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Musculoskeletal manifestations of Lyme disease

Musculoskeletal manifestations of Lyme disease
Author:
Robert T Schoen, MD
Section Editor:
Allen C Steere, MD
Deputy Editor:
Keri K Hall, MD, MS
Literature review current through: Jan 2024.
This topic last updated: Jan 31, 2024.

INTRODUCTION — Lyme disease is a tick-borne illness, which is most commonly caused by one of three pathogenic species of the spirochete Borreliella (previously referred to as Borrelia burgdorferi sensu lato). Lyme disease was first recognized in the United States in the 1970s, presenting as oligoarthritis during an outbreak in children in Lyme, Connecticut [1]. Lyme disease is now the most common vector-borne illness in North America and Europe. Arthritis is the most common manifestation of late Lyme disease in the United States [2].

Because antibiotic treatment of early infection is usually curative, arthritic complications have become less common [2]. However, Lyme arthritis is still the second most frequent manifestation of Lyme disease [3].

The clinical features, diagnosis, and treatment of the musculoskeletal manifestations of Lyme disease will be reviewed here. Issues related to bacteriology, epidemiology, diagnosis, and treatment of Lyme disease, as well as discussions of other clinical manifestations of Lyme disease, are reviewed separately.

(See "Microbiology of Lyme disease".)

(See "Epidemiology of Lyme disease".)

(See "Clinical manifestations of Lyme disease in adults".)

(See "Diagnosis of Lyme disease".)

(See "Treatment of Lyme disease".)

(See "Nervous system Lyme disease".)

(See "Lyme carditis".)

(See "Lyme disease: Clinical manifestations in children".)

CLINICAL FEATURES — The clinical manifestations of Lyme disease can generally be divided into three phases: early localized (erythema migrans [EM]), early disseminated, and late disease (table 1). Patients with early localized or early disseminated Lyme disease may develop migratory arthralgias, which should be distinguished from frank arthritis seen in late disease. Some patients may present in a later stage of Lyme disease without a history of prior signs or symptoms suggestive of earlier disease [4]. (See "Clinical manifestations of Lyme disease in adults", section on 'Clinical stages'.)

Early Lyme disease — Arthralgias are typically seen during the early stages of Lyme disease. Early Lyme disease occurs primarily during the late spring and early summer when nymphal Ixodes ticks are active (figure 1 and figure 2).

Patient with erythema migrans – Erythema migrans (EM) is the characteristic rash of Lyme disease that usually develops at the site of the tick bite (picture 1A-D) [5,6]. Although EM may be the only disease manifestation of early localized infection, migratory arthralgias and myalgias may also be evident.

Patients with early disseminated infection - Within several days to weeks, B. burgdorferi may disseminate to multiple sites (early disseminated disease), including the skin, heart, nervous system, or joints [7]. (See "Clinical manifestations of Lyme disease in adults" and "Lyme disease: Clinical manifestations in children".)

During early disseminated infection, patients may experience migratory pain in joints, bursae, tendons, muscle, or bone in one or a few locations at a time. Some patients develop only migratory arthralgias without arthritis. Arthralgia symptoms may be intermittent or migratory.

Once Lyme disease is diagnosed, arthralgias respond promptly to antibiotic therapy. The treatment of early Lyme disease is discussed in detail elsewhere. (See "Treatment of Lyme disease".)

Late Lyme disease — Lyme arthritis occurs as a late manifestation of Lyme disease. Lyme arthritis may begin in any season, weeks to months after initial infection. Affected individuals are typically active outdoors in locations endemic for Lyme disease (figure 3). The age distribution of Lyme arthritis is bimodal, similar to erythema migrans (figure 4) [3,8]. (See "Epidemiology of Lyme disease".)

In the United States, approximately 30 percent of patients with Lyme disease present with Lyme arthritis (figure 5) [3]. In such patients, signs and symptoms of early disease, including EM, may not have occurred or were not recognized. Although some patients do report a history of antecedent EM, this occurs less frequently now than in the past since EM is more frequently recognized and early treatment is curative. Thus, absence of history of a tick bite or EM should not preclude consideration of Lyme arthritis in patients who have had potential exposure in endemic areas.

The natural history of the articular manifestations of Lyme disease was described in the late 1970s, before the cause of Lyme disease and the role of antibiotics in its treatment were known. The following findings have been observed in patients with Lyme arthritis:

Lyme arthritis is characterized by intermittent or persistent arthritis. Monoarthritis of the knee is most common (picture 2), but Lyme arthritis may also cause an asymmetric oligoarthritis, usually including one or both knees.

The most commonly involved joints, after the knee, are the shoulder, ankle, elbow, temporomandibular joint, and wrist, although any joint can be affected, and occasionally, there is periarticular involvement leading to bursitis and/or tendinitis. Almost always, fewer than five joints are affected. Large joints are most commonly involved; by contrast, small joint involvement of the hands and feet is very unusual.

Attacks of joint swelling tend to begin abruptly and last from several weeks to months. In 10 percent of untreated patients with Lyme arthritis, joint swelling lasts for more than a year.

Large joint effusions are common in the knees and elsewhere and often recur after aspiration. Popliteal cysts occur and can rupture if not aspirated.

Lyme arthritis is not particularly painful, except when there is pressure from a tensely swollen joint. Affected joints are usually very swollen and warm.

For most patients, there is little joint dysfunction after resolution of arthritis. However, if quadriceps atrophy has developed, physical rehabilitation of the quadriceps muscle is important. Moreover, persistent, unremitting arthritis sometimes causes erosion of cartilage and bone and permanent joint damage.

Some patients with Lyme arthritis have accompanying fatigue. However, systemic symptoms are usually minor, if present at all, in patients with Lyme arthritis.

These findings were described in a cohort of 55 patients who were followed prospectively from the onset of disease with EM through later manifestations of the illness [9]. In this study, 60 percent of individuals with untreated early Lyme disease developed Lyme arthritis a mean of six months following EM (range 4 days to 2 years). In addition, 10 of 28 patients with intermittent arthritis and 4 of 6 patients with persistent arthritis had fatigue, but other constitutional symptoms were unusual.

In a small percentage of patients, arthritis may persist after treatment with one to two months of oral and one month of intravenous antibiotic therapy, called post-infectious (also called post-antibiotic or antibiotic-refractory) Lyme arthritis. This is discussed in detail below. (See 'Post-infectious Lyme arthritis' below.)

DIAGNOSIS OF LYME ARTHRITIS — The diagnosis of Lyme arthritis, similar to other manifestations of Lyme disease, is typically made through serologic testing. This section will focus on the approach to diagnosis of Lyme arthritis. A detailed discussion of the diagnosis of Lyme disease in patients with other manifestations of Lyme disease is presented elsewhere. (See "Diagnosis of Lyme disease".)

General approach — Serologic testing is typically used to establish the diagnosis of Lyme arthritis in patients with potential exposure to Ixodes ticks and signs and symptoms of Lyme arthritis. All patients with Lyme arthritis will have positive serum immune globulin (Ig) G serologies for B. burgdorferi. (See 'Late Lyme disease' above and 'Serologies' below.)

When the diagnosis of Lyme arthritis is unclear, polymerase chain reaction (PCR) testing can be performed in addition to serologic testing. However, PCR testing should not be used instead of serologic testing, as sensitivity is inferior compared with serum antibody testing. (See 'Polymerase chain reaction testing' below.)

An elevated synovial fluid white blood cell count, which establishes the presence of an inflammatory arthritis, supports the diagnosis of Lyme arthritis. Typically, mean synovial white blood cells counts are 10,000 to 25,000 cells/microL; however, synovial fluid white blood cell counts as high as 100,000 cell/microL have occasionally been reported [10].

Some patients may have persistent synovial hypertrophy after appropriate treatment (table 2). Such patients still have a positive antibody test for B. burgdorferi, and the diagnosis of post-infectious Lyme arthritis is generally clinical. (See 'Post-infectious Lyme arthritis' below.)

Diagnostic tests

Serologies — Serologic responsiveness to B. burgdorferi in blood is the primary laboratory test for diagnosing Lyme arthritis. A more detailed discussion of serologic testing for the diagnosis of Lyme disease is presented separately and summarized below. (See "Diagnosis of Lyme disease".)

A two-tiered conditional strategy should be used to support the diagnosis of Lyme disease. The traditional algorithm includes an initial enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western blot. According to validated standards determined by the United States Centers for Disease Control and Prevention/Association of State and Territorial Public Health Laboratory Directors, the criteria for Western blot immunoglobulin (IgG reactivity) require the presence of at least 5 of 10 specific bands (table 3) [11,12]. Modified algorithms that use two sequential EIAs with different targets have also been developed and validated [13].

All patients with Lyme arthritis have positive IgG serologies for B. burgdorferi since Lyme arthritis is a late manifestation [14]. Patients with Lyme arthritis usually far exceed the Western blot IgG reactivity criteria. Patients with Lyme arthritis may have IgM reactivity as well [14]; however, IgM responses may be lacking and are not required for the diagnosis of Lyme arthritis [14]. In addition, a positive IgM response alone is not consistent with a diagnosis of Lyme arthritis.

Although the amount of antibody declines into a low-positive range, after successful antibiotic therapy, the Western blot, a non-quantitative test, changes very slowly over a period of years. Thus, most patients with Lyme arthritis remain seropositive for years after successful antibiotic therapy [15,16], this may include IgM seropositivity. Such seroreactivity, in the absence of other evidence for ongoing infection, is not an indication for retreatment. In fact, the robust immune response observed in patients with Lyme arthritis seems to confer protective immunity to reinfection [17].

Synovial fluid should not be analyzed for antibody responses. Western blots of synovial fluid, in particular, are subject to false-positive results.

Polymerase chain reaction testing — Although polymerase chain reaction (PCR) testing of synovial fluid has not been standardized for widespread clinical use, B. burgdorferi DNA is detectable in synovial fluid by PCR in about 70 percent of patients with untreated Lyme arthritis [18]. Synovial fluid PCR testing usually becomes negative after treatment but, on occasion, may persist for weeks or months.

In one study, PCR was used to detect B. burgdorferi DNA in synovial fluid from 63 patients with Lyme arthritis and in synovial tissue from 9 patients with Lyme arthritis [19]. The pre-treatment synovial fluid samples from most patients were positive and usually became negative after treatment. It took longer for the PCR results from patients with antibiotic-refractory Lyme arthritis (defined as arthritis lasting more than three months in spite of antibiotic therapy) to become negative than those from patients with antibiotic-responsive arthritis (arthritis lasting less than three months), and in one patient with antibiotic-refractory Lyme arthritis, the PCR test remained positive for 11 months. However, positive PCR results from patients who had been treated for Lyme arthritis did not correlate with relapse or with subsequent duration of arthritis. In addition, PCR tests performed on synovectomy tissue were negative. In this study, B. burgdorferi messenger RNA, a marker of spirochetal viability, was tested in 11 synovial fluid samples but was not detected, even when obtained prior to initiating antibiotics. This study suggests that the B. burgdorferi organisms detected in the synovial fluid of patients with Lyme arthritis were moribund or dead.

Culture — There are only isolated reports of successful cultivation of B. burgdorferi from synovial fluid [20,21]. However, in clinical practice, it has been difficult to culture B. burgdorferi, except from erythema migrans (EM) skin biopsy specimens [22]. (See "Diagnosis of Lyme disease", section on 'Culture'.)

Differential diagnosis — Lyme arthritis is an infectious arthritis with an inflammatory synovial response. However, it may be confused with a mechanical injury when it presents as an acute monoarticular knee effusion in an active individual. (See "Approach to the adult with knee pain likely of musculoskeletal origin".)

Unlike other forms of infectious arthritis, Lyme arthritis is only occasionally associated with fever or constitutional symptoms and is typically less painful. Lyme arthritis may resemble spondyloarthropathy or oligoarticular juvenile rheumatoid arthritis when it is oligoarticular. It is not usually mistaken for adult-onset rheumatoid arthritis, however, since it is not polyarticular or symmetrical. (See "Septic arthritis in adults" and "Monoarthritis in adults: Etiology and evaluation" and "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults" and "Oligoarticular juvenile idiopathic arthritis" and "Clinical manifestations of rheumatoid arthritis".)

In some patients, fibromyalgia symptoms may be incorrectly attributed to Lyme arthritis. However, fibromyalgia is not an inflammatory or infectious disorder. Patients with fibromyalgia have noninflammatory musculoskeletal pain, cognitive complaints, fatigue, and/or irritability [23], and physical examination often reveals multiple "trigger points" near joints. Thus, the presence of objective evidence of inflammation or organ system dysfunction that is seen in patients with late Lyme disease is a way to distinguish these two clinical entities. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

MANAGEMENT OF LYME ARTHRITIS

Antimicrobial therapy — All patients with Lyme arthritis should be treated with antimicrobial therapy to accelerate resolution of arthritis and to prevent arthritis recurrence and other damage. Although studies of the natural history of Lyme arthritis have demonstrated eventual resolution in most patients, even in the absence of antibiotic therapy, patients with untreated Lyme arthritis can have recurrent, intermittent attacks or persistent knee swelling, which can last for several years [9].

For most patients, initial therapy should be with an oral antibiotic such as doxycycline, amoxicillin, or cefuroxime (table 2) [24]; patients typically respond to treatment within one to two months. Retreatment is warranted for those with persistent symptoms, particularly if there is only a minimal response to initial treatment. Such patients may require retreatment with intravenous (IV) therapy (eg, IV ceftriaxone). A detailed discussion of treatment for Lyme arthritis is presented elsewhere. (See "Treatment of Lyme disease", section on 'Arthritis'.)

Adjunctive therapies — Adjunctive measures, including nonsteroidal anti-inflammatory drugs, may be beneficial. In addition, patients with Lyme arthritis should reduce high levels of activity and high impact on affected joints while the joints are actively inflamed. A period of rest and range of motion physical therapy exercises may hasten recovery, particularly in patients with prolonged arthritis, who may have decreased range of motion and quadriceps atrophy. (See "Overview of joint protection".)

Joint aspiration is indicated for diagnosis; however, reaspiration may be required to treat intensely swollen joints and prevent popliteal cyst rupture. The role of intra-articular steroids is unclear. In a retrospective study of children with residual joint inflammation, intra-articular steroids have been reported to be of value [25]. On the other hand, in adults, there is some evidence that this may delay the resolution of Lyme arthritis [26].

POST-TREATMENT SYNDROMES — There are two major post-treatment syndromes. One, called post-infectious (also called post-antibiotic or antibiotic-refractory) Lyme arthritis, is defined by the development of massive synovial proliferation after oral and intravenous (IV) antibiotic therapy. Such patients usually do not have other symptoms. The other syndrome, called post-treatment Lyme disease syndrome, is characterized by pain, neurocognitive, and/or fatigue symptoms, without objective joint abnormalities.

Post-infectious Lyme arthritis — In a small percentage of patients, arthritis may persist after treatment with one to two months of oral and one month of IV antibiotic therapy, called post-infectious (also called post-antibiotic or antibiotic-refractory) Lyme arthritis. In these patients, the arthritis seems to change after antibiotic treatment. Joint effusions are not as large, but marked synovial proliferation develops, usually in one or both knees, that may even worsen in the post-antibiotic period, lasting months to several years.

The diagnosis of post-infectious Lyme arthritis is based upon the clinical findings of a persistent, inflammatory, proliferative synovitis in a patient who has received at least one course of oral and one course of IV therapy (preferably ceftriaxone) (table 2) [24]. In patients with a known history of Lyme arthritis, further serologic and polymerase chain reaction (PCR) testing are usually not helpful in diagnosing post-infectious arthritis. (See "Diagnosis of Lyme disease".)

Patients with post-infectious, antibiotic-refractory Lyme arthritis should be managed in conjunction with a rheumatologist. Such patients have been successfully treated with disease-modifying antirheumatic drugs (DMARDs; eg, hydroxychloroquine, methotrexate, tumor necrosis factor [TNF] inhibitors), modalities that have been used in rheumatoid arthritis and other chronic inflammatory arthropathies [24]. However, in contrast to the chronic inflammatory arthritides, treatment with DMARDs in Lyme arthritis is generally needed for the short term (for a period of months) and not needed indefinitely.

Some patients may benefit from synovectomy. In a series of 20 such patients treated with arthroscopic synovectomy, 16 (80 percent) had resolution of joint inflammation during or soon after the first months following surgery and remained well at three- to eight-year follow-up [27]. However, synovial tissue must be removed down to the cartilage interface for the procedure to be successful. (See "Synovectomy for inflammatory arthritis of the knee".)

In the absence of treatment, post-infectious Lyme arthritis may persist for months to several years but will eventually resolve spontaneously. It is rare to have persistent synovitis extending past five years. However, the longer the inflammatory response persists, the greater the possibility of damage to cartilage or bone. (See "Diagnosis of Lyme disease", section on 'Post-infectious arthritis'.)

Post-infectious Lyme arthritis occurs more often in patients who were infected with highly inflammatory OspC type A (RST 1) strains of B. burgdorferi, and this strain is particularly prevalent in New England. The basic pathogenetic feature of post-infectious Lyme arthritis is the development of an excessive, dysregulated proinflammatory immune response during the infection that persists in the postinfectious period [28,29]. This response is characterized by exceptionally high levels of interferon gamma coupled with inadequate levels of the anti-inflammatory cytokine interleukin (IL)-10. The consequences of this excessive proinflammatory response in Lyme synovia include vascular damage, autoimmune and cytotoxic processes, and fibroblast proliferation and fibrosis, a histologic picture similar with that in other chronic inflammatory arthritides, including rheumatoid arthritis. An important driver of innate immune responses may be persistence of B. burgdorferi peptidoglycan in synovial fluid, which may be especially difficult to clear [30]. In addition, patients with post-infectious Lyme arthritis often have T and B cell responses to Lyme disease-associated autoantigens. These include vascular antigens such as endothelial cell growth factor, apolipoprotein B-100, annexin A2, or extracellular matrix proteins, including MMP-10, fibronectin-1, laminin B2, or collagen V-alpha-1 [31].

Post-treatment Lyme disease syndrome — Most patients with Lyme disease, whether early or late stage, do not develop persistent symptoms after appropriate antibiotic treatment [32]. However, some patients, particularly those with early Lyme disease, may develop diffuse noninflammatory musculoskeletal pain in conjunction with other subjective symptoms (eg, headache, neurocognitive difficulties, or fatigue) following appropriate treatment, referred to as post-treatment Lyme disease syndrome. Detailed discussions on the clinical manifestations, diagnosis, and management of patients with post-treatment Lyme disease syndrome are presented elsewhere. (See "Clinical manifestations of Lyme disease in adults", section on 'Post-treatment Lyme disease syndrome and chronic Lyme disease' and "Treatment of Lyme disease", section on 'Role of additional antibiotics'.)

Other conditions — It has been reported that patients may develop other forms of inflammatory or autoimmune arthritis following Lyme disease [33]. This may be coincidental, or the infection may trigger other systemic autoimmune diseases, such as rheumatoid arthritis or psoriatic arthritis.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Tick-borne infections (Lyme disease, ehrlichiosis, anaplasmosis, babesiosis, and Rocky Mountain spotted fever)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Lyme disease (The Basics)")

Beyond the Basics topics (see "Patient education: Lyme disease symptoms and diagnosis (Beyond the Basics)" and "Patient education: Lyme disease treatment (Beyond the Basics)" and "Patient education: Lyme disease prevention (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Lyme disease was first recognized in the United States in the 1970s, presenting as oligoarthritis during an outbreak in children in Lyme, Connecticut. Lyme disease is now the most common vector-borne illness in North America and Europe. (See 'Introduction' above.)

Clinical manifestations – The clinical manifestations of Lyme disease can generally be divided into three phases: early localized (erythema migrans), early disseminated, and late disease (table 1). (See 'Clinical features' above.)

Patients with early localized or early disseminated Lyme disease may develop migratory arthralgias, which should be distinguished from frank arthritis seen in late disease. (See 'Early Lyme disease' above.)

Lyme arthritis is characterized by intermittent or persistent arthritis in a few large joints, especially the knee. The most commonly involved joints after the knee are the shoulder, ankle, elbow, temporomandibular joint, and wrist. (See 'Late Lyme disease' above.)

Diagnosis – Serologic testing is typically used to establish the diagnosis of Lyme arthritis in patients with potential exposure to Ixodes ticks and signs and symptoms of Lyme arthritis. All patients with Lyme arthritis have positive immune globulin (Ig) G serologies for Borrelia burgdorferi. When the diagnosis of Lyme arthritis is unclear, polymerase chain reaction (PCR) testing can be performed in addition to serologic testing. (See 'Diagnosis of Lyme arthritis' above.)

Treatment – All patients with Lyme arthritis should be treated with antimicrobial therapy to accelerate resolution of arthritis and to prevent arthritis recurrence and other damage (table 2). The treatment of Lyme arthritis is discussed in detail in a separate topic review. (See "Treatment of Lyme disease".)

Post-infectious arthritis – In a small percentage of cases, Lyme arthritis persists after treatment with oral and intravenous antibiotic therapy, an entity that is called postinfectious (also called post-antibiotic or antibiotic-refractory) Lyme arthritis. Such patients should be managed in conjunction with a rheumatologist as treatment typically consists of disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine, methotrexate, or TNF inhibitor, and/or synovectomy. (See 'Post-infectious Lyme arthritis' above.)

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References

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