As many as 60% of untreated cases of Lyme disease can progress to a late stage composed of arthritis [1]. Lyme arthritis develops months to years after the onset of the initial infection, which is characterized by the dermatologic finding known as erythema migrans, as well as constitutional symptoms [2] such as low-grade fever, malaise, and fatigue. Studies have shown that properly treated Lyme arthritis is associated with a good prognosis [3].

Lyme arthritis, which manifests as oligoarticular arthritis, occurs predominantly in the pediatric population [1]. The knee is the most commonly affected site although other joints such as the hip, elbow, wrist, and ankle may be involved [3]. The affected joints are typically swollen but not as painful. Also, patients are susceptible to developing Baker's cysts.

Differential diagnoses include acute septic arthritis and juvenile rheumatoid arthritis (JRA). Less than 20% of children with Lyme arthritis are recognized on initial presentation [4] since it is a late feature of Lyme disease and patients at this point are unlikely to exhibit a rash. Additionally, the symptomology and laboratory findings of these conditions are similar [5].

Complications

Although uncommon, sequelae include bone and cartilage erosion and pannus formation. Furthermore, approximately a tenth of children with Lyme arthritis will experience chronic knee arthritis.

Physical exam

The intermittent episodes of Lyme arthritis are characterized by warm, edematous, and tender joint(s).

• Fever

  Compared with those with septic arthritis, patients with Lyme disease were more likely to have a tick-bite history, knee involvement, and less likely to have a history of fever or elevated temperature at triage. [ncbi.nlm.nih.gov]

  ) mycoses ( B35-B49 ) O'nyong-nyong fever ( A92.1 ) paratyphoid fever ( A01.1- A01.4 ) Type 1 Excludes arthropathy in Lyme disease ( A69.23 ) gonococcal arthritis ( A54.42 ) meningococcal arthritis ( A39.83 ) mumps arthritis ( B26.85 ) postinfective [icd10data.com]

• Chills

  Associated symptoms ranged from none to malaise, fatigue, chills and fever, headache, stiff neck, backache, myalgias, nausea, vomiting, and sore throat. [ncbi.nlm.nih.gov]

  Mild joint pains, fever, chills etc might occur along with the rash for some time. [boneandspine.com]

  Lyme Disease Symptoms Early symptoms resemble a mild flu and include fever, headache, fatigue, chills and swollen lymph nodes. [arthritis.org]

• Rigor

  Lyme disease: a rigorous review of diagnostic criteria and treatment. J Autoimmun. 2015;57:82-115. doi: 10.1016/j.jaut.2014.09.004 Hodzic E, Feng S, Freet KJ, Borjesson DL, Barthold SW. [infectiousdiseaseadvisor.com]

  These guidelines contained a rigorous assessment of the evidence and found treatment failure rates ranging from 16% to 39% for early treatment. Estimates for patients with chronic Lyme disease are much higher, ranging from 26% to 50%. [lymedisease.org]

  “These have not really been looked at with any rigor,” Auwaerter says, which is why he has referred to LLMDs as a “threat to public health.” “The cynic in me says this is a business model for these physicians,” he says. [yahoo.com]

  Therefore, a more rigorous analysis of myeloid cells recruited to the joint by flow cytometry was performed at various times during infection. [journals.plos.org]

• Arthritis

  Considerable overlap can occur in the clinical presentation of Lyme arthritis and acute septic arthritis. [ncbi.nlm.nih.gov]

• Arthralgia

  This review addresses the clinical presentation of Lyme arthritis as a mono- or oligoarticular relapsing/remitting arthritis primarily affecting the large joints and describes presentations in which arthralgias rather than arthritis are seen. [ncbi.nlm.nih.gov]

  He was treated in the ER one month back for left knee arthralgia with effusion attributed to a twisting injury. The symptoms were resolved following treatment with ibuprofen. [ijcasereportsandimages.com]

  Soon after the onset of Lyme-flu, fatigue, arthralgias and/or myalgias may begin. [lymeneteurope.org]

  Before the onset of arthritis, 57% of the systemic autoimmune group had the typical erythema migrans skin rash, and an additional 23% had other typical Lyme disease symptoms during the summer such as fever and arthralgias. [medpagetoday.com]

  It is manifested by recurrent bouts of arthritis or arthralgia associated with erythema chronicum migrans skin lesions. PATHOLOGY : The resulting pathology is due to two effects: 1. Immune complexes accumulate in the joints. [atsu.edu]

• Joint Effusion

  CONCLUSIONS: For any child presenting with a joint effusion in a Lyme-endemic area of the Northeastern United States, the likely prevalence of Lyme arthritis is 31% overall and 45% in the presence of knee effusion. [ncbi.nlm.nih.gov]

  Cameron, MD MPH Doctors described a 67-year-old avid outdoorsman from central Pennsylvania with a 3-month history of progressive left knee pain and swelling. [1] There was no history of trauma, tick bite, or rash nor evidence of joint effusion, infection [danielcameronmd.com]

  Radiography and ultrasonography display joint effusion, but this finding is non-specific and not helpful, although the latter imaging technique may be used to monitor the consequences of Lyme arthritis. [symptoma.com]

• Knee Pain

  Cameron, MD MPH Doctors described a 67-year-old avid outdoorsman from central Pennsylvania with a 3-month history of progressive left knee pain and swelling. [1] There was no history of trauma, tick bite, or rash nor evidence of joint effusion, infection [danielcameronmd.com]

  pain for three days duration. [orthobullets.com]

• Migratory Polyarthritis

  polyarthritis or monoarthritis, tendonitis, bursitis Lyme carditis relatively rare may have a cardiac conduction abnormality symptoms syncope fatigue dizziness shortness of breath palpitation prognosis good with complete resolution following treatment [orthobullets.com]

It is paramount to diagnose Lyme arthritis, septic arthritis, and other similar diseases as early as possible in order to initiate the proper therapy and prevent complications. The workup includes a thorough patient history, an assessment of the risk factors, a physical exam, and the appropriate studies.

Laboratory tests

According to the Centers for Disease Control and Prevention (CDC), the diagnostic system for Lyme arthritis is composed of two steps: 1) enzyme immunoassay (EIA) or enzyme-linked immunosorbent assay (ELISA), which is followed by 2) a confirmatory Western immunoblot test [6] [7]. Generally, testing of serum is not beneficial in the acute stage of the disease.

To rule out differential diagnoses such as septic arthritis, gout or pseudogout, an arthrocentesis may be performed. Joint fluid in patients with Lyme arthritis is typically associated with a white blood count (WBC) of 25,000 to 125,000/µL.

Laboratory findings may include leukocytosis, elevated erythrocyte sedimentation rate (ESR), increased serum aspartate transaminase (AST), and possibly mild hypercomplementemia. Also, rheumatoid factor (RF) and antinuclear antibody (ANA) are negative in patients with Lyme arthritis.

Imaging

Since Lyme and septic arthritis share clinical and laboratory features, this poses a diagnostic challenge [8]. To distinguish between these conditions, authors advocate for the use of magnetic resonance imaging (MRI) in the evaluation of patients with acute arthritis [2]. Specifically, this modality identifies three abnormalities in Lyme arthritis, which are myositis, lymphadenopathy, and absent subcutaneous edema [2].

Radiography and ultrasonography display joint effusion, but this finding is non-specific and not helpful [9] [10], although the latter imaging technique may be used to monitor the consequences of Lyme arthritis [10].

• Blood Culture Positive

  The clinical features of patients whose blood culture tested positive for Borrelia burgdorferi sensu lato were reviewed, and the association between the proportion of patients with a positive blood culture and various clinical manifestations was examined [ncbi.nlm.nih.gov]

• Synovial Hemangioma

  In conclusion, in children and adolescents synovial hemangioma has to be considered in differential diagnosis of recurrent knee swelling. [ncbi.nlm.nih.gov]

• HLA-DR1

  region of the HLA-DR β1 chain. 21, 22 Rheumatoid arthritis has a secondary association with the presence of HLA-DR1. [nejm.org]

  Differential effect of polymorphism at HLA-DR1 β-chain positions 85 and 86 on binding and recognition of DR1-restricted antigenic peptides. J. Immunol. 150 : 1813 –1821. ↵ Sturniolo, T., E. Bono, J. Ding, L. Raddrizzani, O. Tuereci, U. Sahin, M. [jem.rupress.org]

In two cases, multiple intraarticular corticosteroid injections were required; three patients received additional or consecutive treatment with systemic antirheumatic treatment. [ncbi.nlm.nih.gov]

Generally, the prognosis is excellent. Arthroscopic synovectomy is reserved for refractory cases that do not respond to antibiotics. [ncbi.nlm.nih.gov]

Studies have shown that properly treated Lyme arthritis is associated with a good prognosis. Lyme arthritis, which manifests as oligoarticular arthritis, occurs predominantly in the pediatric population. [symptoma.com]

"Lyme arthritis has an excellent prognosis with appropriate treatment," Dr. Cruz said. "Most patients respond well to a single course of antibiotics. [sciencedaily.com]

The etiology of transient synovitis of the hip is unknown. Lyme arthritis is characterized by brief, often recurrent episodes of oligoarthritis. Lyme arthritis most often affects a single knee, but hip involvement is uncommon. [ncbi.nlm.nih.gov]

Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics 2009;123(3):959–65. [ CrossRef ] [ Pubmed ] Steere AC, Schoen RT, Taylor E. The clinical evolution of Lyme arthritis. [ijcasereportsandimages.com]

MM 337-342; ID 1327-1335 LYME DISEASE SYNONYM : Lyme Arthritis ETIOLOGICAL AGENT : Borrelia burgdorferi, a unicellular, loosely coiled, left-handed helix. It is 30 um in length with seven turns of the coil. [atsu.edu]

The epidemiology and pathophysiology of Lyme disease are directly related to the Borrelia burgdorferi spirochete and its effects on the integumentary, neurologic, cardiac, and musculoskeletal systems. [ncbi.nlm.nih.gov]

Eugene Shapiro, a professor of pediatrics and epidemiology at the Yale School of Medicine, said the study makes a good case for the cause of one very specific and very rare symptom of the disease, but doesn't get at the heart of the debate. [articles.courant.com]

"In general, the diagnosis is multifaceted and involves a thorough understanding of the common clinical and epidemiologic features of the disease, along with careful understanding of the tests used in diagnosis." [sciencedaily.com]

The epidemiology and pathophysiology of Lyme disease are directly related to the Borrelia burgdorferi spirochete and its effects on the integumentary, neurologic, cardiac, and musculoskeletal systems. [ncbi.nlm.nih.gov]

[…] general Due to infection with Borrelia burgdorferi, a spirochete transmitted by Ixodes tick; joints affected weeks to years later Causes chronic arthritis of large joints with pannus formation in 10% Also affects skin, heart, nervous system Precise pathophysiology [pathologyoutlines.com]

8.6 cases/100,000) adults 55-59 (7.8 cases/100,00) geographic locations northeast, midwest, western US (areas with heavy deer population) Maryland to Maine (Ixodes scapularis) Great Lakes region (Ixodes scapularis) Pacific Northwest (Ixodes pacificus) Pathophysiology [orthobullets.com]

Pathophysiology B burgdorferi colonizes Ixodes ticks which is responsible for transmission to humans. Out of four stages of ticks [egg, larva, nymph, and adult], only three -larva, nymph, and adult require bloodmeal. [boneandspine.com]

Abstract Interleukin-35 (IL-35) has been reported to inhibit the production of interleukin-17 (IL-17) as a means of preventing arthritis and other inflammatory diseases. [ncbi.nlm.nih.gov]

It is paramount to diagnose Lyme arthritis, septic arthritis, and other similar diseases as early as possible in order to initiate the proper therapy and prevent complications. [symptoma.com]

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3. Gerber MA, Zemel LS, Shapiro ED. Lyme arthritis in children: clinical epidemiology and long-term outcomes. Pediatrics. 1998;102(4 pt 1):905–908.
4. Culp RW, Eichenfield AH, Davidson RS, Drummond DS, Christofersen MR, Goldsmith DP. Lyme arthritis in children. An orthopaedic perspective. J Bone Joint Surg Am. 1987;69(1):96–99.
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6. Centers for Disease Control and Prevention. Two-step Laboratory Testing Process. CDC. Available http://www.cdc.gov/lyme/diagnosistesting/LabTest/TwoStep/index.html. March 26, 2015; Accessed:December 14, 2016.
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8. Willis AA, Widmann RF, Flynn JM, Green DW, Onel KB. Lyme arthritis presenting as acute septic arthritis in children. J Pediatr Orthop. 2003;23(1):114–118.
9. Arvikar SL, Steere AC. Diagnosis and treatment of Lyme arthritis. Infect Dis Clin North Am. 2015; 29(2): 269–280.
10. Czupryna P, Moniuszko A, Czeczuga A, Pancewicz S, Zajkowska J. Ultrasonographic evaluation of knee joints in patients with Lyme disease. Int J Infect Dis. 2012;16(4):e252-5.