Stages of Lyme disease

Stage 1

• Erythema migrans—a characteristic pathognomonic rash, usually a doughnut-shaped well-defined rash about 6 cm in diameter at the bite site ( Fig 26.3 ).

• ± a flu-like illness: malaise, fever, myalgia, arthralgia, backache.

Stage 2

(weeks or months later)

• Neurological problems, e.g. limb weakness, muscle pain, aseptic meningitis, painful radiculopathies, cranial nerve palsies, e.g. Bell's palsy.

• Cardiac problems: arrhythmias, myocarditis.

Stage 3

• Arthritis (weeks or months later). In children it can be mistaken for juvenile chronic arthritis. In adults, it usually affects one or two joints, especially the knee joints. A LIMP syndrome (localised intermittent musculoskeletal pain) is described, which is severe pain without significant findings on examination.


• Clinical pattern especially rash of erythema migrans. Serology to demonstrate Lyme antibodies, which take about 6 weeks to develop from the onset of the disease.

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