• Clinical science

Lyme disease

Summary

Lyme disease (or borreliosis) is a tick-borne infection caused by certain species of the Borrelia genus (B. burgdorferi in the US), a genus of facultative intracellular bacteria. There are three stages of Lyme disease. Stage I (early localized disease) is characterized by erythema migrans (EM), an expanding circular red rash at the site of the tick bite, and may be associated with flu‑like symptoms. In stage II (early disseminated disease), patients may present with neurological symptoms (e.g., facial palsy), migratory arthralgia, and cardiac manifestations (e.g., myocarditis). Stage III (late disease) is characterized by chronic arthritis and CNS involvement (late neuroborreliosis) with possible progressive encephalomyelitis. Lyme disease is a clinical diagnosis in patients presenting with EM. Serological tests (e.g., Western blot; enzyme-linked immunosorbent assay) can help support the clinical diagnosis, especially if the presence of EM is not known or questionable. Lyme disease is treated with antibiotics; the drugs of choice are doxycycline for localized disease and ceftriaxone for disseminated disease.

Epidemiology

  • Incidence: most commonly reported vector-borne disease in the US
  • Geographical distribution: primarily the Northeast and upper Midwest

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Pathogen
  • Vector
    • Various tick species: mainly Ixodes scapularis (deer or black-legged tick); in the northeastern and upper midwestern US
    • Peromyscus leucopus, the white‑footed mouse, is the primary reservoir of B. burgdorferi in the US.
  • Increased risk of disease for:
    • Outdoor workers (landscapers, farmers, etc.)
    • Outdoor enthusiasts (i.e., hikers, hunters, etc.)

References:[2]

Clinical features

Stage I (early localized Lyme disease)

  • Symptoms develop within 7–14 days after a tick bite.
  • Erythema chronicum migrans (EM)
    • Occurs in 80% of infected individuals
    • Usually a circular, slowly expanding red ring around the bite site with central clearing
    • Typically warm, painless
    • EM is often the only symptom.
    • Self-limiting (typically subsides within 3–4 weeks)
  • Flu‑like symptoms

Stage II (early disseminated Lyme disease)

Stage III (late Lyme disease)


References:[2][3]

Diagnostics

Approach

  • After a tick bite, observe for erythema chronicum migrans. Suspicious rashes may be monitored over several days.
  • If the patient history and clinical presentation indicate Stage I Lyme disease, empiric antibiotics may be started without further testing.
  • If symptoms of Lyme disease arise in a patient with possible exposure (especially if a history of recent travel to an area with high vector density) → conduct two-step serological testing
  • If signs of neuroborreliosis are present and other tests are inconclusive, consider additional procedures, such as a lumbar puncture for cerebrospinal fluid testing.

Two‑step serological testing

Other tests

  • Arthrocentesis
    • Commonly conducted if signs of arthritis are present, but results do not allow differentiation from septic arthritis without PCR
    • Synovial fluid findings
      • Appearance: yellow and cloudy
      • Leukocyte count: 3000–100,000/mm3 with > 50% neutrophils
      • PCR test: positive
      • Negative findings: Gram stain, culture, crystals

References:[4][5][6]

Differential diagnoses

References:[2][4][7]

The differential diagnoses listed here are not exhaustive.

Differential diagnoses of tick bite

Tick-borne diseases (endemic to US) [8] Pathophysiology / Epidemiology

Clinical features

Diagnostics Treatment
Lyme disease
  • Pathogen: Borrelia burgdorferi
  • Vector
    • Ixodes scapularis
    • Ixodes pacificus
  • Distribution: upper midwestern, northeastern US, and West Coast
Tick paralysis
  • Tick neurotoxin
  • Incubation period: 2–7 days
  • Weakness in lower extremities ascending flaccid paralysis that progresses rapidly over 24–48 hourscan lead to respiratory failure due to respiratory muscle weakness
  • No fever or rash
  • Locate and remove the tick!
  • Supportive therapy (e.g., ventilatory support in a patient with respiratory failure)
Rocky Mountain spotted fever (RMSF)
  • Pathogen: Rickettsia rickettsii
  • Vector
    • Dermacentor variabilis
    • Dermacentor andersoni
    • Rhipicephalus sanguineus
  • Distribution: northeast and south US
  • Incubation period: 2–14 days
  • Flu-like symptoms
  • Blanching maculopapular rash (90% of cases): begins on wrists and ankles 2–5 days after onset of fever → spreads to trunk, palms, and soles → becomes petechial and/or hemorrhagic in 50% of cases
  • Ankle and/or wrist swelling
  • Gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain)
  • Meningitis, focal neurological deficits
  • Rapid clinical deterioration with shock and multi-organ dysfunction
Babesiosis
  • Pathogen: Babesia species (typically Babesia microti)
  • Vector: Ixodes scapularis
  • Distribution: midwest and northeast US
  • Incubation period: 1–6 weeks
  • Flu-like symptoms
  • Hemolytic anemia → dark urine and/or icterus
  • Mild splenomegaly and/or hepatomegaly
  • Gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain)
  • Typically no rash
Ehrlichiosis
  • Pathogen: Ehrlichia chaffeensis, Ehrlichia ewingii
  • Vector: Amblyomma americanum
  • Distribution: southeastern and south-central US
  • Incubation period: 1–2 weeks
  • Flu-like symptoms
  • Gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain)
  • Typically no rash
  • Peripheral blood smear shows morulae within leukocytes.
  • Confirmatory test
    • Ehrlichia DNA detection by PCR of blood
      OR
    • Four-fold increase in IgG-specific IFA antibody assay between the acute and convalescent serum samples

Anaplasmosis

  • Pathogen: Anaplasma phagocytophilum
  • Vector
    • Ixodes scapularis
    • Ixodes pacificus
  • Distribution: upper midwest and northeastern US
  • Incubation period: 1–2 weeks
  • Flu-like symptoms
  • Gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain)
  • Cough
  • Typically no rash
  • Peripheral blood smear shows morulae within granulocytes.
  • Confirmatory test
    • Detection of Anaplasma DNA by PCR of blood
      OR
    • Serologic test: Four-fold increase in IgG-specific IFA antibody assay between the acute and convalescent serum samples
Tularemia [9] [10]
  • Pathogen: Francisella tularensis
  • Vector
    • Dermacentor variabilis
    • Dermacentor andersoni
    • Amblyomma americanum
  • Distribution: all states except Hawaii
  • Incubation period: 3–5 days
  • High fever
      • Skin ulcer at the site where F. tularensis enters the body
      • Tender regional lymphadenopathy
  • Confirmatory test
    • Positive culture from skin lesions and/or lymph node aspirate/biopsy
      OR
    • Serologic test: four-fold increase in F. tularensis specific antibody titers between the acute and convalescent serum samples
Tick-borne relapsing fever [11]
  • Pathogen: Borrelia hermsii
  • Vector: Ornithodoros species
  • Distribution: western US
  • Incubation period: 4–18 days
  • Recurring episodes of high fever lasting 3 days followed by an afebrile period of 7 days
  • Arthralgia
  • Gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain)
  • Less commonly, symptoms of meningitis
  • Macular rash or scattered petechiae in 15–20% of cases

Treatment

Stages Presentation General therapy Therapy in pregnant/nursing patients
Localized Lyme disease
Disseminated Lyme disease

Doxycycline is relatively contraindicated in pregnant/nursing women due to its adverse effects on growing bones and teeth! Administer amoxicillin (or cefuroxime axetil) instead!

If infection is likely (e.g., EM is present) → start antibiotic treatment!

References:[12]

Prevention

  • There is no approved vaccine on the market.
  • Avoid areas known for Lyme disease.
  • Prevent and properly manage tick bites to avoid exposure.
    • Wear protective clothing: e.g., long-sleeved shirts, long pants, and light colors.
    • Use tick repellent and pesticides.
    • Check body for tick bites.
    • Remove ticks immediately!
      1. Grasp the tick with tweezers directly above the skin's surface.
      2. Carefully pull upward with even pressure.
      3. Do not use nail polish remover, adhesives, oils, or similar substances to remove the tick. The tick should be removed quickly rather than waiting for it to detach slowly.
      4. Disinfect the site of the bite and dispose of the tick
    • Observe the bite site for early detection of EM.

References:[13]