Does Lyme disease affect the brain?
Rheumatologists often see patients complaining of joint pain, some of whom may live in Lyme-endemic regions. However, as the authors of a new study point out, “Today, Lyme disease with true arthritis occurs far less than cases with arthralgias and neurologic features.”
In their article entitled “Common Neurologic Features of Lyme Disease That May Present to a Rheumatologist,” Govil et al. describe the various ways that Lyme disease can affect the brain. The authors hope to make rheumatologists aware of the most common neurologic presentations of Lyme disease.1
It is particularly important, the authors write, for rheumatologists to take a thorough history for patients exhibiting joint pain and not rely on the presence of an erythema migrans (EM) rash.
“…because skin lesions related to Lyme disease occur at the onset of the disease, and the main symptoms of arthralgias occur later, it is not likely that the rheumatologist would see them when the patient first presents.” Instead, neurologic symptoms are more likely to be present.
When Lyme disease affects the brain it can cause neurologic symptoms, such as facial nerve palsy, the most common presentation, according to Govil.
The authors cited a Canadian study involving 475 patients with late-stage Lyme disease.2 Only 35 (7.4%) manifested true arthritis, while 440 (92.6%) had arthralgias, writes Govil.²
Neurologic manifestations of Lyme disease were more common and present in 259 (54.5%) patients. “Thus, common extracutaneous manifestations are now found to be neurologic,” Govil writes.
The most common neurologic features of early disseminated Lyme disease include:
- cranial nerve VII palsy (rarely other cranial nerves are involved)
- aseptic meningitis syndrome
- acute painful radiculoneuritis
Infrequent neurologic manifestations include:
- cerebrovascular issues, including vasculitis
- intracranial hypertension syndromes (in adolescents)
Early disseminated Lyme disease can also affect the brain and present with a lymphocytic/mononuclear meningitis (indistinguishable from viral meningitis) and acute painful radiculoneuritis.
The most common neurologic features of late-stage Lyme disease include subtle encephalopathy and neuropathies.
Govil also described rare encephalomyelitis, seen more in Europe.
“A mild chronic encephalopathy may be the most common neurologic manifestation in patients with late-stage Lyme disease.”
“The symptoms tend to be diffused and nonspeciﬁc, and patients typically report memory loss, sleep disturbance, fatigue, and depression.”
Whether such neurologic symptoms are due to a persistent infection or resulting from a systemic mechanism is unknown, according to the authors.
Rheumatologist are in an excellent position, writes Govil, to identify patients who may have been missed at the earliest stage of Lyme disease but are now exhibiting rheumatologic and/or neurologic symptoms.
“Preparedness can maximize favorable outcomes for [these] patients.”
“It can be difficult to diagnose a patient with neurologic Lyme disease. Therefore, it is important for a rheumatologist to initially gather a carefully elicited history from the patient.”
“When examining a patient with possible endemic area exposure to B. burgdorferi with rheumatologic complaints, it is important to consider Lyme disease and particularly neurologic Lyme disease as a possible diagnosis.”
When suspecting Lyme disease, keep in mind:
- Arthralgias is more common than arthritis
- Neurologic manifestations are far more frequent than arthritis
- Skin lesions most often do not have the classic Bull’s-eye appearance
- Neurologic involvement in Lyme disease is common
- Early identification and timely treatment are important
- Govil S, Capitle E, Lacqua A, Khianey R, Coyle PK, Schutzer SE. Common Neurologic Features of Lyme Disease That May Present to a Rheumatologist. Pathogens. Apr 9 2023;12(4)doi:10.3390/pathogens12040576
- Johnson KO, Nelder MP, Russell C, et al. Clinical manifestations of reported Lyme disease cases in Ontario, Canada: 2005-2014. PLoS One. 2018;13(6):e0198509. doi:10.1371/journal.pone.0198509