So, now the staging of Lyme Disease, Dr Donta talked a little bit about the different classifications. I use a very simple classification, acute Lyme Disease being less than one month since infection and Chronic Lyme Disease being greater than three months since infection. There are other terms used to describe this but that’s kind of a simple way to think of the disease. Also, in terms of classification, there are patients who have predominantly musculoskeletal symptoms and these can be either fixed or migratory joint problems and muscle aches and also in contrast people have predominant neurologic symptoms and these can be either cranial neuropathies, meningeal encephalitis or unexplained cognitive defects and this is another simple way to kind of break down the primary symptoms of Chronic Lyme Disease.
Now, you have heard a little bit about the classic features of Lyme Disease and this is shown on this slide. A tick bite, of course, is a classic feature, but only 70 to 80% or perhaps less of patients with Lyme Disease actually recall a tick bite and often this is because as you saw the ticks can be very small and as I mentioned bites around the head and neck can be more commonly associated with neurologic disease.
The second classic feature is a bull’s eye rash or E.M. However, only 60% of patients and even less than that in some studies ever get an E.M. rash and there is also a variable appearance and location which I will show you in a minute.
The third classic feature is the frank arthritis which was described in the original cases in Lyme Connecticut but as Dr Donta mentioned only 30% of patients get actual joint swelling and this symptom can often be masked by the use of anti-inflammatory medications which we use pretty commonly now and also the joint fluid in those patients may be culture - negative but sometimes PCR positive for Borrelia so it may be difficult to make the diagnosis based on culture but sometimes PCR is helpful in that situation.
Just to show you some E.M. rashes. You can see that some of them are nice round bull’s eyes like that one, but others can be sort of polygonal or big and sort of difficult to see as a bull’s eye so there is a lot of variability in what an E.M. rash can look like.
This is a study from Nantucket and I’ll just show you this slide, actually Dr Donta alluded to it, but these were symptoms in patients from Nantucket. Now, Nantucket is this island off the coast of Massachusetts and essentially the entire population of Nantucket has Lyme Disease, I mean, they have all been bitten by ticks and gotten infected so this was a study done comparing those patients to controls from the mainland who didn’t have Lyme Disease and in virtually every category shown here except for palpitations there were significantly greater symptoms in the Lyme Disease patients than in the controls and this also shows you the joint swelling in the Lyme Disease patients only 23% of those patients had actual joint swelling but 61% of them had joint pain so joint ‘pain’ is significantly more common than ‘swelling’ of the joints in Lyme Disease. Now, what was the conclusion of this study? Well, what the authors did was they did neurological testing on everybody and they found that the Lyme patients had no difference in their neurological testing that the controls so the conclusion was well, that there was no chronic sequelae of Lyme Disease in spite of all these symptoms, interesting conclusion.
Now, distinctive symptoms of Lyme Disease, you’ve again heard most of this in terms of musculoskeletal symptoms. One very typical complaint that I hear a lot is migratory joint pains. A patient will say you know one day I had this pain in my elbow and it was killing me and the next day it was completely gone and there are very few things in medicine that really do that, that give you that kind of symptomology. Usually when you have a symptom it kind of stays there that is what you would expect but with Lyme Disease that’s not the case.
Temporo-Mandibular Joint disorder, where pain in the TMJ is also very common in Lyme Disease and very, very typical in that disease.
Another joint symptom is heel pain and there is this peculiar sharp heel pain that patients get and nobody really knows why but that is a very typical symptom of the disease.
And finally, myoclonus, or muscle twitching, is also very, very common in this disease. Patients come in complaining that they can’t sleep at night because their muscles are twitching and one of my favourite stories is that I had a patient who was an attorney and he came in primarily with this symptom and I treated him and his muscle twitching got better but his wife wanted him to go somewhere where they knew what they were doing so he went to Stanford University and went to the Chief of Neurology and got sort of the whole work up at Stanford and finally the Chief of Neurology walked into the room and sat down in front of him and said “OK now, twitch” and he said, well you don’t understand, it doesn’t work like that I can’t control my twitching and she said that well, you don’t have Lyme Disease, Lyme Disease doesn’t do this. Go away, we can’t help you. So, that’s kind of where we are with that.
Now, in terms of neurological symptoms, visual migraines are very common. These are the visual equivalents of migraine headaches. Patients often describe a kind of a saw tooth pattern in their visual field and that is actually some kind of a vascular phenomenon that is like a migraine but it affects the vision. Very common in Lyme Disease.
Bell’s Palsy you have heard about. We will talk about that.
Holmes-Adie Pupil is another complication of Lyme Disease which we described several years ago. This is a pupil that is very sluggishly reactive and this is probably a type of neuropathy that occurs in the eye and it is due to Lyme Disease.
Acute Psychosis can be seen and also any psychiatric syndrome can be seen in this disease.
Another very peculiar thing that we described recently was musical hallucinations in this disease. I have had several patients who had formed musical hallucinations. One heard the Star Spangled Banner. She heard this over and over and over again and it would wake her up from sleep and was really very annoying. Another patient heard Italian Opera. She could remember that this was one of the earliest things that her parents would play for her and this was quite a pleasant memory. Usually these things come from sort of way back in the subconscious and they are brought out by this infection. And they got better, by the way, when they were treated with IV antibiotics.
Cardiac manifestations of Lyme Disease. Interestingly, much more common on the east coast of the United States than the west coast, we don’t see this very often at all. On the east coast, patients can get palpitations, that is the most common symptom, and also frank arrhythmias with atrioventricular block, this can lead to serious consequences including cardiac arrest. Also pericarditis, inflammation around the heart, can be seen and frank heart failure but again we don’t see this very much in California; this may have to do with the strain of Borrelia which we have. There are about 300 different strains of Borrelia throughout the world so it may be that ours don’t do this.
Sleep Disorders. Also mentioned by Dr Donta. I am sure you can’t read this, but this is a study done by Eileen Hilton in New York showing that every single patient with Lyme Disease which she looked at had some problem with sleep even when they weren’t aware that they had a problem with sleep they either had a delayed sleep, they had trouble getting to sleep, or trouble staying asleep or staying in deep sleep and this is a huge problem of Lyme Disease that probably is responsible for a lot of the fatigue that patients have in that disease. If you can’t get good quality sleep at night, you are going to be tired for the rest of the time.
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