A. Rheumatologic Symptoms of Lyme Disease

1. Migratory joint pains
2. Arthralgias and Myalgias
3. Monoarthritis and Oligoarthritis
4. Very rare myositis and fasciitis

B. Initial Manifestations

1. Intermittant episodes of joint, periarticular pain
2. Rare frank arthritis initially
3. Myalgias and arthralgias are very common

C. Arthritis

1. Considered a late manifestation of Lyme Disease
2. Knees are nearly always involved, >90% of cases
3. Shoulder involvement in ~50% of cases
4. Ankle in ~40%
5. Elbow, Temporomandibular (TMJ), and hip joints are involved <30%
6. Arthritis may persist for years, with decrease of ~15% of patients per year
7. Persistant joint inflammation for >1 year is chronic arthritis

D. Chronic Arthritis

1. Appears to be associated with HLA-DR4 and DR2 alleles
2. Suggests that genetic/immunological factors play a role in establishing chronic disease
3. B. burgdorferi OspA (outer surface protein A) DNA can be detected in chronic joint fluid
4. Spirochete DNA can also be detected in joint fluid with PCR, even with negative culture results [4]
5. Antibiotic treatment lowers OspA DNA in joint fluid
6. Some patients develop chronic arthritis without organisms or proteins in their joints

E. Diagnosis

1. Lyme Enzyme-Linked Immunosorbant Assay (ELISA) test
   1. High frequency of false positives
   2. These occur in the general population and patients with history of syphilis, etc.
   3. All patients with a positive ELISA test should have a Western Blot done
2. Western Blot Test
   1. Detection of Borrelia specific proteins by patient's sera
   2. A minimum of 5 protein bands must be recognized by the sera for a true positive
   3. Most common band sizes are 18,23 (OspC),28,30,39,41 (fla),45,58,66,93 Kilodaltons
   4. Most patients with true Lyme disease will have >7 Lyme-specific antibodies
3. Lyme disease can also cause a false positive RPR (serologic test for syphilis)
4. Polymerase Chain Reaction (PCR)
   1. Persistant arthritis is apparently related to persistant Lyme-Specific DNA in joint fluid
   2. PCR can be used to detect residual organisms
   3. It is unclear if these organisms are alive or dead, or how long DNA simply persists [5]
5. Differential includes reactive arthritis, Reiter's Syndrome

F. Treatment of Lyme Arthritis [3]

1. Arthritis is a manifestation of late Lyme Disease, and may deserve Intravenous therapy
2. Ceftriaxone 2gm iv qd x 2-4 weeks (longer recommended with previous oral therapy)
   1. Ceftriaxone has been demonstrated to be superior to iv penicillin [2]
   2. Parenteral antibiotics initially for patients with neurological or cardiac disease
   3. Doxycycline 100mg po bid x 4-6 wks may be used first as initial treatment
   4. Amoxicillin 500mg + Probenecid 500mg each qid x 4-6 weeks is an alternative
   5. Doxycycline should not be used in children <8 years old
3. Non-steroidal anti-inflammatory agents may be helpful
4. Glucocorticoids
   1. Intrarticular glucocorticoids, eg. 80mg Depomedrol® in the knee, are often effective
   2. These should be used in patients who have failed antibiotic therapy
   3. PCR of joint fluid may be performed first to determine if organism has been eradicated
   4. Glucocorticoid injections should likely be used with concomitant antibiotic therapy
5. Arthroscopic Synovectomy may be required for symptoms in resistant arthritis cases [7]
6. Alternative, sulfasalazine or plaquenil [6] therapy could be attempted

G. Vaccination Against Lyme Disease [9,10]

1. Vaccines based on B. burgdorferi outer-surface lipoporein A (OspA)
2. Aluminum hydroxide based adjuvant was used in one of the vaccines []
3. Vaccine efficacies were 50-60% in first year after two injections
4. Vaccine efficacies were 75-95% in second year after three injections
5. Vaccines were nearly 100% effective at preventing Lyme symptoms during second year
6. Cases of Lyme arthritis and other severe symptoms were reduced by close to 100%
7. Vaccine generally well tolerated; mild to moderate local or systemic symptoms
8. Vaccine associated symptoms lasted 2-7 days

References

1. Steere AC. 1995. Am J Med. 98(Sup 4A):44S
2. Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ. 1988. Lancet. i:1191
3. Steere AC, Levin RE, Polloy PJ. 1994. Arthritis Rheum. 37:878
4. Nocton JJ, Dressler F, Rutledge BJ, et al. 1994. NEJM. 330:229
5. Bradley JF, Johnson RC, Goodman JL. 1994. Ann Intern Med. 120:487
6. Coblyn JS and Taylor P. 1981. Arthritis Rheum. 24:1567
7. Schoen RT, Aversa JM, Rahn DW, Steere AC. 1991. Arthritis Rheum. 34:1056
8. Med Let. 1997. 39(1000):47
9. Steere AC, Sikand VK, Meurice F, et al. 1998. NEJM. 339(4):209
10. Sigal LH, Zahradnik JM, Lavin P, et al. 1998. NEJM. 339(4):216