrounding area of clearance and then an erythematous ring.
If one sees this rash in the setting of a tic exposure or certainly even hiking in
or being exposed to a part of the country with ixodes scapularis, the tic,
then the diagnosis of Lyme disease is a near certainty.
In secondary or second stage Lyme disease,
one may see multiple such lesions spread throughout the body which again makes sense
because that is when the Borrelia has disseminated throughout the body
and one can have multiple areas of immunologic reaction to deposition of that organism in the capillary beds.
Treatment of Lyme disease,
Treatment in part depends on the stage at which the patient is experiencing their illness or is coming to diagnosis.
Ideally, all patients would be discovered, diagnosed and treated in early stage,
the first stage of Lyme disease and if so they can be treated with doxycycline or any beta lactam
- amoxicillin, cephalosporin would work.
Doxycycline is listed as the primary choice here
because many such patients presenting with early stage Lyme disease,
may have an unwitnessed or a suspected tick bite and there may be other diseases
carried by ticks in that region that doxycycline would treat and amoxicillin would not,
to which you might think of Rocky Mountain spotted fever, Ehrlichiosis, or something similar.
So, doxycycline or amoxicillin in the first stage of Lyme disease.
Pregnant women and children would respond less well to doxycycline,
they would respond beautifully to amoxicillin but cefuroxime, a cephalosporin is suggested
or even ceftriaxone as an intermediary to avoid any of the toxic effects of doxycycline in pregnancy.
It is a class C teratogen so there’s a potential of causing birth defects to the fetus
of a woman who’s treated with doxycycline.
And then all other manifestations of Lyme disease, whether it’s second stage, third stage,
chronic, etc. can be successfully treated with ceftriaxone
but they also could be treated quite successfully with other beta lactam antibiotics including amoxicillin.