Diagnosis and Treatment of Lyme Arthritis

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Key points

  • Lyme arthritis is a late disease manifestation, usually beginning months after the tick bite. Patients may not report an antecedent tick bite or erythema migrans.

  • Patients have intermittent or persistent attacks of joint swelling and pain, primarily in 1 or a few large joints, especially the knee, without prominent systemic manifestations.

  • The diagnosis is supported by 2-tier serologic testing for Borrelia burgdorferi by enzyme-linked immunosorbent assay and immunoglobulin G Western blotting.

Epidemiology

Lyme arthritis was recognized originally because of an outbreak of monoarticular and oligoarticular arthritis in children in Lyme, Connecticut, in the 1970s.1 It then became apparent that Lyme disease was a complex, multisystem illness affecting primarily skin, nervous system, heart, or joints.2 Before the use of antibiotic therapy for treatment of the disease, about 60% of untreated patients developed Lyme arthritis, a late disease manifestation.3 In recent years, more than 30,000 cases of

Patient history

During the 1970s, before the cause of the disease was known, the natural history of Lyme arthritis was elucidated in a study of 55 non–antibiotic-treated patients who were followed prospectively from onset of erythema migrans (EM), the initial skin lesion, through the period of arthritis.3 Clinical features of the infection in these patients included the following:

  • Arthritis began from 4 days to 2 years (mean, 6 months) after the EM skin lesion.

  • Patients had intermittent or persistent attacks of

Physical examination

Patients with Lyme arthritis typically have the following features on physical examination.

  • Monoarthritis or oligoarthritis most commonly affecting the knees, but other large or small joints may be affected, such as an ankle, shoulder, elbow, or wrist.

  • Affected knees may have very large effusions with warmth, but in contrast with typical bacterial (eg, staphylococcal) septic arthritis, they are not particularly painful with range of motion or weight bearing. Baker’s cysts may be present in the

Serologic Testing for Lyme Disease

The mainstay in diagnosing Lyme arthritis is serologic testing. In the United States, the CDC currently recommends a 2-test approach in which samples are first tested for antibodies to B burgdorferi by enzyme-linked immunosorbent assay and those with equivocal or positive results are subsequently tested by Western blotting, with findings interpreted according to the CDC criteria.26 In contrast with early infection, when some patients may be seronegative, all patients with Lyme arthritis, a late

Treatment

Treatment of Lyme arthritis is based on several small, double-blind or randomized studies and observational studies (summarized in Table 1). The efficacy of antibiotics was first demonstrated in a double-blind, placebo-controlled trial of intramuscular benzathine penicillin, 2.4 million units weekly for 3 weeks versus placebo. In that study, 7 of 20 antibiotic-treated patients (35%) had complete resolution of arthritis, whereas all 20 placebo treatment patients continued to have arthritis.33

Summary

Arthritis is a late manifestation of Lyme disease, usually beginning months after the tick bite. However, a history of EM or tick bite may be lacking. Patients have intermittent or persistent attacks of joint swelling and pain, primarily in 1 or a few large joints, often the knee, over a period of months to several years, with few systemic manifestations. The diagnosis is established by 2-tier serologic testing for B burgdorferi by enzyme-linked immunosorbent assay and IgG Western blotting,

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