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The most common late-stage symptoms are pauciarticular arthritis affecting large joints, especially the knees, which may manifest weeks to months (mean four months) after the tick bite.

Arthritis can occur without a history of earlier stages of illness.

Source: Dr L Robbin Lindsay, Research Scientist, Field Studies (for the Public Health Agency of Canada’s Lyme Disease Surveillance Group).

EM Erythema migrans; Ig Immunoglobulin Reproduced from reference 14 with permission from the American Society for Microbiology.

There can be either a single erythema migrans rash or multiple rashes without extracutaneous manifestations.

However, fever, malaise, headache, mild neck stiffness, myalgia and arthralgia often accompany EM.

Figure 1) The life cycle of black-legged ticks and Lyme disease.

Reproduced with permission from the United States Centers for Disease Control and Prevention (Atlanta, USA): gov/ticks/life_cycle_and_Black-legged tick populations are well established in parts of British Columbia, Manitoba, Ontario, Quebec, New Brunswick and Nova Scotia, and may be expanding.

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Macrolides (azithromycin, clarithromycin and erythromycin) have lower efficacy.Two-tiered testing is necessary because the ELISA may yield false-positive results from antibodies directed against other spirochetes, viral infections or autoimmune diseases.Figure 5) Two-tiered serological testing for Lyme disease.EM is usually asymptomatic (although it may produce a burning sensation) but is not painful to the touch, like a cellulitis.EM can be confused with a localized hypersensitivity reaction from a tick or insect bite, which is usually swollen, smaller in size and pruritic).

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