Background

Lyme disease is a tick-borne illness caused by 6 species of the parasitic Borrelia spirochete. It is the most common tick-borne infection in the US and Europe. Approximately 500,000 people are diagnosed with Lyme disease yearly in the US, and the incidence is increasing.  The annual total cost of the disease is $1.3 billion.

The majority of cases occur in the summer due to increased tick activity.  The Deer tick (Ixodes Scapularis) is responsible for transmission in the US.  The states with the highest transmission rates are Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, & Wisconsin.  Ticks need to feed for 48 hours to transmit infection. Nymphs (immature ticks) are more prone to cause infection because of their decreased size and increased feeding time.  The reservoir for the spirochetes is small mammals, especially the white-footed mouse in the northeast and birds. The spirochetes are primarily geographically distributed in the north-central, northeastern, and western north US. Incidence of disease displays a bimodal pattern, primarily affecting males aged 5-10 and 35-55.   

B. Burgdorferi is the principal agent in the US, while B. afzelli, B. burgdorferi and B. garinii cause infection in Europe. B. mayonii can cause Lyme disease in the US, principally in the upper midwest. There are different manifestations for the US and European strains; this guide will focus on the US strains.  Lyme disease was initially described in 1977 in a group of Connecticut children initially thought to have juvenile rheumatoid arthritis.  Lyme disease is a multi-system disease that has myriad symptoms and varying severity.  Lyme disease has

overlap, and patients can present in the late stage of disease without prior symptoms.   Early localized disease is characterized by erythema migrans (EM).  Constitutional symptoms may be present or absent.  

Erythema migrans usually appears within one month of an infected tick bite. Early disseminated disease presents with multiple erythema migrants lesions and cardiac or neurological symptoms.  This usually occurs days to weeks after infection; however, patients may not have any antecedent symptoms.  Late Lyme disease involves a persistent arthritis, sometimes following a migratory arthritis.  The knee is often involved in Lyme arthritis.  Neurological symptoms such as encephalopathy and polyneuropathy may develop.  Late Lyme disease occurs months to years after initial infection. Co-infection with other infectious agents such as Anaplasma phagocytophilum, deer tick virus, and Babesia microti can occur. 

Rates of co-infection vary between 4-28% based upon geographic region., Co-infection results in increased severity of symptoms.  Patients with persistent fever after 48 hours or with cytopenias should be worked up for possible co-infection. Properly treated pregnant women are not predisposed to fetal demise or congenital abnormalities.,, three stages: early localized, early disseminated, and late Lyme disease.  Clinical manifestations often

overlap, and patients can present in the late stage of disease without prior symptoms.   Early localized disease is characterized by erythema migrans (EM).  Constitutional symptoms may be present or absent.  

Erythema migrans usually appear within one month of an infected tick bite. Early disseminated disease presents with multiple erythema migrans lesions and cardiac or neurological symptoms.  This usually occurs days to weeks after infection; however, patients may not have any antecedent symptoms.  Late Lyme disease involves persistent arthritis, sometimes following migratory arthritis.  The knee is often involved in Lyme arthritis.  Neurological symptoms such as encephalopathy and polyneuropathy may develop.  Late Lyme disease occurs months to years after initial infection. Co-infection with other infectious agents such as Anaplasma phagocytophilum, deer tick virus, and Babesia microti can occur. 

Rates of co-infection vary between 4-28% based upon geographic region., Co-infection results in increased severity of symptoms.  Patients with persistent fever after 48 hours or with cytopenias should be worked up for possible co-infection. Properly treated pregnant women are not predisposed to fetal demise or congenital abnormalities.

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