Information on Lyme arthritis

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.

Click here: Second Opinion Arthritis Treatment Kit

Lyme disease is an infectious disease which affects the joints, skin, heart, and nervous system. Lyme arthritis is a major component of Lyme disease.

It is caused by an organism called a spirochete and transmitted by a 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.

While Lyme disease has been reported to go through three stages, it does not always do so.

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 manifestation of Lyme disease is the skin lesion, erythema chronicum migrans (ECM). This commonly 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 expand up to about 8 inches in diameter. These lesions can last for up to a month and can be painful. Other skin rashes may also occur. Generalized joint and muscle aches occur. Headache, sore throat, irritation of the eyes (conjunctivitis), swollen lymph nodes, and swollen testicles may occur.

Stage two. This occurs weeks to months after a tick bite. Eight per cent of people will develop heart involvement with 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 other peripheral nerves. The peripheral nerve pain can be excruciating. Persistent muscle and joint aches can be a problem. Occasionally, tendons may be inflamed. Eye inflammatory syndromes have also been reported.

Stage three. This happens more than 5 months after onset. The musculoskeletal events are a significant part of this stage. This often begins as a migratory process involving multiple joints, bursae, and tendons. It evolves over 1-2 days into a single inflamed joint involving the knee, ankle, and wrist in decreasing frequency. 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. Polyarticular (multiple joint) episodes also may occur.

About 10% of the patients with Lyme arthritis have persistence of spirochetal DNA in a given joint for a year or more, often despite antibiotic treatment. The largest series of patients has been reported to have unremittent Lyme arthritis for approximately 4 years.

Chronic neurological syndromes, a significant part of the stage 3 syndrome, can also develop leading to 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 should raise suspicion. Increases in antibody level do not begin until 2 to 4 weeks after infection. Antibiotic treatment or steroid therapy administered prior to this time frame 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 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 in making the diagnosis. Fifty per cent of patients with Lyme disease do not remember having a tick bite and ECM may be missed.

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 possible exposure are indicated. The use of preventive antibiotics may have merit in highly endemic areas. Early signs of Lyme disease should be treated aggressively with oral antibiotics such as doxycycline. Significant joint, heart, and nervous system disease warrant intravenous antibiotic therapy such as ceftriaxone.

Steroid therapy may possibly prolong the course of Lyme disease, particularly in those cases where inadequate antibiotic therapy has been rendered. Patients with chronic arthritis may need surgical management. Patients with heart involvement severe enough to cause heart block may need electrical pacing. 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 have fibromyalgia.

The existence of "chronic Lyme disease" is controversial; however, the discovery of the presence of spirochetal DNA in the joints of patients even after appropriate antibiotics lends credence to the syndrome.

For people with chronic arthritis involving the knee, occasionally arthroscopic synovectomy is helpful.

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