Symptoms of Lyme disease

What a tick bite looks like

The most identifying mark from a tick bite is likely to be a red spot – this is caused by an allergic reaction to the tick’s saliva.

You can draw a circle round the site of the bite with a pen. If you develop a reddish skin rash in a ring shape around the bite the tick may have been infected and you may have contracted Lyme disease.


One of the tell-tale signs that you may be infected is if the bite expands, with another circle appearing around the original site of the bite. This gives the bite the appearance of a red bull's-eye, called erythema migrans (EM); however this doesn’t have to be present in order for Lyme disease to occur. The skin may be warm but is not usually painful. It is usually considered that a rash that extends beyond 5 cm after a tick bite is likely to be Lyme disease
A rash, which is not EM can develop as a reaction to a tick bite that:
  • Usually develops and recedes within 48 hours from the time of the tick bite
  • Is more likely than EM to be hot, itchy or painful
  • May be caused by an inflammatory reaction or infection with a common skin pathogen [66]

What are the symptoms of Lyme disease?

Rash The most common symptom is a distinctive circular rash at the site of the tick bite, usually 2-30 days after being bitten. The rash is often described as looking like a bull’s eye on a dart board. Not everyone with Lyme disease gets a rash - about one in three people will not develop a rash. The affected area of the skin will be red and the edges feel slightly raised. Some people may develop several rashes in different parts of the body. Atypical rashes are also found and make diagnosis difficult for GP and clinicians who are not experienced in diagnosis of Lyme disease.

The most common symptom (in 60-80% of all cases) erythema migrans (EM) which looks like a red circle of 5 to 15 cm (2 to 6 inches) around the tick bite that grows gradually while the centre often become lighter in colour.
The rash occurs 2 -30 days after the tick bite (generally 7 to 14 days), the redness is not painful and disappears after a few weeks, therefore it can pass unnoticed.[78].
Flu-like symptoms
  • Some people with Lyme disease also experience flu-like symptoms in the early stages, such as tiredness (fatigue), muscle pain, joint pain, headaches, a high temperature (fever), chills and neck stiffness.
  • Facial paralysis, headache and fever in the tick season (April to October) has been shown to predict Lyme disease in children.
  • Lyme carditis presenting as heart block is an uncommon early sign requiring urgent referral to a cardiologist.

Lyme disease in untreated patients

Death due to Lyme disease is an extremely rare outcome. In an untreated patient Lyme disease usually demonstrates three clinical phases [68].

Phase 1: Early localised Lyme borreliosis


Early localised Lyme borreliosis occurs at a median of 21 days following a tick bite (range 3-82 days). 60–90% of cases develop an expanding target-like rash of erythema migrans (EM). The border can be raised with a diameter of 5 – 75 cm (mean 15cm). Studies indicate that around 50-70% of patients recall a tick bite. A patient may be symptomatic in the early phase or may suffer from associated non-specific flu-like symptoms include chills, tiredness, headache, arthralgia or myalgia.


Phase II: Early disseminated Lyme borreliosis


Several weeks or months after initial symptoms a patient may develop a disseminated stage in which cardiac and neurological involvement occurs. Patients may develop multiple ‘secondary’ EM lesions, usually less than 5cm in diameter.
Differences in clinical presentation and intensity of the host’s inflammatory response to Lyme disease appears to be due to different genomic species of Borrelia (Anecdotal evidence).


Phase III: Late Lyme borreliosis


Late Lyme disease, which is less common, presents some months or years after the initial infection. It may involve the joints, skin, central and peripheral nervous system. The diagnosis of late neurological abnormalities have proved the most challenging.
Less than 5% of European neuroborreliosis (NB) patients present with late (> 6 months to several years) symptoms.
Central nervous system (CNS) manifestations include encephalitis, encephalomyelitis with tetraparesis, tetraspastic syndrome and/or spastic ataxic gait disorder, cognitive impairment and psychiatric disturbances.
In the UK NB is the most common complication, with symptoms including: meningitis, myeloradiculitis, cranial neuropathies and mononeuritis multiplex.

Differences in the clinical presentation of Lyme disease

There are some differences in the symptoms people with Lyme disease have in Europe compared with North America


  There are many similarities between European and North American LD, some differences have emerged:
Multiple EM rashes and chronic arthritis features are more common in the USA than in Europe. [68]In Europe neuroborreliosis (NB) is more common and most often presents as the triad of Bannworth syndrome:
  • cranial neuropathy
  • lymphocytic meningitis
  • painful radiculitis

The unusual skin conditions of Borrelia lymphocytoma (< 1% of cases) and acrodermatitis are almost unique to Europe and rare if ever reported in the USA.

Contacting your GP

You should contact your GP if:

  • You see a rash that spreads out from the bite
  • You start to feel unwell after you have been bitten, or think you have been bitten or after you have spent time outdoors  - about 1 in 3 people may develop symptoms without a rash

You do not need to go to your GP if you have had a tick bite and have no symptoms

Antibiotic prophylaxis following a tick bite is not routinely recommended.

What you should tell your GP:

History

  • When you were bitten
  • Where on your body the tick bite was
  • How you feel
  • What your symptoms are and when they started

What happens if you have symptoms of Lyme disease and you do not get treatment?

More serious conditions may develop - such as swelling in joints or problems with the nerves or heart