LYME Disease

In the United States, Lyme disease ranks as the most common vector-borne illness despite being frequently missed or misidentified in clinical practice. This tick-borne infection presents in diverse and often nonspecific ways, making early recognition and appropriate management a persistent challenge. From subtle skin changes and flu-like symptoms to joint inflammation and cardiac or neurologic involvement, the disease unfolds across multiple stages that can puzzle even experienced clinicians.

When a patient shows signs of Lyme disease, the primary diagnostic approach is two-tiered serologic testing. The testing includes the Western blot and enzyme-linked immunosorbent assay, which provide indirect diagnosis by detecting antibodies against Borrelia burgdorferi.

Acrodermatitis chronica atrophicans is a skin-related complication that appears in the advanced phase of Lyme disease, typically after prolonged, untreated infection. This condition involves thinning and discoloration of the skin, often on the limbs, and is more frequently seen in Europe than in the United States.

In contrast, fatigue, myalgias, and arthralgias are vague symptoms that can show up at any point during the illness and are not exclusive to the late stage.

In early-stage Lyme disease-associated arthritis, joint inflammation tends to target the knees. This arthritis typically appears with noticeable swelling and fluid buildup in a migratory pattern and affects one or both knees. The shoulders, ankles, and elbows can become involved in late-stage Lyme disease-associated arthritis.

A common symptom of Lyme disease-associated carditis is heart palpitations. Lyme disease-associated carditis occurs in the early phase of Lyme disease and often presents with other symptoms such as lightheadedness, syncope, chest pain, and shortness of breath.

Antibiotics can be considered if the tick has been attached to the skin for more than 36 hours. This approach is based on studies showing that the risk for Lyme disease transmission increases significantly when a tick, particularly I scapularis, remains attached for more than 36 hours.

The 12-hour mark does not reliably predict transmission risk or warrant prophylaxis. Antibiotic prophylaxis is not universally advised for all tick bites, including the I pacificus bite; prophylactic administration of antibiotics carries the risk of promoting antibiotic resistance.

Ocular Manifestations of Lyme Disease: can be seen at any stage of the infection, from early inflammation of the conjunctiva to more serious, vision-threatening conditions in later stages. These signs often result from inflammation caused by the bacterium Borrelia burgdorferi affecting different parts of the eye and the nervous system.    Early-stage ocular signs include:

• Conjunctivitis: A mild, follicular "pink eye" is the most common early eye symptom, occurring in about 10–11% of patients. Symptoms include eye redness, itching, and discharge.
• Episcleritis: Inflammation of the tissue between the conjunctiva and sclera can cause sectoral (patchy) eye redness, discomfort, and light sensitivity.
• Periorbital edema: Swelling around the eye socket can occur.
• Photophobia: Some patients experience sensitivity to light. 

• Optic neuritis: Inflammation of the optic nerve can cause blurred vision, eye pain (especially with movement), vision loss, and reduced color vision.
• Papilledema: Optic disc swelling due to increased pressure inside the skull. Symptoms can include headaches, double vision, and temporary episodes of vision loss.
• Cranial nerve palsies: The most common is Bell's palsy, which affects the seventh cranial nerve, causing facial drooping and potentially preventing the eye from closing completely. Palsies of other cranial nerves (III, IV, and VI) can result in double vision.
• Horner's syndrome: A rare sign that affects the nerves to the eye and face, causing a droopy eyelid, a constricted pupil, and decreased sweating on one side of the face. 

• Uveitis: Inflammation of the uvea, the middle layer of the eye. This can include:
  • Iritis (Anterior Uveitis): Inflammation of the iris, causing pain, redness, blurred vision, and light sensitivity.
  • Intermediate Uveitis: Inflammation of the vitreous humor (the gel-like substance that fills the eyeball), which can lead to blurred vision and floaters.
  • Retinal Vasculitis: Inflammation of the blood vessels of the retina, which can be vision-threatening.
• Keratitis: Inflammation of the cornea, the transparent front part of the eye. This can appear as blurry vision, watery eyes, and scarring.
• Scleritis: Inflammation of the sclera, the white part of the eye. It can cause eye redness, pain, and blurred vision. 

• Blurred or "static" vision: A loss in visual contrast sensitivity is reported by some patients, along with a visual static or "snow".
• Double vision (Diplopia): Often caused by cranial nerve damage affecting the eye muscles.
• Floaters: Patients may notice specks or moving clouds in their vision, particularly with intermediate uveitis.
• Visual processing issues: Lyme can disrupt visual processing in the brain, leading to binocular vision dysfunction. This may cause difficulty with reading, depth perception, and spatial orientation. 

If you have Lyme disease or suspect that you may have it, go to an ER or see your PCP/HCP right away.

Author

Paddy Kalish OD, JD and B.Arch Author and Blogger