A comprehensive clinical and laboratory evaluation of 224 patients with persistent symptoms attributed to presumed tick-bite exposure

PLoS One. 2021 Mar 18;16(3):e0247384. doi: 10.1371/journal.pone.0247384. eCollection 2021.


Background: Persistent symptoms attributed to presumed tick-bite exposure constitute an unresolved medical controversy. We evaluated whether Swedish adults who met the criteria for post-treatment Lyme disease syndrome (PTLDS) exhibited characteristics distinguishable from adults who did not, but who displayed similar symptoms and disease course after suspected previous tick-bite infection (TBI).

Methods and findings: During 2015-2018, 255 patients-referred to the Centre for Vector-borne Infections, Uppsala University Hospital, Sweden with symptoms lasting longer than six months-were recruited. Of this group, 224 completed the study. Each patient was examined by an infectious disease specialist and, besides a full medical history, underwent a panel of blood and cerebrospinal fluid laboratory tests including hematological, biochemical, microbiological and immunological analyses, and the RAND-36 scale to measure quality of life. For analysis purposes, patients were divided into five subgroups, of which one represented PTLDS. According to serological results indicating TBI and documented/ reported objective signs of Lyme disease, 85 (38%) patients fulfilled the criteria for PTLDS and were compared with the other 139 (62%) serologically classified patients. In the PTLDS group, erythema chronicum migrans (ECM) was documented/reported in 86% of patients, previous neuroborreliosis in 15%, and acrodermatitis chronica atroficans (ACA) in 3.5%. However, there were no significant differences regarding symptoms, laboratory results or disease course between patients with PTLDS and those without laboratory evidence of Borrelia exposition. Most reported symptoms were fatigue-related (70%), musculoskeletal (79%), neurological (82%) and neurocognitive (57%). Tick bites were recalled by 74%. The RAND-36 score was significantly below that of the general Swedish population. Signs of immunological/inflammatory reactivity with myositis antibodies were detected in 20% of patients, fibrinogen levels were moderately increased in 21% and elevated rheumatoid factor in 6%.

Conclusions: The PTLDS group did not differ exclusively in any respect from the other subgroups, which either lacked previously documented/reported evidence of borreliosis or even lacked detectable serological signs of exposure to Lyme disease. The results suggest that symptoms often categorized as Chronic-Lyme-Disease (CLD) in the general debate, cannot be uniquely linked to Lyme disease. However, approximately 20% of the total group of patients showed signs of autoimmunity. Further studies are needed to elucidate the underlying causes and mechanisms of PTLDS and there is reason to consider a multifactorial approach.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acrodermatitis / diagnosis
  • Adult
  • Animals
  • Bites and Stings / complications
  • Erythema Chronicum Migrans / diagnosis
  • Fatigue / etiology
  • Female
  • Humans
  • Lyme Disease / diagnosis
  • Lyme Neuroborreliosis / diagnosis
  • Male
  • Middle Aged
  • Post-Lyme Disease Syndrome / metabolism
  • Post-Lyme Disease Syndrome / physiopathology*
  • Quality of Life
  • Sweden / epidemiology
  • Tick Bites / complications*
  • Tick Bites / epidemiology
  • Tick-Borne Diseases / epidemiology*
  • Ticks / microbiology

Grants and funding

This work was supported by Uppsala County Council, project grant 41403, 42309, 1040311, held by BO, KN and AM respectively The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.