Lyme Arthritis: Pathogenesis, Clinical Presentation, and Management
Section snippets
Pathogenesis of acute and chronic arthritis in Lyme disease
After the initial tick bite, B burgdoferi changes the expression of several immunostimulatory outer-surface lipoproteins that probably play a role in dissemination to the synovial tissue and in the pathogenesis of inflammation in the joint itself [6]. The acute arthritis results from the spirochete-induced infiltration of mononuclear cells into the synovial tissue and the accumulation of neutrophils, immune complexes, complement, and cytokines in the synovial fluid. In untreated Lyme arthritis,
Spectrum of clinical presentation
The most complete description of the natural history of Lyme arthritis probably remains the article by Steere and colleagues [22] chronicling the musculoskeletal manifestations of 55 untreated patients who had erythema migrans observed during the years 1976 to 1979, before the treatment of Lyme disease with antibiotics was established. Of these 55 patients, 11 (20%) had no musculoskeletal symptoms after the resolution of erythema migrans. The remaining 44 (80%) had joint involvement of some
Diagnosis of Lyme arthritis
The diagnosis of Lyme arthritis begins with the appropriate determination as to whether a patient suffering from arthritis has an active infection with B burgdorferi. The basis of this determination is the clinical picture as described earlier together with the standard two-tier serologic test—a sensitive ELISA or immunofluorescence assay followed by a Western blot for confirmation of any positive or indeterminate ELISA [23]. In Lyme arthritis, immunoglobulin (Ig)G serologies are almost always
Management of Lyme arthritis
Appropriate antibiotic therapy at the time of early localized or early disseminated infection has been shown to prevent the development of subsequent arthritis. In a study of 140 patients who had early disseminated Lyme disease (mostly erythema migrans) and received early treatment with ceftriaxone or doxycycline [33], only one patient had objective evidence of arthritis after 21 days of doxycycline therapy, which then resolved after a course of ceftriaxone. Initial antibiotic therapy of Lyme
Arthralgias in the initial presentation of Lyme disease
Of the 55 patients who had untreated Lyme disease observed by Steere and colleagues [22] (as previously discussed in an earlier section of this article), 10 (18%) developed arthralgias or pain in periarticular structures without ever developing corresponding objective joint abnormalities. These symptoms had their onset up to 8 weeks after the onset of erythema migrans, tended to affect one or two sites at a time (large or small joints, tendons, bursae, muscles, bones, or entheses), and were
Post-Lyme pain syndromes
A subset of patients may experience an array of chronic symptoms including musculoskeletal symptoms for months to years after Lyme disease. In the absence of an objective abnormality (eg, a joint effusion), however, no evidence of persistent infection has been documented [41]. These more chronic and persistent symptoms should be distinguished from the arthralgias seen in acute or untreated infection, in that they occur after the spirochete has most likely been eliminated by appropriate
Summary
Lyme arthritis is an inflammatory arthritis caused by B burgdorferi infection that is likely mediated by the immune response to the spirochete in the joint. It is easily distinguished from septic arthritis and tends to follow a relapsing/remitting course, affecting large joints (predominantly the knee) more frequently than small joints, usually with an asymmetric distribution. Diagnosis rests on standard serologic and clinical definitions of Lyme disease coupled with a typical mono- or
Acknowledgments
The authors thank Dr. Linden Hu for his insightful comments on this manuscript.
References (43)
- et al.
Chemokines and toll-like receptors in Lyme disease pathogenesis
Trends Mol Med
(2005) - et al.
Autoimmune mechanisms in antibiotic treatment-resistant Lyme arthritis
J Autoimmun
(2001) - et al.
Molecular characterization of the OspA(161-175) T cell epitope associated with treatment-resistant Lyme arthritis: differences among the three pathogenic species of Borrelia burgdorferi sensu lato
J Autoimmun
(2004) Lyme arthritis
Infect Dis Clin North Am
(2005)Mechanism of action of hydroxychloroquine as an antirheumatic drug
Semin Arthritis Rheum
(1993)- et al.
Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities
Arthritis Rheum
(1977) - et al.
Lyme disease—a tick-borne spirochetosis?
Science
(1982) - et al.
Borrelia burgdorferi in joint fluid in chronic Lyme arthritis
Ann Intern Med
(1986) - et al.
Detection of Borrelia burgdorferi DNA by polymerase chain reaction in synovial fluid from patients with Lyme arthritis
N Engl J Med
(1994) - et al.
The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America
Clin Infect Dis
(2006)
Elucidation of Lyme arthritis
Nat Rev Immunol
Solving a sticky problem: new genetic approaches to host cell adhesion by the Lyme disease spirochete
Mol Microbiol
Host metalloproteinases in Lyme arthritis
Arthritis Rheum
Induction of host matrix metalloproteinases by Borrelia burgdorferi differs in human and murine Lyme arthritis
Infect Immun
Lack of Borrelia burgdorferi DNA in synovial samples from patients with antibiotic treatment-resistant Lyme arthritis
Arthritis Rheum
Intracellular persistence of Borrelia burgdorferi in human synovial cells
Rheumatol Int
Association of chronic Lyme arthritis with HLA-DR4 and HLA-DR2 alleles
N Engl J Med
Association of treatment-resistant chronic Lyme arthritis with HLA-DR4 and antibody reactivity to OspA and OspB of Borrelia burgdorferi
Infect Immun
Identification of LFA-1 as a candidate autoantigen in treatment-resistant Lyme arthritis
Science
Development of autoimmunity in Lyme arthritis
Curr Opin Rheumatol
Antibiotic-refractory Lyme arthritis is associated with HLA-DR molecules that bind a Borrelia burgdorferi peptide
J Exp Med
Cited by (61)
Lyme arthritis
2022, Revue du Rhumatisme MonographiesClinical and laboratory evidence of Lyme disease in North India, 2016–2019
2021, Travel Medicine and Infectious DiseaseCitation Excerpt :Since frequent blood CSF barrier dysfunction occurs in LNB patients, it is always recommended to perform intrathecal production of antibodies in CSF which improves the diagnosis of LNB instead of performing a single absorbance value in serum or CSF. Oligoarthritis is a crucial late manifestation of Lyme disease in most western studies [33]. In a study from the USA, Lyme disease was diagnosed in 13% of the patients with oligoarthritis [34].
Vector-Borne Infections
2021, A Rational Approach to Clinical Infectious Diseases: A Manual for House Officers and Other Non-Infectious Diseases CliniciansLyme periprosthetic joint infection in total knee arthroplasty
2018, Arthroplasty TodayCitation Excerpt :Although common, the pathophysiology of Lyme arthritis is not fully understood but thought to be a product of hematogenous dissemination to the synovial tissue. Once in the synovium, the organism likely stimulates an immune response that includes recruitment of inflammatory cells, immune complexes, cytokines, and complements [13]. Lyme arthritis is a late manifestation of Lyme disease and often develops months after the tick bite.
Disorders of the Neurologic System
2018, Equine Internal Medicine: Fourth EditionLyme Disease Manifestations in the Foot and Ankle: A Retrospective Case Series
2016, Journal of Foot and Ankle SurgeryCitation Excerpt :Should joint aspiration be considered to rule out septic arthritis, the synovial fluid analysis in the presence of LD arthritis will typically generate a white blood cell count of 21,000 to 24,000 cells/μL. Some evidence has suggested, however, that the use of arthroscopic synovectomy for cases of LD arthritis persisting for >3 to 6 months can be effective (10). New research on LD arthritis in the field of rheumatology is showing promise for possible new treatments aimed at the immune response.