in terms of the clinical manifestations really the most common is the erythema migrants rash uh which is seen in 70 of patients followed by arthritis and then some of the neurologic complications like uh facial falsies neuropathy and meningitis carditis is fairly uncommon but we do see it and it's important to to look for it so in the early uh phase of lyme disease really we're looking at flu-like symptoms so somebody who comes in with you know fevers chills fatigue muscle joint aches um after a tick bite especially in the spring and summer months we really do want to think about lyme disease um erythema migrants is considered patho mnemonic for lyme disease however i want to point out some some exceptions so not everybody who has lyme disease will have an erythema migrans rash or a rash at all it's typically described as a target or bullseye lesion but sometimes the rashes don't look that way some of the good characteristics to keep in mind uh to differentiate them from other things is that they're usually not itchy or painful it's it's pretty much a rule if the lesion is less than five centimeters in size it's not going to be related to lyme disease so it's more likely to be a bug bite or something like this but almost all of the lime rashes are greater than five centimeters in size so that's a very uh important feature it's also uh important if you see somebody early on in disease they may have a small lesion but it may expand over uh the next couple of days so it's always important to tell patients you know if if your lesion is expanding please let us know so this just shows you um various patients who have differing uh rashes related to a lyme disease so the first one is the classic target or bullseye lesion um where you see like the central red area and then a clearing and then another ring here's uh other ones so this one has irregular borders and kind of a central kind of area there this is a patient who has disseminated uh erythema migraines but you can see that she has a bluish kind of hue in the in the center sometimes you won't see anything in the middle you'll just see a clearing and then you'll see this ring but by far the most common is this last one where you have this uh slightly raised um oval uh confluent erythema that's the most common rash that's seen with lyme disease so important to just be aware of it because so many of the lyme diagnosis really come from the em rash this is a rash that is uh related to a another tick-borne illness called starry or southern tick associated rash illness and it can have a central clearing just like lyme disease so it's important to keep this in mind you may have patients who report a tick bite and then have a lime appearing rash so again it's called southern tick associated rash illness the bacteria or the agent that causes it causes it is unknown uh typically patients just get the early symptoms so they can get rash fever myalgia's fatigue but they typically don't go on to go on to have arthritis neurologic disease or chronic symptoms it's associated with this lone star tick and sometimes patients can tell you yes i pulled up a tickets bigger than the sodius scapularis tick and it has this distinctive white dot on its back so we talked about early lyme disease now just the manifestations for early disseminated disease which can happen weeks to months so for the neurologic manifestations they're going to have they're going to occur in 15 of patients who are untreated and they present typically with meningitis cranial palsies or or some kind of radiculopathy a bilateral cranial uh nerve palsy very few things do that and one of them is lyme disease so if you see this in the summer it lyme disease should be very high up on the uh differential in terms of cardiac manifestations that most commonly varying degrees of av block um and sometimes you can't also see ocular manifestations but this is uh not as common the late late disease can happen months to years after the initial infection and uh about 50 to 60 percent of people who don't get treated with that have lyme disease will go on to develop this late uh lyme arthritis and of the folks that are treated about 10 will have persistent arthritic symptoms despite getting one or two courses of antibiotic therapy so this is one of the primary reasons why we treat lyme disease uh is is to prevent this from happening so it's sometimes people will worry about the neurologic manifestations they're somewhat rare to see um and uh so the and the clinical diagnosis can be difficult so it's uh it's it's a little bit hard sometimes to really distinguish many patients will come thinking that they have late neurologic lyme disease but again it's fairly rare and um it's just fairly rare to see this