Lyme Arthritis Treatment After Knee Replacement

Lyme arthritis can mimic a prosthetic joint infection after knee replacement
Early diagnosis may prevent unnecessary revision surgery
This case highlights how antibiotics helped one patient avoid additional surgery

Lyme arthritis treatment after knee replacement can be challenging because Lyme disease may resemble a serious prosthetic joint infection. In this case, a 67-year-old man developed progressive knee swelling months after surgery and ultimately improved with antibiotics alone, avoiding additional orthopedic surgery.

Although this report describes a patient with a prosthetic knee, Lyme arthritis most commonly affects native knee joints and remains one of the most treatable manifestations of Lyme disease.

Doctors described a 67-year-old avid outdoorsman who received treatment for Lyme arthritis after having undergone knee surgery. Ten months earlier, the man had received a partial knee replacement of his left knee because of advanced single-compartment degenerative arthritis.

Over a 3-month period, the man developed progressive left knee pain and swelling. He later presented with a moderate joint effusion but did not have an erythema migrans rash, warmth, instability, or significant pain with range of motion.

There was no history of a tick bite or trauma to the knee, nor was there evidence of joint effusion before symptom onset, bacterial infection, or a Baker’s cyst.

Aspiration of the knee revealed turbid purulent pleocytosis with 91.8% neutrophils, elevated inflammatory markers, and a positive Borrelia burgdorferi polymerase chain reaction (PCR).

Serologic testing demonstrated an elevated erythrocyte sedimentation rate (ESR), C-reactive protein of 0.7 mg/dL, a positive B. burgdorferi antibody enzyme immunoassay (EIA), and reactivity to all 10 immunoglobulin G (IgG) Western blot bands.

Lyme arthritis diagnosis

Based on the detection of B. burgdorferi sensu stricto DNA by PCR, clinicians diagnosed Lyme arthritis involving a prosthetic knee joint, an unusual form of periprosthetic joint infection (PJI).

The diagnosis was based on criteria established by the Musculoskeletal Infection Society and the Infectious Diseases Society of America (IDSA).

“Although there was no communicating sinus tract or direct result from traditional microbiological culture, our patient met these criterion for PJI based upon elevated synovial fluid leukocyte count (>3000 cell/µL), elevated synovial neutrophil count (>65%), purulence, and evidence of a microorganism with identification to the level of genus and species,” according to Wright and colleagues from the Division of Infectious Disease, Department of Medicine, Memorial Medical Center in York, Pennsylvania.

The authors emphasized the seriousness of prosthetic joint infections.

“Periprosthetic joint infection is a devastating complication following joint arthroplasty that causes significant morbidity with an estimated cumulative incidence of 1% to 2% for both hips and knees.”

Can Lyme disease cause knee swelling after surgery?

Yes. Lyme disease can occasionally present with a swollen knee months after orthopedic surgery, making it difficult to distinguish from a prosthetic joint infection caused by more common bacteria. Patients may have a large joint effusion with surprisingly little pain, warmth, or fever. In endemic areas, Lyme disease should remain part of the differential diagnosis when routine cultures are negative or the clinical picture is atypical.

Lyme arthritis most commonly affects the knee and often produces significant swelling due to inflammation within the joint. PCR testing of synovial fluid, together with Lyme serology, can help establish the diagnosis in appropriate clinical settings.

IDSA treatment guidelines not directly applicable

Wright and colleagues concluded that standard Lyme arthritis recommendations did not completely apply to this patient because of the presence of a prosthetic joint.

They cited recommendations noting that:

1. Late Lyme arthritis can usually be treated successfully with oral doxycycline, amoxicillin, or cefuroxime for 28 days in patients without neurologic disease.
2. Previous studies have demonstrated the effectiveness of intravenous ceftriaxone 2 grams daily for 14 to 28 days in selected patients with late Lyme disease.

Management of Lyme arthritis should be individualized. While many patients improve with oral antibiotic therapy, intravenous ceftriaxone may be appropriate in selected clinical situations. In this case, the presence of a prosthetic knee joint made treatment decisions more complex than those encountered in typical Lyme arthritis.

Successful treatment with antibiotics

The patient initially received doxycycline 100 mg twice daily while awaiting confirmation of the diagnosis. After Lyme disease was confirmed, treatment was changed to intravenous ceftriaxone 2 grams daily for six weeks.

The outcome was favorable.

“Clinically, the patient had cessation of his knee pain, resolution of joint effusion, normalization of synovial infection and inflammatory parameters, and negative end-of-therapy detection of B. burgdorferi DNA by PCR.”

The authors cautioned, however, that this approach should not automatically be generalized to every patient with an infected prosthetic joint.

“Although this patient’s clinical outcome was achieved without the need for surgical incision and drainage or staged excision arthroplasty procedure, it is unclear whether this same strategy would produce similar results in patients with other types of joint arthroplasties.”

Can Lyme arthritis be cured with antibiotics?

Most patients with Lyme arthritis improve with appropriate antibiotic treatment. While many patients respond to oral antibiotics, intravenous ceftriaxone may be appropriate in selected clinical situations. Persistent joint inflammation can occasionally remain after the infection has resolved, requiring additional evaluation and management. This unusual case suggests that prompt recognition of Lyme disease may occasionally help patients with prosthetic joints avoid additional surgery. Because this is a single case report, larger studies are needed before similar treatment strategies can be recommended routinely.

Authors’ conclusion

“This case highlights how early prompt diagnosis and adequate antimicrobial therapy may obviate the need for additional aggressive orthopedic surgical intervention.”

“This case also highlights the value of an aggressive need to further investigate and interpret unexpected findings in clinical practice.”

Clinical Perspective

In my practice, patients are occasionally referred after knee replacement because persistent swelling is assumed to represent mechanical failure or a typical bacterial prosthetic joint infection. Lyme disease may not initially be considered, particularly when there is no recalled tick bite or erythema migrans rash. In endemic regions, Lyme disease should remain in the differential diagnosis for an unexplained swollen knee after surgery, especially when routine cultures are negative or the clinical presentation is atypical.

Because Lyme arthritis can resemble septic arthritis or mechanical failure of a joint replacement, collaboration between orthopedic surgeons, rheumatologists, and clinicians experienced in Lyme disease may improve diagnostic accuracy. Early recognition may allow appropriate antibiotic treatment and, in selected cases, help patients avoid unnecessary orthopedic procedures.

Frequently Asked Questions

Can Lyme disease cause knee swelling after knee replacement?

Yes. Although uncommon, Lyme arthritis can develop after knee replacement and mimic a prosthetic joint infection. Patients may develop significant swelling and joint fluid with relatively little pain or fever. In areas where Lyme disease is common, testing should be considered when routine cultures are negative or the clinical picture is unusual.

Can Lyme arthritis be cured?

Most patients recover with appropriate antibiotic treatment, although swelling may take weeks or months to completely resolve. A small proportion of patients develop persistent post-infectious inflammatory arthritis that requires a different treatment approach. Early diagnosis generally improves the likelihood of a favorable outcome.

How long does Lyme arthritis last?

Joint swelling often improves over weeks to months after treatment, although recovery varies. Some patients experience persistent inflammation despite successful elimination of the infection, while others recover completely with antibiotics alone.

Can Lyme disease affect an artificial knee?

Yes, but it is rare. This case illustrates that Borrelia burgdorferi can involve a prosthetic knee joint and resemble a bacterial prosthetic joint infection. Prompt diagnosis may allow treatment before more invasive surgery becomes necessary.

Clinical Takeaway

Lyme arthritis should remain in the differential diagnosis for patients who develop an unexplained swollen knee after joint replacement, particularly in regions where Lyme disease is endemic. Careful clinical evaluation, Lyme serology, and synovial fluid testing may identify patients whose symptoms are due to Borrelia burgdorferi rather than a typical bacterial prosthetic joint infection.

Early recognition and individualized management may help selected patients avoid unnecessary revision surgery while preserving joint function.

Related Articles

Learn more about Lyme arthritis, diagnosis, and treatment:

5 cases of Lyme arthritis following an operation
Will steroid injections help children with Lyme arthritis of the knee?
Preventing unnecessary surgery for children with Lyme arthritis
Lyme arthritis treatment
Delayed Lyme disease diagnosis

References

1. Wright WF, Oliverio JA. First Case of Lyme Arthritis Involving a Prosthetic Knee Joint. Open Forum Infect Dis. 2016;3(2):ofw096.
2. Cohen JR, Bradley AT, Lieberman JR. Preoperative Interventions and Charges Before Total Knee Arthroplasty. J Arthroplasty. 2016.
3. Fallon BA, Keilp JG, Corbera KM, et al. A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy. Neurology. 2008;70(13):992-1003.
4. Cameron DJ. Consequences of treatment delay in Lyme disease. J Eval Clin Pract. 2007;13(3):470-472.
5. Steere AC, Strle F, Wormser GP, et al. Lyme borreliosis. Nat Rev Dis Primers. 2016;2:16090.
6. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis. 2021;72(1):e1-e48.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention