Prevalence of tick-borne encephalitis and Lyme borreliosis in a defined Swedish population

Sera from 346 individuals living on Lis?, an area south of Stockholm, endemic for tick-borne encephalitis (TBE) and Lyme borreliosis, were tested for antibody activity to TBE-virus (TBEV) and Borrelia burgdorferi, using a sonicate antigen, by haemagglutination-inhibition and ELISA, respectively. 10/346 (3%) individuals had a history of previous serologically confirmed TBE with encephalitic symptoms, and 33/346 (10%) had a history of previous erythema chronicum migrans (ECM). Four individuals (1%) had been treated for neuroborreliosis and another 4 (1%) for acrodermatitis chronica atrophicans (ACA). Antibodies to TBEV and B. burgdorferi were detected in 40/346 (12%) and 89/346 (26%) individuals, respectively. The seroprevalence of Lyme borreliosis increased with age, time spent on Lis?, and number of reported tick-bites. For TBE there was a correlation between seropositivity and time spent on Lis? only. In sera from 50 healthy blood-donors, living in a non-endemic area, no antibody activity to TBEV could be detected and only 1/50 (2%) had antibodies to borrelia. In sera from 150 age and sex matched control individuals, living in the city of Stockholm, antibody activity to TBEV and borrelia was found in 8/150 (5%) and 13/150 (9%), respectively.     

Seroprevalence of tick-borne Lyme borreliosis in a defined population in Estonia.

Sera from 200 randomly selected individuals living in Karksi Nuia, south Estonia, near an area endemic for tick-borne encephalitis and Lyme borreliosis (LB), were tested for antibodies to Borrelia burgdorferi. Antibodies were detected by enzyme-linked immunosorbent assay in 6 individuals (3%; 95% CI: 1-5%), who were middle-aged, asymptomatic anti-nuclear and anti-smooth muscle antibody negative. Our data show that there is low seroprevalence rate of antibodies to B. burgdorferi in an unselected south Estonian population.     

Tired of Lyme borreliosis. Lyme borreliosis in the Netherlands

Lyme borreliosis has become the most common vector-borne illness in North Eastern USA and Europe. It is a zoonotic disease, with well-defined symptoms, caused by B. burgdorferi sensu lato, and transmitted by ticks. Lyme borreliosis is endemic in the Netherlands with a yearly incidence of approximately 133 cases/100,000 inhabitants. Similar to another spirochetal disease, syphilis, it can be divided into three stages; early, early disseminated and late disseminated manifestations of disease, of which the specific clinical presentations will be discussed in detail. The diagnosis of Lyme borreliosis is based on a history of potential exposure to ticks and the risk of infection with B. burgdorferi s.l., development of specific symptoms, exclusion of other causes, and when appropriate, combined with serological and/or other diagnostic tests. The specific indications for, but also the limitations of, serology and other diagnostic tests, including the polymerase chain reaction (PCR), are detailed in this review. Lyme borreliosis is treated with antibiotics, which are usually highly effective. Recent literature discussing the indications for antibiotic treatment, the dosage, duration and type of antibiotic, as well as indications to withhold antibiotic treatment, are reviewed. This review presents the most recent, and when available Dutch, evidence-based information on the ecology, pathogenesis, clinical presentation, diagnosis, treatment and prevention of Lyme borreliosis, argues against the many misconceptions that surround the disease, and provides a framework for the Dutch physician confronted with a patient with putative Lyme borreliosis.     

Spatial risk assessment for Lyme borreliosis in Denmark

A study of nymphal and adult Ixodes ricinus density was performed in well-defined spruce and beech forest habitats with different levels of roe deer abundance and soil water capacity. In 35 habitats, a total of 489 larvae, 1,611 nymphs and 193 adult I. ricinus ticks were collected. Tick density was found to be influenced by roe deer abundance and soil water capacity. Based on this evaluation, a model predicting increasing number of ticks with increasing roe deer abundance and soil water capacity was suggested. A total of 1,045 nymphs and 106 adult ticks were tested for infection with Borrelia burgdorferi sensu lato Of these, 53 nymphs and 6 adults were found to be infected, leading to an general infection rate of 5% and 6% for nymphs and adults, respectively. Prevalences of Borrelia burgdorferi sensu lato in nymphal I. ricinus were found to be independent of roe deer abundance and soil water capacity. The correlation between human neuroborreliosis incidence and the estimated number of I. ricinus based on roe deer abundance and soil water capacity was examined. Differences in human neuroborreliosis incidence were found to correspond with the expected spatial differences in tick density in 12 counties in Denmark.     

The experience of a serological examination of the rural population in a territory endemic for Lyme borreliosis

Serological surveys have been performed in two communities (Kirovsk District, Leningrad Province) endemic for Lyme's borreliosis. 736 individuals (51% of the population) have been examined. Standard capillary blood samples (drops from the finger on a filter paper) have been investigated by indirect immunofluorescence. Blood sera of residents from nonendemic territories and patients with various rheumatic diseases served as a control. Serum dilution 1:80 was considered as a reliable screening titre. In general, the seroprevalence was shown to account for 9%.     

Effect of gender on clinical and epidemiologic features of Lyme borreliosis

The aim is to highlight the influence of patients' gender on Lyme borreliosis and especially erythema migrans (EM), focusing on exposure to tick bites, epidemiology, and the clinical picture. All studies were conducted in the county of Blekinge, located in southeastern Sweden. A prospective study was conducted in 235 individuals (women, n=110; men, n=125) engaged in recreational or occupational activities focusing on exposure to tick bites. A retrospective epidemiologic study evaluating 123,495 electronic patients' records (women, n=61,712; men, n=61,783) and a prospective clinical study including 118 patients (women, n=54; men, n=64) 18 years or older seeking care for EM >or= cm in diameter with genospecies verified by polymerase chain reaction (PCR) were conducted. Women 40 years or older had a 48% higher risk than men 40 years or older and 42% higher risk than women younger than 40 years of attracting tick bites (0.0188 versus 0.0127 and 0.0188 versus 0.0132 tick bites respectively per hour). Additionally they had a 96% higher risk than men younger than 40 years of attracting tick bites (0.0188 versus 0.0096). The annual incidence rate of EM in women was 506 and in men 423 cases per 100,000 inhabitants (p<0.001). Significant differences in incidence rates occurred in those 40 years or older. Odds ratios for males infected with Borrelia afzelii developing nonannular EM were 0.09 (95% confidence interval [CI] 0.03 to 0.33) in comparison to females infected by Borrelia afzeli. Significant gender differences in the risk of contracting tick bites, incidence rates, and clinical picture of EM have been observed. Exposure to tick bites alone may not explain these observations and further studies need to be done to clarify the biologic, immunologic, and sociological mechanisms causing these differences.     

Relative frequency of Lyme borreliosis and of its clinical manifestations in Europe

Summary  To survey the frequency of Lyme borreliosis (LB) and to evaluate its clinical presentation in Europe, we performed a questionnaire interview of a sample of physicians involved in the care of patients with LB. Reference laboratories in 15 European countries agreed to participate by distributing questionnaires to those clinicians who most frequently requested LB serology for their patients. The mean number of cases of LB per physician per country showed a longitudinal geographical gradient, with a higher number of patients seen in Eastern and Central Europe than in Western Europe. Skin involvement was seen in 58.9% of the patients, neurological involvement in 34.3%, joint involvement in 15.4% and cardiac involvement in 2%. About 30% of the patients had multisystem involvement. The frequency of the different manifestations varied greatly between countries. The frequency of diagnosis of LB and the number of serological tests requested were inversely correlated.     

Therapy of Lyme borreliosis in children

Summary A retrospective open study was conducted to determine the efficacy of penicillin and ceftriaxone in children with skin manifestations of Lyme borreliosis (solitary erythema migrans, multiple erythemata, borrelial lymphocytoma) and neuroborreliosis, respectively. One hundred sixty children were treated with penicillin and 41 with ceftriaxone for an average of 12 days. Serum antibodies to borreliae were determined before therapy and 2–3 and 4–6 weeks thereafter. At admission 44%/26%, 8%/42%, and 40%/35% of erythema migrans, borrelial lymphocytoma and neuroborreliosis patients, respectively, were IgM/IgG positive. Four to 6 weeks after treatment the percentage of seropositives was 20%/15%, 8%/61%, and 21%/44%, respectively. A 3 months follow-up was completed with 151 children. No child showed clinical evidence of illness, nor were there abnormalities in laboratory parameters.

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Therapie der Lyme-Borreliose bei Kindern

Zusammenfassung In einer offenen, retrospektiven Studie an Kindern wurde die Wirksamkeit von Penicillin bei der Behandlung von Hautmanifestationen der Lyme-Borreliose (Erythema migrans, n=160, Borrelien-Lymphozytom, n=26) und die Wirksamkeit von Ceftriaxon zur Behandlung der Neuroborreliose (n=41) untersucht. Die Therapiedauer betrug durchschnittlich 12 Tage. Serum-Antikörper wurden vor der antibiotischen Behandlung und 2–3 und 4–6 Wochen danach bestimmt. Zum Zeitpunkt der ersten Untersuchung waren 44%/26%, 8%/42% und 40%/35% der Erythema migrans-, Borrelien-Lymphozytom-bzw. Neuroborreliose-Patienten IgM/IgG positiv. Vier bis 6 Wochen nach Behandlung war der Anteil der Seropositiven 20%/15%, 8%/61% bzw. 21%/44%. Untersuchungen 3 Monate nach Behandlung konnten bei 151 Kindern (65%) durchgeführt werden. Keines der Kinder zeigte klinische Anzeichen einer Erkrankung oder einer chronischen Form der Lyme-Borreliose, ebenso gaben die Ergebnisse der Laboratoriumsuntersuchungen keinen Hinweis auf Anomalien.

     

Acute myocarditis and cardiomyopathy in Lyme borreliosis

Heart involvement of Lyme disease occurs in about 4-10% of patients with Lyme borreliosis. The most common manifestation is acute, self-limiting Lyme carditis, which manifests mostly as transient conduction disorders of the heart, pericarditis and myocarditis. Laboratory tests (ELISA, immunoblotting and PCR) usually have limited sensitivity and specificity, and criteria of performance and interpretation have not yet been fully evaluated. Therefore the laboratory evidence should only be interpreted in conjunction with other clinical and diagnostic features. Recently there has been convincing evidence published that long standing dilated cardiomyopathy in many cases is associated with a chronic Borrelia burgdorferi (BB) infection. Several studies showed a higher prevalence of BB antibodies in patients with severe heart failure in endemic areas (e.g., 26% versus 8% in healthy individuals). The isolation of spirochetes from the myocardium gave further evidence that BB may cause chronic heart muscle disease. In several studies antimicrobial treatment showed an improvement of the left ventricular function in patients with dilated cardiomyopathy associated with BB. However the duration of dilated cardiomyopathy before treatment plays an important part in the clinical outcome of BB-associated chronic myocarditis.     

The prevalence and incidence of lower extremity amputation in a diabetic population.

OBJECTIVE--To describe the incidence of lower extremity amputations and sores or ulcers and investigate risk factors for these complications. DESIGN--Cohort. SETTING--Primary care. PARTICIPANTS--Population-based sample (N = 1210) of younger-onset diabetic persons (diagnosed before age 30 years and taking insulin) and a stratified random sample (N = 1780) of older-onset diabetic persons (diagnosed after age 30 years). Baseline and 4-year follow-up examinations were completed by 996 and 891 younger-onset persons, respectively, and by 1370 and 987 older-onset persons, respectively. MAIN OUTCOME MEASURES--Amputations and sores or ulcers of the lower extremities. RESULTS--Four-year incidence of amputations was 2.2% in both groups. Incidence of sores or ulcers was 9.5% in younger-onset and 10.5% in older-onset persons. In younger-onset persons, significant risk factors for amputation with odds ratios (and 95% confidence intervals) include age, 2.0 for 10 years (1.2 to 3.1), history of sores or ulcers, 10.5 (3.7 to 29.8), diastolic blood pressure, 2.1 for 10 mm Hg (1.3 to 3.5), and pack-years smoked, 1.3 for 10 years (1.0 to 1.6). Risk factors for sores or ulcers include glycosylated hemoglobin, 1.6 for 2% (1.3 to 2.0), retinopathy, 1.3 for two steps (1.1 to 1.6), and current smoking, 2.3 (1.0 to 5.6). In older-onset persons, risk factors for amputation are history of sores or ulcers, 4.6 (1.7 to 12.2), proteinuria, 4.3 (1.6 to 11.5), glycosylated hemoglobin, 1.5 for 2% (1.0 to 2.2), sex, 2.8 for males (1.0 to 7.5), and duration of diabetes, 1.8 for 10 years (1.0 to 3.2). For sores or ulcers, risk factors are glycosylated hemoglobin, 1.6 for 2% (1.3 to 2.0), duration, 1.5 for 10 years (1.0 to 2.1), proteinuria, 2.2 (1.1 to 4.3), and diastolic blood pressure, 0.8 for 10 mm Hg (0.6 to 1.0). CONCLUSIONS--Several factors offer potential for modification for the prevention of amputations but require further study. These include blood pressure, glycosylated hemoglobin, and smoking.     

IgG seroprevalence of Lyme borreliosis in the population of the Aland Islands in Finland

This is a study of people living in Aland, a group of islands in the Baltic Sea between Finland and Sweden. 500 blood donors and 3,248 health service clients who did not have Lyme borreliosis were examined for Borrelia burgdorferi IgG antibodies. The method used was an ELISA containing a selection of diagnostic antigens to a Borrelia burgdorferi PKo strain. It was found that the distribution according to sex, age and titre values was identical in the 2 groups, which were therefore treated as one. 19.7% of all the sera was positive. The prevalence in men was 23.6%, and in women 16.7%. The prevalence rises with age, the highest prevalence being seen in men (44.7%) and women (37.0%) over 70 y of age. The data show that the Aland islands are strongly endemic for Lyme borreliosis compared with international levels of infection.     

Laboratory diagnosis and seroepidemiology of Lyme borreliosis

Summary Laboratory diagnosis of Lyme borreliosis is performed by direct detection ofBorrelia burgdorferi in body fluids and tissue samples. This can be achieved by cultivation of the organisms, staining techniques, or demonstration of parts of the genome. Although the best aetiologic proof in case of positivity, these methods cannot yet serve as routine techniques: they are too time consuming and expensive. Currently, the usual method for establishing the diagnosis of Lyme borreliosis is serologic testing (indirect detection). Immunofluorescence, hemagglutination, ELISA tests with whole cell antigen should be considered as screening methods. Assays with selected fractions ofB. burgdorferi antigens or tests using selected recombinant antigens should be considered as more specific. Immunoblotting (Western blotting) may be considered as a confirmatory test. However, the interpretation of test results requires an experienced investigator. Laboratory diagnosis ofB. burgdorferi infections of the central nervous systems (CNS) is the most highly developed method. Demonstration of intrathecally produced specific antibodies, and, moreover, demonstration of specific oligoclonal bands may very well prove the actual infection of the CNS and/or the nerve roots. Seroepidemiological investigations identify neurological manifestations as the most frequent ones among European cases of Lyme borreliosis. The true incidence and prevalence of Lyme borreliosis, however, cannot be determined with current diagnostic methods and must await the development of methods to identify actual infection.

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Diagnose und Seroepidemiologie der Lyme-Borreliose

Zusammenfassung Die Laboratoriumsdiagnose der Lyme-Borreliose erfolgt direkt durch den Nachweis vonBorrelia burgdorferi in Körperflüssigkeiten und Gewebeproben. Dies kann durch Anzüchtung der Organismen, Färbetechniken oder Nachweis von Genombestandteilen erfolgen. Obwohl im positiven Fall der sicherste Beweis, können diese Methoden nicht als Routineverfahren eingesetzt werden; sie sind zu zeitaufwendig und kostspielig. Zur Zeit sind es überwiegend serologische Verfahren (indirekter Nachweis), die zur Laboratoriumsdiagnostik der Lyme-Borreliose eingesetzt werden. Immunfluoreszenz-, Hämagglutinations-, ELISA-Tests mit Ganzzell-Antigen sollten als Suchtests betrachtet werden. Testverfahren mit ausgewählten Antigenen sollten als spezifischer eingeschätzt werden. Die Immunoblot- Technik (Westernblot) kann als Bestätigungsverfahren betrachtet werden, sofern die Interpretation der Ergebnisse durch einen sehr erfahrenen Untersucher erfolgt. Die Laboratoriumsdiagnostik derB. burgdorferi- Infektionen des Zentralnervensystems ist am weitesten entwickelt. Der Nachweis von intrathekal gebildeten spezifischen Antikörpern und von spezifischen oligoklonalen Banden kann mit hoher Wahrscheinlichkeit als Beweis der aktuellen Infektion angesehen werden. Seroepidemiologische Untersuchungen weisen neurologische Erkrankungen der Lyme-Borreliose als die häufigsten unter den europäischen Erkrankungsfällen aus. Jedoch kann die wahre Inzidenz und Prävalenz der Lyme-Borreliose erst ermittelt werden, wenn Verfahren zum Nachweis der aktuellen Infektion verfügbar sind.

     

Gonarthritis, lymphadenopathy and disseminated choroiditis as a primary manifestation of Lyme borreliosis. Case report and discussion of diagnostic possibilities in Lyme borreliosis

A 26-year-old female patient was admitted to the hospital because of bilateral gonarthritis, lymphadenopathy and disseminated chorioiditis as primary manifestation of Lyme borreliosis. Antibody titers against Borrelia burgdorferi did not reach diagnostic levels as determined by an indirect immunofluorescence assay. However, diagnosis was established by the detection of IgG and IgM antibodies in Western blot analysis, and by the demonstration of an enhanced T-cell proliferation to Borrelia burgdorferi in a lymphocyte proliferation assay. This case report indicates that arthritides may already occur in stage II (disseminated infection) of Lyme borreliosis. Therefore, Lyme borreliosis must be considered in patients with chorioiditis and pauciarticular arthritis. In the case of non-diagnostic antibody titers in indirect immunofluorescence tests (or ELISA), Western blot analysis and lymphocyte proliferation assays should be performed in addition.     

The epidemiology of irritable bowel syndrome in a random population: prevalence,incidence, natural history and risk factors

Abstract. Objectives . The aim of the study was to assess prevalence, incidence, recovery, and risk factors of irritable bowel syndrome according to different definitions in a large random population. Design . A 5 year follow-up study of a sex- and age-stratified random sample of 4581 Danes interviewed about abdominal symptoms. Setting . The Glostrup Populations Studies Unit at Glostrup County Hospital. Main outcome measures . Prevalence, incidence, recovery, and the association of risk factors to irritable bowel syndrome (IBS). The percentage of subjects common to the populations selected by the various definitions of IBS. Results . According to various definitions, the prevalence of IBS varied from 5 to 65% and the incidence varied from 1 to 36%. At the 5 year follow-up only 5% of subjects with IBS were completely free of all symptoms. Psychological vulnerability and the experience of having problems were strongly associated with prevalence and incidence of IBS, whereas lifestyle factors only showed a very weak or no relationship to IBS. Populations defined as suffering from IBS according to the various definitions had less than 50% of the subjects in common. Conclusions . Irritable bowel syndrome is frequent but fluctuating in the general population. Psychological factors seem to be of greater aetiological importance to IBS than lifestyle factors. However, a generally accepted and precise definition is essential to make future studies comparable and to allow general conclusions to be drawn. Furthermore, it still needs to be verified whether the syndrome is a disease entity or just an acceptable, common life-condition.