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Lyme disease

Last updated: February 4, 2021

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Lyme disease (or borreliosis) is a tick-borne infection caused by certain species of the Borrelia genus (B. burgdorferi in the US, predominantly B. afzelii and B. garinii in Asia and Europe), a genus of obligate intracellular bacteria. There are three stages of Lyme disease. Stage I (early localized disease) is characterized by erythema migrans (EM), an expanding circular red rash at the site of the tick bite, and may be associated with flu‑like symptoms. In stage II (early disseminated disease), patients may present with neurological symptoms (e.g., facial palsy), migratory arthralgia, and cardiac manifestations (e.g., myocarditis). Stage III (late disease) is characterized by chronic arthritis and CNS involvement (late neuroborreliosis) with possible progressive encephalomyelitis. In Asia and Europe, further skin manifestations may also occur in stage II (lymphadenitis cutis benigna) and stage III (acrodermatitis chronica atrophicans). Lyme disease is a clinical diagnosis in patients presenting with EM. Serological tests (e.g., Western blot; enzyme-linked immunosorbent assay) can help support the clinical diagnosis, especially if the presence of EM is not known or questionable. Lyme disease is treated with antibiotics; the drugs of choice are doxycycline for localized disease and ceftriaxone for disseminated disease.

  • Incidence: most commonly reported vector-borne disease in the US
  • Geographical distribution: primarily the Northeast and upper Midwest of the US


Epidemiological data refers to the US, unless otherwise specified.

  • Pathogen
    • In the US: Borrelia burgdorferi, an anaerobic, obligate intracellular spirochete bacteria
      • Atypical and cystic forms of B. burgdorferi can persist in the body for years.
    • In Europe and Asia: B. afzelii and B. garinii
      • Rarely B. valaisiana, B. lusitaniae, B. spielmanii, and B. bavariensis infect humans.
  • Vector
    • Various tick species: mainly Ixodes scapularis (deer or black-legged tick); in the northeastern and upper midwestern US
      • Ixodes pacificus (western black-legged tick) in the northwestern US
      • Ixodes ricinus (castor bean tick) in Europe
    • Typically found in forests or fields on tall brush or grass
    • The incidence of Lyme disease is highest between April and October (especially from June to August).
    • Peromyscus leucopus, the white‑footed mouse, is the primary reservoir of B. burgdorferi in the US.
    • Increased risk of disease for:
      • Outdoor workers (landscapers, farmers, etc.)
      • Outdoor enthusiasts (i.e., hikers, hunters, etc.)
  • Reservoir hosts: deer, cattle


Stage I (early localized Lyme disease)

Symptoms develop within 7–14 days after a tick bite.

  • Erythema chronicum migrans (EM)
    • Pathognomonic of early Lyme disease
    • Occurs in approx. 70–80% of infected individuals [3]
    • Usually a slowly expanding red ring around the bite site with central clearing (“bull's eye rash”)
    • Typically warm, painless
    • EM is often the only symptom.
    • Self-limiting (typically subsides within 3–4 weeks)
  • Flu‑like symptoms: fever, fatigue, malaise, lethargy, headache, myalgias, and arthralgias

Stage II (early disseminated Lyme disease)

Symptoms develop 3–10 weeks after a tick bite

Stage III (late Lyme disease)

Symptoms develop months to years after the initial infection

  • Chronic Lyme arthritis (10% of cases)
    • Lasts over a year and may be intermittent or persistent
    • Typically in large joints (especially knee or elbow)
  • Late neuroborreliosis manifestations include:
  • Acrodermatitis chronica atrophicans (ACA, also called Herxheimer's disease): in Europe and Asia
    • Chronic progressive dermatological disease due to infection with Borrelia afzelii that occurs only in Europe and Asia and most commonly affects women > 40 years of age
    • Manifestation on the extensor side of extremities
    • Stages in the course of the disease:
      1. Edematous stage with inflammatory reaction (livid discoloration)
      2. Atrophic stage: hairless, sclerotic skin plaques

To remember important symptoms of Lyme disease, think of someone making a FACE (Facial nerve palsy, Arthritis, Carditis, Erythema migrans) when biting into a lime.


Two‑step serological testing

Other tests

Borrelia-specific intrathecal antibodies with normal protein and without pleocytosis indicate a past infection. Detection of elevated antibodies alone does not provide conclusive evidence of an active infection

  • Arthrocentesis
  • Rule of 7s: Children who meet all of the following criteria can be identified as at low risk for Lyme meningitis and may be treated accordingly in an outpatient setting until lab results become available.



The differential diagnoses listed here are not exhaustive.

Tick-borne diseases (endemic to US) [10] Pathophysiology / Epidemiology

Clinical features

Diagnostics Treatment
Lyme disease
Tick paralysis
  • Locate and remove the tick!
  • Supportive therapy (e.g., ventilatory support in a patient with respiratory failure)
Rocky Mountain spotted fever (RMSF)
  • Pathogen: Rickettsia rickettsii
  • Vector
  • Distribution: northeast and south US


Tularemia [11][12]
  • Pathogen: Francisella tularensis (facultative intracellular bacterium)
  • Vector
  • Reservoir: rodents (e.g., hares, rabbits)
  • Transmission without a vector is possible:
    • Inhalation of contaminated dust or aerosols
    • Ingestion of contaminated food or water
  • Distribution: all states except Hawaii
Colorado tick fever (CTF) [13][14]
  • No specific treatment; supportive management only
Tick-borne relapsing fever [15]
  • Pathogen: Borrelia hermsii
  • Vector: Ornithodoros species
  • Distribution: western US
  • Incubation period: 4–18 days
  • Recurring episodes of high fever lasting 3 days followed by an afebrile period of 7 days
  • Arthralgia
  • Gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain)
  • Less commonly
  • Macular rash or scattered petechiae in 15–20% of cases
Southern tick‑associated rash illness (STARI)
  • Treatment for Lyme disease

Stages Presentation General therapy Therapy in pregnant/nursing patients
Localized Lyme disease
Disseminated Lyme disease

Doxycycline is relatively contraindicated in pregnant/nursing women due to its adverse effects on growing bones and teeth! Administer amoxicillin (or cefuroxime axetil) instead!

If infection is likely (e.g., EM is present), start antibiotic treatment!

Possible complications following successful antibiotic treatment

  • Post-Lyme disease syndrome (PLDS)
    • Description: a somewhat controversial syndrome (the medical community does not agree on its existence) following successful treatment of Lyme disease that is associated with pain, fatigue, and difficulty concentrating that lasts > 6 months [16]
    • Differential diagnosis: somatoform disorders, unsuccessfully treated chronic Lyme disease
    • Treatment: symptomatic treatment with general medical and psychosomatic support


  • There is no approved vaccine on the market for Lyme disease. There was a Lyme disease vaccine in the past that offered temporary protection, but it was discontinued in 2002 because of low demand.
  • Avoid prime habitats in areas known for Lyme disease.
  • Prevent and properly manage tick bites to avoid exposure.
    • Wear protective clothing: e.g., long-sleeved shirts, long pants, and light colors.
    • Use tick repellent and pesticides.
    • Check body for tick bites.
    • Remove ticks immediately!
      1. Grasp the tick with tweezers directly above the skin's surface.
      2. Carefully pull upward with even pressure.
      3. Do not use nail polish remover, adhesives, oils, or similar substances to remove the tick. The tick should be removed quickly rather than waiting for it to detach slowly.
      4. Disinfect the site of the bite and dispose of the tick
    • Observe the bite site for early detection of EM.

References: [18]

Post‑exposure prophylaxis (PEP) [19]

  • Although controversial, PEP may be considered for patients who meet all of the following criteria:
    • The attached tick can be identified as an adult or nymphal Ixodes scapularis tick.
    • The tick has been attached for ≥ 36 hours (based on degree of engorgement or amount of time since exposure).
    • Prophylaxis can be started within 72 hours of tick removal.
    • The local rate of tick infection with B. burgdorferi is ≥ 20% (known to occur in parts of New England, parts of the mid‑Atlantic states, and parts of Minnesota and Wisconsin).
    • The patient can take doxycycline (e.g., the person is neither pregnant nor breastfeeding, nor a child < 8 years of age).
  • If the patient meets all the above criteria, 200 mg of doxycycline can be given to adults and 4 mg/kg to children ≥ 8 years (maximum dose: 200 mg).
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  5. Eckman EA, Clausen DM, Herdt AR, Pacheco-Quinto J, Halperin JJ. Specificity and Diagnostic Utility of Cerebrospinal Fluid CXCL13 in Lyme Neuroborreliosis. Clinical Infectious Diseases. 2020 . doi: 10.1093/cid/ciaa335 . | Open in Read by QxMD
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  11. Sexton DJ, Calderwood SB, Mitty J. Tick Paralysis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: February 2, 2016. Accessed: October 10, 2017.
  12. Lyme disease - Lyme disase vaccine. Updated: November 17, 2015. Accessed: February 8, 2017.
  13. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2006; 43 (9): p.1089-1134. doi: 10.1086/508667 . | Open in Read by QxMD
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  15. Tularemia. Updated: September 27, 2016. Accessed: December 11, 2017.
  16. Penn RL. Clinical Manifestations, Diagnosis, and Treatment of Tularemia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: May 27, 2016. Accessed: December 11, 2017.
  17. Colorado Tick Fever. Updated: January 13, 2015. Accessed: December 11, 2017.
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  19. Tick-borne Relapsing Fever (TBRF). Updated: January 8, 2016. Accessed: December 11, 2017.
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