Lyme disease follows from the bite of in infected Ixodes (deer) tick. Tick bites are usually not observed. These ticks are very small. The tick has a two year life cycle. It starts out as a larvae, the size of a period at the end of a sentence. These forms are sometimes infected and may transmit the illness. The second state, the nymph, is the size of a poppy seed, and is probably the most common form of the tick to transmit the illness. Even the adult ticks are quite small with the female somewhat larger than the male. People look for a classic "Bulls Eye" rash but this is rare. The Lyme rash is called Erythem Chronicum Migrans (ECM) and typically looks like a red patch resembling a sunburn, which can take any shape. Central clearing as in a bulls eye is usually absent or may occur after the rash has been present for many days. The acute illness may be associated with flu like symptoms, stiff neck, headache, fatigue and generalized aches and pains. A rash is frequently absent. So the disease has been called the "summer flu" at times. Initially typical blood tests used in the diagnosis are absent, so your physician will only make the correct diagnosis is he/she is astute and has a high index of suspicion. Acute Lyme has many other presentations as well, but what I am interested in here is chronic Lyme.
Patients with chronic Lyme can have symptoms all over the map. However, there is a consistent pattern, a recurring theme that I see in the vast majority of patients. It is this symptom complex that I would first like to describe. Typically, patients have had symptoms form many months, or more often years. They have seen a variety of physicians without a clear cut diagnosis having been made. Patients are frequently labeled with fibromyalgia, reactive arthritis, depression or non-specific chronic pain disorders. These patients complain of fatigue which does not improve with sleep. They generally have poor exercise tolerance, although this is a variable feature. They complain of generalized pains, which frequently move from location to location. The pains may be focused on joints, both small and large, muscles, tendons, ligaments or some combination of the above. The most consistent symptoms have to do with the nervous system. Lyme attacks all parts of the nervous system, including the brain. Patients may have headaches, a loss of balance, numbness and tingling of the extremities and progressive cognitive impairments. It is the cognitive impairments which most concern me as a clinician. It seems to start with word retrieval problems. Patients cannot recall names and numbers and other facts which previously were easily at their disposal. They complain of difficulty with concentration and short term memory. In some cases it seems like they have suddenly developed symptoms of attention deficit disorder. ADD is a lifetime disorder and does not develop suddenly. Patients describe "brain fog". Their cognitive processing slows down. They may have episodes of frank confusion and disorientation. Mood symptoms, including depression and irritability are common, but these symptoms frequently clear with antibiotics, not with psychotropic medication. A wide array of psychiatric symptoms have been linked to Lyme disease. Work related to this has been extensively published by Dr. Fallon, a psychiatrist and Lyme researcher at Columbia University in New York. These are the patients which I see over and over again in my practice. I will discuss patients with less common symptoms at a later point.