Lyme borreliosis

Lyme borreliosis is a complex infectious process that primarily involves the skin, heart, joints, and nervous systems. The infectious agent is the spirochete B burgdorferi, which is transmitted by the Ixodes genus of ticks. The clinical presentations of Lyme disease are protean because of the overlap of stages and varied organ system involvement. Furthermore, as previously mentioned, approximately one-third of Lyme patients are unable to recall a tick bite. Lyme borreliosis should be suspected in anyone with a tick bite. The findings of an EM lesion and flu-like symptoms strongly favor the diagnosis of stage 1 disease. Stage 2 evolves weeks to months after a tick bite, with cardiac and neurological findings as well as musculoskeletal pain. Stage 3 primarily manifests itself as arthritis associated with continuing or additional neurologic complications. Serologic studies are currently the most practical laboratory aid in diagnosis, because almost all infected individuals have a positive antibody response to the spirochete. Treatment with antibiotics usually proves successful, although longer courses of therapy may be needed in later stages of the disease, and some patients may not respond.     

Clinical manifestations and epidemiological aspects leading to a diagnosis of Lyme borreliosis: neurological and psychiatric manifestations in the course of Lyme borreliosis

Lyme disease is associated with various systemic and neurological manifestations. The neurological and psychiatric manifestations of Lyme disease are more frequently observed during its secondary phase (stage 2) than during its late tertiary phase (stage 3). In stage 2, cerebrospinal fluid and bacterial tests are consistent with the ongoing infection. Painful meningoradiculitis, encephalomyelitis and encephalitis, and symptoms of depression are the most characteristic at this stage. The diagnosis should be based on the association of clinical, epidemiological, and biological features. Adequate treatment usually leads to recovery. In stage 3 of the disease, the link between neurological manifestations and initial infection is uncertain. Distal axonal polyneuropathy and chronic encephalopathy are the most frequently reported presentations.     

Cardiac manifestations of Lyme borreliosis

Lyme borreliosis is increasing in Poland in both incidence and recognition with 655 cases reported in 1997 and 3574 in 2003. Approximately 4% of patients will develop cardiac manifestations--the least well documented complication of Lyme disease. Cardiac involvement usually occurs within weeks to months of the infecting tick bite and includes varying degrees of atrioventricular block as the commonest manifestation and tachyarrhythmias, myopericarditis, mild cardiac muscle dysfunction. There has been evidence that long standing dilated cardiomyopathy may be associated with chronic Borrelia burgdorferi infection. Patients with atrioventricular block have good prognosis. Most cases resolve within 1 to 2 weeks. Temporary, but almost never permanent, cardiac pacing may be required for some patients. Cardiac manifestations of Lyme disease are treatable with antibiotics. Lyme carditis should be taken into consideration in patients with acute as well as chronic heart diseases.     

Biologic diagnosis of Lyme borreliosis

Lyme borreliosis (LB) is a multisystemic infection transmitted by ticks. Its diagnosis is based on clinical and biological criteria. These criteria could be different in Europe than in the USA, because of the existence of multiples strains of borrelia in Europe. In primary stage of LB, the diagnosis is often clinical. In the secondary stage, LB diagnosis is established with an Elisa serology confirmed by a Western blot. The interpretation criteria of these laboratory tests should follow European recommendations (EUCALB). LB with neurological involvement should be confirmed by screening for intrathecal synthesis of borrelia antibodies in CSF. LB with rheumatologic expression could be confirmed by screening for borrelia in joint fluid by PCR. There is no strong marker of activity of the disease. Follow-up for LB is difficult, because antibodies may persist for years and LB does not confer immunization.     

Ophthalmic manifestations in Lyme borreliosis

We reviewed ophthalmic manifestations in Lyme borreliosis, concentrating on clinical and laboratory diagnosis, differential diagnosis and treatment options. Ocular involvement may occur in every stage of the disease. Conjunctivitis and episcleritis are the most frequent manifestations of the early stage. Neuro-ophthalmic disorders and uveitis occur in the second stage whereas keratitis, chronic intraocular inflammation and orbital myositis have been reported in the third stage of borreliosis.     

Non antibiotic treatments of Lyme borreliosis

Non-antibiotic treatment of Lyme borreliosis is only indicated in a few specific clinical situations. In chronic Lyme arthritis, intra-articular steroids are useful to immediately relieve symptomatic joint effusion. Nevertheless, 4 studies with weak methodological evidence were convergent enough to recommend not proposing intra-articular injection before or even immediately after antibiotic treatment. The injection can only be recommended in the treatment of patients whose joint effusion persists despite 2 courses of oral antibiotherapy or one course of IV antibiotherapy. For some experts, the injection can only be made after negative PCR assessment of the joint fluid for spirochetes. This recommendation, although logical, has never been evaluated. Radiation synovectomy may be indicated in persistent synovitis after antibiotherapy and before surgical synovectomy. Further studies are mandatory to confirm the role of radiation synovectomy in the local therapy. Arthroscopic synovectomy can reduce the period of joint inflammation when persistent synovitis is associated with significant pain or limited function. Several experts recommend using the procedure only if synovitis persists after 2 months of antibiotherapy and a negative PCR joint fluid assessment. Non-steroidal anti-inflammatory drugs are often prescribed for their symptomatic effects. Experimental data is consensual on the deleterious consequences of systemic corticosteroid therapy. Corticosteroids are not indicated in Lyme's disease. In post Lyme's disease syndrome, patient complaints may lead to a multidisciplinary therapeutic management and the use of neuro-psychiatric drugs.     

Potential foci of Lyme borreliosis in towns

In 1997 the presence of ticks Ixodes ricinus infected with the agent of Lyme borreliosis was detected on the vegetation of Kosice urban agglomeration. The density of ticks on the vegetation of pericentral area islands of forest stands and neglected gardens was 2.4 times lower than that observed in a peripheral park forest. Only sporadical findings of ticks were reported from the industrial central part of town with remnants of uncultivated vegetation. Central parks and housing estates were actually tick-free. Borrelia-infected ticks, from 12.8 to 15% were found in the park forest and pericentral areas. The results indicate potential risks for humans and domestic animals coming in contact with borrelia-infected ticks, also in the territory of large towns.     

Prevalence of Lyme borreliosis in The Netherlands]

In the autumn of 1989 a seroepidemiological study was carried out among 440 owners of hunting dogs and 1052 blood donors from different regions in the Netherlands. To detect IgG antibodies to Borrelia burgdorferi an enzyme-linked immunosorbent assay was performed. The prevalence of antibodies to B. burgdorferi in owners of hunting dogs was 15%, which was significantly higher than in blood donors (9%). In both groups the prevalence of seropositivity increased with age. There was no difference between men and women. The prevalence of antibodies to B. burgdorferi in blood donors from different regions varied significantly, ranging from 2% to 17%. Only 3% of the owners of hunting dogs could recall having had symptoms most likely to be due to Lyme borreliosis. Of the 68 seropositive hunters 64 (94%) were asymptomatic. The results of this study indicate that in the Netherlands asymptomatic infections with B. burgdorferi are common in individuals highly exposed to ticks and that there is considerable variation in the prevalence of seropositivity in the general population. Hence caution is called for in the clinical interpretation of IgG test results.     

Unusual features in the epidemiology of Lyme borreliosis

In this study two cases of Lyme borreliosis are presented. First, the author describes how he contracted Lyme borreliosis 24 hours after he visited an endemic area. The second case described is that of a woman who developed Lyme borreliosis symptoms, when intestinal content of an infected tick came into contact with her conjunctiva. In both cases the diagnosis is based on clinical picture and positive serological tests. The first case shows the probability of contracting Lyme borreliosis when the duration of the tick's attachment to the skin is less than 24 hours. The second case, described demonstrates transmission of B. burgdorferi by contact.     

Treatment of Lyme borreliosis secondary and tertiary stages

The treatment of secondary and tertiary Lyme borreliosis is difficult because of antibiotic lack of efficacy. This fact may be explained by several factors: the specific pathophysiology, involving not only the presence of bacteria, but also immunological reactions. There is no specific method of diagnosis resulting in difficulties for good indication of treatment and to evaluate treatment efficacy. The literature review shows that ceftriaxone and doxycycline are the two most efficient antibiotics in this indication. Even if the methodology of the published studies is not always convincing, these two antibiotics proved their efficacy in articular as well as in neurological forms of the disease. In the late stage of borreliosis, antibiotics are less efficient. Various treatment modalities with different dosage or duration of treatment cannot let us conclude on a convincing regimen.     

Epidemic spread of Lyme borreliosis, northeastern United States

We examined the degree of host specialization of different strains of Borrelia burgdorferi, the tickborne pathogen that causes Lyme borreliosis in the northeastern United States. We first assessed the genetic population structures of B. burgdorferi in ticks obtained from different mammalian host species and in questing ticks sampled in a woodland ecosystem in Connecticut. By comparing the patterns found in our study with data from another cross-sectional study, we demonstrate that B. burgdorferi is a generalist microparasite and conclude that efficient cross-species transmission of B. burgdorferi is a key feature that has allowed the rapid spread of Lyme borreliosis across the northeastern United States.     

Microscopy procedures for direct pathogen detection in Lyme borreliosis

Dark-field microscopy, fuchsin stain and Fontana silver stain were used for a rapid detection of spirochaetes in fresh materials from patients with Lyme-borreliosis. The spirochaetes were shown to be present in 2 cerebrospinal fluids, 2 synovial fluids and in one brain cyst fluid. It is pointed out that these techniques require further improvement and optimization.