Lyme disease in adolescents doesn’t always start with the classic bull’s-eye rash. Rashes can appear as solid red patches or unusual shapes, sometimes mistaken for spider bites, eczema, or skin infections. Teens may also show signs like fatigue, irritability, headaches, or limb pain. Because symptoms vary so much, misdiagnosis is common. That’s why healthcare providers play a crucial role in asking about outdoor activities, pets, or possible tick exposure — and in starting treatment promptly when Lyme is suspected.

Patient Story 1: Early Recognition Prevented a Missed Diagnosis

One of my patients, a 15-year-old girl, was brought in after her parents noticed an unusual rash on her leg along with persistent fatigue. The rash wasn’t the textbook bull’s-eye but rather a solid red patch. Because I suspected Lyme early, we began antibiotics immediately instead of waiting for blood test confirmation.

Within days, her fatigue improved, and over the following months with careful follow-up, she was able to return to school full-time. Today, she is thriving — a clear example of how early recognition and prompt treatment can prevent further complications.

Patient Story 2: When Retreatment Caught What Could Have Been Missed

Another patient, a 16-year-old boy, initially improved after a standard antibiotic course for Lyme arthritis. But several weeks later, he returned with recurring joint pain and new headaches that interfered with school. Instead of dismissing these symptoms as stress or growing pains, we re-assessed his case and with re-treatment, his symptoms gradually resolved.

This case shows why ongoing monitoring is essential. Some adolescents may require re-treatment.

Patient Story 3: Missed Early Signs, Later Nervous System Involvement

A 17-year-old girl came to my practice after months of worsening dizziness, headaches, and abdominal pain. She had already been evaluated by cardiology and gastroenterology, where she was diagnosed with POTS and possible gastroparesis. But no one had considered that an earlier untreated tick bite could be driving these problems.

When we revisited her history, it became clear that a summer rash had been dismissed as “ringworm.” Testing and a careful clinical evaluation pointed to Lyme disease as the underlying cause. Treatment brought her some stability, but she continues to need support for ongoing autonomic issues.

Her story shows how Lyme disease in teens can be overlooked when symptoms go beyond fatigue or joint pain. In some cases, it appears as neurological or digestive problems that even experienced specialists may not immediately connect to Lyme.

Complex Presentations

Not every teen presents with joint pain or a rash. Some develop complex, systemic symptoms that can puzzle even experienced clinicians. These may include:

1. PANS (Pediatric Acute-onset Neuropsychiatric Syndrome): Sudden onset of obsessive-compulsive behaviors, tics, or mood changes triggered by various infections and immune activation.

2. POTS (Postural Orthostatic Tachycardia Syndrome): Dizziness, palpitations, and fainting spells in teens after Lyme, reflecting autonomic dysfunction.

3. Gastroparesis and GI dysmotility: Severe nausea, early satiety, or abdominal pain that interferes with nutrition. Case reports describe intestinal pseudo-obstruction associated with Lyme.

4. Other autonomic dysfunctions: Temperature regulation issues, bladder frequency, and sleep disturbance have also been reported in adolescents.

These examples highlight why complications of Lyme in adolescents are rarely one-dimensional.

Providers must think beyond “joint swelling” and consider infection-driven immune and autonomic disruption.

Supporting Families

Managing Lyme disease symptoms in adolescents requires more than prescribing medication. Providers need to:

1. Validate ongoing symptoms rather than attributing them to stress or anxiety

2. Reassess for relapse or co-infections if symptoms return after treatment

3. Monitor school performance, growth, and development, as brain fog, fatigue, or POTS can interfere with learning

4. Provide prevention counseling including daily tick checks, repellents, and protective clothing

Final Word

Lyme disease symptoms in adolescents can be missed if providers only look for a bull’s-eye rash or swollen joints. Some patients improve quickly with early antibiotics, while others develop complex conditions like PANS, POTS, autonomic dysfunction, or gastroparesis that require long-term monitoring.

The stories of my adolescent patients illustrate both ends of the spectrum: one teen who recovered quickly with early care, another who needed retreatment after relapse, and a third whose autonomic dysfunction was missed until later.

Both early recognition and careful follow-up are key to helping adolescents with Lyme disease regain their quality of life.

Resources

1. 1. 1. Neuropsychiatric Presentations
      2. POTS : An autonomic disorder in Lyme disease patients
      3. Management of Pediatric Lyme Disease: Updates From 2020 Lyme Guidelines