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Iowa Lyme Disease Network |
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Iowa Lyme Disease Network |
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Diagnostic HintsLyme Disease Symptom
Checklist Symptom ChecklistLyme Disease Symptom
Checklist by Dr. Joseph Burrascano, JR, MD Early Lyme DiseaseThe most important method for preventing chronic Lyme disease is recognition of the early manifestations of the disease and prompt treatment. Early Lyme disease classically presents with a single erythema migrans (EM or ‘bullseye’) rash. The EM rash is 100% indicative of Lyme borreliosis. The EM rash may be absent in over 50% of Lyme disease cases, however. Absence of the rash alone should not be used to rule out Lyme disease. Patients should be made aware of the significance of a range of rashes beyond the classic EM, including multiple, flat, raised or blistering rashes. Central clearing was absent in over half of a series of EM rashes. Rashes can also mimic other common presentations and are often misdiagnosed as spider bite, ringworm, allergic response, or cellulitis. Other tick borne illnesses such as Rocky Mountain Spotted Fever, Ehrlichiosis, and Bartonella can present with dermatological findings and should also be considered. Co-infections complicate the treatment of Lyme borreliosis and will impact the treatment outcome. Physicians should be aware that fewer than 50% of all Lyme disease patients recall a tick bite! Considering the size of nymphal ticks (poppy seed) this is not surprising. Most Iowans are not even aware they should be looking for ticks routinely. History of possible tick exposure and travel should be considered. Deer ticks are prevalent throughout Iowa and the potential for infection has drastically increased over the last decade. Early Lyme disease should also be considered in an evaluation of ‘off-season’ onset when flu-like symptoms, fever and chills occur in the summer and fall. Early recognition of atypical early Lyme disease presentation is most likely to occur when the patient has been educated on this topic. Late (Tertiary) Lyme Disease PresentationsUndiagnosed and under treated Lyme borreliosis becomes complicated as chronic Lyme disease with multi-system involvement. Most patients diagnosed with chronic Lyme disease have an indolent onset and variable course. Symptoms often wax and wane. Neurological and rheumatologic symptoms are characteristic, and increased severity of symptoms on wakening is common. Neuropsychiatric symptoms alone are more often seen in chronic than acute Lyme disease. Although many studies have found that such clinical features are often not unique to Lyme disease, the striking association of musculoskeletal and neuropsychiatric symptoms, the variability of these symptoms and their recurrent nature may support a diagnosis of the disease. Neuroborreliosis can mimic virtually any type of encephalopathy or psychiatric disorder and is often compared to neurosyphilis. Both are caused by spirochetes, are multi-systemic, and can affect a patient neurologically, producing cognitive dysfunction and organic psychiatric illness. Such symptoms may be dormant, only surfacing years later. Inflammation of skeletal muscle is a consistent feature of Lyme borreliosis, both in humans and in experimental animal models of infection. Less commonly, under treated people can develop cardiac problems and hepatitis. Heart symptoms occur in 6-10% of untreated people. Electrical conduction in the heart may be affected (heart block), sometimes requiring temporary insertion of a pacemaker, and inflammation of the heart muscle (myocarditis) may occur. The presentation of chronic Lyme disease can be identical to that of other multisystem disorders, including systemic lupus erythematosus, rheumatoid arthritis and fibromyalgia. Neurological presentations that LD can mimic are MS, ALS, Parkinson's, movement disorders and Alzheimer's. Neurological Complications of Lyme DiseaseNeurological complications most often occur in the second stage of Lyme disease, which may not appear until weeks, months, or years after a tick bite due to the dormancy factor. Late stage complications present with numbness, pain, weakness, muscle twitching, Bell's palsy (fewer than 5%), visual disturbances, tinnitis, and meningitis symptoms such as fever, stiff neck, hyperacusis, photosensitivity, sensorineural hearing loss, and severe headache. Some 15% of the patients have neurological symptoms expressed as a triad of meningitis, cranial neuritis and polyradiculitis. Other findings frequently associated include an encephalopathic presentation with hypo perfusion to the brain, causing decreased concentration, irritability, memory and sleep disorders, and depressive states. Varying degrees of permanent joint or nervous system damage may develop in patients with late chronic Lyme disease resulting in permanent disability. In severe cases, some individuals may die from Lyme disease and its complications. The more severe neurological symptoms or disorders associated with late-stage Lyme disease: • Progressive dementias • Seizure disorders • Strokes • ALS-like syndrome or motor neuron disease (similar to Lou Gehrig’s Disease) • Guillain-Barre like syndrome • Multiple sclerosis-like syndrome • Parkinson’s disease-like syndrome • Other extra pyramidal disorders • Visual disturbances or loss, sensorineural hearing loss Differential DiagnosisThe differential diagnosis of Lyme disease requires consideration of both infectious and noninfectious etiologies. A detailed history may be helpful for suggesting a diagnosis of chronic Lyme disease. Among noninfectious causes are thyroid disease, degenerative arthritis, metabolic disorders (vitamin B12 deficiency, diabetes), heavy metal toxicity, vasculitis and primary psychiatric disorders. Infectious causes can mimic certain aspects of the typical multi-system illness seen in chronic Lyme disease. These include viral syndromes such as parvovirus B19 or West Nile virus infection, and bacterial mimics such as relapsing fever borrelia, syphilis, leptospirosis and mycoplasma. The clinical features of chronic Lyme disease can be indistinguishable from fibromyalgia and chronic fatigue syndrome. These illnesses must be closely scrutinized for the possibility of etiological B. burgdorferi infection. Limited Physical FindingsA comprehensive physical examination should be performed, with special attention to neurological, rheumatologic and cardiac symptoms associated with Lyme disease. Early physical findings are nonspecific and often normal, but arthritis, meningitis and Bell’s palsy may sometimes be noted. Available data suggest that objective evidence alone is inadequate to make treatment decisions, because a significant number of chronic Lyme disease cases may occur in symptomatic patients without objective features on examination or confirmatory laboratory testing. Often times objective clinical findings are present after severe neurological damage has been done due to undiagnosed and untreated late Lyme disease. Factors other than physical findings, such as a history of potential exposure, known tick bites, rashes or symptoms consistent with the typical multi-system presentation of Lyme disease, must also be considered in determining whether an individual patient is a candidate for antibiotic therapy. Serological Testing and Sensitivity limitationsAccording to the Centers for Disease control and ILADS (International Lyme and Associated Diseases Society) treatment decisions should not be based routinely or exclusively on laboratory findings. It is maintained that Lyme disease remains a clinical diagnosis. The CDC's case criteria is for surveillance purposes only. If a clinical diagnosis of Lyme borreliosis is made, medical providers should not wait for serological testing results to begin treatment. Validated laboratory tests can be very helpful but are not generally recommended when a patient has erythema migrans as this already represents a confirmed case. In Lyme Borreliosis, the western blot is the preferred serologic test. The two-tier diagnostic criteria, requiring both a positive ELISA and western blot, lacks sensitivity and leaves a significant number of individuals with Lyme borreliosis undiagnosed and untreated. These diagnostic criteria were intended to improve the specificity of tests to aid in identifying well-defined Lyme disease cases for research studies. Though arbitrarily chosen, these criteria have been used as rigid diagnostic benchmarks that have prevented individuals with Lyme disease from obtaining treatment. Diagnosis of Lyme disease by two-tier confirmation fails to detect up to 90% of cases and does not distinguish between acute, chronic, or resolved infection. The CDC considers a western blot positive if at least 5 of 10 IgG bands or 2 of 3 IgM bands are positive. However, other definitions for western blot confirmation have been proposed to improve the test sensitivity. In fact, several studies showed that sensitivity and specificity for both the IgM and IgG western blot range from 92 to 96% when only two specific bands are positive. What is more important than the numbers of positive bands is if the bands are specific for borreliosis infection. Serological tests do not detect measurable levels of antibodies to Borrelia burgdorferi until weeks after the bite of an infected tick, therefore, they may be falsely negative in patients with erythema migrans rash. Unexplained skin lesions and rashes should undergo biopsy for PCR and careful histology. You need to alert the pathologist to look for spirochetes! Lumbar puncture has also been disappointing as a diagnostic test to rule out concomitant central nervous system infection. In Lyme disease, evaluation of cerebrospinal fluid is unreliable for a diagnosis of encephalopathy and neuropathy because of poor sensitivity. Testing Ticks More Information:Lyme Disease Surveillance Case
Definition Sources: International Lyme and Associated Diseases Society, US Centers for Disease Control, and National Institutes of Health NINDS |
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