Signs and Symptoms

 These symptoms can occur three to 30 days after a tick bite:  

• Fever
• Chills
• Headache
• Fatigue
• Muscle aches
• Joint aches
• Swollen lymph nodes
• Erythema migrans (EM) lesions:
  • Presents as a flat to mildly raised, annular, erythematous lesion
  • Expands gradually over several days, reaching up to 12 inches (30 cm) or more across
  • May feel warm to the touch but is rarely itchy or painful
  • Sometimes clears as it enlarges, resulting in a target or bull’s-eye appearance but has a variety of appearances 

Lyme carditis most typically presents as atrioventricular nodal block. Varying degrees of heart block can occur, which can progress to or fluctuate between complete heart block. Pericarditis and myocarditis may also occur. Symptoms may include:

• dyspnea
• palpitations
• syncope
• chest pain
• exercise intolerance
• edema
  
  

An ECG does not need to be performed routinely on all patients with Lyme disease. However, an ECG should be performed urgently for any patient with suspected Lyme carditis.

Meningitis
Presentation of Lyme meningitis is similar to enteroviral and other aseptic meningitis. This may include:

• Fever
• Headache
• Photosensitivity
• Neck stiffness or pain
• CSF studies may reveal lymphocytic pleocytosis
  
  

The presence of the following may increase the likelihood of Lyme meningitis*:

• Co-occurrence of facial nerve palsy
• Mononuclear cell predominant CSF pleocytosis
  
  

Cranial Neuritis
Cranial neuritis usually involves the facial nerve (CN VII) and less often, the trigeminal (CN V), oculomotor and abducens (CN III, VI), and vestibulocochlear nerves (CN VIII). When the cranial nerves are affected, facial palsy can occur on one or both sides of the face.

Man with facial palsy.

Radiculoneuritis
This presentation is rare in children, but if present, may include:

• Numbness
• Tingling
• “Shooting” pain
• Weakness in arms or legs
  
  

*Robert A. Avery, Gary Frank, Joseph J. Glutting, Stephen C. Eppes; Prediction of Lyme Meningitis in Children From a Lyme Disease–Endemic Region: A Logistic-Regression Model Using History, Physical, and Laboratory Findings. Pediatrics January 2006; 117 (1): e1–e7. 10.1542/peds.2005-0955

Marked swelling primarily affecting large joints, most commonly the knee. This is the most common presentation of late Lyme disease in children. Predictors of Lyme arthritis include:

• known history of tick bite
• isolated knee involvement
• lack of fever
  
  

Lyme arthritis can be difficult to differentiate from septic arthritis. Predictors of septic arthritis may include

• absolute neutrophil count >10k cells/mm³
• ESR >40 mm/hour
• hip involvement
• pain with short arc motion
  
  Lyme arthritis in the knee.

Although a two- to four-week course of antibiotics cures most cases of Lyme disease, patients sometimes report symptoms of pain, fatigue, or difficulty thinking that last for more than six months after they finish treatment.

It is not known why some patients experience these symptoms. Studies funded by the National Institutes of Health have found that long-term outcomes are no better for patients who received additional prolonged antibiotic treatment than for patients who received placebo treatments.