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
which is worth a thousand more of my words than me stumbling
So erythema chronicum migrans develops in nearly all
and it typically occurs up to a month after that primary
occurs as the immune reaction is getting going.
Along with that, about 2/3 of patients will develop systemic
but the systemic symptoms in primary lyme disease are very
headache, low grade fever, maybe they’ll have rigors,
maybe they’ll have myalgias, muscle aches; maybe they’ll
have regional lymphadenopathy.
And whatever they have, will sort of smoulder 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
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
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
nearly all patients up to a 100% at some point in their
disease course will 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,
meningoencephalitis - you name it, this is a very big
Also, eight to even ten percent of the patients may develop
along with their secondary or second stage Lyme disease.
The most often diagnosed cardiac dysfunction is
so patients may have dysrhythmias or tachyarrhythmias from a
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
liken this to an atypical form of encephalopathy.
All of these can take place, none of these are specific to
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 patients deserve an appropriate and full evaluation
in that setting
but again, one has to have a high index to suspicion to
evaluate for and exclude Lyme disease.
Here, as promised is the thousand words condensed into a
picture, erythema chronicum migrans rash,
a targetoid or a very prominent rash with a central
a surrounding area of clearance and then an erythematous
If one sees this rash in the setting of a tick exposure or
certainly even hiking in
or being exposed to a part of the country with Ixodes
scapularis, the tick,
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
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
Pregnant women and children would respond less well to
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 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.