Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Case Study
  • Published:

A case revealing the natural history of untreated Lyme disease

Abstract

Background A 71-year-old woman presented to a rheumatologist with what she believed to be a 2-year history of Lyme disease, progressing from erythema migrans to Lyme arthritis.

Investigations History, physical examination and serologic testing confirmed the diagnosis of Lyme disease.

Diagnosis Lyme disease.

Management The patient refused antibiotic therapy during the first 2 years of her illness. During the next 2 years, she consulted a rheumatologist, but declined antibiotic therapy. She continued to have recurrent episodes of arthritis, following which she was successfully treated with doxycycline, given initially for 2 weeks, with a second, 4-week cycle administered 2 months later. This case illustrates the natural history of untreated Lyme disease, which is rarely observed in most patients since diagnosis almost always leads to successful antibiotic treatment. Furthermore, this case also demonstrates that infection with Borrelia burgdorferi can persist for years in untreated patients; however, antibiotic therapy is still likely to be effective, despite long-term infection.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Timeline of the case illustrating the natural history of Lyme disease.
Figure 2: The spectrum of Lyme disease, including its associated manifestations and causative strains.
Figure 3: The percentage of patients with Lyme arthritis who experience recurrent episodes decreases by year of disease.

References

  1. Steere, A. C. et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis Rheum. 20, 7–17 (1977).

    Article  CAS  Google Scholar 

  2. Steere, A. C., Schoen, R. T. & Taylor, E. The clinical evolution of Lyme arthritis. Ann. Intern. Med. 107, 725–731 (1987).

    Article  CAS  Google Scholar 

  3. Burgdorfer, W. et al. Lyme disease—a tick-borne spirochetosis? Science 216, 1317–1319 (1982).

    Article  CAS  Google Scholar 

  4. van Dam, A. P. et al. Different genospecies of Borrelia burgdorferi are associated with distinct clinical manafestations of Lyme borreliosis. Clin. Infect. Dis. 17, 708–717 (1993).

    Article  CAS  Google Scholar 

  5. Dennis, D. T. & Hayes, E. B. in Lyme Borreliosis: Biology, Epidemiology and Control (eds Gray, J. S., Kahl, O., Lane, R. S. & Stanek, G.) 251–280 (CABI, Oxfordshire, 2002).

    Book  Google Scholar 

  6. Steere, A. C. Lyme disease. N. Engl. J. Med. 321, 586–596 (1989).

    Article  CAS  Google Scholar 

  7. Steere, A. C. et al. The early clinical manifestations of Lyme disease. Ann. Intern. Med. 99, 76–82 (1983).

    Article  CAS  Google Scholar 

  8. Wormser, G. P. et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Disease Society of America. Clin. Infect. Dis. 43, 1089–1134 (2006).

    Article  Google Scholar 

  9. Steere, A. C. & Angelis, S. M. Therapy for Lyme arthritis: strategies for the treatment of antibiotic-refractory arthritis. Arthritis Rheum. 54, 3079–3086 (2006).

    Article  CAS  Google Scholar 

  10. Bacon, R. M., Kugeler, K. J. & Mead, P. S. Surveillance for Lyme disease—United States, 1992–2006. MMWR Surveill. Summ. 57, 1–9 (2008).

    PubMed  Google Scholar 

  11. Smith, R. P. et al. Clinical characteristics and treatment outcomes of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann. Intern. Med. 136, 421–428 (2002).

    Article  Google Scholar 

  12. Steere, A. C. et al. The spirochetal etiology of Lyme disease. N. Engl. J. Med. 308, 733–740 (1983).

    Article  CAS  Google Scholar 

  13. Benach, J. L. et al. Spirochetes isolated from the blood of two patients with Lyme disease. N. Engl. J. Med. 308, 740–742 (1983).

    Article  CAS  Google Scholar 

  14. Wormser, G. P. et al. Brief communication: hematogenous dissemination in early Lyme disease. Ann. Intern. Med. 142, 751–755 (2005).

    Article  Google Scholar 

  15. Fraser, C. M. et al. Genomic sequence of a Lyme disease spirochaete, Borrelia burgdorferi. Nature 390, 580–586 (1997).

    Article  CAS  Google Scholar 

  16. Liang, F. T. et al. An immunodominant conserved region within the variable domain of VlsE, the variable surface antigen of Borrelia burgdorferi. J. Immunol. 163, 5566–5573 (1999).

    CAS  PubMed  Google Scholar 

  17. Craft, J. E., Grodzicki, R. L. & Steere, A. C. The antibody response in Lyme disease: evaluation of diagnostic tests. J. Infect. Dis. 149, 789–795 (1984).

    Article  CAS  Google Scholar 

  18. Dressler, F., Whalen, J. A., Reinhardt, B. N. & Steere, A. C. Western blotting in the serodiagnosis of Lyme disease. J. Infect. Dis. 167, 392–400 (1993).

    Article  CAS  Google Scholar 

  19. Aguero-Rosenfeld, M. E. Lyme disease: laboratory issues. Infect. Dis. Clin. North Am. 22, 301–313 (2008).

    Article  Google Scholar 

  20. Pal, U. et al. Borrelia burgdorferi basic membrane proteins A and B participate in the genesis of Lyme arthritis. J. Exp. Med. 205, 133–141 (2008).

    Article  CAS  Google Scholar 

  21. Berger, B. W., Kaplan, M. H., Rothenberg, I. R. & Barbour, A. G. Isolation and characterization of the Lyme disease spirochete from the skin of patients with erythema chronicum migrans. J. Am. Acad. Dermatol. 13, 444–449 (1985).

    Article  CAS  Google Scholar 

  22. Syndman, D. R., Schenkein, D.P., Berardi, V. P., Lastavica, C. C. & Pariser, K. M. Borrelia burgdorferi in joint fluid in chronic Lyme arthritis. Ann. Intern. Med. 104, 798–800 (1986).

    Article  Google Scholar 

  23. Schmidli, J., Hunziker, T., Moesli, P. & Schaad, U. B. Cultivation of Borrelia burgdorferi from joint fluid three months after treatment of facial palsy due to Lyme borreliosis. J. Infect. Dis. 158, 905–906 (1988).

    Article  CAS  Google Scholar 

  24. Nocton, J. J. et al. Detection of Borrelia burgdorferi DNA by polymerase chain reaction in synovial fluid in Lyme arthritis. N. Engl. J. Med. 330, 229–234 (1994).

    Article  CAS  Google Scholar 

  25. Treatment of Lyme disease. Medical Letter on Drugs and Therapeutics 52, 53–54 (2010).

  26. Steere, A. C., Duray, P. H. & Butcher, E. C. Spirochetal antigens and lymphoid cell surface markers in Lyme synovitis. Comparison with rheumatoid synovium and tonsillar lymphoid tissue. Arthritis Rheum. 31, 487–495 (1988).

    Article  CAS  Google Scholar 

  27. Iliopoulou, B. P. & Huber, B. T. Infectious arthritis and immune dysregulation: lessons from Lyme disease. Curr. Opin. Rheumatol. 22, 451–455 (2010).

    Article  CAS  Google Scholar 

  28. Schoen, R. T., Aversa, J. M., Rahn, D. E. & Steere, A. C. Treatment of refractory chronic Lyme arthritis with arthroscopic synovectomy. Arthritis Rheum. 34, 1056–1060 (1991).

    Article  CAS  Google Scholar 

  29. Coblyn, J. S. & Taylor, P. Treatment of chronic Lyme arthritis with hydroxychloroquine. Arthritis Rheum. 24, 1567–1569 (1981).

    Article  CAS  Google Scholar 

  30. Holzbauer, S. M. Kemperman, M. M. & Lynfield, R. Death due to community-associated Clostridium difficile in a woman receiving prolonged antibiotic therapy for suspected Lyme disease. Clin. Infect. Dis. 51, 369–370 (2010).

    Article  Google Scholar 

Download references

Acknowledgements

Written consent for publication was obtained from the patient.

Author information

Authors and Affiliations

Authors

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schoen, R. A case revealing the natural history of untreated Lyme disease. Nat Rev Rheumatol 7, 179–184 (2011). https://doi.org/10.1038/nrrheum.2010.209

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrrheum.2010.209

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing