How to treat borreliosis after a tick bite in adults?

Understanding Borreliosis (Lyme Disease)

What is Borreliosis?

Causative Agent and Transmission

Borrelia burgdorferi sensu lato complex comprises spirochetes that cause Lyme disease in humans. The most common pathogenic species are B. burgdorferi (North America), B. afzelii and B. garinii (Europe and Asia). These bacteria are thin, helically coiled organisms that penetrate host tissues through flagellar motility and express surface proteins enabling adherence to extracellular matrix components.

Transmission occurs exclusively through the bite of infected Ixodes ticks. Key vectors include:

Ixodes scapularis (eastern and north‑central United States)
Ixodes pacificus (western United States)
Ixodes ricinus (Europe)

Ticks acquire the spirochetes during larval or nymphal blood meals from reservoir hosts such as small mammals (e.g., white‑footed mice), birds, and certain reptiles. Infection of humans requires the tick to remain attached for typically ≥ 36 hours, allowing spirochetes to migrate from the midgut to the salivary glands and enter the host’s skin. After transmission, Borrelia disseminates via the bloodstream to skin, joints, nervous system, and cardiac tissue, establishing the clinical spectrum addressed in therapeutic protocols.

Stages of Borreliosis

Borreliosis progresses through three clinically distinct stages, each associated with specific manifestations and therapeutic considerations.

The first stage appears within days to weeks after the tick attachment. Common signs include erythema migrans, flu‑like symptoms, and occasional headache. Oral doxycycline for 10–21 days is the preferred regimen; alternatives such as amoxicillin or cefuroxime may be used in patients with contraindications to tetracyclines. Prompt initiation at this point prevents bacterial spread and reduces the risk of later complications.

The second stage emerges weeks to months after the bite and reflects hematogenous dissemination. Typical presentations comprise multiple erythema migrans lesions, cranial nerve palsies (especially facial), cardiac involvement (e.g., atrioventricular block), and migratory arthralgias. Intravenous ceftriaxone for 14–28 days is recommended for neurologic or cardiac manifestations; oral doxycycline remains appropriate for milder disseminated disease. Monitoring of cardiac rhythm and neurologic status is essential during therapy.

The third stage develops months to years later and represents chronic infection. Manifestations include persistent arthritis of large joints, neurocognitive deficits, and, rarely, chronic skin changes. Extended oral doxycycline (up to 28 days) or a course of intravenous ceftriaxone may be required, followed by anti‑inflammatory agents for arthritic symptoms. Re‑evaluation for co‑existing conditions and consideration of retreatment are advised when symptoms persist after initial therapy.

Key clinical features per stage:

Early localized: erythema migrans, fever, malaise.
Early disseminated: multiple skin lesions, facial palsy, myocarditis, migratory joint pain.
Late disseminated: chronic arthritis, neurocognitive impairment, persistent skin lesions.

Symptoms of Borreliosis in Adults

Early Localized Stage («Erythema Migrans»)

Early localized Lyme disease presents with a single erythema migrans lesion at the tick‑bite site, typically appearing within 3–30 days. The rash expands gradually, reaching 5–70 cm in diameter, and may be accompanied by flu‑like symptoms such as fever, headache, fatigue, and myalgia. Diagnosis relies on clinical recognition; serologic testing is often negative at this stage and therefore not required for initiating therapy.

First‑line oral regimens for adults include:

Doxycycline 100 mg twice daily for 14 days (preferred, also covers possible co‑infections).
Amoxicillin 500 mg three times daily for 14 days (alternative for doxycycline‑intolerant patients).
Cefuroxime axetil 500 mg twice daily for 14 days (alternative when amoxicillin is unsuitable).

If doxycycline is contraindicated due to pregnancy, lactation, or severe gastrointestinal intolerance, amoxicillin or cefuroxime should be used. Intravenous therapy is unnecessary in the early localized stage unless oral absorption is impossible.

Monitoring consists of:

Clinical assessment at the end of treatment to confirm rash resolution and symptom improvement.
Patient education on signs of disease progression (multiple erythema migrans, neurologic or cardiac manifestations) that require prompt reassessment.

Failure to respond within 2–3 weeks warrants repeat evaluation, possible extension of oral therapy, or escalation to intravenous ceftriaxone 2 g daily for 14–21 days. Evidence indicates that a 14‑day course of the recommended oral agents achieves cure rates exceeding 90 % when administered promptly after rash onset.

Early Disseminated Stage («Neurological and Cardiac Manifestations»)

The early disseminated phase of Lyme disease in adults often presents with neurological signs—such as facial palsy, meningitis, or radiculopathy—and cardiac involvement, most commonly atrioventricular block. Prompt antimicrobial therapy is essential to prevent permanent damage.

Antibiotic regimens

Doxycycline 100 mg orally twice daily for 14–21 days; preferred when meningitis is absent and the patient tolerates oral medication.
Intravenous ceftriaxone 2 g once daily for 14–28 days; indicated for meningitis, severe radiculopathy, or high‑grade cardiac block.
Intravenous cefotaxime 2 g three times daily for 14–28 days; an alternative to ceftriaxone when the latter is unavailable.
Oral cefuroxime axetil 500 mg twice daily for 14–21 days; acceptable for mild neurological symptoms without meningeal involvement.

Adjunctive measures

Cardiac monitoring with continuous ECG for any degree of AV block; temporary pacing considered for second‑ or third‑degree block persisting beyond 24 hours.
Analgesics for neuropathic pain; gabapentin or pregabalin can be used as needed.
Corticosteroids are not recommended as primary therapy; they may be employed only for severe inflammatory complications under specialist supervision.

Follow‑up

Neurological examination at 2‑week intervals until symptom resolution.
Repeat ECG after completion of intravenous therapy; longer surveillance for patients with documented conduction abnormalities.
Serologic testing is not useful for monitoring treatment response; clinical assessment remains the standard.

Effective management relies on selecting the appropriate antimicrobial route, ensuring adequate treatment duration, and providing vigilant cardiac and neurological surveillance throughout the course of therapy.

Late Disseminated Stage («Arthritis and Chronic Symptoms»)

Late disseminated Lyme disease in adults often manifests as persistent joint inflammation and systemic complaints that develop months after the initial bite. Diagnosis relies on a combination of clinical presentation, serologic confirmation of Borrelia burgdorferi infection, and imaging of affected joints when swelling is pronounced. Synovial fluid analysis may reveal elevated leukocytes and, occasionally, presence of spirochetes.

Standard antimicrobial therapy for arthritis and chronic symptoms consists of a 28‑day course of intravenous ceftriaxone (2 g daily) or, when intravenous access is impractical, oral doxycycline (100 mg twice daily) for the same duration. Alternative agents such as cefotaxime or penicillin G are acceptable if ceftriaxone is contraindicated. For patients who fail to improve after the initial regimen, a second 4‑week course of intravenous ceftriaxone is recommended, followed by oral doxycycline for an additional 4 weeks.

Adjunctive measures support recovery:

Non‑steroidal anti‑inflammatory drugs (ibuprofen, naproxen) to reduce pain and swelling.
Physical therapy focused on range‑of‑motion exercises and muscle strengthening.
Joint aspiration in cases of large effusions to relieve pressure and obtain diagnostic material.
Periodic assessment of inflammatory markers (CRP, ESR) and repeat serology to monitor treatment response.

Patients with refractory arthritis may benefit from a short trial of low‑dose corticosteroids, but long‑term steroid use is discouraged due to the risk of immune suppression. In rare instances of persistent symptoms despite adequate antibiotics, referral to a specialist in infectious disease or rheumatology is advised for evaluation of alternative diagnoses, such as post‑treatment Lyme disease syndrome.

Follow‑up visits should occur at 2‑week intervals during therapy, with clinical examination of joints and documentation of symptom trends. Completion of the full antibiotic course, combined with supportive care, yields the highest likelihood of symptom resolution and prevents further joint damage.

Diagnosis of Borreliosis After a Tick Bite

Clinical Evaluation

Clinical evaluation of suspected Lyme disease after a tick bite in an adult begins with a detailed exposure history. The clinician records the date of the bite, geographic region, estimated duration of tick attachment, and any previous prophylactic antibiotics. Symptoms such as fever, headache, fatigue, myalgias, arthralgias, or a skin lesion are documented, with particular attention to the appearance and timing of erythema migrans.

The physical examination focuses on:

Inspection of the bite site for erythema migrans or other cutaneous manifestations.
Neurological assessment for facial nerve palsy, meningitis signs, or radiculopathy.
Joint examination for swelling, warmth, or limited motion, especially in large joints.
Cardiovascular evaluation for conduction abnormalities or myocarditis, including auscultation and pulse assessment.

Laboratory testing is reserved for cases without a characteristic rash or when symptoms extend beyond the early localized stage. Recommended investigations include:

Two-tier serology: enzyme‑linked immunosorbent assay (ELISA) followed by a Western blot for confirmation.
Cerebrospinal fluid analysis when neuroborreliosis is suspected, assessing pleocytosis, protein elevation, and intrathecal antibody production.
Polymerase chain reaction (PCR) on synovial fluid or skin biopsy in selected chronic presentations.

Interpretation of serologic results must consider the stage of infection; early disease may yield false‑negative results, whereas late disease often shows IgG positivity. The clinician integrates history, physical findings, and laboratory data to confirm diagnosis, determine disease stage, and guide therapeutic decisions.

Laboratory Testing

Antibody Tests («ELISA and Western Blot»)

Antibody testing is a central component of the diagnostic work‑up for adult patients who develop Lyme disease after a tick bite. The two most widely used assays are the enzyme‑linked immunosorbent assay (ELISA) and the immunoblot (Western blot).

ELISA serves as the initial screen. It detects IgM and IgG antibodies against Borrelia burgdorferi antigens. Sensitivity rises after the first two weeks of infection; testing earlier may yield false‑negative results. Positive ELISA results require confirmation because cross‑reactivity with other spirochetes or viral infections can produce false positives.

Western blot provides that confirmation. Separate IgM and IgG blots are interpreted according to CDC criteria: IgM is considered positive when at least two of three specific bands (23 kDa, 39 kDa, 41 kDa) appear; IgG is positive when at least five of ten bands are present. IgM is reliable only within the first month of symptom onset; beyond that, IgG becomes the primary indicator.

Key considerations for clinicians:

Order ELISA no earlier than 2 weeks post‑exposure unless strong clinical suspicion justifies early testing.
If ELISA is negative but symptoms are acute and classic, repeat testing after 1–2 weeks.
Use Western blot to confirm any positive ELISA; do not rely on Western blot alone.
Recognize that serology may remain positive for months after successful treatment; a rising antibody titer is more informative than a single static result.
In cases of early localized disease (erythema migrans), treatment can commence without serologic confirmation.

Understanding the timing, interpretation, and limitations of ELISA and Western blot enables accurate identification of Borrelia infection and informs appropriate antimicrobial therapy in adult patients.

PCR Testing

Polymerase chain reaction (PCR) is the primary molecular method for detecting Borrelia DNA in clinical specimens after a tick bite in adult patients. The test confirms infection when serology is equivocal or when early dissemination is suspected.

Specimens: skin biopsy from erythema migrans, synovial fluid, cerebrospinal fluid, or whole blood.
Timing: optimal within the first few weeks of symptom onset; sensitivity declines after antimicrobial therapy.
Interpretation: a positive result indicates active infection; a negative result does not exclude disease, especially in later stages.
Limitations: false‑negative results may occur with low bacterial load; contamination can cause false positives; PCR does not provide antibiotic susceptibility data.

When PCR confirms Borrelia presence, the therapeutic regimen follows established guidelines for adult patients, typically doxycycline 100 mg twice daily for 14–21 days, or alternative agents for contraindications. PCR results also guide the decision to extend treatment in cases of persistent symptoms or neurologic involvement.

Treatment Approaches for Borreliosis in Adults

Antibiotic Therapy

Early Stage Treatment Protocols

Early Lyme disease in adults after a tick bite requires prompt antimicrobial therapy to prevent dissemination and chronic complications. The primary regimen recommended by major health authorities consists of doxycycline 100 mg orally twice daily for 10–14 days. Doxycycline is preferred because it covers common co‑infecting agents such as Anaplasma and Babesia, and it penetrates well into skin and joint tissues.

When doxycycline is contraindicated—due to allergy, pregnancy, or severe gastrointestinal intolerance—alternative options include:

Amoxicillin 500 mg orally three times daily for 14 days (safe in pregnancy).
Cefuroxime axetil 500 mg orally twice daily for 14 days.

In regions with high rates of macrolide‑resistant Borrelia, azithromycin is not recommended as first‑line therapy. For patients presenting with a bull’s‑eye rash (erythema migrans) but no systemic symptoms, a 10‑day doxycycline course may be sufficient, while those with fever, arthralgia, or neurological signs should complete a full 14‑day course.

Adjunctive measures:

Remove the attached tick promptly with fine‑tipped tweezers; avoid crushing the body.
Document the bite date to calculate the appropriate treatment window.
Advise patients to monitor for new skin lesions, joint swelling, or neurological symptoms for at least 30 days after therapy.

Follow‑up evaluation, performed 2–4 weeks post‑treatment, should include:

Physical examination focusing on the former erythema migrans site and musculoskeletal system.
Serologic testing only if symptoms persist, as antibodies may remain positive from prior exposure.
Consider repeat antibiotic course (e.g., intravenous ceftriaxone 2 g daily for 14 days) if persistent neurologic or cardiac manifestations develop.

These protocols aim to eradicate the pathogen swiftly, minimize tissue damage, and reduce the likelihood of long‑term sequelae.

Disseminated Stage Treatment Protocols

The disseminated stage of Lyme disease in adults requires systemic antimicrobial therapy to eradicate Borrelia spp., address organ involvement, and prevent long‑term complications. Evidence‑based protocols emphasize agents with reliable central nervous system penetration when neuroborreliosis is present, and intravenous administration for severe musculoskeletal or cardiac manifestations.

Intravenous ceftriaxone 2 g once daily for 14–28 days; preferred for meningitis, encephalitis, cranial nerve palsies, and high‑grade atrioventricular block. Adjust dose for renal impairment.
Intravenous cefotaxime 2 g every 4 hours for 14–28 days; alternative when ceftriaxone is contraindicated.
Oral doxycycline 100 mg twice daily for 21 days; suitable for milder disseminated presentations without CNS involvement, such as multiple erythema migrans lesions or peripheral arthritis.
Oral amoxicillin 500 mg three times daily for 21 days; option for patients intolerant to doxycycline and without neurologic disease.

Adjunctive measures include:

Baseline and periodic assessment of renal and hepatic function, especially during prolonged intravenous therapy.
Electrocardiographic monitoring for patients with known cardiac involvement.
Evaluation of symptom resolution at the end of treatment; persistent fatigue or pain may warrant extended therapy or referral to a specialist.

Contraindications and cautions:

Doxycycline is avoided in pregnancy, lactation, and children under eight years due to teeth staining.
Ceftriaxone requires caution in patients with biliary sludge risk; consider alternative agents if indicated.
Patients with severe allergy to β‑lactams should receive alternative regimens, such as oral azithromycin 500 mg daily for 21 days, though efficacy data are limited.

Follow‑up includes clinical examination at 4–6 weeks post‑therapy, serologic testing only when relapse is suspected, and imaging (MRI, echocardiography) if neurologic or cardiac symptoms persist. Early identification of treatment failure allows timely escalation to second‑line regimens or combination therapy.

Duration of Treatment

The recommended length of antimicrobial therapy for adult patients who have been bitten by a tick and develop Lyme disease varies with the clinical stage and organ involvement.

For early localized infection, characterized by erythema migrans, a single oral agent—doxycycline 100 mg twice daily, amoxicillin 500 mg three times daily, or cefuroxime axetil 500 mg twice daily—is administered for 10–14 days. Extending treatment beyond two weeks does not improve outcomes for this stage.

Early disseminated disease, presenting with multiple skin lesions, cardiac involvement, or neurologic signs, requires longer courses. Oral therapy is maintained for 14–21 days for cutaneous manifestations. When meningitis, cranial nerve palsy, or radiculopathy occurs, intravenous ceftriaxone 2 g daily is given for 14–28 days. Some clinicians extend to 28 days if symptoms persist after the initial two‑week regimen.

Late manifestations, such as arthritis or chronic neurologic deficits, are treated with oral doxycycline, amoxicillin, or cefuroxime for 28 days. Intravenous ceftriaxone for 28 days is advised for refractory neurologic disease or severe arthritis unresponsive to oral agents.

Treatment duration may be adjusted based on clinical response, laboratory markers, and tolerability. Relapse after a completed course is uncommon; however, persistent symptoms may warrant re‑evaluation and possible extension of therapy.

Management of Symptoms and Complications

Pain Management

Pain associated with Lyme disease often emerges early, manifesting as localized tenderness, arthralgia, or neuropathic sensations. Prompt control of discomfort improves adherence to antimicrobial therapy and reduces functional limitation.

Pharmacologic options include:

Non‑steroidal anti‑inflammatory drugs (ibuprofen, naproxen) for inflammatory pain and joint swelling.
Acetaminophen for mild to moderate nociceptive pain when NSAIDs are contraindicated.
Short‑course opioid analgesics (e.g., tramadol) reserved for severe pain unresponsive to other agents, with careful monitoring for dependence.
Gabapentinoids (gabapentin, pregabalin) for neuropathic symptoms such as burning or tingling.
Low‑dose corticosteroids may be considered for intense inflammatory reactions, but only after evaluating infection control.

Non‑pharmacologic measures complement medication:

Gentle range‑of‑motion exercises and supervised physical therapy to maintain joint mobility.
Application of heat for muscle stiffness or cold packs for acute joint swelling.
Adequate rest combined with gradual activity increase as pain diminishes.
Use of supportive devices (braces, orthotics) when joint instability is present.

Pain assessment should be repeated at each clinical visit. Escalation to stronger analgesics or referral to pain specialists occurs if pain persists beyond two weeks despite standard therapy, or if neuropathic features dominate. Monitoring for side effects and drug interactions remains essential throughout treatment.

Physical Therapy and Rehabilitation

Physical therapy becomes relevant once antibiotic therapy has reduced acute infection signs but residual musculoskeletal or neurological impairments persist. Rehabilitation focuses on restoring strength, coordination, and functional mobility that may be compromised by joint inflammation, peripheral neuropathy, or chronic fatigue.

Effective interventions include:

Therapeutic exercise – low‑impact aerobic activity, progressive resistance training, and proprioceptive drills to improve muscle endurance and joint stability.
Manual therapy – joint mobilization and soft‑tissue techniques aimed at reducing stiffness and enhancing range of motion.
Neuromuscular re‑education – gait training, balance exercises, and functional task practice to compensate for peripheral nerve involvement.
Modalities – intermittent electrical stimulation, heat or cold applications to alleviate pain and facilitate tissue healing when appropriate.

Timing of rehabilitation should align with the patient’s medical status. Initiation is advisable after the acute phase, typically when inflammatory markers decline and physician clearance is obtained. Sessions are scheduled 2–3 times per week, with gradual progression based on pain levels, fatigue, and functional gains.

Outcome monitoring relies on objective measures such as joint range, muscle strength grades, timed up‑and‑go test, and patient‑reported symptom scales. Adjustments to the program are made in response to these metrics, ensuring that therapy remains targeted and efficient throughout recovery.

Prevention of Borreliosis

Tick Bite Prevention Strategies

Repellents and Protective Clothing

Effective prevention of Lyme disease after a tick encounter relies on chemical barriers and appropriate attire.

DEET formulations ranging from 20 % to 30 % provide reliable repellency for up to six hours. Picaridin at 20 % offers comparable protection with a milder odor, suitable for sensitive skin. Oil of lemon eucalyptus (20 % concentration) delivers shorter‑duration efficacy but may be preferred by individuals avoiding synthetic chemicals. All repellents must be applied to exposed skin and re‑applied according to label instructions, especially after sweating or water exposure.

Permethrin‑treated clothing creates an insecticidal surface that kills or repels attached ticks. Factory‑pretreated garments retain activity through at least 70 washes; home treatment kits require a 0.5 % permethrin solution and thorough drying before wear. Clothing should be light‑colored, tightly woven, and cover as much skin as practical—long sleeves, full‑length trousers, and closed shoes. Tucking shirt cuffs into pants and using gaiters further limit tick access.

Combining a DEET or picaridin repellent with permethrin‑treated garments reduces tick attachment risk by more than 90 % in field studies. This dual approach complements prompt tick removal and, when applied consistently, diminishes the probability of infection, thereby reducing reliance on prophylactic antibiotic regimens.

Key practices:

Apply repellent to all uncovered skin before entering tick‑infested areas.
Wear long, light‑colored, tightly woven garments treated with permethrin.
Perform a thorough body check after outdoor activities; remove any attached ticks promptly.

Adherence to these measures forms a cornerstone of adult Lyme disease management after a tick bite.

Tick Checks and Removal

Regular inspection of the skin after outdoor exposure reduces the risk of infection. Examine the entire body, including hidden areas such as the scalp, behind the ears, underarms, groin and between the legs. Perform the check within 24 hours of returning from a tick‑prone environment; early detection allows prompt removal before the pathogen can be transmitted.

When a tick is found, follow a standardized removal protocol:

Use fine‑pointed tweezers or a dedicated tick‑removal tool; avoid blunt instruments.
Grasp the tick as close to the skin as possible, targeting the mouthparts.
Apply steady, downward pressure to extract the whole organism without twisting or crushing.
Disinfect the bite site with an antiseptic solution and wash hands thoroughly.
Preserve the tick in a sealed container if laboratory confirmation is needed.

After extraction, monitor the bite area for erythema, expanding rash or flu‑like symptoms for up to four weeks. Document the date of removal, tick stage and attachment duration; these data guide therapeutic decisions for Lyme disease management in adults. If symptoms develop, initiate antibiotic therapy according to current clinical guidelines.

Post-Exposure Prophylaxis («PEP»)

Post‑exposure prophylaxis (PEP) for Lyme disease is administered promptly after a confirmed or high‑risk tick bite to prevent infection in adults. The intervention is indicated when the tick is identified as Ixodes species, has been attached for ≥36 hours, and the local incidence of Borrelia burgdorferi exceeds 20 cases per 100 000 population. In these circumstances a single dose of doxycycline 200 mg taken orally within 72 hours of removal is the recommended regimen.

If doxycycline is contraindicated—due to allergy, pregnancy, lactation, or severe gastrointestinal disease—alternative options include:

Amoxicillin 2 g orally as a single dose, administered within 72 hours.
Cefuroxime axetil 1 g orally as a single dose, administered within 72 hours.

The chosen antibiotic must be started as early as possible; delays beyond the 72‑hour window markedly reduce efficacy. Evidence from randomized controlled trials shows a relative risk reduction of approximately 85 % when doxycycline is used within the specified timeframe.

Monitoring after PEP involves:

Assessing the bite site for erythema migrans or other skin changes during the subsequent 30 days.
Documenting any adverse drug reactions, especially gastrointestinal upset or photosensitivity with doxycycline.
Advising patients to seek medical evaluation if systemic symptoms such as fever, arthralgia, or neurological signs develop, as these may indicate breakthrough infection requiring full therapeutic courses.

PEP does not replace the need for definitive treatment if Lyme disease manifests; it serves solely as a preventive measure for a defined exposure scenario.

When to Seek Medical Attention

Warning Signs After a Tick Bite

After a tick attaches, the emergence of specific symptoms signals possible infection and warrants immediate medical evaluation. Early recognition of these indicators can prevent progression to systemic disease.

Expanding erythema (a circular rash that enlarges beyond the bite site, often with central clearing)
Fever exceeding 38 °C (100.4 °F)
Severe headache or neck stiffness
Muscle or joint pain, particularly in large joints such as the knee
Fatigue that is disproportionate to recent activity
Neurological disturbances, including facial palsy, tingling, or numbness
Cardiac irregularities, such as palpitations or unexplained shortness of breath

Presence of any listed sign within weeks of the bite should prompt prompt consultation with a healthcare professional experienced in tick‑borne illnesses. Laboratory testing for Borrelia antibodies may be ordered, but treatment should not be delayed while awaiting results if clinical suspicion is high. Early antibiotic therapy, typically doxycycline for adults, reduces the risk of chronic complications and accelerates recovery.

Follow-Up Care

After completing antibiotic therapy for adult Lyme disease, systematic follow‑up is essential to confirm therapeutic success and detect complications early.

The first post‑treatment visit should occur 2–4 weeks after the last dose. During this encounter the clinician evaluates residual or new manifestations, reviews laboratory results, and reinforces preventive measures.

Key elements of follow‑up care include:

Symptom assessment – Document joint pain, neurological deficits, fatigue, or cardiac signs. Compare current findings with baseline to identify improvement or progression.
Serologic testing – Repeat ELISA and Western blot only if clinically indicated; persistent IgM/IgG positivity does not alone indicate treatment failure.
Physical examination – Focus on musculoskeletal, neurologic, and cardiovascular systems. Palpate joints, test reflexes, and auscultate for murmurs or conduction abnormalities.
Imaging – Order MRI or echocardiography when neurological or cardiac symptoms persist despite therapy.
Specialist referral – Involve rheumatology for chronic arthritis, neurology for persistent neuropathy, or cardiology for conduction disturbances.

If symptoms resolve and no new findings emerge, schedule a final evaluation at 3 months to close the episode. Persistent or relapsing manifestations warrant extended or alternative antibiotic regimens, guided by infectious disease expertise.

Patient education should cover tick‑avoidance strategies, proper removal techniques, and the importance of reporting any delayed symptoms promptly. Continuous documentation of outcomes supports quality improvement and informs future management protocols.