Princeton Lyme Disease Center
Princeton Infectious Disease Associates, based in Plainsboro, New Jersey, can diagnose and treat all stages of Lyme disease. We have extensive clinical experience and can manage any disease complication. Richard Porwancher M.D. and Arunima Mamidi M.D. will assess you in-person and deliver medical care specific to your needs. The following monograph is provided for general educational purposes only. Tick-bite management and references used for the Lyme disease monograph below are included under the Resources drop-down menu.
Lyme Disease: Overview
Lyme disease is caused by a spirochete (bacterium) called Borrelia burgdorferi and is transmitted to humans by a deer tick bite (also known as Ixodes scapularis). Only 25% of patients with Lyme disease recall a tick bite, so failure to remember a bite does not exclude this illness.
Lyme disease is the most common tick-borne disease in the US and the Centers for Disease Control and Prevention (CDC) estimate that approximately 476,000 people are infected yearly.
Early Lyme disease first manifests as a rash called erythema migrans, developing within the first month after the bite.
It is important to diagnose and treat Lyme disease in its earliest stages, a time when it is highly curable with antibiotics. If left untreated, serious complications such as arthritis, neurological disease, and cardiac disease can develop [1].
If you suspect that either you or a loved one may have Lyme Disease or a co-infection, it is important to get appropriate medical attention quickly.
Princeton Infectious Diseases Associates
can provide prompt and appropriate diagnosis and treatment.
Lyme Disease: Symptoms
The symptoms of Lyme disease often mimic those of other diseases and can vary greatly from person-to-person. Approximately 70% to 90% of patients with Lyme disease will develop a rash within 3 to 30 days after a deer tick bite (typically within 1 to 2 weeks) [2, 3]. A single flat, confluent, round or oval skin lesion called erythema migrans may appear over the trunk, groin, armpits, or extremities [2]. While most patients with Lyme disease develop a single rash, about 20% will demonstrate multiple skin lesions [2] (See figure 1 above). Skin lesions in the head and neck region are more commonly seen in children [4]. A rash due to Lyme disease is a minimum of 2 inches across (5 cm) and typically expands over time. The classic “bull’s-eye” rash with central clearing and a surrounding red ring may take 2 or more weeks to develop [5] (See bull's-eye skin lesion image); this type of rash is seen less commonly now because of earlier antibiotic treatment. About 65% of patients notice systemic (flu-like) symptoms [5], including:
Fever and chills,
Fatigue and muscle pain,
Achy, stiff, or swollen joints,
Headache and/or neck stiffness,
Night sweats,
Cognitive changes, such as difficulty concentrating or memory loss, and
Numbness and tingling in the extremities.
Skin lesions may last for several days to several weeks before resolving, although antibiotic treatment hastens improvement. Small skin lesions that last less than 48 hours, particularly if itchy, are more likely due to allergic reactions to insect bites [5].
Appropriate diagnosis and antibiotic treatment given when the above symptoms first develop are often successful is preventing chronic complications.
At Princeton Infectious Diseases Associates, we are experienced in treating the above conditions.
Lyme Disease: Testing
Blood tests are too often inaccurate for diagnosis of the skin rash called erythema migrans, the earliest manifestation of Lyme disease. Erythema migrans is therefore diagnosed clinically rather than by blood test. The two most common blood tests look for antibodies (protective proteins) manufactured by the immune system to fight infection. These two tests are called the ELISA test (enzyme-linked immunosorbent assay) and the Western blot (also called an immunoblot); it may take 2 to 6 weeks after a tick bite before these tests can detect antibodies [6]. Some laboratories use non-standard methods, such as urine tests or laboratory-developed (in-house) Western blots, for diagnosis; blood and urine reports using non-standard methods (not approved by the CDC) should be interpreted with caution [1, 7].
The accuracy of the tests used for diagnosing Lyme disease is crucial for the effective treatment of patients. However, recent research by Drs. Richard Porwancher, Andrew Levin, and Rosalie Trevejo have shown that some laboratories have made changes to the CDC-advocated immunoblot interpretative criteria, leading to unreliable test results. Their findings, published in the journal Pathogens in October 2023, argue against any changes to the current CDC immunoblot criteria. We must adhere to these criteria to ensure that patients receive accurate diagnoses and appropriate treatment. For more information on this Lyme disease research, please click here.
Your doctor will also inquire about your symptoms and perform a physical exam.
Lyme Disease Treatment
Is Lyme disease curable?
Early-stage Lyme disease is usually curable with oral antibiotics [1]. Oral doxycycline for 10 days, and oral amoxicillin or cefuroxime for 14 days are at least 90% successful for skin infection [8]. If the disease has affected the joints or nervous system, a longer treatment course (3 to 4 weeks) or intravenous antibiotics may be required, although a favorable treatment outcome is still likely [1].
Most symptoms fully resolve within 1 to 3 months after antibiotic treatment for early Lyme disease. Some patients may experience residual fatigue, muscle soreness, joint pain, and cognitive symptoms that resolve more slowly. Up to 10% of patients may experience symptoms lasting more than 6 months after completing treatment for early Lyme disease [1, 8]. The cause of long-term symptoms, known as post-treatment Lyme disease syndrome (PTLDS), is unknown, but longer courses of standard antibiotic therapy do not help [1]. Recent studies suggest that the immune system may be responsible for ongoing symptoms in these few patients and is the focus of active research for new treatments [9]. Later stages of Lyme disease (such neuropathy, chronic arthritis, and brain involvement), typically demonstrate strong antibody responses, but may require intravenous antibiotics for resolution of infection; delayed diagnosis and treatment can lead to longer-term symptoms. Although long-term symptoms often improve over time, referral to neurology or rheumatology specialists may be needed.
Prevention
Deer ticks are quite small, particularly in the nymph phase (early Spring). See Figure 3. Fortunately, fewer than 5% of patients develop Lyme disease following a deer tick bite [10]. There are multiple means to prevent tick bites, including covering exposed skin with appropriate clothing when hunting, hiking, camping, or gardening, utilizing insect repellants on clothing and bathing after returning home [8]. Careful skin inspection may detect ticks that have not yet had a chance to feed; pay particular attention to the head and neck of children. Ticks removed within 24 to 36 hours of attachment are less likely to transmit Lyme disease. Blood-engorged ticks have almost always been feeding for longer than 24 hours and are more likely to spread disease. See Figure 4. Tick removal kits are available in most pharmacies. Attach tweezers to the tick’s mouthparts (not head) at the bite site and gently exert upward pressure (using a magnifying glass is recommended). It is important to remove the tick with the head intact, otherwise, infection may develop; Consultation with a healthcare professional may be needed if unable to fully remove all tick parts. If a tick has been feeding for longer than 24 to 36 hours, a single dose of oral doxycycline is usually effective in preventing Lyme disease. Expert help should be sought when treating pregnant women. Blood tests following tick bites are not helpful with management. Although there are a few exceptions, testing ticks for Lyme disease is not routinely recommended; even ticks that are carrying the Lyme disease spirochete (B. burgdorferi) may not have been attached long enough to transmit this infection.
Co-infections
Deer tick bites can spread multiple diseases besides Lyme disease, either separately or concurrently with Lyme disease. Babesiosis, anaplasmosis, Ehrlichiosis, and Powassan virus infections have all been reported. Bartonella infections following tick bites are extremely rare. Co-infected Individuals typically demonstrate higher fever and more constitutional symptoms than typical of Lyme disease alone; severe headache and muscle pain, fever greater than 103 degrees F, and unusual skin rashes have been reported. Laboratory tests may demonstrate liver inflammation as well as reduced numbers of white blood cells and platelets in patients with co-infections. Expert help is needed when co-infections are suspected.
Please see our monograph on tick bite management.