The symptoms and signs of Lyme disease are categorized according to three stages, depending on organ system involvement and duration of infection: (1) early localized disease, which occurs in the first month after an infected tick bite; (2) disseminated disease, which occurs 1 to 4 months after a bite; and (3) late disease, which generally occurs 4 months to years after a bite:
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Clinical Spectrum of Lyme Disease
Early disease (1 mo)
Erythema migrans
Flu-like symptoms
Disseminated disease (1 to 4 mo)
CNS manifestations
Meningitis
Neuropathies
Cardiac abnormalities (atrioventricular block)
Intermittent arthritis
Late disease (4 mo to years)
Chronic, disabling arthritis
CNS manifestations
Encephalopathy
Fatigue
CNS – central nervous system
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Clinical manifestations
The hallmark of early localized Lyme disease is erythema migrans an expanding erythematous patch or ring appearing within 30 days (mean, 9 days) after inoculation of skin with B burgdorferi by an infected tick (figures 1 through 3). According to surveillance criteria from the Centers for Disease Control and Prevention (CDC), the rash must exceed 5 cm in diameter, show expansion, and persist for more than 1 week. The features of the skin lesion that are most suggestive of B burgdorferi infection are expansion at a rate of about 1 cm/day to a final diameter of 10 to 30 cm, central pallor, persistence for 2 to 3 weeks, and a central puncture indicating the site of previous tick attachment. Results of biopsy and culture of tissue from the expanding margins of skin lesions have shown that expansion indicates peripheral migration of B burgdorferi within the superficial and deep dermis.
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A minority of patients with erythema migrans report a range of systemic symptoms, including transient chills, fever, myalgias, arthralgias, headache, sore throat, stiff neck, and fatigue within the first month after B burgdorferi infection. Although this spectrum of symptoms has been termed flu-like, respiratory symptoms (cough and sore throat) that typify influenza are distinctly unusual in Lyme disease. Also, early Lyme disease occurs in the summer months, when tick exposure is most frequent and febrile viral illnesses are much less common. These toxic systemic symptoms are thought to reflect release of cytokines as a component of the immune response to the spirochetal infection.
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Not all cases of Lyme disease present with erythema migrans. In early studies, about one third of patients presented with manifestations of disseminated or late disease. According to more recent estimates, erythema migrans is present in 80% or more of cases. The most important factors in management of Lyme disease are early recognition of erythema migrans and prompt institution of therapy.
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Erythema migrans may be confused with other dermatologic disorders unrelated to B burgdorferi infection. Bites from harmless insects or ixodid or other types of ticks can result in pruritic ery-thema at the bite site, but the diameter is usually only 1 to 3 cm, duration is 1 to 5 days, and pruritus is often intense. In contrast, erythema migrans is typically nonpruritic. Cellulitis may resemble erythema migrans but is far more tender and hot, generally spreads more rapidly, is typically accompanied by a higher fever, and usually follows preexisting focal skin infection or ulceration. Scaling disorders, such as contact dermatitis and tinea corporis, are characterized by epidermal scale atop erythematous patches or rings, whereas ery-thema migrans is a purely dermal process, sparing the epidermis. Granuloma annulare presents with erythematous or flesh-colored papules in a slowly expanding ring, but the diameter rarely exceeds 5 cm, enlargement occurs over months to years, and no tick bite or central punctum is present.
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