Intended for healthcare professionals

Clinical Review State of the Art Review

Lyme borreliosis: diagnosis and management

BMJ 2020; 369 doi: (Published 26 May 2020) Cite this as: BMJ 2020;369:m1041
  1. Bart Jan Kullberg, professor of internal medicine and infectious diseases1,
  2. Hedwig D Vrijmoeth, Lyme disease project leader and, consultant1,
  3. Freek van de Schoor, Lyme disease project leader and consultant1,
  4. Joppe W Hovius, professor in vector-borne infections and head2
  1. 1Department of Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
  2. 2Amsterdam University Medical Centers, location AMC, Department of Medicine, Division of Infectious Diseases, and Amsterdam Multidisciplinary Lyme borreliosis Center, Amsterdam, Netherlands
  1. Correspondence to BJ Kullberg BJ.Kullberg{at}


Lyme borreliosis is the most common vectorborne disease in the northern hemisphere. It usually begins with erythema migrans; early disseminated infection particularly causes multiple erythema migrans or neurologic disease, and late manifestations predominantly include arthritis in North America, and acrodermatitis chronica atrophicans (ACA) in Europe. Diagnosis of Lyme borreliosis is based on characteristic clinical signs and symptoms, complemented by serological confirmation of infection once an antibody response has been mounted. Manifestations usually respond to appropriate antibiotic regimens, but the disease can be followed by sequelae, such as immune arthritis or residual damage to affected tissues. A subset of individuals reports persistent symptoms, including fatigue, pain, arthralgia, and neurocognitive symptoms, which in some people are severe enough to fulfil the criteria for post-treatment Lyme disease syndrome. The reported prevalence of such persistent symptoms following antimicrobial treatment varies considerably, and its pathophysiology is unclear. Persistent active infection in humans has not been identified as a cause of this syndrome, and randomized treatment trials have invariably failed to show any benefit of prolonged antibiotic treatment. For prevention of Lyme borreliosis, post-exposure prophylaxis may be indicated in specific cases, and novel vaccine strategies are under development.


  • Acknowledgments: HV and FvdS are supported by the Netherlands Organization for Health Research and Development ZonMw; JWH is supported by the European Union INTERREG program, as part of the NorthTick project.

  • Contributors: HDV and FvdS performed the primary literature review for this manuscript. BJK wrote the sections on therapy, trials of prolonged therapy, and management of patients with persistent Lyme attributed symptoms. JWH wrote the sections on incidence and epidemiology, co-infections, prevention, and vaccination. FvdS wrote the section on clinical manifestations. FvdS and JWH wrote the section on laboratory support. HDV wrote the sections on chronic symptoms attributed to Lyme borreliosis and guidelines. BJK guided the writing of the full manuscript and assumed primary responsibility. All authors reviewed all sections of the manuscript, providing suggestions for included content and references, and approved the published version.

  • Competing interests We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Further details of The BMJ policy on financial interests are here:

  • Provenance and peer review: commissioned; externally peer reviewed.

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