Borrelia infection and Rheumatic disease 3.78/5 (18)

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Ticks in various stages By Alan R Walker - Own work, CC BY-SA 3.0,


Erythema migrans

Erythema migrans grow annularly. Moon S, 2013. CC BY NC 3.0

Borrelia infection, Lyme Borreliosis, Tick bite disease ICD-10; A69.2


Borrelia infection (Borreliosis) is due to infection with the bacterium Borrelia burgdorferi which is transmitted by bit by ticks. Both children and adults can be attacked, but only a small proportion (about 2%) of those who are bitten become ill.

Borrelia infection is distinguished from infection with TBE ("Tick Born Encephalitis") due to a virus that can also be transmitted by forest ticks. Towards TBE exists vaccine.


Forest ticks exists in Norway along the coast from Østfold to the Helgeland coast. The risk of infection depends on the proportion of Ixodes Ricinus which contain Borrelia bacterium in it. Infection has been found ranging from 1-2% to over 60% of the ticks. How long the tick gets sucked blood before it is removed is also important.


A tick that has sucked blood causes common itching, much like a mosquito bite. The itch continues a few days after the tick has been removed. If parts of the tick remain, the itching may continue.

Borrelia infection

Borrelia/Lyme disease

Borrelia infection with erythema migrans in 9 years old boy. Orczyk K, 2017. CC BY 4.0

Stadium 1

  • Erythema migrans is a rash that occurs in approx. 80% within the first 1-4 weeks among those who get borrelia infection. An annular rash grows from the site to several cm in diameter. The rash causes little trouble, fades and recedes by itself, but to prevent the risk of complications (see below), antibiotic therapy is important.
  • There are no special blood tests to detect infection at this early stage

Stage 2

  • Symptoms from joints, nerves or the heart may occur 1-3 months after the tick bite.
  • Blood, joint and / or spinal fluid samples show typical rashes.

Hovent right knee (arthritis) during borrelia infection. Stinco G, Ruscio, ScientificWorldJournal (2014). Open-in

Arthritis (arthritis)

Arthritis and joint pain is the most common complication at this stage (60%)

  • Borrelia arthritis most often occurs in one knee that feels stiff, swollen, and somewhat painful
  • The joint fluid is examined to ensure the diagnosis

Nervous system (neuroarrhythmia)

About 15% of those infected get symptoms from the nervous system at this stage. The symptoms occur weeks to months after the infection. New symptoms are usually evident. Nerves can be attacked so that numbness (early symptom) or pain is felt in the skin in certain areas.


Inflammation of the heart muscle (myocarditis) can be detected by dysrhythmia in ECG (AV block?) and special examinations are required

Chronic borrelia infection

Lyme disease: chronic atrophic dermatitis of the left foot. Stinco G, 2014. CC Openi

Stadium 3

Months to years after tick bite, chronic symptoms may occur if previous stages are not adequately treated. Most common is red-blue / violet, thin paper-like skin on the stretch side of arms or legs (Acrodermatitis chronica atroficans). For unknown reasons, women over the age of 40 get this most commonly. Often nerves in the same area are affected so that the area feels numb. Hard knots beneath the skin above the joints or above larger parts of the body (like at morfea) can also be seen.

  • Chronic arthritis, most often in the knee, can also be seen at this stage (about 10%)


The diagnosis of borrelia infection is based on typical symptoms of tick bite (see above). Blood sample and / or joint fluid with typical rash in borrelia antibody. However, these appear only after 6-XNUM weeks from being infected. B. burgdorferi DNA in synovial fluid is detected by «polymerase chain reaction »(PCR) and ensures the diagnosis. Other blood tests: CRP, sedimentation rate (ESR), CK and liver enzymes (AST, ALT) are slightly to moderate increased in some.

  • Up to 18% of healthy subjects have borrelia antibodies in blood (serum) and some also in spinal fluid, most often due to previous infection. This does not give symptoms and is not a treatment indication.

Unusual borrelia infection

Borrelia burgdorferi sensu lato is the most common borrelia bacterium that is transmitted via tick bites is (10-30%). Unusual borrelia infections are:

  • Candidatus Neoehrlichia mikurensis (2-17%)
  • Anaplasma phagocytophilum (0-4%)
  • Borrelia miyamoti is a rare bacterium (1%) that can also infect via tick bites, also in Norway. People with compromised immune systems (for example, using immunosuppressive agents against rheumatic disease) are most susceptible to infection. Symptoms of infection are milder and different. Infection with borrelia miyamoti is suspected to be one of the causes Recurrent fever syndrome
  • The infections can be treated effectively with antibiotics

Incorrect diagnosis (similar conditions / differential diagnoses)

Treatment (recommendations in Norway per 2017)

A forest tick should be removed from the skin as soon as it is detected. It should not be scraped or pinched, but pulled straight out, either with fingers or a special tweezers available at a pharmacy. A disinfectant cream (for example Brulidine) can be applied to the bite site.

  • Antibiotic tablets are not recommended for every tick bite.
  • However, if complications occur, an antibiotic must be given (see below)

Stadium 1

Uncomplicated erythema migrans

Antibiotics in tablet form for 10 to 14 days. In Norway, penicillin (For example, Phenoxymethylpenicillin for adults 1,3 g / 2 MIU x3 for 10-14 days) or amoxicillin is usually prescribed. For penicillin allergy, doxycycline 200mg x 1 for adults and azithromycin for children for 10-14 days are alternatives.

Stadium 2

More broad spectrum antibiotics are used, and the cure is stretched to 3 weeks. Also, this treatment leads to healing, but some may have a few ailments for longer periods of treatment.

Borrelia arthritis

  • In Norway, doxycycline tablets 200 mg x 1 are often given for three weeks

Carditis (Heart Inflammation)

  • Ceftiaxone iv 2 gx 1 for at least 14 days or doxycycline tablets 200 mg x 1 for at least 14 days is appropriate


  • Doxycycline 200mg x 1 for three weeks can be given


  • Several treatment options over 2-4 weeks, such as treatment with doxycycline tablets (200 mg x 1) or intravenous (iv) ceftriaxone (2g x 1), iv Penicillin (5 million IU x 4) or ivcefotaxime (2g x 3). In case of symptoms from the brain, iv ceftriaxone is often preferred.

Late Nevro Borreliosis

  • Three weeks of treatment with topical doxycycline (200 mg x 1) or iv ceftriaxone (2g x 1). For central nervous system symptoms, iv ceftriaxone (2g x 1) is often recommended.

Children with neuro-borreliosis

  • As in adults, however, the doses should be adjusted to weight. Doxycycline is contraindicated at age below 8 years.

Pregnancy and breast-feeding

Borrelia infection during pregnancy has not been shown to increase the risk of fetal injury if the disease is treated properly. Antibiotics are used with the exception of types that should not be used by pregnant women (eg doxycycline). Borrelia infection is not transmitted to children by breastfeeding.

Medical prognosis

An uncomplicated tick bite becomes symptom-free within a few days after the tick has been removed. After proper antibiotics, a possible borrelia infection is expected to pass without further complications.


  • There is no vaccine for Borrelia infection in Norway
  • Vaccine against encephalitis virus (TBE vaccine) that can also be transmitted by tick bite does not prevent borreliosis

Recommendations / guidelines

EULAR recommendations for early arthritis (Combe B, 2016).


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