Lyme Disease (Lyme borreliosis)

Lyme disease (Lyme borreliosis) is the most common tick-borne disease in the USA and one of the most frequently diagnosed tick-borne infections globally. The illness is divided into three stages: early localised, early disseminated and late disease [1].

Aetiology

• Caused by the spirochaete Borrelia burgdorferi (USA) and B. afzelii or B. garinii (Europe).

• Transmitted via tick bite, primarily from Ixodes (deer tick).

History

The disease was first described in 1976 in children from Lyme, Connecticut, presenting with the characteristic “bull’s-eye” rash (erythema migrans) and a distinct form of arthritis. In 1982, Borrelia was identified as the causative agent [2].

Stages and Clinical Presentation

Stage 1 – Early localised disease

• Erythema migrans (EM) at the tick bite site — a red, ring-shaped rash that expands.

• Symptoms: flu-like complaints (low-grade fever, headache, myalgia, arthralgia).

• May also include mild conjunctivitis.

Stage 2 – Early disseminated disease

• Occurs 3–12 weeks after infection; lasts 12–20 weeks.

• Multiple EM lesions.

• Neurological symptoms: cranial nerve palsy (CN VII, facial palsy), meningitis, radiculopathy.

• Cardiac symptoms: myopericarditis, heart block, arrhythmias.

• Joint pain: especially knees, ankles, wrists (mono-/pauciarticular).

• Other: Borrelial lymphocytoma (rare; earlobe/nipples).

Stage 3 – Late disease

• Months to years after infection.

• Joints: Lyme arthritis (large joints, most often the knees).

• Neurology: encephalopathy, neuropathy, radiculopathy, memory impairment, depression, irritability.

• Skin: acrodermatitis chronica atrophicans (especially hands/feet, older women).

• Heart: less common arrhythmias, transient AV block.

Prevalence and Epidemiology

• USA: 30,158 (2010) → 38,069 (2015) confirmed cases [2].

• 95% of cases occur in 14 states (e.g., Connecticut, New York, Pennsylvania).

• Highest incidence: children 5–14 years (8.6/100,000).

• Seasonal peak: May–August.

Diagnosis

• Clinical diagnosis based on erythema migrans in endemic areas.

• Serology (ELISA, Western blot) useful in later stages.

• Lumbar puncture for neurological symptoms.

• ECG for cardiac symptoms.

Treatment

• Early stage: doxycycline or amoxicillin.

• Neurological/cardiac symptoms: ceftriaxone i.v.

• Late disease: doxycycline or ceftriaxone (for arthritis/neurology).

Comorbidities

• Babesiosis: Babesia microti; a parasite co-transmitted with Borrelia. Haemolytic anaemia, fever, fatigue. High risk in older, immunosuppressed and splenectomised patients [6].

• Chronic fatigue syndrome (CFS): Associated with positive Borrelia serology even without classic Lyme diagnosis [7].

• Fibromyalgia: Studies suggest association with Borrelia infection; multifactorial aetiology [8].

• Cardiac dysfunction: Myocarditis, AV block, arrhythmias. Symptoms: bradycardia, tachycardia, dizziness, syncope [9].

Controversies

• “Chronic Lyme disease” is not widely recognised within medical communities, including in Australia [3].

Prevention

• Wear skin-covering clothing in tick-endemic areas.

• Perform tick checks after outdoor activities.

• Early tick removal.

Differential Diagnoses

• Tinea, nummular eczema (skin rash).

• Viral meningitis, Guillain–Barré syndrome (neurology).

• Septic arthritis (joints).

• Borrelial lymphocytoma vs lymphadenitis.

Neurological Comorbidities

Neurological and psychiatric comorbidities develop in approximately 5% of patients with Lyme borreliosis, particularly if inadequately treated in the early phase [9].

Common neurological symptoms:

• Radiculopathy: radiating pain and paraesthesia.

• Sensory disturbances: numbness and tingling in the extremities.

Psychiatric symptoms:

• Mild cognitive impairment.

• Mood disorders: depression, anxiety and emotional lability [10].

Autism

Although debated as a comorbidity of Lyme borreliosis, newer studies suggest a possible correlation. Chronic infections, including Borrelia, may impair the foetal or neonatal immune system and increase the risk of autism spectrum disorders [11].

Prevention

• Avoid wooded/tick-infested areas, especially in summer.

• Wear long trousers, long-sleeved shirts, closed shoes; preferably light-coloured clothing (ticks easier to spot).

• Check the body thoroughly after outdoor activities; remove ticks within 36 hours to reduce transmission risk.

• Shower after outdoor exposure; wash clothes at high temperature (tumble drying kills ticks).

• Remove ticks with tweezers (steady, straight pull).

• Clean the bite site with soap and water; apply antiseptic [4].

Pharmacological Management

Acute Lyme disease:

• Doxycycline, amoxicillin or cefuroxime p.o. for 14–21 days are first-line options.

• A single 200 mg dose of doxycycline may be considered after a tick bite in an endemic area (not recommended routinely). Contraindicated in pregnancy and in children <8 years [12].

Neurological Lyme disease / third-degree heart block:

• Ceftriaxone i.v. for 14–28 days.

• With persistent Lyme arthritis after the first antibiotic course: an additional 4 weeks of oral antibiotics.

Chronic symptoms (e.g., arthralgia/fatigue):

• No evidence supports persistent infection after adequate antibiotic therapy.

• Additional antibiotics provide no benefit and carry risks.

• Symptomatic treatment: antirheumatic agents and NSAIDs [9].

NB! Immunity does not develop; reinfection is possible.

Diagnostics

• Clinical: erythema migrans + tick bite.

• ELISA (screening) → Western blot (confirmation).

• PCR or culture (skin biopsy) for EM.

• Lumbar puncture for neuroborreliosis.

• Serology requires careful interpretation: high rates of false positives/negatives, especially in non-endemic areas [13].

Causes

• Borrelia species, primarily B. burgdorferi in the USA.

• Transmitted by the forest tick (Ixodes), which also bites humans, cats, dogs, horses and others.

• Risk increases when the tick remains attached >48 hours (full blood meal) [14].

Systemic Involvement

• Untreated disease can disseminate to the CNS, heart and joints (cf. clinical presentation).

Medical Treatment

• Doxycycline: first-line (>8 years).

• Amoxicillin or cefuroxime: children <8 years.

• Ceftriaxone: CNS manifestations or severe cardiac involvement.

• Ocular Lyme: topical steroids + i.v. antibiotics.

• Lyme arthritis: usually self-limiting (6–8 weeks); if persistent: NSAIDs or DMARDs.

• Jarisch–Herxheimer reaction may occur at treatment initiation.

• Post-treatment Lyme disease syndrome: non-specific symptoms without evidence of persistent infection; antibiotics not indicated.

Physiotherapy in Lyme Borreliosis

Physiotherapy plays an important supportive role, particularly in patients with prolonged symptoms insufficiently responsive to antibiotics. The goals are to:

• Relieve pain.

• Help physically deconditioned patients regain sufficient capacity to complete a home exercise programme.

• Teach correct training methods regarding intensity, duration and load to achieve health gains without exacerbating Lyme-related symptoms [15].

Physiotherapy Interventions

• Massage

• Joint mobilisation and stretching

• Myofascial release.

• Modalities such as ultrasound, heat packs and paraffin baths (NB: ice therapy and electrical stimulation are generally not recommended, but evidence is limited).

Exercise Programme

• Emphasis on strength and gradual conditioning.

• Whole-body programme with stretching, light calisthenics and light resistance training (low load, high repetitions) [15].

Neurological Complications

Patients with neurological symptoms, such as facial palsy, may also be referred for physiotherapy.

• Electrical stimulation is sometimes used to stimulate paralysed facial muscles after Lyme infection, but research shows no clear benefit; many therapists wait several months to allow natural neuro-recovery before considering this [16].

• Neuromuscular facial re-education has demonstrated efficacy [17].

• EMG biofeedback may support rehabilitation [18].

Lyme Arthritis

Physiotherapists should be aware of Lyme arthritis, which typically appears about four months after erythema migrans. The knee is most often affected, but other large joints may be involved [19].

Differential Diagnoses

When erythema migrans is present, history and clinical examination are often sufficient for diagnosis. With extra-cutaneous symptoms the differential diagnosis is more challenging. Important conditions to exclude include:

• Ankylosing spondylitis, rheumatoid arthritis

• AV block

• Cellulitis

• Contact dermatitis

• Gout and pseudogout

• Granuloma annulare

• Prion-related diseases

• Acute memory disorders

Conclusion

The prognosis for treated Lyme borreliosis is generally good, without lasting sequelae in most patients. Some may develop reinfection or late complications with neurological or musculoskeletal symptoms. Lyme carditis can cause AV block requiring temporary pacing. The disease is rarely fatal. Post-treatment Lyme disease syndrome remains controversial and lacks robust scientific support [1].

References

1. Skar GL, Simonsen KA. Lyme Disease. InStatPearls [Internet] 2018 Oct 27. StatPearls Publishing.: https://www.ncbi.nlm.nih.gov/books/NBK431066/

2. Lyme Disease. Centers for Disease Control and Prevention. http://www.cdc.gov/lyme. Published August 19, 2016. Accessed March 23, 2017.

3. The Department of Health, Australia. Lyme Disease. : https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-lyme-disease.htm

4. Goodman CC, Fuller K. Pathology: Implications for the Physical Therapist. 4th ed. St. Louis: Saunders Elsevier; 2014.

5. CDC Division of Vector-borne Infectious Diseases website. Lyme Disease. http://www.cdc.gov/ncidod/dvbid/Lyme. .

6. Babesia. CDC website. http://www.cdc.gov/babesiosis.

7. Treib J, Grauer M, Haass A, Langenbach J, Holzer G, Woessner R. Chronic fatigue syndrome in patients with lyme borreliosis. Eur Neurol [serial online]. 2000 Feb;43(2):107-109.

8. Buskila D, Atzeni F, Sarzi-Puttini P. Etiology of fibromyalgia: The possible role of infection and vaccination. Autoimmunity Reviews [serial online]. 2008 Oct;8(1):41-43.

9. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009.

10. Rudnik I, Konarzewska B, Zajkowska J, Juchnowicz D, Markowski T, Pancewicz S. [The organic disorders in the course of Lyme disease]. Polski Merkuriusz Lekarski: Organ Polskiego Towarzystwa Lekarskiego [serial online]. 2004 Apr;16(94):328-331.

11. Bransfield R, Wulfman J, Harvey W, Usman A. The association between tick-borne infections, Lyme borreliosis and autism spectrum disorders. Medical Hypotheses [serial online]. 2008;70(5):967-974.

12. Lyme Disease. New England Journal of Medicine. 2014;371(7):683-684. doi:10.1056/nejmc1407264.

13. NSW government Lyme disease factsheet https://www.health.nsw.gov.au/Infectious/factsheets/Pages/Lyme_disease.aspx

14. Mayo Clinic website. Lyme Disease. http://www.mayoclinic.com/health/lyme-disease/DS00116.

15. Burrascano JJ. Advanced Topics in Lyme Disease: diagnostic hints and treatment guidelines for lyme and other tick borne illnesses. 15th ed. 2005. http://www.lymediseaseassociation.org/drbguide200509.pdf

16. Ohtake PJ, Zafron ML, Poranki LG, Fish DR. Evidence in Practice. Physical Therapy. 2006;86:1558-1564.

17. Manikandan N. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. Clin Rehabil. 2007 Apr;21(4):338-43

18. Bossi D, Buonocore M et al. Usefulness of BFB/EMG in facial palsy rehabilitation. Disabil Rehabil. 2005 Jul 22;27(14):809-15

19. Arvikar S, Crowley J, Sulka k, et al. Autoimmune Arthritides, Rheumatoid Arthritis, Psoriatic Arthritis, or Peripheral Spondyloarthritis Following Lyme Disease: Arthritis; Rheumatology. Published online December 28, 2016. DOI: 10.1002/art.39866.