Correspondence

The Presenting Manifestations of Lyme Disease and the Outcomes of Treatment

N Engl J Med 2003; 348:2472-2474June 12, 2003

Article

To the Editor:

A trial of vaccination against Lyme disease provided an opportunity for us to determine the relative frequencies of the presenting manifestations of Lyme disease and the outcomes of treatment in a large population.1 Our goal was to identify all cases of Borrelia burgdorferi infection that occurred among the 10,936 participants in 10 states where the infection is endemic during the 20-month study period.

Of the 1917 participants who were evaluated for Lyme disease, 269 met the prospectively defined criteria for definite, possible, or asymptomatic infection.1 After completion of the study, post hoc analyses were performed for patients who had microbiologically confirmed erythema migrans,2 systemic symptoms without erythema migrans,3 or asymptomatic seroconversion.4 In addition, for the latter two groups, serum samples were retested with a sensitive and specific enzyme-linked immunosorbent assay that used a peptide of the sixth invariant region of the VlsE lipoprotein of B. burgdorferi 5; this test had not been available during the vaccine study.

Seventy to 80 percent of the patients presented with erythema migrans (Table 1Table 1Frequency of Presenting Manifestations of Lyme Disease.), the initial skin lesion that often occurs at the site of a tick bite. The unexpected finding was that about 18 percent of the participants presented during the summer with nonspecific systemic symptoms without erythema migrans. Headache and arthralgia, sometimes associated with fever, were their most common symptoms; upper respiratory tract and gastrointestinal symptoms were absent.3 Only 2 to 3 percent of the patients presented with later systemic involvement associated with disseminated infection, such as facial palsy, trigeminal neuropathy, or Lyme arthritis; among them was one patient who initially had asymptomatic seroconversion.4

The patients with early infection were treated with oral doxycycline or amoxicillin for two to four weeks, except for two patients with facial palsy and erythema migrans, who received intravenous ceftriaxone.2,3 Although 11 to 16 percent of these patients had subjective symptoms for weeks or months after treatment, late manifestations of Lyme disease did not develop in any patient.

The important point is that most of the study participants with Lyme disease had early symptoms of the infection and had a good response to treatment. Particularly when erythema migrans is not present early in the illness, patients may not go to a physician or Lyme disease may not be recognized until the more debilitating, harder-to-treat late manifestations of the infection become apparent. The challenge for patients and physicians is early recognition and treatment of the infection, particularly when patients present during the summer with nonspecific systemic symptoms.

Allen C. Steere, M.D.
Massachusetts General Hospital, Boston, MA 02129

Vijay K. Sikand, M.D.
Tufts University School of Medicine, Boston, MA 02111

5 References

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