Lyme Arthritis Key Points

• Borrelia burgdorferi is the most common source of Lyme disease.

• Lyme titer is diagnostic but might have a high false-negative ratio.

• False-positive titers can be caused by RA or lupus.

• About 80% of Lyme disease patients have classic erythema migrans rash.

Lyme disease is caused by the Ixodes tick-borne spirochete Borrelia burgdorferi and was first described in 1975 after an apparent outbreak of juvenile RA in Lyme, Connecticut. The characteristic target rash of erythema migrans (EM) develops within 1 month (mean 1 week) of a tick bite and can be complicated by CNS disease (meningitis, neuritis), cardiac disease (atrioventricular conduction blocks), and arthritis. It occurs most often in northeastern states (New York, Connecticut, Massachusetts, New Jersey, Rhode Island, Pennsylvania) and upper midwestern states (Wisconsin, Minnesota). As with other rheumatologic diseases, Lyme disease is a clinical diagnosis, with laboratory tests used only to clarify the diagnosis.

Although most patients with Lyme disease do not recall an actual tick bite, most (80%) manifest the EM rash, which might be confluent or have central clearing or darkening. This rash may enlarge quickly and may be accompanied by arthralgia, myalgia, fatigue, fever, and chills. Weeks to months after the EM rash, neurologic involvement can occur. A facial nerve palsy is common, although most facial nerve palsies are not caused by Lyme disease, even in endemic areas. As with neurologic signs, carditis might be the first presenting symptom, often manifesting as a first-, second-, or third-degree atrioventricular block or bundle branch block. Cardiac symptoms normally do not occur for 1 to 2 months after onset of symptoms.

Arthritis can occur in approximately half of untreated Lyme patients but is rare in treated patients. Rheumatic symptoms occurring late in the clinical course include polyarthralgias, a migratory polyarthritis, or an oligoarticular arthritis with few systemic symptoms. In those untreated patients developing an arthritis, some develop a chronic arthritis resistant to antibiotics.

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