Lyme Disease: Symptoms, Complaints, Signs

The following symptoms and complaints may indicate Lyme disease:

Note: The disease manifests itself differently from individual to individual, i.e., it can occur with any of the various early or late manifestations!

Stage I (days to about 5 weeks after the tick bite)

Leading symptom of stage I

  • Erythema migrans (wandering redness; erythema chronicum migrans) – this is observed in 70-90% of cases: circular or oval redness (usually diameter ≥ 5 cm, -15 cm; possibly more) around the site of the bite, usually with a light border and central lightening; can also occur on other parts of the body! ; without treatment, the erythema (skin redness) fades from the center within days to weeks (median: 4 weeks), so that the initially disk-shaped redness is later seen as a ring-shaped redness; the efflorescence (skin change) is painless, but may be accompanied by itching; often very discrete inflammatory reaction that is overlooked by the patient because of the lack of symptoms. Notice: In the early stages and when < 5 cm in diameter, it may initially appear ambiguous, e.g., as homogeneous erythema or as marginal erythema with central livid (“bluish”) tangles.Also, papular (“nodular”), nodular (“nodular”), and also ulcerated (“ulcerated”) lesions have been described in confirmed acute Lyme disease.To erythema migrans:
    • Onset: days to about 10 weeks after tick bite (mean latency 7-14 days).
      • Multiple erythema migrantia (MEM): in 10% of cases, multiple (multiple) occurrences of erythema migrans (= sign of hematogenous dissemination (“distributed over the whole body by the bloodstream”/early infection/)! )Clinical picture: flu-like symptoms of illness with mild fever, myalgia (muscle pain), arthralgia (joint pain), cephalgia (headache) and lymphadenopathy (lymph node enlargement).
    • Predilection sites (body regions where the disease occurs preferentially): groin and popliteal region (back of the knee) and.
      • Especially in children: Head-neck area and axillary region; uncharacteristic transient erythema may also occur on the face
    • Healing: usually spontaneous after an average of 10 weeks (with and without therapy), longer persistence and local recurrence (recurrence at the same site) are possibleCaution! Spontaneous disappearance of erythema migrans is not evidence that healing has occurred!If an initial infection was adequately treated, recurrences of erythema are to be evaluated as evidence of reinfection.
    • Differential diagnoses: nonspecific sting reactions or hyperergic insect sting reaction (hyperergic, ie, exaggerated immune response; see below insect sting), note: the sting reaction is visible a few hours after the event, a “free interval” as for the early form of cutaneous Lyme disease does not exist; erysipelas, drug reaction, fixed, erythema anulare centrifugum, tinea, erythema infectiosum.
  • It is called erythema chronicum migrans when the erythema migrans persists for several weeks and months
  • Lymphadenosis cutis benigna Bäfverstedt (Borrelia lymphocytoma) – usually occurring during the early phase of a Borrelia infection (stage I) in the area of the tick bite, small, reddish to bluish skin swelling (reactive hyperplasia of lymphoid cells) that may be the center of erythema migrans (incidence: Children 7% and adults 2%); often associated with one (or more) erythema migrans; may also occur in stage IIPredilection sites (areas of the body where the disease preferentially occurs):
    • In children, earlobes, mammillary region (“region around the nipple“) and the genitoanal area.
    • In women, mammillary region and labia (labia).
    • In men, scrotal skin (“testicular skin”);

    In about 25% of cases, regional lymphadenopathy (lymph node enlargement) is found.

In about 20% of affected people, the erythema migrans does not occur. Accompanying symptoms (“Lyme disease flu“; Lyme flu; about 10-14 days after borrelia infection has occurred; frequency: about 10-30% of cases).

  • Fever (subfebrile temperatures).
  • Conjunctivitis (conjunctivitis)
  • Cephalgia (headache)
  • Myalgia (muscle pain)
  • Arthralgia (joint pain)
  • Lymphadenopathy (lymph node enlargement)

Stage II (weeks to months after the tick bite)

Leading symptom of stage II

  • Lymphocytic meningopolyneuritis Garin-Bujadoux-Bannwarth – most common clinical manifestation of disseminated (“scattered”) infection with radicular (originating from the nerve roots) pain that may exacerbate (worsen), especially at night; subsequently, asymmetric polyneuritis (inflammation of nerves) with cranial nerve loss, primarily of the facial nerve supplying facial muscles, is usually observed.

Other symptoms of stage II

  • Severe headache
  • Meningismus (painful stiffness of the neck)
  • Fever
  • Chills
  • Cough without sputum
  • Myalgia (muscle pain, wandering)
  • Arthralgia (joint pain, migratory).
  • Fatigue
  • Generalized swelling of the lymph nodes
  • Splenomegaly (enlargement of the spleen)
  • Hepatitis (inflammation of the liver)
  • Pharyngitis (pharyngitis)
  • Conjunctivitis (conjunctivitis)
  • Iritis (rainskin inflammation)
  • Testicular swelling
  • Early neuroborreliosis (acute neuroborreliosis), which often presents as a painful meningoradiculitis (meningitis with inflammation of adjacent spinal nerve roots) (synonym: Bannwarth syndrome) (ca. 3-6 weeks (range: 1-18 weeks) after primary infection) (3-15% of Borrelia infections; children have a higher risk of developing neuroborreliosis than adults: probably due to sting site in head/neck area):
    • Meningitis (meningitis) (esp. in children: often discrete)Note: 30% of pediatric neuroborreliosis cases occur without cranial nerve palsy.
    • Cranial nerve palsies (cranial nerves): facial nerve palsy with unilateral drooping of the corner of the mouth ((in one-third of patients in the form of bilateral facial palsy; bilateral facial palsy is associated with Lyme disease in about 96 percent of cases) (esp. in children) and abducens nerve.
    • Radiculitis (nerve root inflammation) develops on average 4 to 6 weeks (maximum 1-18) after the tick bite or after erythema migrans; radicular (“originating from the nerve roots”) pain, especially at night; often multilocular (“many places”) and migratory
    • Inflammatory cerebrospinal fluid syndrome
  • Temporary blindness in children due to pressure on the optic nerve (optic nerve).
  • Lyme arthritis (joint inflammation; mid to late manifestation) – in the early phase, transient and migratory arthralgia (joint pain); later, Lyme arthritis proper (as mono- or oligoarthritis/occurrence of arthritis (joint inflammation) in fewer than 5 joints); usually large joints are affected, such as the knee joint; very often extensive popliteal cysts (Baker’s cysts) are found, which can rupture (“tear”); manifestation: Late disease phase (several weeks to months/possibly up to two years after pathogen transmission).
  • Lyme carditis (collective term for the inflammatory diseases of the heart; occurrence: Weeks to months after the bite):
  • Lymphadenosis cutis benigna Bäfverstedt (Borrelia lymphocytoma) – usually occurring during the early phase of a Borrelia infection (stage I) in the area of the tick bite, small, reddish to bluish skin swelling that may be the center of erythema migrans; may also occur at stage II

Up to 15% of affected individuals experience only these nonspecific symptoms.

Stage III (months to years after the tick bite)

Stage III symptoms

  • Lyme arthritis in the sense of oligoarthritis – joint inflammation of several joints; usually large joints are affected, such as the knee joint
  • Acrodermatitis chronica atrophicans Herxheimer (ACA) – inflammatory skin disease of the ends of the body (preferentially on the extensor side of the extremities); triad:
    • Skin atrophy (thinning of the skin; cigarette paper thin).
    • Homogeneous reddish (to livid) coloration of the skin and
    • Enhanced vascular drawing

    Predilection sites: Dorsum of hands and feet, elbows and knees: differential diagnoses: chronic venous insufficiency, arterial occlusive disease (PAOD), senile atrophy of the skin.

  • Arthropathy (pathological changes in the joints).
  • Late neuroborreliosis (chronic neuroborreliosis; <2% of cases):