The early symptoms of LD can be mild and easily overlooked. People who are aware of the risk of LD in their communities and who do not ignore the sometimes subtle early symptoms are most likely to seek medical attention and treatment early enough to be assured of a full recovery. The first symptom is usually an expanding rash (called erythema migrans, or EM, in medical terms) which is thought to occur in 80% to 90% of all LD cases. An EM rash generally has the following characteristics: • Usually (but not always) radiates from the site of the tickbite • Appears either as a solid red expanding rash or blotch, OR a central spot surrounded by clear skin that is in turn ringed by an expanding red rash (looks like a bull’s-eye) • Appears an average of 1 to 2 weeks (range = 3 to 30 days) after disease transmission • Has an average diameter of 5 to 6 inches • (range = 2 inches to 2 feet) • Persists for about 3 to 5 weeks • May or may not be warm to the touch • Is usually not painful or itchy EM rashes appearing on brown-skinned or sun-tanned patients may be more difficult to identify because of decreased contrast between light-skinned tones and the red rash. A dark, bruise-like appearance is more common on dark-skinned patients. Other symptoms such as joint pains, chills, fever, and fatigue are common, but they may not seem serious enough. As the LD spirochete continues spreading through the body, a number of other symptoms including severe fatigue, a stiff, aching neck, and peripheral nervous systems (PNS) involvement such as tingling or numbness in the extremities or facial palsy (paralysis) can occur. LD has 3 stages. Following are the symptoms according to the stages of LD- Localized Early (Acute) Stage: • Solid red or bull’s-eye rash, usually at site of bite • Swelling of lymph glands near the tick bite • Generalized achiness • Headache Early Disseminated Stage: • Two or more rashes not at site of the bite • Migrating pains in joints/tendons • Headache • Stiff, aching neck • Facial palsy (facial paralysis similar to Bell’s palsy) • Tingling or numbness in extremities • Multiple enlarged lymph glands • Abnormal pulse • Sore throat • Changes in vision • Fever of 100 to 102 F • Severe fatigue Late Stage: • Arthritis (pain/swelling) of one or two large joints • Disabling neurological disorders (disorientation; confusion; dizziness; short-term memory loss; inability to concentrate, finish sentences or follow conversations; mental “fog”) • Numbness in arms/hands or legs/feet Complications Associated with Lyme Disease • Meningitis is characterized by headaches that fluctuate in intensity from mild to severe with or without associated nausea, vomiting, light sensitivity, neck stiffness, or pain on eye movement. • Encephalitis is commonly accompanied by sleepiness, mood swings and irritability, atypical spontaneous tearfulness or personality change, cognitive problems (typically with word-finding problems, memory loss, slowed mental speed), balance problems, and sensory hyperarousal (e.g., vision, hearing). • Cranial neuritis – CN VII Palsy (facial nerve weakness) is a form of cranial neuritis that is thought by many physicians to be common, however, studies suggest that it may be seen in as few as 10% of patients with neurologic Lyme disease. However, in a patient from a Lyme endemic area or in an individual who has previously visited a Lyme endemic area, a presentation of a facial nerve palsy should lead the physician to test for Lyme disease. • Radiculoneuritis – When the infection in Lyme disease affects the nerve roots, it is called radiculoneuropathy. • Encephalopathy – Patients may develop cognitive problems from Lyme disease either early or many months or years after the initial infection. The cognitive problems most commonly include problems with short- term memory, problems with verbal fluency such as in name or word retrieval, and problems with slower speed of thinking. • Neuropsychiatric Lyme Disease – Neuropsychiatric symptoms can emerge either early or late in the disseminated phase of infection. These symptoms commonly appear as cognitive symptoms and as irritability, easy tearfulness, anxiety, and depression. Rarely, patients with undetected Lyme disease may present with obsessive-compulsive disorder, paranoia, auditory/visual hallucinations, or full-blown mania.