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Lyme disease - Management
When should I suspect a diagnosis of Lyme disease?
- Make a clinical diagnosis of early Lyme disease in people with erythema migrans and a history of a recent tick bite or possible exposure to ticks (recreation, residence, or work in a forested, heathland, or moorland area, or even in suburban parkland).
- Suspect early Lyme disease in people with a history of a tick bite or possible exposure to ticks when they present with any of the following:
- Flu-like symptoms — these may include fever, headache, tiredness, nausea, vomiting, arthralgia (joint pain), and myalgia (muscle pain); there are no significant respiratory symptoms.
- Neurological symptoms — occur in up to 10% of untreated people, and may present days to months after infection. People may present with one or more of the following:
- Unilateral or bilateral facial nerve palsy (or, rarely, other cranial nerve involvement).
- Radiculopathy (usually associated with pain and/or paresis).
- Meningitis or (rarely) encephalomyelitis.
- Mononeuropathy multiplex — involvement of multiple, anatomically unrelated nerves.
- Cardiac symptoms
- Carditis is a rare manifestation of Lyme disease in the UK.
- It may present with syncope (fainting), breathlessness, or chest pain, usually within 2 months of infection.
- An electrocardiogram shows varying degrees of atrioventricular or first-degree heart block.
- Borrelia lymphocytoma
- This is uncommon in Europe, and extremely rare in the US.
- It is a bluish-red, solitary swelling, with a diameter of up to a few centimetres, most often seen on ear lobes or nipples.
- Consider the possibility of late Lyme disease in people with a history of a tick bite or possible exposure to ticks when they present with any of the following:
- Arthritis
- Rare with UK-acquired infection, but more common when the disease is acquired in some other parts of Europe or in the US.
- Involves recurrent brief attacks of joint swelling in one or more large joints (most commonly the knee or, less frequently, a hip, ankle, shoulder, or temporomandibular joint) and occasionally progresses to chronic arthritis.
- A large knee effusion (that is often out of proportion to the pain) is typical and a Baker's cyst may develop and rupture.
- Neurological disease
- Late neurological Lyme disease can present as a slowly progressive central nervous system disorder (encephalomyelitis) or peripheral neuropathy.
- Acrodermatitis chronica atrophicans
- This is an uncommon, bluish-red discolouration and swelling, on the extensor surfaces of legs and arms, that develops several years after infection.
- There is often associated peripheral neuropathy.
- If the person may have been bitten by a tick whilst abroad, consider the possibility of other tick-borne diseases (or possible co-infection), particularly if the person has symptoms atypical of Lyme disease.
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