Lyme disease starts with flulike symptoms and a circular rash at the site of the tick bite Table 01 Figure 03. A red, circular rash (erythema migrans) develops anywhere from 1 to 30 days after the tick bite (most commonly within 7 to 10 days). While redness, pain, and swelling may develop within hours at the site of any insect bite or sting, erythema migrans (EM) will appear around the bite as an expanding red, painless area with a central clearing. Sometimes the rash will appear as multiple concentric rings, as in a bulls-eye pattern. About 10% of patients with EM will have multiple lesions that occur when B. burgdorferi spreads from a single tick bite. Although bites can appear anywhere, particularly common sites include the groin, thighs, and armpits, presumably because ticks prefer warm, moist areas. Some people experience flulike symptoms (fever, fatigue, malaise, headache, and muscle and joint aches) without a rash, and others have neither a rash nor other symptoms. If a rash appears, however, it will generally clear within a few weeks to a month, even without treatment.
Figure 03. Lyme Disease Rash
Other common viral symptoms, including rhinitis and upset stomach, are relatively uncommon in Lyme disease. If you experience these symptoms, or have severe fever or fatigue, your doctor will likely suspect that you have something other than Lyme disease.
You may experience joint pain and stiffness if your disease progresses without treatment. More than half of untreated patients with Lyme disease experience joint pain and stiffness. Usually one or two joints are affected at a time, the knee being the most common site, followed by the shoulder, ankle, elbow, and hip. Simultaneous involvement of many joints, or involvement of small joints is unusual, and should prompt investigation into other arthritic disorders. Initially, joint discomfort may be transitory, coming and going within hours or days. After months of infection, more typical symptoms of arthritis occur, with swelling, redness, and pain in the affected joint that may last for months.
Without treatment, a number of neurological symptoms can develop. Some patients have no symptoms, despite evidence in the spinal fluid of the bacteria that cause Lyme disease. Others develop typical symptoms of meningitis, which include headache, stiff neck, and light avoidance. Nerve inflammation can manifest as facial muscle paralysis, often with just one side affected, causing a distorted appearance and drooling, or as pain or paralysis in the arms or legs. Seizures, eye inflammation, emotional changes, depression, and poor memory and concentration can also develop. Children tend to develop irregular, jerky movements of the arms, legs, or face. Neurological symptoms usually resolve within a few months.
Temporary heart symptoms occur in up to 10% of patients with untreated Lyme disease. Heart symptoms manifest as abnormal rhythms, which may be noticeable as palpitations, or as confusion, fatigue, dizziness, or fainting. Sometimes patients are not aware of symptoms, but have detectable changes on their EKG. Cardiac problems tend to resolve within weeks.
People with Lyme disease may develop chronic disease, which is characterized by continuing joint problems and, less commonly, neurological deficits. Lyme disease can continue to cause intermittent joint pain and swelling. As in the earlier stage, usually one weight-bearing joint such as the knee or hip is affected at a time. This chronic arthritis can be severe, with breakdown of cartilage and bone, and sometimes requires removing the lining of the joint (synovectomy) to relieve the pain.
Neurological changes can also persist, with memory and concentration deficits, sleep disturbances, fatigue, and personality changes. Specific nerve disorders may also persist, causing partial paralysis in affected muscles.
Sometimes musculoskeletal problems become chronic, even after Lyme disease treatment has been apparently successful. It is sometimes difficult to determine whether problems that persist despite adequate antibiotic therapy should be attributed to persisting Lyme disease, or to other conditions. Lyme disease has symptoms similar to those of chronic fatigue syndrome, including chronic pain, headache, fatigue, joint stiffness, and sleep disturbances. All are difficult to diagnose with certainty. Fibromyalgia, which can occur after Lyme disease, is also characterized by similar symptoms.
Table 1. Symptoms of Lyme Disease
Early localized stage Early disseminated stage Late stage Redness around the bite with central clearing (EM)HeadacheFeverMalaiseAchy joints and muscles Multiple EMTransitory joint painHeadacheStiff neckPhotophobiaParalysis of muscles in face, arms, or legsSeizuresMoodinessMemory and concentration deficitsHeart rhythm changesDizzinessFaintingConfusionFatigue Swelling and pain in jointsMemory and concentration deficits Personality changesInsomnia and fatiguePartial or transitory paralysis in various muscles
People who spend time in natural settings in endemic areas have the greatest risk of acquiring Lyme disease. People who live or work in areas surrounded by woods or overgrown brush, and those who visit natural areas for recreational purposes are at greatest risk for acquiring Lyme disease.
Lyme disease persists with greater frequency in localized regions throughout the United States, Europe, the former Soviet Union, South Africa, Australia, and Asia. In 1996, more than 90% of reported cases of Lyme disease in the U.S. were from Connecticut, Rhode Island, New York, New Jersey, Delaware, Pennsylvania, Maryland, and Wisconsin. In each state, high-risk areas are usually concentrated in specific localities. Focal endemic areas also exist in Europe, the former Soviet Union, South Africa, Australia, Japan, Korea, and China.
Being outside during warm-weather months increases your risk of acquiring Lyme disease. In the U.S., ticks thrive during the warm-weather months of April through September (except in the western U.S., where the high-risk season is January through May). Ticks favor the moist, shaded environment provided in leaf litter or low-lying vegetation in wooded, brushy, or overgrown grassy habitats.
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