Healthy Living

Rheumatoid Arthritis After Lyme Disease

Rheumatoid Arthritis After Lyme Disease: How Common Is It?

It is not uncommon for those who have had Lyme disease to develop joint problems under the umbrella of refractory Lyme arthritis; however, researchers are urging to look further into the diagnosis, as it may be something else.

Refractory Lyme vs. rheumatoid arthritis

When you go to your doctor and explain that you're having problems with your joints, and that you have had Lyme disease in the past, they likely will not skip a beat before informing you of your refractory Lyme arthritis. However, researchers are discovering that, while sometimes the case, that diagnosis is not always true. Their studies have shown that rheumatoid arthritis sometimes occurs after one has Lyme disease, but is completely different from refractory Lyme arthritis. Therefore, it is important to ensure the correct diagnosis is attained.

Sheila Arvikar, M.D. is a rheumatologist at Massachusetts General Hospital, and she explains, "making the distinction isn't always easy."

Arvikar, along with her colleagues, recently headed a retrospective study of patients who had been referred to the Lyme arthritis clinic at the hospital between 2003 and 2015. What they found was that 30 patients actually had a type of systemic autoimmune joint disease instead of the Lyme arthritis that they had been referred to the clinic for. Clearly, this pattern of misdiagnosis was common enough to be a bit of an issue.

In the study, when the researchers compared the patients who had been misdiagnosed to those who actually had Lyme arthritis, they found that the group was older and at a higher likelihood of showing early symptoms of Lyme disease. They also found that the group had an increased likelihood of a family history of autoimmune disorders.

Lyme arthritis

So, what exactly is Lyme arthritis? How is it different from other types of arthritis?

People began being aware of Lyme arthritis in the 1970s, and it has been found that over half (around 60 percent) of those who experience Lyme disease but forego antibiotic treatment will be plagued with Lyme arthritis. When people undergo treatment for the Lyme disease (usually tick-borne Borrelia burgdorferi), curing the Lyme disease tends to also end the Lyme arthritis. While this is the case for most, some will still suffer from Lyme arthritis and require treatment after curing the Lyme disease, often via anti-inflammatories.

Dr. Arvikar and her teammates have found that antibiotic-refractory Lyme arthritis has an autoimmune component that is closely entwined with the dysregulation of the CD4+ T effector/T regulatory ratio. However, Lyme arthritis does not usually expand to multiple joints like other types of arthritis. Usually, one joint will be impacted (often the knee), and only requires a treatment that is relatively short term, whereas rheumatoid arthritis takes time to cope with, as it is an autoimmune disease

RA after Lyme disease

Unfortunately, there is only very limited information regarding having rheumatoid arthritis after one has been through Lyme disease, as many assume it is simply Lyme arthritis and look no further. However, there was one study that took place in 1989 and found that "of 51 patients with reactive arthritis tested, 9 had antibodies for B. burgdorferi infection, indicating past Lyme." What this implies is that B. burgdorferi might be capable of acting as a trigger for autoimmunity like some other infections; however, since that study was published no further information has been put forth to bolster the argument. Therefore, the link remains unproven and relatively unsupported.

Dr. Arvikar commented, and stated that there is a possibility that diagnoses of autoimmune disorders in those who have already experienced Lyme could be nothing more than a coincidence; however, she states that the median amount of time in autoimmune patients at Mass General clinic from the initial point of Lyme infection to new-onset joint symptoms was four months, which is not very different to the amount of time it takes to develop Lyme arthritis. As a result, Arvikar and her team think that there is potential that a connection exists.

Because the amount of time each takes to develop is so similar, and that the symptoms can almost appear identical, misdiagnosis can easily happen. Therefore, they wanted to study these patients to aid in a more accurate system of referrals to the Lyme arthritis clinic because if the patients actually have any other types of arthritis (rheumatoid, psoriatic, spondylo) then they should be seeking an alternative form of treatment that will be more effective for them.

Arvikar explains, "it seemed like they were suspected to continue to have Lyme disease or Lyme arthritis, so they kept being treated for those conditions rather than the appropriate treatment for the new type of arthritis."

The study

By comparing 30 patients who had been diagnosed with non-Lyme arthritic disorders to 43 who were enrolled in an arthritis cohort study, Arvikar's team was able to find 15 cases of rheumatoid arthritis, 13 cases of psoriatic arthritis, and 2 of spondyloarthritis and in the Lyme arthritis, the patients were older with a median age of 55 instead of the former's 44. Their body mass indexes were also higher, which references that their known risk factors for obesity were certainly higher as well - which connects to their risk for autoimmune disorders such as psoriatic arthritis. The non-Lyme autoimmune patients were also at a higher risk for a first-order relative to have another non-Lyme autoimmune disorder.

Those who were subsequently diagnosed with an autoimmune disorder (not include Lyme arthritis) were at a higher likelihood to display signs of Lyme disease, such as the common "bull's eye" rash, and symptoms similar to those experienced during bouts of the flu. Those who had been diagnosed with Lyme arthritis were not as likely to display these types of symptoms. As a result, it is possible that Lyme arthritis is simply a consequence of an untreated disease, as mentioned by Dr. Arvikar. Because Lyme disease is becoming more commonly known, and more people experience it at some point in their lives, those who display symptoms early into the infection are more likely to be able to treat it before allowing it to get to the stage where Lyme arthritis would become a possibility.

Changing diagnoses

So, clearly if there are so many misdiagnoses, something needs to change. But how does one best make these alterations? Dr. Arvikar explained that it is important to look into three differentiations of the possibilities. These are active joint infection, post-infectious Lyme arthritis, and secondary inflammatory arthritis emerging post-Lyme. An active joint infection is able to be treated by antibiotics and post-infectious Lyme arthritis requires anti-inflammatories should antibiotic treatment not sufficiently relieve symptoms.

It is also important to look into the family history regarding autoimmune disorders, body mass indexes, age, and more, to assess the possibility of rheumatoid arthritis instead of Lyme arthritis. Arvikar points out that it is important for doctors to check on multiple joint involvement, as this is a major difference between Lyme and rheumatoid arthritis. Presence or absence of skin psoriasis, blood tests, testing for Lyme antibodies, and more can also be indicators.

She also points out that doctors may need to consider a potential relationship between Lyme and other autoimmune diseases that occur later.