Lyme Arthritis

In the United States, arthritis is the major late manifestation of Lyme disease, usually beginning months after the tick bite. However, because of greater recognition and treatment of early disease which prevents later arthritis, a history of EM or other early disease manifestations is now often lacking in patients with LA. Patients have intermit-tent or persistent attacks of joint swelling and pain, primarily in one or a few large joints, often the knee, during a period of months to several years, with few systemic manifestations. The diagnosis is established by two-tier serologic testing for B. burgdorferi by ELISA and IgG Western blotting, which typically shows strong re-sponses to many spirochetal proteins with many bands present. PCR testing of syno-vial fluid for B. burgdorferi DNA is often positive before antibiotic therapy, but the test is not a reliable indicator of spirochetal eradication following antibiotic treatment. The recommended initial treatment is a 30-day course of oral doxycycline or amoxicillin. However, for patients with minimal or no response to oral therapy, IV ceftriaxone for 2 to 4 weeks may be needed for successful treatment. A small percentage of patients may have persistent arthritis for months or several years after both oral and IV anti-biotic therapy, which may be treated successfully with anti-inflammatory agents, DMARDs, or synovectomy, depending on the severity of arthritis. The antibody response to B. burgdorferi declines slowly after treatment, but the test typically re-mains positive for years after therapy.