Lyme disease is one of the most common vector-borne diseases in the world, and the number one in the United States. A vector-borne disease is one transmitted through an insect bite, in this case, ticks infected with a bacterium called Borrelia burgdorferi. Most patients do not recall any tick bite, and they only display an array of signs and symptoms that we will describe in this article.
It is especially important to be attentive on these signs and symptoms if you’re a pet owner, work with animals, or live near them, especially if you have found ticks walking around your house. In many cases, people get infected with Borrelia burgdorferi after traveling to the countryside or any other place with animals. Thus, if you encounter these signs and symptoms in yourself or any of your family members and suspect there is a possibility you may have Lyme’s disease, contact your doctor right away to perform relevant screening tests and start an early treatment.
The most relevant signs and symptoms of Lyme disease are as follows:
Fever
The first stage of the disease features a type of fever that is very difficult to differentiate and diagnose, and starts up to 30 days after being bitten by an infected tick. Fever is a common symptom in many infectious diseases, and in the early stage, it is difficult to point out the cause unless there are additional signs and symptoms to look over, especially the associated skin rash.
Fever results from a state of alarm in the human body. When the bacterium starts to colonize, it is detected by cells in our immune system, and these cells start releasing inflammatory mediators and cytokines. When they reach the brain and the temperature regulator centers, the normal reaction as a means to eradicate the disease is increasing body temperature through muscle contraction and heat maintenance.
Enlarged lymph nodes
As it happens with many other infectious diseases, Lyme disease may include enlarged lymph nodes as one of the most common signs. These lymph nodes might be dispersed throughout the body, or they might be regional lymph nodes near skin lesions and other external manifestations of the disease.
The reason why lymph nodes start to swell in the event of an infectious disease such as Lyme disease is that these structures are an important part of the immune system. They are filled with lymphocytes, ready to be replicated. When there’s colonization by bacteria, lymphocytes take a sample of this bacteria, travel through the lymph vessels into the lymph nodes, and deliver this information to the newly replicating lymphocytes. The lymph nodes become active, creating more and more lymphocytes to fight the invasion. That is why they become larger.
Enlarged nodes are useful for the diagnosis in association with other signs and symptoms that we will further mention in this article. In all cases, your doctor will be qualified to know the difference between a simple viral infection that does not require any treatment and Lyme disease, which needs to be treated as soon as possible.
Skin rash
The type of skin rash in Lyme disease is called erythema migrans, and it can be found in these patients as an early manifestation in stage 1 of the disease or later. Two-thirds of patients display this sign, and it often appears one week after being bitten by an infected tick. The first manifestation of skin rash usually appears right in the spot where the patient was bitten, and may or may not itch or feel like burning. Then, as the name erythema migrans implies, the rash starts expanding in the same area creating concentric rings in the skin, and finally, they start appearing in other parts of the body.
When skin manifestations are not treated, they usually take up to 3 weeks to disappear, and sometimes these patients may display only one erythema migrans that do not replicate in other areas of the body. In 20% of patients, there are multiple lesions, and these patients should be aware and take care of their disease because it might be associated with a hematogenous dissemination of the disease.
Flu-like symptoms
Flu-like symptoms are a very important part of the early manifestations in Lyme disease. These patients often have a low-grade fever, general malaise, chills, and other symptoms that may be attributed to any infection. These symptoms usually last no longer than one week and may include joint pain, neck pain, neck stiffness, and headache. Sometimes they resolve without any medical intervention, but you should be careful around neck stiffness, headache, and fever because they sometimes point out at a neurological problem that requires urgent medical assistance.
In other cases, patients may also have a series of respiratory symptoms or gastrointestinal symptoms, and most of us would be misled to think there is an infection in either one of these body systems. If the symptoms are mild, it is recommended to wait instead of initiating medical therapy, but if your symptoms are severe, your doctor might recommend lab tests and medical therapy right away. Thus, if you feel your symptoms are uncommon and disturbing, it is better to talk to your doctor and follow his advice instead of taking the stand of “waiting and seeing.”
Ocular manifestations
The earliest ocular manifestation in the first stage of the disease is redness in the eyes due to conjunctivitis. Sometimes patients may have photophobia as well, but this conjunctivitis-related photophobia should be differentiated from photophobia in the second stage of the disease when it is associated with meningeal signs.
In the second stage of the disease, more ophthalmic manifestations may start to appear, including blurred vision and severe vision disturbances. When examining your eye, your doctor might detect something called papilledema, an internal swelling of the optic nerve. It may even lead to optic atrophy and other problems. These optic nerve issues are more common in children than adults, which is why it is recommended to stay vigilant and talk to your doctor if you find disturbing signs and symptoms in your children. Other alterations include keratitis, pars planitis, vitreitis, and many others.
Borrelial lymphocitoma
This manifestation is not as common as the ones we have already mentioned, but may be present in the second stage of the disease, which usually starts within weeks 3 and 10. Borrelial lymphocitoma appears in 1% of Lyme disease patients, and it is a nodule or plaque that is located in the earlobe or the scrotum in children or the nipples in adults. It grows a few centimeters, and it is usually accompanied with enlarged lymph nodes close by. It looks like a blueish or reddish discoloration of the skin with swelling.
Joint pain
Musculoskeletal manifestations are common in the second stage of the disease, and not every patient goes through that stage of the disease. It usually starts 3 to 10 weeks after the tick bite, and no more than 25% of patients develop these symptoms. When the articulations are taken by the disease, joint pain similar to inflammatory arthritis may start in a migratory polyarticular fashion. It means that not one but many different joints may start hurting at the same time, and it is not always the same articulation. After this migratory polyarticular joint problem, patients usually experience a monoarticular process, which means that the disease stays in just one articulation after a few days of migrating from one to the other.
Lyme disease affects tendons, the bursae, and other parts of the joint, and it usually involves the articulation of the knee, wrists, and ankles. In the majority of cases, these articular problems start within the first 6 months after erythema migrans appears, and they don’t usually last longer than one week. It may have a few recurrence episodes involving one joint, especially when patients do not undergo medical treatment. In other cases, stage 3 of the disease starts, and arthritis is maintained for a longer time.
Headache and meningitis symptoms
Patients with a long-standing Lyme disease usually develop meningitis symptoms as well. This is common in the second stage of the disease that features hematogenous dissemination of the disease to other organs, including the central nervous system. These symptoms usually appear within 2 to 10 weeks after infection, and the most common symptoms are headache, neck stiffness, and neck pain. Patients also have photophobia, which is a high sensitivity to light. All of these signs are enclosed together as meningeal symptoms because they are indicative of meningeal irritation.
The severity of the symptoms is highly variable. These symptoms might be experienced in the first phase of the disease as well, but not with photophobia. The full extent of the meningeal signs is usually present in the second stage only. Headache is variable and usually not persistent. In these patients, it is important to rule out meningitis, and doctors might need to examine their case very closely, sometimes as an in-patient.
Cranial nerve palsy
It is not as common as erythema migrans or fever, but if you’re suspecting Lyme disease, you need to know there’s a possibility to experience a series of cranial nerve dysfunctions as a result of a second stage Lyme disease. The second stage of the disease is experienced by 25% of patients and start after 3 to 10 weeks of inoculation, and only 3% of patients experience a cranial nerve palsy, usually involving the facial nerve.
This is also known as Bell palsy, and it is especially common in children. These patients usually have a headache and meningitis-like symptoms as well, and facial palsy is basically a paralysis of the facial nerves leading to an inability to move the muscles in one half of the face.
Depression, anxiety, psychosis
Additional to the meningeal symptoms and cranial nerve palsy, sometimes patients experience mild confusion with memory problems, difficulty to concentrate, mood swifts, sleep disturbances, and even changes in their personality. These changes might be associated with psychiatric problems such as depression as well, and usually, start a few months after the initial infection.
Neuropsychiatric problems are a late-stage disease finding, and may even include psychosis that is quite similar to schizophrenia symptoms, bipolar disorder, dementia and memory problems, as well as anxiety and depression.
Heart problems
Patients with a dissemination of the disease may have cardiac problems as well, especially when their disease has not been correctly treated. In most cases, cardiac problems feature atrioventricular conduction abnormalities, and sometimes patients may even have a heart block that requires a device called pacemaker, a small device that sends a signal to regulate your heart’s beating.
In other cases, patients may also experience severe consequences such as cardiac tamponade, heart failure, myocarditis, and pericarditis. This is another reason why it is important to talk to your doctor if you suspect Lyme disease in yourself or any other family member. After treating the disease, the chance of having hematogenous dissemination to the heart and other structures is significantly reduced.
Besides Lyme disease, your doctor might need to rule out co-infection with other microorganisms such as Babesia microti and Ehrlichia spp. Around 15% of patients with Lyme disease have coinfection with one of these micro-organisms that are usually transmitted at the same time. This is especially the case when there are atypical manifestations such as very high fever with quick rises of temperature and severe shivering.
The majority of patients only experience symptoms of a stage 1 disease. Stage 2 Lyme disease and further stages are usually a result of a disseminated disease that becomes more difficult to eradicate. Thus, talk to your doctor right away, because sometimes patients with disseminated disease have some give-out signs and symptoms from the start, and your therapy might be able to address these issues before entering a stage 2 Lyme disease.
References
Feder Jr, H. M. (2008). Lyme disease in children. Infectious disease clinics of North America, 22(2), 315-326.
Stanek, G., & Strle, F. (2009). Lyme borreliosis: a European perspective on diagnosis and clinical management. Current opinion in infectious diseases, 22(5), 450-454.
Mead, P. S. (2015). Epidemiology of Lyme disease. Infectious Disease Clinics, 29(2), 187-210.
Wormser, G. P., McKenna, D., Scavarda, C., Cooper, D., El Khoury, M. Y., Nowakowski, J., … & Demarest, V. (2019). Co-infections in Persons with Early Lyme Disease, New York, USA. Emerging Infectious Diseases, 25(4), 748-752.