Neurological manifestations of lyme borreliosis

Neurological manifestations of lyme borreliosis     

甘肃省迭部和铧尖地区4种蜱自然感染莱姆病伯氏疏螺旋体的调查

目的 调查甘肃省迭部和铧尖地区4种蜱自然感染莱姆病伯氏疏螺旋体(Bb)情况,为莱姆病的防治提供科学依据。方法 2010年3月至6月,在甘肃省迭部和铧尖地区岷山北麓迭部林区（秦岭山脉）和肃南祁连山北麓铧尖林区,对4种优势蜱（森林革蜱、草原革蜱、日本血蜱和青海血蜱）自然感染莱姆病Bb进行流行病学检测。采用夹夜法,每隔10 m布夹,晚放晨收,将捕获的啮齿类动物逆毛检虫法采集寄生蜱,同时采用拖旗法采集游离蜱。对采集的4种活的成蜱,清洗消毒后解剖取其中肠内容物分别涂片,置暗视野镜下观察莱姆病Bb;对所分离到的螺旋体再用Bb单克隆和多克隆抗体鉴别试验加以证实。结果 共采集到蜱类2科8属36种,即硬蜱科6属33种,软蜱科2属3种。解剖森林革蜱、草原革蜱、日本血蜱和草原硬蜱4种201只蜱的肠道,暗视野观察出携带莱姆病Bb的阳性蜱25只,阳性率为12.44％(25/201);接种培养森林革蜱、草原革蜱和日本血蜱3种65只蜱,从12只蜱体内培养分离出莱姆病Bb,阳性率为18.46％(12/65)。结论 森林革蜱、草原革蜱和日本血蜱均有程度不同地莱姆病Bb的自然感染。     

Mimicry of lyme arthritis by synovial hemangioma

To report on the differential diagnosis of lyme arthritis and synovial hemangioma due to similar clinical and radiological signs and symptoms. A 15-year-old boy presented at the age of 9 with recurrent rather painless swelling of the right knee. Altogether four episodes lasting for 1–2 weeks each occurred over a period of 18 months before medical advice was sought. Physical examination revealed only a slightly limited range of motion. Living in an endemic area of borreliosis, he reported a tick bite 6 months prior to onset of his symptoms with erythema migrans and was treated for 10 days with amoxicillin. Serology revealed two positive unspecific bands in IgG immunoblot (p41 and 66) with slight positivity for ELISA. Ultrasound revealed synovial thickening and increased fluid. Despite the weak positive serology a diagnosis of lyme arthritis could not be excluded and intravenous antibiotic treatment with ceftriaxone was started. After two further relapses antiinflammatory therapy including intraarticular steroids were introduced with no long lasting effect. A chronical disease developed with alternate periods of swelling and almost complete remission. Ultrasound as well as MRI demonstrated ongoing signs of synovitis, therefore after further progression, a diagnostic arthroscopy was performed showing an inconspicuous knee joint. A second MRI showed focal suprapatellar enhancement and was followed by open arthrotomy revealing a histopathological proven synovial cavernous juxtaarticular hemangioma. To our knowledge, the differential diagnosis of lyme arthritis and synovial hemangioma has not yet been reported despite obvious clinical similarities. In conclusion, in children and adolescents synovial hemangioma has to be considered in differential diagnosis of recurrent knee swelling. Early diagnosis is important to prevent prolonged suffering from chronic joint swelling with probable joint damages, unnecessary treatment procedures and as well school and sports absenteeism.     

Heart stopping tick

Although Lyme carditis is relatively rare within 4-6 wk of exposure, it can uncommonly present as the first sign of disseminated Lyme disease. Here we present 17 year old boy who presented to the emergency department with chest discomfort and was later found to have complete atrioventricular block due to lyme carditis. He had uneventful recovery after empiric treatment with ceftriaxone. Our case highlights the importance of considering reversible causes of complete AV block since appropriate therapy can avoid the need for permanent pacemaker insertion.     

实验性小鼠莱姆病肝组织病理形态学观察

目的 为深入研究阿尔泰山林区莱姆病伯氏疏螺旋体致病之病理特征。方法 采用从当地林区媒介分离到的螺旋体接种于20d龄的实验小鼠腹腔和皮下,于接种后30d、60d、90d分别处死实验鼠,取肝脏做病理切片,HE染色,光镜下观察。结果 肝组织切片,实验鼠9张（只）,对照鼠3张（只）,光镜下7只实验鼠肝组织呈散在嗜酸性变,肝细胞核固缩,胞浆红染,肝细胞浊肿,散在肝细胞坏死,淋巴细胞浸润于静脉血管周围。结论 小白鼠感染伯氏螺旋体后可导致肝细胞损害,致肝细胞坏死改变。     

Entzündliche Herzerkrankungen bei primär extrakardialen Erkrankungen

As systemic immunological disorders, internal diseases in gastroenterology, rheumatology and infectiology can, in addition to the bowels, potentially involve the musculo-skeletal system, the immunological system and heart structures. All structures and functions of the heart can be affected. Pericarditis in lupus erythematosus and chronic inflammatory bowel disease, myocarditis in HIV infection and lyme disease are examples of cardiac manifestations of internal diseases. The pathogenetic causes can be manifold, such as direct cytotoxic effects in HIV or Borrelia burgdorferi infections, induced vasculitis and local activation of coagulation factors as in lupus erythematosus or chronic inflammatory bowel disease. Improved treatment options have led to more long-lasting courses of internal diseases, such as in infectious diseases, lupus erythematosus and chronic inflammatory bowel disease, thus cardiovascular complications such as pericarditis and myocarditis gain increasing importance as a consequence of chronic disease and therapy-related damage.     

Effects of rheumatoid factor, antinuclear antibodies and plasma reagin on the serologic assay for Lyme disease.

Rheumatoid factor (RF), antinuclear antibodies (ANA) and the presence of other spirochetal infections have been reported to be the source of false positive serologic tests of Lyme disease. To evaluate this, we studied their effect upon the Lyme assay in use in our clinical laboratory. Of 64 rapid plasma reagin (RPR) test positive sera, 2 had positive Lyme antibody tests, not statistically different than controls. Of 43 RF positive sera, 2 had positive lyme tests, no different than controls, and 1 of 53 ANA containing sera had positive Lyme tests, again, not different from controls. There was no relationship of titer of RPR or ANA with Lyme results, nor of ANA pattern. Sera containing high titer RF, however, had slight interference, producing an increase in equivocal Lyme assay results. From the other point of view, sera that were Lyme test positive had no increased frequency of RPR or RF, but had an increased frequency of ANA. Therefore, neither RPR, RF or ANA were found to markedly interfere with the Lyme assay. However, Lyme antibodies may interfere with the ANA test.     

Outcome of patients with arthritis and parvovirus B19 DNA in synovial membranes

To investigate the follow-up of the 17 patients during the period of 1995–2001 of the outpatient Clinic for Rheumatology at the University Hospital of Zurich with arthritis and the presence of parvovirus B19 DNA demonstrated by PCR in synovial biopsies. Seventeen patients of 163 with arthritis, which were routinely examined by needle arthroscopy during 1995–2001 with a positive parvovirus B19 DNA by PCR of synovial biopsy were reevaluated. Investigations included medical history, clinical examination and blood tests. Joint fluid was taken on patients with joint effusion. The observation period of the 17 patients (F:M = 11:6) was 2–8 years (Ø = 6.5 years). In 8 of 17 patients the arthritis could not be classified neither at entry nor during the follow up of the study. The arthritis could be diagnosed in six patients early in the onset of the disease and included three cases of lyme arthritis of the knee joint, two cases with arthritis following a gastrointestinal infection (one with Salmonella typhimurium—positive faecal test—and the other one with a culture negative agent), one patient probably had an infection-associated arthritis after a gastrointestinal infection with Entamöeba histolytica (Schirmer et al. in Rheumatol Int 18:37–38, 1998; Kasliwal in Am J Proctol Gastroenterol Colon Rectal Surg 32:12, 16, 28, 1981; Haslock and Wright in J R Coll Phys Lond 8:1554–162, 1974; Than-Saw et al. in Trop Geogr Med 44:355–358, 1992) with remission after antibiotic therapy. After a disease course of 9 months one patient could be classified as rheumatoid arthritis in the presence of anti-cyclic citrullinated antibodies but lack of rheumatoid factor. One patient with polyarthritis developed psoriasis of the skin 22 months later. From the nine patients with unclassified arthritis 4 (45%) got into complete remission with no symptoms or signs of joint inflammation after a disease course of 9–45 months, whereas 5 (55%) still demonstrate active non erosive arthritis (disease duration between 3 and 10 years). The presence of parvovirus B19 DNA in synovial tissue of patients with joint inflammation does not allow the diagnosis of parvovirus induced arthritis. If the arthritis remains unclassified and without erosions over time a virus associated aetiology may be assumed. However, no definitive diagnosis is possible even in the presence of parvovirus B19 DNA in synovial tissue.     

Loss of an apurinic/apyrimidinic site endonuclease increases the mutagenicity of N-methyl-N''-nitro-N-nitrosoguanidine to Escherichia coli.

xthA- Escherichia coli, which are missing a major cellular apurinic/apyrimidinic (AP) endonuclease, are 5- to 10-fold more sensitive than xthA+ bacteria to mutagenesis by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) under conditions that induce the "adaptive response." The xthA(-)-dependent mutations are also dependent on SOS mutagenic processing and consist of both transversion and transition base substitutions. When MNNG-adapted xthA- bacteria are challenged with a high dose of MNNG, more xthA(-)-dependent SOS-dependent mutations are induced, and transversions are enhanced relative to transitions. The mutations induced by challenge are eliminated in xthA- alkA- bacteria, which are also deficient for 3-methyladenine glycosylase II activity. These data are consistent with the hypothesis that AP sites, at least some of which are produced by glycosylase activity, are mutagenic intermediates following cellular DNA alkylation.     

The cost of evolution and the imprecision of adaptation.

Comparisons of six hypothetical cases suggest that Haldane overstimated the cost of natural selection by allele substitution. The cost is reduced if recessive alleles are advantageous, if substitutions are large and few, if selection is strong and substitutions are rapid, if substitutions are serial, and if substitutions in small demes are followed by deme-group substitutions. But costs are still so heavy that the adaptations of complex organisms in complex and changing environments are never completed. The rule probably is that most species most of the time are not fully adapted to their environments, but are just a little better than their competitors for the time being.     

Recommendations of the Task Force on Record-Keeping and Blood Distribution Systems

Abstract. The objectives of an automated donor record system are reviewed and recommendations as to file content and structure of a computer-based system are outlined. Four sections are suggested, data related to donor identification, demography, date of last donation and special services requirements. Alternative means of data entry and donor-donation links are discussed as well as desirable capabilities of unit record and patient record systems. Two types of blood distribution systems are outlined, namely the reactive type where hospital blood bank inventories are replenished on demand and the predictive type where inventory requirements are predicted in advance and inventories are replenished on a fixed, previously agreed on schedule.     

Obesity and endocrine disease.

Several endocrine abnormalities are reported in obesity. Some of these abnormalities are considered as causative factors for the development of obesity, whereas others are considered to be secondary effects of obesity and usually are restored after weight loss. Thyroid hormones usually are normal in obesity, with the exception of T3 which is elevated. Prolactin is normal but prolactin response to different stimuli is blunted. GH is low and GH response to stimuli is blunted. IGF-I levels are normal or elevated. Cortisol, ACTH, and urine free cortisol levels are usually normal; however, a hyperresponsiveness of the HPA axis with increased cortisol and ACTH response to stimulatory tests is observed in centrally obese individuals. Total testosterone and SHBG levels are low, but free testosterone levels are usually normal in obese men. LH and FSH levels usually are normal and estrogens are elevated. Norepinephrine levels are elevated, whereas epinephrine levels are low or normal. Aldosterone levels are elevated but renin activity is usually normal. Parathyroid hormone levels are elevated with normal serum calcium levels and increased urine calcium levels. Monogenic mutations that result in severe obesity have been described in several individuals. Also, several endocrine diseases have obesity as one their clinical manifestations. Hypothyroidism, Cushing's syndrome, GH and testosterone deficiency, polycystic ovarian syndrome, insulinoma, hypothalamic lesions, and genetic syndromes often present with obesity. In most of these conditions, appropriate treatment of the primary disease results in weight loss. In addition, the fat cell has been found to be an endocrine organ that produces several peptides that are bioactive and participate in the regulation of adipocyte function.     

The epidemiology of drug use during pregnancy.

It is posited that drug-taking behaviors related to pregnancy are socially conditioned patterns and are subject to reeducation. Drug-taking behaviors of pregnant women are reviewed. It is uniformly found that multiple drug agents are consumed by the average pregnant woman during the gestation period. The unique vulnerability of the fetus and the teratogenic potential of numerous drugs are discussed. Recommendations are offered for the judicious use of drugs during pregnancy.     

Markers to define ischemia: Are they ready for prime time use in patients with acute coronary syndromes?

Optimal treatment of patients who present with chest pain is predicated on accurate identification of those patients with a cardiac etiology of their discomfort. Serial troponins and electrocardiograms are very sensitive for the detection of myocardial infarction but they are insensitive for the detection of ischemia. There are many analytes that are being actively evaluated for routine use to facilitate the identification of patients with myocardial ischemia. At present, only one assay is US Food and Drug Administration-approved for the exclusion of ischemia; many other analytes are under clinical evaluation and are briefly reviewed. At present, none of these analytes are yet appropriate for routine clinical use.     

Environnement domestique. Allergie aux végétaux

Plant substances are used widely in the course of human activities. Numerous particles arising from plants and cut or dried flowers in apartments can be inhaled. Decorative home plants are frequently manipulated. Vegetable gums are frequently present in food, and they are also present in cosmetics. Thus, human interaction with plants can be the source of many allergic reactions. Why have these reactions, which are well known to occupational disease specialists, been ignored in the home environment remains a question? This question is all the more relevant since there are many interactions between plants and food. Allergic cross-reactions are likely and mechanisms of induction of sensitization are probably similar.     

Is light-induced fluorescence better than the endoscopist's eye?

While recognizing advanced tumours with endoscopy does not generally pose a challenge, cure rates are relatively low, depending on the size and stage of the tumour. Screening tests for cancer are advantageous for diagnosing cancers before the date after which a cure is no longer an option. Many gastrointestinal cancers are diagnosed after the date on which a cure is possible. The present article discusses some of the limitations of conventional white light endoscopy in screening and presents some of the fluorescent-based diagnostics that are being investigated as complements to white light endoscopy. Autofluorescence and fluorescence due to exogenous photosensitizers or precursors are two sources of fluorescence that are being studied. Preliminary results of current investigations are presented, and future research directions are described.     

A giant Brunner's gland adenoma presenting as gastrointestinal hemorrhage

Brunner's gland adenomas are rare tumors of the duodenum that are usually small in size. Only a few cases of tumors more than 4 to 5 cm in size are reported in the literature. Although the majority of patients are asymptomatic, hemorrhage and obstruction are the most clinically significant manifestations. We report a case of Brunner's gland adenoma in which the patient presented with major gastrointestinal bleeding. Endoscopic, radiologic, and endosonographic appearances are illustrated.     

Deep venous thrombosis: an overview

The patients at high risk of deep venous thrombosis are defined. Factors in the formation of intravenous thrombi are described. The roles of endothelium, formed elements, clotting factors, and their interrelationships are correlated. Diagnostic modalities and their application are described, and the commonly used medical and surgical therapies are specifically outlined.     

Scanning electron microscopic study of the tegumental surface of adult Schistosoma sinensium

The SEM study of tegumental surface of adult Schistosoma sinensium reveals that the male tegument lacks tubercles or bosses; instead it is corrugated with small pits or perforated ridges. On the dorsal surface, spines are present whose number and size progressively increase towards the posterior end of the body. In addition, there are three types of papillae interspersed among the ridges and spines. The first type of papillae has crater-like holes surrounded by a circular doughnut-shaped elevation; some are ciliated and others are non-ciliated. They are generally found on the dorsal and ventral surfaces. The second is sensory papillae which are hemispherical in shape bearing apical cilia. They are found to be concentrated around the oral sucker and on the posterior end of the worm. The third is fungiform papillae without cilia which are found on the posterior end. There are short spines present on the tegument lining the gynecophoral canal of the male worm. The tegument of the female S. sinensium is corrugated with ridges on the ventral surface. Small spines are present on the anterior portion of the dorsal surface. They become larger and increased in number towards the posterior end of the worm. The three types of papillae are present but they are much fewer and less developed than those in the male worm.     

Numbers needed for treatment and their respective confidence intervals: useful tools to assess clinical significance and uncertainty associated with medical interventions]

This is a narrative review of a concept--number needed to treat (NNT). The proprieties of NNTs are described. Furthermore NNTs as important tools for medical decision are discussed. In particular, conditions that make calculus and the interpretation of NNTs somewhat more complex are commented. Namely, we consider situations where the results are not primarily binary or are expressed as "time to event" or come from a meta-analysis. The inconsistencies that might occur when NNTs are calculated from meta-analysis are discussed in some detail. Definitions for parameters derived from NNTs, as numbers needed to harm (NNH), unqualified success (NNTUS) and unmitigated failure (NNHUF) are given. Finally the usefulness of NNTs and absolute risk reductions to communicate risk to individual patients are considered. It is concluded that despite NNTs being powerful tools for medical decision, in the case of communicating risks to the individual patient absolute risks might be preferable.