By the end of this presentation, the clinician will be able to:

1. Create an appropriate differential diagnosis in patients presenting with symp­tomatology that seems u-like, but may carry signs of early Lyme disease, in the consciousness that seemingly trivial symptoms and signs can only be put in the right context where the patient is observed and carefully examined combined with an extensive medical history taking including possible travel, occupational, and recreational and/or weather- and disaster-related exposures.

5. Discuss the potentially serious consequences of a misdiagnosis or delay in reach­ing a correct diagnosis when the patient is handled only by phone, and not seen, observed, and examined in person.

6. Recognize the different faces and disguises Lyme disease may present itself with, especially in the early stage.

In contrast to these serious symptoms and signs during the evolution of Lyme disease in a patient, before the multiplication and quick spread of the bacteria in the infected patient [9], the rst presentation may be a very mild, inuenza-like set of symptoms and signs, which may be misleading, as was the case in the clinical pre­sentation [10]. It takes 2–3weeks before the rst humoral antibodies are formed and become detectable as IgM through ELISA in laboratory testing [11–13]. If present,

Aucott and Seifter described in 2011 a case of a 58-year-old woman, otherwise healthy, who had a phone consultation with the physician based on “u-like” symp­toms, including headache, generalized achiness, and a subfebrile temperature of

3. HIV acute retroviral syndrome: The acute retroviral syndrome may also resem-

Lyme disease was misdiagnosed as summer inuenza A, as a result from a diagnosis made by a phone consultation, without taking into account the patient’s exposure history and also without seeing the patient and without performing a physical exam­ination on the patient. No laboratory testing was performed either. The misdiagnosis could have been avoided if the patient was seen personally, and a complete medical history, physical examination and laboratory evaluation would have been done.

A physician’s consultation through the phone is extremely sensitive to misdiagno­sis, especially in case of a rst presentation of a health condition by a patient. The consultation is then limited to a listen and ask conversation, and important details captured by vision and interaction with the patient are lost. The medical history is to be taken extensively, despite any busy physician’s ofce. It is the medical history that is able to reveal occupational, recreational, travel, and other exposure details that from a patient’s perspective may be trivial but for the physician’s differential

diagnosis may be holding the key. As in many cases of misdiagnosis, with the initial presentation of the patient with u-like symptoms and signs, it is the medical history about possible exposures that will hint in the correct direction. Furthermore, only if the physician takes this into account and the concerning questions are asked to the patient will the key information come to light. In the current case, it was when the symptoms and signs persisted and extended that the direction was found. An impor­tant condition is that the physician should be well aware of the related exposures and exposure conditions in relation to the clinical picture presented. In the case report described above [10], it was not possible for the physician to have a physical examination of the patient during the telephone consultation; however, if physical inspection would have been done, either the rash or the previously present typical tick bites, with or without one or more ticks still present, would have been observed. Especially when patients do not consider physical locations to be relevant to their symptoms and signs or when patients cannot look at their body areas properly, the actual presence at the doctor’s ofce and the physical examination make the differ­ence. The presence of erythema migrans, recognizable by the annular rash spread­ing centrifugally, and which develops in the rst 7 to 14 days after infection [7–9], is a key nding and results from several alterations of the skin with development of several inammatory markers in the skin, which is where the rst immune response process against Borrelia burgdorferi takes place. Furthermore, Marques and coworkers have shown that during the skin inammation, a local immunosuppres­sion process evolves, which permits and mediates the quick spread of Borrelia to elsewhere in tissues and organs of an infected patient [14]. It is therefore fundamen­tal to diagnose Lyme disease in a patient as early as possible and start treatment immediately, since delays in treatment with subsequent hematogenous dissemina­tion may lead to a more serious clinical picture including neurological, cardiac, and long-term arthritis complications [3, 7, 8]. Steere documented the erythema migrans skin lesion to be the earliest manifestation of Lyme disease, present in 70–80% of patients within 7 to 14days after a tick bite [7]. Since both neurologic (10–15%) and cardiac symptoms (1–2%) may develop already from within weeks up to months after a tick bite [15], any delay in diagnosis must be avoided. The typical Lyme disease arthritis, which affects isolated large joints and has a pattern of migration in time, may affect up to 30% of patients and occurs mostly around 6months or longer after a tick bite.

when it seems innocent, are a pitfall that must be avoided.

2. Body and organ descriptions by patients themselves carry substantial risks and

may only be used as a part of medical history but may never substitute the physi­cal examination of the patient, which should be done with the patient in person.

3. Always be extremely careful with patients who express a presentation of a u-

like disease, since a broad spectrum of infectious diseases present themselves as a u-like set of symptoms and signs during the rst days, sometimes even in the rst 2 weeks. The physician must always check for exposure to specic diseases, and especially insect bites or soaring local irritations must be asked for and eval­uated carefully.

The difference between the innocent versus serious underlying condition requires two fundamental elements. First is not only the specic knowledge but also the specic attention of the physician for details in the medical history that point to or may even be pathognomonic for serious underlying conditions. It cannot be assumed that the patient may be aware of these details and would mention them spontane­ously or even by answering on an “anything else” basis. Second is the specic knowledge and attention of the physician regarding what to include or exclude at physical examination, as well as in the following diagnostic procedures as labora­tory testing, etc.

Lyme disease belongs to the serious diseases and must be recognized, diagnosed, and treated as soon as possible. It is a diagnosis that cannot be made by telephone consultation; otherwise it will be missed easily. Since early treatment is simple but extremely important, it must be specically considered when u-like symptoms and signs are presented by patients, and the patient should be seen, spoken to, and exam­ined in person by the physician.