Lyme disease has become one of the most common vector-borne infectious diseases in the U.S., with more than 300,000 new cases each year. As case numbers continue to rise, so do the numbers of patients with Lyme arthritis and other Lyme-associated conditions.
If untreated, Lyme disease has musculoskeletal symptoms at all stages, noted John Aucott, MD, Associate Professor of Medicine and Director of the Lyme Disease Research Center at Johns Hopkins University School of Medicine. About 60% of patients with untreated Lyme disease develop inflammatory oligoarthritis in late infection, and a minority of patients treated for acute infection may develop a broad range of post-infection syndromes, including inflammatory arthropathies.
“Lyme was first described in Europe in the early 20th century as a skin and nerve disease,” Dr. Aucott said. “It was re-discovered in the U.S. during an outbreak of juvenile arthritis in Lyme, Connecticut, in the mid-1970s. We have more arthritis due to the infectious agent in North America, Borrelia burgdorferi. Lyme has spread slowly and steadily and has been reported in most states and across Southern Canada.”
Dr. Aucott discussed the latest findings in Lyme arthritis during Lyme Disease & Other Tick-Borne Illnesses: What Every Rheumatologist Must Know. The session, which was originally presented Sunday, Nov. 7, can be viewed by registered meeting participants through March 11, 2022.
Most acute Lyme infections can be treated with oral doxycycline, but many patients are never treated, because either they fail to notice the typical bull’s-eye rash surrounding the initial tick bite or the symptoms are minor. It is harder to ignore the chronic late Lyme arthritis that can develop a few months to a few years after the initial infection.
“We tend to see these patients with a new and sudden swelling of a knee,” Dr. Aucott said. “Because so many people are not treated for the initial Lyme infection, Lyme arthritis in late infection is not uncommon.”
Testing is a two-step process starting with enzyme-linked immunosorbent assay (ELISA) antibody screening. A positive ELISA screen must be confirmed with a western blot. Immunoglobulin G serology for late Lyme arthritis is highly sensitive, Dr. Aucott noted. Current guidelines from the ACR, the Infectious Diseases Society of America, and the American Academy of Neurology strongly recommend serum antibody testing over polymerase chain reaction testing or culture of either blood or synovial fluid/tissue.
Borrelia culture is rarely helpful because the organism reproduces slowly and is often not seen in culture or in tissue samples, he added.
Treatment is usually 14 to 21 days of oral doxycycline, followed by 30 days of intravenous ceftriaxone for arthritis that does not respond to oral antibiotics. Many commonly used antibiotics are ineffective, including quinolones, macrolides, and Keflex.
Treatment of late Lyme arthritis is 90% effective, Dr. Aucott said, although synovitis may persist for months after the infection has been cleared. About 10% of patients develop post-infectious arthritis, possibly the result of autoimmune processes. Disease-modifying antirheumatic drugs are generally effective, although some patients may need biologic agents, most often TNF inhibitors.
Rheumatologists are also likely to see patients with post-Lyme syndromes following early Lyme treatment. The most common is Post-Treatment Lyme Disease Syndrome (PTLDS).
“Post-infection syndromes are not specific to Lyme,” said Sheila Arvikar, MD, Director of Quality and Safety in Rheumatology, Allergy and Immunology and Co-Director of the Lyme Disease Clinic at Massachusetts General Hospital. “They are seen after many infections, especially viral infections, including COVID-19. These are syndromes because there is no functional impairment, but the symptoms of non-specific joint and muscle pain, fatigue, and neurocognitive problems are very real.”
Post-treatment syndromes can present with no overt inflammation, as post-infectious Lyme arthritis with limited autoimmunity and inflammation in a few joints, or as systemic autoimmunity with systemic inflammation and polyarthritis. Risk factors include female sex, severe disease, comorbidities, delays in diagnosis, and steroid use. Mimics include fibromyalgia, chronic fatigue syndrome/myalgic encephalomyelitis, rheumatic disease, and other infections.
There are no approved treatments for these post-Lyme syndromes, Dr. Arvikar said. Some patients, advocacy groups, and clinicians may press for antibiotic treatment of what is often called “chronic Lyme,” but the 2020 guidelines strongly recommend against additional antibiotics for nonspecific symptoms, she noted.
“We can — and should — treat the symptoms, much like we would treat fibromyalgia or rheumatoid arthritis,” Dr. Arvikar said. “Exercise and physical therapy may help, or cognitive behavioral therapy and mind-body medicine.”
In a Massachusetts General Hospital cohort of 30 PTLDS patients with systemic arthropathies, most responded well to DMARDs, she added. Patients who resist DMARDs or biologics are at risk for progression of their rheumatic symptoms.
“As the incidence of Lyme disease is increasing, we need to be aware of these post-treatment syndromes,” Dr. Arvikar said. “And we should always consider entities that mimic Lyme disease as well as other infections that can confuse the diagnosis.”