Ep 81 – Lyme disease

Lyme disease can present a number of particular difficulties in primary care, and these are often linked to clinical findings and the availability and timing of testing. In this podcast, Dr Roger Henderson discusses those and looks at Lyme disease’s three stages — early, disseminated and late — and whether it can be diagnosed clinically if erythema migrans is or is not present. He also looks at diagnostic difficulties and whether acute or convalescent serological testing is helpful. Treatment with antibiotics is also discussed along with prognostic indicators.

Key references

1. NICE. Lyme disease (NG95). 17 October 2018.
2. Infectious Diseases Society of America. Lyme Disease. Accessed 24 October 2023. 
3. BMJ. Lyme disease. 25 September 2023.
4. Dubrey SW, et al. Postgrad Med J. 2014 Jan;90(1059):33-42. doi: 10.1136/postgradmedj-2012-131522.
5. NICE. Clinical Knowledge Summaries. Differential diagnosis. What else might it be? June 2023. 
6. NICE. Lyme disease (QS186). 10 July 2019. 
7. NICE. Clinical Knowledge Summaries. Scenario: Management of Lyme disease. June 2023. 

Key take-home points

• Lyme disease is an infection caused by a number of bacteria belonging to the Borrelia genus, including Borrelia burgdorferi. These are spirochetes, with many similarities to syphilis, and different strains can cause different clinical presentations.
• The treatment of Lyme disease in different countries may vary because of the sometimes-contested differing classifications of Lyme disease globally.
• Lyme disease is not a notifiable disease in the UK but since October 2010 under the Health Protection (Notification) Regulations 2010, every microbiology laboratory (including those in the private sector) in England is required to notify all laboratory diagnoses of Lyme disease to the UK Health Security Agency.
• Symptoms depend on the disease stage and some people are asymptomatic.
• The usual classification of Lyme disease is early (stage 1 or localised), disseminated (stage 2) and late (stage 3).
• In early disease the classical presentation is the rash erythema migrans and this may be the only presenting feature.
• When considering an erythema migrans rash there is a long list of possible differential diagnoses.
• Initial treatment should be with antibiotics, with the dose, duration and type determined by the symptoms.
• A Jarisch–Herxheimer reaction may develop in up to 15% of people in the first 24 hours of treatment with any antibiotic for Lyme disease.
• If Lyme disease is suspected in people without erythema migrans, offer the patient an enzyme-linked immunosorbent assay test for Lyme disease.
• If patients are diagnosed and treated properly with recommended antibiotic therapy, Lyme disease is usually curable.