Answer: D - Stage I Lyme disease begins with a rash at the bite within 2 to 30 days. Then the patient develops Flu-like symptoms that last 7 to 10 days and may reoccur at a later date. Neurological symptoms occur in stage II, and arthralgias and inflamed joints occur in stage III.
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For reference, the NIH says
Lyme is classified into 3 stages: localized, disseminated, and persistent.
The first two stages are part of early infection and the third stage is part of persistent or chronic disease. Stage 3 usually occurs within 12 months of the infection.
Stage 1: Early localized disease that may present with erythema migrans and alow grade fever. This stage usually occurs within 1-28 days following the tick bite.
The classic rash is seen in 70% of patients and may develop between 5-7 days following the tick bite. The uniform rash usually occurs at the site of the tick bite, may burn, itch or be asymptomatic. The rash tends to expand for a few days and concentric rings may be visible. If left untreated, the rash persists for 2-3 weeks. About 20% may have recurrent episodes of the rash and multiple lesions are not uncommon. At the same time, flu-like symptoms may be present. The fever is low grade and may be associated with myalgia, neck stiffness, and headache. Visual problems include eye redness and tearing. About 30% of patients with the rash will have no further progression of symptoms
Stage 2: Usually develops 3-12 weeks after the initial infection. Features may include general malaise, fever, neurological features (dizziness, headache), muscle pain, and cardiac symptoms (chest pain, palpitations, and dyspnea). Cranial neuropathy may present as diplopia. Eye pain and keratitis have also been reported. The knee, ankle, and wrist joints are often involved. These symptoms may last 12-20 weeks, but recurrence is rare. Often when a single joint is involved, it may be mistaken for septic arthritis. About 20% of patients have CNS involvement including encephalopathy, meningitis, and cranial nerve neuropathy. Bell palsy is seen in about 5% of patients. When meningeal symptoms are present, a lumbar puncture is warranted to rule out other causes. Encephalopathy presents with deficits in concentration, cognition, memory loss, and changes in personality. Extreme irritability and depression are also common.
Borrelia lymphocytoma is a rare presentation of early Lyme disease that has been reported in Europe. It presents as a nodular red-bluish swelling that usually occurs on the ear lobe or areola of the nipple. The lesions can be painful to touch.
Stage 3: Late Lyme disease may occur many months or years after the initial infection. The typical features include neurological and rheumatological involvement. Many patients may not have a history of erythema migrans. However, these individuals may present with aseptic meningitis, Bell palsy, arthritis, or dysesthesias. Cognitive deficits are common. The key feature of late-stage Lyme is arthritis which tends to affect the knee. the neurological and psychiatric symptoms mimic fibromyalgia. Radicular pain is common. Borrelia encephalomyelitis is rare and can present with ataxia, seizures, hemiparesis, autonomic dysfunction, and hearing loss. Acrodermatitis chronica atrophicans is typically seen in older women and tends to occur on the dorsum of the hands and feet.
