Lyme borreliosis: diagnosis and management

Abstract

Lyme borreliosis is the most common vectorborne disease in the northern hemisphere. It usually begins with erythema migrans; early disseminated infection particularly causes multiple erythema migrans or neurologic disease, and late manifestations predominantly include arthritis in North America, and acrodermatitis chronica atrophicans (ACA) in Europe. Diagnosis of Lyme borreliosis is based on characteristic clinical signs and symptoms, complemented by serological confirmation of infection once an antibody response has been mounted. Manifestations usually respond to appropriate antibiotic regimens, but the disease can be followed by sequelae, such as immune arthritis or residual damage to affected tissues. A subset of individuals reports persistent symptoms, including fatigue, pain, arthralgia, and neurocognitive symptoms, which in some people are severe enough to fulfil the criteria for post-treatment Lyme disease syndrome. The reported prevalence of such persistent symptoms following antimicrobial treatment varies considerably, and its pathophysiology is unclear. Persistent active infection in humans has not been identified as a cause of this syndrome, and randomized treatment trials have invariably failed to show any benefit of prolonged antibiotic treatment. For prevention of Lyme borreliosis, post-exposure prophylaxis may be indicated in specific cases, and novel vaccine strategies are under development.

Tick bite

“…Around 70-80% of patients with Lyme disease report a classic red rash called erythema migrans 79. Guidelines from the National Institute for Health and Care Excellence (NICE)7 recommend considering Lyme disease as a possible diagnosis in patients presenting with several generalised or focal symptoms listed in table 1, especially if there is history of tick exposure in high risk areas.…”

“…It is usually painless, more than 5 cm in diameter with gradually increasing size, and has a central clearing that gives the appearance of bull’s eye (fig 1, fig 2). 7 The appearance can vary, however 9. The rash can appear any time from three days after the initial tick bite, but usually becomes visible after 1-4 weeks.…”

“…Investigations include serological tests for Lyme disease. Offer testing in patients with no erythema migrans rash but a high clinical suspicion of Lyme disease based on symptoms and a confirmed or risk of tick exposure 79…”

“…Explain that most tick bites are harmless and do not transmit Lyme disease 79. Apart from in high risk areas, most ticks (≥85%) are not infected 9. In Europe, including the UK, between 5% and 40% of ticks may be infected 1.…”

“…In Europe, including the UK, between 5% and 40% of ticks may be infected 1. Only 2-3% of people with a tick bite develop Lyme disease 9…”