A. Rheumatologic Symptoms of Lyme Disease ![navigator](../../Images/navigator.gif)
- Migratory joint pains
- Arthralgias and Myalgias
- Monoarthritis and Oligoarthritis
- Very rare myositis and fasciitis
B. Initial Manifestations![navigator](../../Images/navigator.gif)
- Intermittant episodes of joint, periarticular pain
- Rare frank arthritis initially
- Myalgias and arthralgias are very common
C. Arthritis ![navigator](../../Images/navigator.gif)
- Considered a late manifestation of Lyme Disease
- Knees are nearly always involved, >90% of cases
- Shoulder involvement in ~50% of cases
- Ankle in ~40%
- Elbow, Temporomandibular (TMJ), and hip joints are involved <30%
- Arthritis may persist for years, with decrease of ~15% of patients per year
- Persistant joint inflammation for >1 year is chronic arthritis
D. Chronic Arthritis![navigator](../../Images/navigator.gif)
- Appears to be associated with HLA-DR4 and DR2 alleles
- Suggests that genetic/immunological factors play a role in establishing chronic disease
- B. burgdorferi OspA (outer surface protein A) DNA can be detected in chronic joint fluid
- Spirochete DNA can also be detected in joint fluid with PCR, even with negative culture results [4]
- Antibiotic treatment lowers OspA DNA in joint fluid
- Some patients develop chronic arthritis without organisms or proteins in their joints
E. Diagnosis![navigator](../../Images/navigator.gif)
- Lyme Enzyme-Linked Immunosorbant Assay (ELISA) test
- High frequency of false positives
- These occur in the general population and patients with history of syphilis, etc.
- All patients with a positive ELISA test should have a Western Blot done
- Western Blot Test
- Detection of Borrelia specific proteins by patient's sera
- A minimum of 5 protein bands must be recognized by the sera for a true positive
- Most common band sizes are 18,23 (OspC),28,30,39,41 (fla),45,58,66,93 Kilodaltons
- Most patients with true Lyme disease will have >7 Lyme-specific antibodies
- Lyme disease can also cause a false positive RPR (serologic test for syphilis)
- Polymerase Chain Reaction (PCR)
- Persistant arthritis is apparently related to persistant Lyme-Specific DNA in joint fluid
- PCR can be used to detect residual organisms
- It is unclear if these organisms are alive or dead, or how long DNA simply persists [5]
- Differential includes reactive arthritis, Reiter's Syndrome
F. Treatment of Lyme Arthritis [3] ![navigator](../../Images/navigator.gif)
- Arthritis is a manifestation of late Lyme Disease, and may deserve Intravenous therapy
- Ceftriaxone 2gm iv qd x 2-4 weeks (longer recommended with previous oral therapy)
- Ceftriaxone has been demonstrated to be superior to iv penicillin [2]
- Parenteral antibiotics initially for patients with neurological or cardiac disease
- Doxycycline 100mg po bid x 4-6 wks may be used first as initial treatment
- Amoxicillin 500mg + Probenecid 500mg each qid x 4-6 weeks is an alternative
- Doxycycline should not be used in children <8 years old
- Non-steroidal anti-inflammatory agents may be helpful
- Glucocorticoids
- Intrarticular glucocorticoids, eg. 80mg Depomedrol® in the knee, are often effective
- These should be used in patients who have failed antibiotic therapy
- PCR of joint fluid may be performed first to determine if organism has been eradicated
- Glucocorticoid injections should likely be used with concomitant antibiotic therapy
- Arthroscopic Synovectomy may be required for symptoms in resistant arthritis cases [7]
- Alternative, sulfasalazine or plaquenil [6] therapy could be attempted
G. Vaccination Against Lyme Disease [9,10] ![navigator](../../Images/navigator.gif)
- Vaccines based on B. burgdorferi outer-surface lipoporein A (OspA)
- Aluminum hydroxide based adjuvant was used in one of the vaccines []
- Vaccine efficacies were 50-60% in first year after two injections
- Vaccine efficacies were 75-95% in second year after three injections
- Vaccines were nearly 100% effective at preventing Lyme symptoms during second year
- Cases of Lyme arthritis and other severe symptoms were reduced by close to 100%
- Vaccine generally well tolerated; mild to moderate local or systemic symptoms
- Vaccine associated symptoms lasted 2-7 days
References ![navigator](../../Images/navigator.gif)
- Steere AC. 1995. Am J Med. 98(Sup 4A):44S
![abstract](../../Images/abstract.gif)
- Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ. 1988. Lancet. i:1191
- Steere AC, Levin RE, Polloy PJ. 1994. Arthritis Rheum. 37:878
![abstract](../../Images/abstract.gif)
- Nocton JJ, Dressler F, Rutledge BJ, et al. 1994. NEJM. 330:229
![abstract](../../Images/abstract.gif)
- Bradley JF, Johnson RC, Goodman JL. 1994. Ann Intern Med. 120:487
![abstract](../../Images/abstract.gif)
- Coblyn JS and Taylor P. 1981. Arthritis Rheum. 24:1567
![abstract](../../Images/abstract.gif)
- Schoen RT, Aversa JM, Rahn DW, Steere AC. 1991. Arthritis Rheum. 34:1056
![abstract](../../Images/abstract.gif)
- Med Let. 1997. 39(1000):47
![abstract](../../Images/abstract.gif)
- Steere AC, Sikand VK, Meurice F, et al. 1998. NEJM. 339(4):209
![abstract](../../Images/abstract.gif)
- Sigal LH, Zahradnik JM, Lavin P, et al. 1998. NEJM. 339(4):216
![abstract](../../Images/abstract.gif)