# Clinical Manifestations of Lyme Borreliosis in Europe: Burden of Lyme Disease Study (BOLD), 2021–2022

## TL;DR

This study analyzed the clinical manifestations of Lyme disease across six European countries, finding significant variation in symptoms and treatment patterns.

## Contribution

The study provides the first comprehensive, multi-country analysis of Lyme disease manifestations in Europe using standardized case definitions.

## Key findings

- Erythema migrans was the most common manifestation in most countries, but Lyme arthritis dominated in Slovakia.
- The proportion of disseminated disease varied widely, from 1.1% in Slovenia to 78.0% in Slovakia.
- Doxycycline was the most commonly prescribed antibiotic across all countries.

## Abstract

Lyme borreliosis (LB), the most common European tick-borne disease, can manifest as an erythema migrans (EM) rash or as disseminated LB. The prospective Burden of Lyme Disease (BOLD) study evaluated the frequency of LB clinical manifestations, including signs, symptoms, and treatment patterns in 14 healthcare practices in endemic regions of six European countries: the Czech Republic, Germany, Poland, Slovakia, Slovenia, and Sweden. Between April 2021 and December 2022, patients with suspected LB were evaluated using predefined case definitions that were applied by investigators to identify medically attended LB cases. Enrolled cases were interviewed about their symptoms. Among the 797 LB cases, 615 (77.2%) had EM and 182 (22.8%) had disseminated disease; 154 of the disseminated cases had Lyme arthritis (LA), five had Lyme neuroborreliosis, and three had Lyme carditis. Geographically, the proportion of disseminated disease varied by country, from 1.1% in Slovenia to 78.0% in Slovakia. Overall, 76.3% of all LB cases in Slovakia were LA. Antibiotic use varied by country, although every country prescribed doxycycline. The frequency of LB manifestations varied substantially between countries. EM was the most common manifestation in all countries except Slovakia, where LA was most common. This study underscores the need for improved prevention strategies.