is a tick-transmitted infection caused by the spirochete Borrelia spp. Early symptoms can include an erythema migrans rash, which may be followed weeks to months later by neurologic, cardiac, or joint abnormalities. Diagnosis is primarily clinical in early-stage disease, but serologic testing can help diagnose cardiac, neurologic, and rheumatologic complications that occur later in the disease. Prompt treatment is essential.
Spirochetes are distinguished by the helical shape of the bacteria. Pathogenic spirochetes include Treponema, Leptospira, and Borrelia. Both Treponema and Leptospira are too thin to be seen using brightfield microscopy but are clearly seen using darkfield or phase microscopy. Borrelia are thicker and can also be stained and seen using brightfield microscopy.
Lyme disease has 3 stages:
The early and late stages are usually separated by an asymptomatic interval.
Early localized stage
Erythema migrans, the hallmark and best clinical indicator of Lyme disease, is occasionally the first sign of the disease. Research has determined it is only found to occur in less than 10% of patients. Beginning as a red macule or papule at the site of the tick bite, usually on the proximal portion of an extremity or the trunk (especially the thigh, buttock, or axilla), between 3 and 32 days after a tick bite. Because tick nymphs are so small, most patients do not realize that they have been bitten.
The area expands, often with clearing between the center and periphery resembling a bull’s eye, to a diameter ≤ 50 cm. Darkening erythema may develop in the center, which may be hot to the touch and indurated. Without therapy, erythema migrans typically fades within 3 to 4 weeks.
Evanescent lesions may appear as erythema migrans resolves. Mucosal lesions do not occur. Apparent recurrences of erythema migrans lesions after treatment are caused by reinfection, rather than relapse, because the genotype identified in the new lesion differs from that of the original infecting organism.
Early disseminated stage
Symptoms of early-disseminated disease begin days or weeks after the appearance of the primary lesion, when the bacteria spread through the body. Soon after onset, nearly half of untreated patients develop multiple, usually smaller annular secondary skin lesions without indurated centers. Cultures of biopsy samples of these secondary lesions have been positive, indicating dissemination of infection.
Patients also develop a musculoskeletal, flu-like syndrome, consisting of malaise, fatigue, chills, fever, headache, stiff neck, myalgias, and arthralgias that may last for weeks. Because symptoms are often nonspecific, the diagnosis is frequently missed if erythema migrans is absent; a high index of suspicion is required. Frank arthritis is rare at this stage. Less common are backache, nausea and vomiting, sore throat, lymphadenopathy, and splenomegaly.
Symptoms are characteristically intermittent and changing, but malaise and fatigue may linger for weeks. Some patients develop symptoms of fibromyalgia. Resolved skin lesions may reappear faintly, sometimes before recurrent attacks of arthritis, in late-stage disease.
Neurologic abnormalities develop in about 15% of patients within weeks to months of erythema migrans (generally before arthritis occurs), commonly last for months, and usually resolve completely. Most common are lymphocytic meningitis (cerebrospinal fluid [CSF] pleocytosis of about 100 cells/microL) or meningoencephalitis, cranial neuritis (especially Bell palsy, which may be bilateral), and sensory or motor radiculoneuropathies, alone or in combination.
Myocardial abnormalities occur in about 8% of patients within weeks of erythema migrans. They include fluctuating degrees of atrioventricular block (1st-degree, Wenckebach, or 3rd-degree) and, rarely, myopericarditis with chest pain, reduced ejection fractions, and cardiomegaly.
In untreated Lyme disease, the late stage begins months to years after initial infection. Arthritis develops in about 60% of patients within several months, occasionally up to 2 years, of disease onset (as defined by erythema migrans). Intermittent swelling and pain in a few large joints, especially the knees, typically recur for several years. Affected knees commonly are much more swollen than painful; they are often hot but rarely red. Baker cysts may form and rupture. Malaise, fatigue, and low-grade fever may precede or accompany arthritis attacks. In about 10% of patients, knee involvement is chronic (unremittent for ≥ 6 months).
Other late findings (occurring years after onset) include an antibiotic-sensitive skin lesion (acrodermatitis chronica atrophicans) and chronic CNS abnormalities, either polyneuropathy or a subtle encephalopathy with mood, memory, and sleep disorders.
Some patients have symptoms such as fatigue, headache, joint and muscle aches, and cognitive problems after successful antibiotic treatment. These symptoms are collectively referred to as post-treatment Lyme disease syndrome (PTLDS). Although some patients with such subjective symptoms are assigned the diagnosis of chronic Lyme disease, it is a subject of debate among professionals.
Lyme disease is the most common tick-borne illness in Canada
Burrascano ILADS Symptom Checklist
Why Can't I Get Better
The Horowitz Lyme-MSIDS Questionnaire is not intended to replace the advice of your own physician or other medical professional. You should consult a medical professional in matters relating to health, and individuals are solely responsible for their own health care decisions regarding the use of this questionnaire. It is intended for informational purposes only and not for self-treatment or diagnosis.
Different Lyme Bacteria Forms
Characteristic morphology of Borrelia burgdorferi seen by various techniques following one week of culture in BSKII medium. A and B: Dark field microscopy images of Borrelia burgdorferi strain B31 showing the usual spiral form of spirochetes (A) and their agglomeration into colony-like masses (B). Similar spiral morphology of strain B31 is illustrated by OspA immunoreactivity (C) and by atomic force microscopy (AFM) imaging (D). E and F: Dark field microscopy images showing the typical spiral form (E) and colony formation (F) of Borrelia burgdorferi strain ADB1. G: Similar spiral morphology of strain ADB1 shown by immunostaining with a polyclonal anti-Borrelia burgdorferi antibody (Biodesign, B65302R). The green fluorescent immunoreaction was revealed with an FITC tagged secondary antibody. H: Similar morphology of strain ADB1 revealed by silver impregnation with the Bosma Steiner microwave technique.
Ticks Species Known to carry Lyme
Twelve(12) tick species in Canada have been found to carry Lyme disease. Public Health of Canada (PHAC) only acknowledges two species as those that transmit Lyme, the Black-legged tick (Ixodes scapularis) and the Western Black-legged tick (Ixodes pacificus), but research studies dating back 20 years show there are other species known to transmit, these include; Ixodes angustus, Ixodes banksi, Ixodes cookei (groundhog tick), Ixodes gregsoni, Ixodes muris (mouse tick), Ixodes spinipalpis, Haemaphysalis leporispalustris (rabbit tick), and Dermacentor albipictus (winter tick),lone star tick (Amblyomma americanum ) and the Dermacentor variabilis (American dog tick)
A Handbook of Ticks in Canada -Biological Survey of Canada
Lyme Disease Bacterium, Borrelia burgdorferi Sensu Lato, Detected in Multiple Tick Species at Kenora, Ontario, Canada
Extensive Distribution of the Lyme Disease Bacterium, Borrelia burgdorferi Sensu Lato, in Multiple Tick Species Parasitizing Avian and Mammalian Hosts across Canada
Vector competence of Ixodes angustus (Acari: Ixodidae) for Borrelia burgdorferi sensu stricto.
Ability of the Lyme disease spirochete Borrelia burgdorferi to infect rodents and three species of human-biting ticks (blacklegged tick, American dog tick, lone star tick) (Acari:Ixodidae).
Lyme Rashes/Erythema migrans
Erythema migrans, the hallmark and best clinical indicator of Lyme disease, is occasionally the first sign of the disease. Research has determined it is only found to occur in less than 10% of patients. Although they are often referred to as a Bull's eye rash they vary in appearances and can difficult to identify by seasoned Dermatologists and Infectious disease physicians.
The rash area is known to expand, often with clearing between the center and periphery resembling a bull’s eye, to a diameter ≤ 50 cm. Darkening erythema may develop in the center, which may be hot to the touch and indurated. Without therapy, erythema migrans typically fades within 3 to 4 weeks.