|
|
|
|
Stage 3 / Chronic Infection
Although late manifestations of Lyme disease are often caused by persistent infection with B. burgdorferi, chronic symptoms in some patients may have an autoimmune mechanism. For this reason, stage 3 disease presents major diagnostic and therapeutic challenges to the clinician. Months after the initial infection, patients may develop intermittent attacks of monoarticular or oligoarticular arthritis, most commonly in the knees and shoulders. In contrast to subjective migratory arthralgias typical in earlier stages, patients show objective joint involvement at this stage. Steere carefully studied untreated patients with erythema migrans and found that approximately one-half developed intermittent attacks of arthritis, but only 11 percent developed chronic synovitis, and less than 5 percent had erosive joint destruction. Steere also discovered that chronic Lyme arthritis may have an autoimmune component; patients with HLA-DR4 often did not respond to multiple courses of antibiotics. Nevertheless, even persons with sustained arthritis rarely have active joint inflammation for longer than several years. |
The spectrum of nervous system abnormalities with chronic Lyme disease is broad. Distinct syndromes include:
encephalopathy, polyneuropathy, and encephalomyelitis. These
manifestations occur months to years after the initial illness, and are
variable from patient to patient. Subacute encephalopathy is the most common chronic neurological syndrome and is manifested by
disturbances in mood, sleep, and memory. Polyneuropathy is generally manifested by sensory disturbances including spinal pain,
radicular pain, or distal paresthesias. Axonal polyneuropathy maybe
confirmed by electromyography. Rarely, patients may have a
leukoencephalitis that mimics multiple sclerosis or dementia. Patients with late Lyme disease may also complain of severe fatigue.
Chronic neurologic involvement may persist for 10 years or longer.
A small subset of patients develops acrodermatitis chronica atrophicans. This uncommon chronic skin lesion has been observed predominately in European patients and often develops at a previous site of erythema migrans; it is characterized by skin swelling and a bluish-red discoloration. Additionally, atrophy of the skin may develop and mimic cutaneous scleroderma. Isolation of B. burgdorferi from acrodermatitis chronica atrophicans skin lesions has provided strong support for the presence of persistent infection. |