Lyme disease Lyme disease is a tick-borne illness most commonly caused by one of three pathogenic species of spirochete Borreliella. B. burgdorferi is the primary cause of the disease in the U.S. All three pathogenic species, B. burgdorferi, B. afzelii , and B. garinii , occur in Europe, and the latter two species have been identified in Asia. Other species of Borreliella that have been recovered from humans include B. mayonii, B. spielmanii, B. bavariensis, B. valaisiana, B. lusitaniae , and B. bissettii . Lyme disease has a broad spectrum of clinical manifestations, and it also varies in severity due, in part, to differences in the infecting species (Hu, 2021). Lyme disease in the U.S. is most frequently reported in the upper midwestern, northeastern, and mid-Atlantic states, with high-incidence states including Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Washington D.C., West Virginia, and Wisconsin (CDC, 2022c). The clinical manifestations of Lyme disease can generally be divided into three phases: Early localized, early disseminated, and late disease (Table 4). However, according to Hu (2021), the clinical features of each stage can overlap, and some patients present in a later stage of Lyme disease without a history of prior signs or symptoms suggestive of earlier Lyme disease. Table 4. Lyme Disease Phases Phase Definition Early localized disease Characterized by the appearance of the characteristic skin lesion, erythema migrans, with or without constitutional symptoms. Erythema migrans usually occur within one month following the tick bite. Early disseminated disease Characterized by multiple erythema migrans lesions (typically occur days to weeks after infection) and/or neurologic and/or cardiac findings (typically occur weeks to months after infection). Some of these patients have no history of antecedent early localized Lyme disease. Late Lyme disease Typically associated with intermittent
several days before the slow expansion of the lesion begins. Erythema migrans (EM) lesions typically have the following characteristics. ● They are often found in or near the axilla, inguinal region, popliteal fossa, or at the belt line. ● They are not particularly painful, although erythema migrans lesions may occasionally burn or itch and are hot to the touch. ● They typically expand slowly over days or weeks, often with central clearing , and may reach more than 20 cm diameter. During the first days, erythema migrans lesions may be uniformly red. Some central clearing often develops as they expand, and they may have a more complex target or bull’s eye appearance. During the first days or weeks of infection, patients with early, localized, or disseminated Lyme disease often also have nonspecific signs and symptoms resembling a viral syndrome. Patients from the U.S. are more likely to have constitutional symptoms than are patients in Europe (Hu, 2021). In a prospective study of 79 patients with culture-confirmed EM, common clinical manifestations included the following. ● Fatigue ● Anorexia ● Headache ● Neck stiffness ● Myalgias ● Arthralgias ● Regional lymphadenopathy ● Fever Figure 6. Erythema Migrans
or persistent arthritis involving one or a few large joints, especially the knee (sometimes preceded by migratory arthralgias), and/or certain rare neurologic problems, primarily a subtle encephalopathy or polyneuropathy. Late Lyme disease may develop months to a few years after the initial infection. Arthritis may be the presenting manifestation of the disease.
Erythema Migrans A rash that appears at the tick bite site, usually within 7 to 14 days after the bite (range 3 to 30 days; Hu, 2021). While early erythema at the tick bite site is common due to a reaction to antigens in the tick saliva, this early allergic reaction must be differentiated from erythema migrans, which requires at least
From Garthany, J. (2007). Erythema migrans. https://phil.cdc.gov/ Details.aspx?pid=9875. In public domain. (Garthany, 2007)
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