Diagnose symptoms Lyme disease
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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From the Arthritis Foundation and the National Institutes of Health
Lyme disease is an infectious process which affects the joints, skin, heart, and nervous system. It is caused by an organism called a spirochete and transmitted by a deer tick.
The spirochete responsible for Lyme disease is Borrelia burgdorferi. This infectious agent is transmitted by a variety of ticks. The most common species of tick transmitting Lyme disease in the U.S. is Ixodes.
Most cases of Lyme disease in the U.S. occur in the Northeast and in the upper Midwest around the Great Lakes. Lyme disease is seasonal occurring in late spring and early summer.
Lyme disease often goes through three stages.
Stage one Lyme disease occurs three days to 4 weeks after infection. Patients complain of fatigue, flu-like symptoms, and may have a fever. The classic early sign of Lyme disease is the skin lesion, erythema chronicum migrans (ECM). This occurs on an extremity or in the groin or armpit at the site of a tick bite. ECM has a central zone of clearing surrounded by an area of redness. The area of redness can extend to about 8 inches in diameter. Other skin rashes may also occur. Generalized joint and muscle aches occur. Headache, sore throat, conjunctivitis, and swollen lymph nodes may occur.
Stage two Lyme occurs weeks to months after a tick bite. Eight per cent of people will develop heart block due to infection of the heart muscle. Neurological symptoms occur in 15 per cent with encephalitis, paralysis of cranial nerves (Bell’s palsy), and inflammation of peripheral nerves. Persistent muscle and joint aches can be a problem. Occasionally, tendons will be inflamed. Eye inflammation has been noted.
Stage three Lyme happens after more than 6 months post onset. Fifty to 70 per cent of patients will have one or two inflamed joints usually in the legs. The most common joint affected is the knee. Typically, a patient will present with a painful swollen knee joint that contains a large amount of inflammatory fluid. Chronic neurological syndromes can also develop causing chronic encephalitis and inflamed peripheral nerves.
Blood tests for Lyme disease have been difficult to standardize. Serologic increases in IgG antibodies or IgM against Borrelia are suggestive. Increases in antibody level do not begin until 2 to 4 weeks after infection. Antibiotic treatment or steroid therapy given before this time can lead to false negative results.
The current standard for diagnostic testing (screening) is the ELISA method with Western Blot tests reserved for those with equivocal findings. In those situations where doubt exists, polymerase chain reaction (PCR) studies may help to confirm the diagnosis. Unfortunately, variation in assays as well as false positive and false negative results can cause much confusion.
Cross reactions occur with other spirochetal illnesses such as syphilis.
Other abnormal lab test results that can be seen include an elevated erythrocyte sedimentation rate (ESR), anemia, and an inflammatory type of joint fluid.
The presence of ECM is helpful for diagnosis. Fifty per cent of patients with Lyme disease do not remember having a tick bite and ECM may be overlooked.
Lyme disease may be confused with viral arthritis, lupus, Still’s disease, and inflammatory spondyloarthropathy.
Lyme disease is best managed by prevention. In endemic areas, protective clothing, insect repellants, and careful surveillance after exposure are indicated. The use of preventive antibiotics have been recommended. Early signs of Lyme disease should be treated aggressively with oral antibiotics like doxycycline. Significant joint, heart, and nervous system disease warrant intravenous antibiotic therapy with ceftriaxone.
Steroid therapy may prolong the course of Lyme disease. Patients with chronic arthritis may need surgical management. Patients with heart involvement severe enough to cause heart block may need a pacemaker. Patients who receive adequate antibiotic therapy but who continue to have aches, pains, and fatigue are extremely difficult to manage.
Patients who receive appropriate antibiotics in the first 4 weeks of disease generally have a good prognosis. Patients who have a delay in diagnosis or who do not respond to antibiotics can have persistent symptoms such as joint pains and neurological complaints. Some patients with chronic aches and pains as well as fatigue appear to develop fibromyalgia.
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