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Lyme disease, which is epidemic in certain communities, primarily in the northeastern United States, is caused by the tick-borne spirochete Borrelia burgdorferi (also called Borreliella burgdorferi). When untreated, the disease usually occurs in stages with different manifestations at each stage (1). In the northeastern United States, the infection usually begins with a slowly expanding skin lesion, erythema migrans (stage 1), often accompanied by nonspecific symptoms, including headache, myalgias, arthralgias, fever, malaise, and fatigue. Within weeks (stage 2), neurologic or cardiac abnormalities may develop. Months later (stage 3), usually following a latent period, intermittent or persistent monoarticular or oligoarticular arthritis commonly develops, lasting for several years, accompanied by minimal, if any, systemic symptoms. Rarely, patients have late neurologic involvement, characterized by a subtle encephalopathy or sensory polyneuropathy. Thus, in most patients, the natural history of Lyme disease, without treatment, is one of persistent infection for several years, with latent periods and changing system involvement. Treatment and ongoing disease manifestations Depending on the disease manifestation, the infection can usually be treated successfully with 2–4 weeks of oral antibiotic therapy. However, arthritis, a late disease manifestation, can be more difficult to treat. We start with oral antibiotic therapy, usually doxycycline, for 30 days (2). If patients have minimal or no response, we treat with IV antibiotics, usually ceftriaxone, for another month, and in [...] Viewpoint

Posttreatment Lyme disease syndromes: distinct pathogenesis caused by maladaptive host responses