Risk assessment in Lyme borreliosis

A 3-year EU-funded project (EUCALB), initially involving 14 countries and more than 30 scientists and physicians, was undertaken with the main objective of identifying practical risk assessment criteria for Lyme borreliosis. A major part of the project was dedicated to the improvement of data quality. European case definitions were formulated and quality assurance schemes were developed for serological diagnosis and the detection of infection in ticks. Studies on the standardisation of immunoblot interpretation criteria are still in progress. Data on the clinical risk from tick bites were obtained and considerable progress was made in elucidating the complex ecology of the disease. A study on habitat assessment throughout Europe concluded that high risk was associated with highly heterogeneous recreational woodland and case data from both high and low incidence countries suggested that most infections were acquired in recreational areas. Considerable work is still required to relate clinical data to the epidemiology and ecology of the disease in order to assess risk in Lyme borreliosis.     

Prevention of Lyme borreliosis

Lyme borreliosis, the most common tick-borne disease in both North America and Europe, is acquired through the bite of certain tick species in the genus Ixodes. The number of Ixodes ticks in the environment can be reduced by relatively simple interventions such as removing leaf litter and brush, which increases exposure of the tick to sun and air and takes advantage of the tick's vulnerability to desiccation, or by application of acaricides to property. Deer elimination or exclusion, application of topical acaricides to mice or deer, and application of systemic acaricides to deer are more complex approaches. However, none of these methods for reducing tick numbers, nor any of the recommended personal prevention measures, such as reducing the amount of exposed skin, use of tick repellents on exposed skin or clothing, and frequent tick checks to remove attached ticks expeditiously, has been demonstrated to decrease significantly the incidence of Lyme borreliosis in humans. Only two strategies have been shown to do so. A recombinant outer surface protein A (OspA) vaccine was approximately 80% effective in clinical trials in the United States, and a single 200 mg dose of doxycycline given within 72 hours of an I. scapularis tick bite, was shown to be 87% effective. The OspA vaccine is no longer manufactured due to poor sales. Consequently, single-dose doxycycline prophylaxis is rapidly gaining acceptance in the United States. Limiting single-dose doxycycline to just the highest risk tick bites can be accomplished if the health care provider has learned to differentiate engorged from unengorged I. scapularis ticks. Limitations of single-dose doxycycline prophylaxis are that the majority of patients with Lyme borreliosis do not recall a tick bite, and that there is no evidence that other Ixodes transmitted infections, such as human granulocytic ehrlichiosis, would be prevented. A safe, effective, inexpensive and well-accepted vaccine would be welcome.     

免疫转印法检测白色念珠菌菌丝组分蛋白抗体

目的　为了探讨血清中白色念珠菌菌丝相蛋白组分抗体的实验室诊断意义。方法　应用超声粉碎和ConA Sepharose4B亲和层析除去细胞壁甘露糖和甘露糖蛋白后 ,收集蛋白抗原 ,通过免疫转印技术 ,检测血清标本中相应抗原的抗体。结果　血库血清 40份中 ,1例阳性 ;白色念珠菌培养阳性的 90名患者 ,抗体阳性 5 8例 ;热带念珠菌培养阳性的 17名患者 ,10例抗体阳性。使用大量抗菌药物和 /或免疫抑制剂治疗而培养阴性的 14名患者中 ,抗体阳性 7例。抗体阳性的 75例结果中 ,15例出现 2 9ku和 47ku条带 ,5 1例单独出现 47ku条带 ,9例仅出现 2 9ku条带。结论　免疫转印法检测抗体可作为深部念珠菌感染的参考指标 ,并可提供抗体动态变化模式 ,为深入研究打下基础。     

Antibiotic treatment of Lyme borreliosis

Unlike most bacterial infections, where diagnosis is by identification of the causal organism, diagnosis of infection by Borrelia burgdorferi (Lyme's borreliosis) relies mostly upon indirect techniques. This situation has some short-comings. As long as no technology permits a microbiological diagnosis of this infection, controversy will exist as to the clinical symptoms and the criteria for the cure of the disease. Despite the lack of consensus upon both the clinical definition and the treatment of Lyme's borreliosis, it is widely agreed that the affection is best understood if regarded as a progressive general infectious disease. Indeed, following a bite with local infection, there occurs a fairly rapid dissemination of the spirochaetes. In vivo therapeutic trials have shown the potential effectiveness of beta-lactams and tetracyclines, but no treatment is considered universally effective. Most of the first trials were empirical, as antibiograms were not used. Antibiotic concentrations reached with some oral therapies are too low for the protection of certain sites such as the central nervous system. In vitro studies conducted on various strains of B. burgdorferi both in the US and in Europe are very enlightening. Among the more perplexing results of some of these studies, it is worth noting the high resistance rate of some B. burgdorferi strains to penicillin, reported by Johnson et al. and by Preac Mursic et al. Therapy for Lyme's borreliosis is discussed in light of both the in vivo and in vitro studies.     

Late stage Lyme borreliosis in children

These cases illustrate that late stage Lyme borreliosis can occur in children without a history of tick bite or ECM; this disorder can manifest itself initially as a seventh cranial nerve palsy, heart block, or arthritis, and the arthritis syndrome can mimic oligoarticular juvenile rheumatoid arthritis. The diagnosis of Lyme borreliosis depends upon clinical recognition. In the absence of ECM, tests for antibodies to Borrelia burgdorferi can provide an invaluable tool in assisting in the diagnosis. Children who live in or visit areas endemic for Lyme borreliosis and who have arthritis, heart block, or neurologic disorders such as facial palsy should be tested for antibodies to Borrelia burgdorferi if no other cause for the disease syndrome is identified clinically.     

Lyme borreliosis and multiple sclerosis

There is now general consensus that tertiary Lyme borreliosis affecting the central nervous system does exist. Clinical, neuropathologic, laboratory and epidemiologic features indicate clearly that tertiary Lyme borreliosis of the CNS is a distinct entity and there is no etiologic association with multiple sclerosis.     

The outcome of Lyme borreliosis in children

Austria is an endemic area for Lyme borreliosis. The IgG seroprevalence of healthy blood donors as investigated by a DAKO flagellum-ELISA in Graz/Styria is 13%. In order to determine whether this high seroprevalence is caused by infection in childhood, 36 children aged 3 to 18 years (mean, 10.1 years) were followed up over 2 to 20 months (mean, 11.1 months) and reinvestigated for clinical symptoms and antibodies against B. burgdorferi by a commercial flagellum ELISA and a commercial B. garinii Western blot (WB). Twenty-seven children had erythema migrans (EM), one of them with reinfection, 5 had borrelia lymphocytoma (BL), 2 EM and BL, 1 acrodermatitis chronica atrophicans and 1 ACA/circumscribed scleroderma. Before treatment with either phenoxymethylpenicillin, amoxicillin, or minocyclin for 3-4 weeks, 64% of the patients were IgM and 44%, IgG seropositive. Clinically, all but 5 patients with EM recovered from Lyme borreliosis. Among these 5 patients--one of them with reinfection of EM--3 had mild arthralgia, 1 recurrent headache and 1 concentration disturbance. Only 2 children with arthralgia were IgM positive by ELISA and WB. One of 5 BL patients had a persistent swelling of the ear lobe although with a negative serology before and after several antibiotic treatments and at follow up. In 16 children serological investigations were performed after more than 12 months (range, 13-20 months). Eighteen percent of them had IgM antibodies by ELISA, 25% by WB, and 6% IgG antibodies by ELISA and 6% by WB. Although there was a decline of antibody response from 64% to 18% for IgM and from 44% to 6% for IgG as measured by ELISA, children remain seropositive for more than 1 year with or without clinical symptoms. The relevance of the association with clinical symptoms can be raised by combining several diagnostic methods. It is assumed that recurrent, often silent, infections might increase antibody titres. It should be noted that antibody titres also generally increase with the age of individuals.     

Multiple sclerosis and Lyme borreliosis

In a deductive approach the two disease entities of multiple sclerosis and chronic progressive neuroborreliosis are discussed. Various clinical features, seroepidemiology, neuroimaging, CSF findings, CSF serology, specific proteins within the CSF and antibodies against neuronal structures as well as the most recent findings of different dendritic cells within the CSF are discussed as a means of differentiating these two disease entities.     

Vaccination against Lyme borreliosis.

Lyme borreliosis is a worldwide family of tick-borne infections caused by the spirochete Borrelia burgdorferi sensu lato. It is the most common tick-borne human infection in the Western world. There are several subgroups of the spirochete. Two monovalent vaccines against this infection have been presented in the USA, both of which use the borrelial outer surface protein A (OspA) as antigen. The first of these vaccines has been released for general use. A European polyvalent vaccine using the antigen OspC is undergoing clinical trial in the Aland Islands in Finland. Lately, another antigen group, decorin-binding proteins (Dbp), has been considered for immunization purposes. A European vaccine must be effective against several subgroups of the borrelia spirochete, and this complicates the situation compared with that in the USA, where one spirochete subspecies dominates the scene.     

Epidemiology and diagnosis of Lyme borreliosis

The multisystem disease Lyme borreliosis is the most frequent tick-transmitted disease in the northern hemisphere. In Europe Lyme borreliosis is most frequent in Central Europe and Scandinavia (up to 155 cases per 100,000 individuals) and is caused by the species, B. burgdorferi sensu stricto, B. afzelii and B. garinii. The recently detected genospecies A14S may also play a role in skin manifestations. Microbiological diagnosis in European patients must consider the heterogeneity of borreliae for development of diagnostic tools. According to guidelines of the USA and Germany, serological diagnosis should follow the principle of a two-step procedure (enzyme-linked immunosorbent assay (ELISA) as first step, if reactive; followed by immunoblot). The sensitivity and standardization of immunoblots has been considerably enhanced by use of recombinant antigens (p100, p58, p41i, VlsE, OspC, DbpA) including those expressed primarily in vivo (VlsE and DbpA) instead of whole cell lysates. VlsE is the most sensitive antigen for IgG antibody detection, OspC for IgM antibody detection. At present, detection rates for serum antibodies are 20%-50% in stage I, 70%-90% in stage II, and nearly 100% in stage III Lyme disease. Detection of the etiological agent by culture or polymerase chain reaction (PCR) should be confined to specific indications and specialized laboratories. Recommended specimens are skin biopsy specimens, cerebrospinal fluid (CSF) and synovial fluid. The best results are obtained from skin biopsies with culture or PCR (50%-70%) and synovial tissue or fluid (50%-70% with PCR). CSF yields positive results in only 10%-30% of patients except when the duration of symptoms is shorter than 2 weeks (50% sensitivity). Methods which are not recommended or adequately documented for diagnosis are antigen tests on body fluids, PCR of urine, and lymphocyte transformation tests.     

Epidemiology and diagnosis of Lyme borreliosis

The multisystem disease Lyme borreliosis is the most frequent tick‐transmitted disease in the northern hemisphere. In Europe Lyme borreliosis is most frequent in Central Europe and Scandinavia (up to 155 cases per 100,000 individuals) and is caused by the species, B. burgdorferi sensu stricto, B. afzelii and B. garinii. The recently detected genospecies A14S may also play a role in skin manifestations. Microbiological diagnosis in European patients must consider the heterogeneity of borreliae for development of diagnostic tools. According to guidelines of the USA and Germany, serological diagnosis should follow the principle of a two‐step procedure (enzyme‐linked immunosorbent assay (ELISA) as first step, if reactive; followed by immunoblot). The sensitivity and standardization of immunoblots has been considerably enhanced by use of recombinant antigens (p100, p58, p41i, VlsE, OspC, DbpA) including those expressed primarily in vivo (VlsE and DbpA) instead of whole cell lysates. VlsE is the most sensitive antigen for IgG antibody detection, OspC for IgM antibody detection. At present, detection rates for serum antibodies are 20%–50% in stage I, 70%–90% in stage II, and nearly 100% in stage III Lyme disease. Detection of the etiological agent by culture or polymerase chain reaction (PCR) should be confined to specific indications and specialized laboratories. Recommended specimens are skin biopsy specimens, cerebrospinal fluid (CSF) and synovial fluid. The best results are obtained from skin biopsies with culture or PCR (50%–70%) and synovial tissue or fluid (50%–70% with PCR). CSF yields positive results in only 10%–30% of patients except when the duration of symptoms is shorter than 2 weeks (50% sensitivity). Methods which are not recommended or adequately documented for diagnosis are antigen tests on body fluids, PCR of urine, and lymphocyte transformation tests.     

Procalcitonin levels in patients with Lyme borreliosis

BACKGROUND: Serum and cerebrospinal fluid (CSF) procalcitonin levels were assessed and compared for different groups of patients with Lyme borreliosis. PATIENTS AND METHODS: 50 adult patients with Lyme borreliosis, referred to our department from March to June 2001, were included in this prospective study. Patients were divided into three groups. The first group consisted of 20 consecutive patients with typical solitary erythema migrans, representing early localised Lyme borreliosis, the second group comprised 20 patients with early disseminated Lyme borreliosis (10 with multiple erythema migrans and 10 with neuroborreliosis), and 10 patients with acrodermatitis chronica athrophicans represented the group with chronic Lyme borreliosis. Blood specimens were taken from all patients included in the study, but CSF samples were restricted to those with disseminated and chronic Lyme borreliosis. The serum and CSF procalcitonin levels were determined utilizing the LUMI PCT (an immunoluminometric assay using two antigen-specific monoclonal antibodies). RESULTS: Serum and CSF procalcitonin levels were in normal range in the large majority of patients. The levels of serum procalcitonin did not differ in the three groups of patients with Lyme borreliosis (p = 0.5006). The corresponding values for patients with solitary erythema migrans (early localised Lyme borreliosis), early disseminated Lyme borreliosis, and chronic Lyme borreliosis were 0.26 (0.11-0.43), 0.22 (0.10-0.67), and 0.28 (0.13-0.66) microgram/ml, respectively. Moreover, procalcitonin levels in CSF were also low and comparable for patients with multiple erythema migrans (median 0.38, range 0.24-0.54 microgram/ml), neuroborreliosis (median 0.16, range 0.10-0.47 microgram/ml), and acrodermatitis chronica athrophicans (median 0.30, range 0.15-0.45 microgram/ml). The differences were not statistically significant (p = 0.7579). CONCLUSIONS: In the large majority of patients with Lyme borreliosis procalcitonin values are within normal range. Serum and CSF procalcitonin levels are of no value for differentiation between early localised, early disseminated and chronic Lyme borreliosis.     

Lyme borreliosis and peripheral facial palsy

From 1994 to 1996, 114 consecutive patients older than 15 years who presented at the Department of Infectious Diseases, University Medical Centre, Ljubljana, fulfilled the criteria for inclusion into this study on the borrelial aetiology of peripheral facial palsy (PFP). The study was restricted to patients without a conceivable explanation for their PFP, erythema migrans or history of erythema migrans, clinical signs/symptoms of frank meningitis or any other neurological manifestation in addition to PFP. In 22 (19.3%) of these 114 patients borrelial infection was confirmed by one of the following: in 3 (13.6%) by the isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid (CSF), in 11 (50%) by the presence of intrathecal antibody production, and in 8 (36.4%) by seroconversion to borrelial antigens. Additional 20 (17.5%) patients interpreted as having had a probable borrelial infection, had positive (> or = 1:256) IFA IgM and/or IgG borrelial serum antibody titres, and in 9 (7.9%) patients borderline borrelial antibody titres (1:128) were found (interpreted as a possible infection). In 63 (55.3%) patients the serological tests remained negative. Lymphocytic pleocytosis was found at the first visit in 12/22 (54.5%) patients with confirmed borrelial infection, in 3/20 (15%) with probable infection, in 1/9 (11.1%) with possible infection, and in 10/63 (15.9%) patients with symptoms of unknown aetiology. Patients with confirmed borrelial infection had abnormal CSF findings significantly more often than did patients with symptoms of unknown aetiology (p = 0.0139 for lymphocytic pleocytosis and/or elevated CSF protein levels, and p = 0.0010 for lymphocytic pleocytosis). Local and systemic signs/-symptoms were also more common in patients with confirmed borrelial infection than in those with an symptoms of unknown aetiology (p = 0.0258). In Slovenia which is a highly endemic region for Lyme borreliosis, borrelial infection is a frequent cause of PFP in adult patients. PFP may occur early in the course of LB, prior to measurable antibody response, indicating the need for serologic follow-up. Abnormal CSF results and the presence of additional local and/or systemic symptoms are factors indicating a higher possibility of borrelial aetiology of PFP and should alert physicians to suspect LB.     

Lyme borreliosis in Finland in 1986-1988

In 1986-1988 there were 123 patients with positive serology for Lyme borreliosis out of 4000 sera referred to the Department of Bacteriology and Immunology, University of Helsinki. Of the 63 patients with positive serology in 1986-1987 20 showed a predominant involvement of the nervous system, 18 complained of joint symptoms and 11 patients merely showed a skin involvement including 8 patients with erythema chronicum migrans (ECM) and 3 patients with acrodermatitis chronica atrophicans (ACA). Two of the patients had unspecific general symptoms and in 5 patients the type of involvement remained unknown. The serology was considered to be falsely positive in 2 patients with tuberculous meningitis, in one with syphilis and in another with recurrent fever.     

Lyme disease: a confusing multisystem borreliosis

Lyme disease, a tick-borne infection caused by the spirochete Borrelia burgdorferi, involves many organ systems. Three clinical stages of involvement have been described; patients with the disease may have cutaneous, arthritic, neurologic, or cardiac symptoms, or a constellation of manifestations. Specific antibody testing and antibiotic agents are available for Lyme disease, but a high index of suspicion must be exercised to recognize atypical manifestations.     

Clinical and epidemiological features of Lyme borreliosis in Bulgaria

INTRODUCTION: Data on disease expression and epidemiological characteristics of Lyme borreliosis in south-eastern Europe are scarce. PATIENTS: To reveal features of Lyme borreliosis in Bulgaria, clinical data and epidemiological characteristics of 1257 patients reported between 1999 and 2002 were analysed. RESULTS: The most affected age group was 5-9 years, followed by 45-49 years, 50-54 years, and 10-14 years. Most of the patients (68%) lived in a rural area or were attacked by ticks during activities in a rural area. Lyme borreliosis cases occurred throughout the year with two peaks--one in June and second smaller one in September. The most common clinical manifestation was erythema migrans (EM), diagnosed in 868 (69.1%) of the patients. Rashes had a median diameter of 11 cm and were predominantly located on lower extremities. Forty-four per cent of the rashes consisted of homogenous erythema and 56% had central clearing. Multiple EM was detected in 4.3% of the EM cases. Neuroborreliosis was the second most common presentation of Lyme borreliosis, diagnosed in 19% of the patients. Lyme arthritis was found in 8% of the patients. Heart and ocular manifestations were recorded in 1.1% and 0.9% of the patients, respectively. Borrelial lymphocytoma and acrodermatitis chronica atrophicans were very rare (0.3%). Twenty-seven patients (2.1%) had multiple organ involvement. CONCLUSIONS: The results of the study show that the epidemiology and clinical manifestations of Lyme borreliosis in Bulgaria are similar to those in the majority European countries but possess some distinguishing characteristics.     

Detection of Borrelia burgdorferi DNA by polymerase chain reaction in the urine and breast milk of patients with Lyme borreliosis

Current laboratory diagnosis of Lyme borreliosis relies on tests for the detection of antibodies to Borrelia burgdorferi with known limitations. By using a simple extraction procedure for urine samples, B. burgdorferi DNA was amplified by a nested PCR with primers that target the specific part of the flagellin gene. To control possible inhibition of the enzyme (polymerase), a special assay using the same primers was developed. We examined 403 urine samples from 185 patients with skin manifestations of Lyme borreliosis. Before treatment, B. burgdorferi DNA was detected in 88 of 97 patients with Lyme borreliosis. After treatment, all but seven patients became nonreactive. Six of these seven persons suffered from intermittent migratory arthralgias or myalgias, and one from acrodermatitis chronica atrophicans. Two of 49 control patients with various dermatologic disorders and none out of 22 presumably healthy persons were reactive in the PCR. In addition to urine, breast milk from two lactating women with erythema migrans was tested and also found reactive. Borrelia burgdorferi DNA can be detected with high sensitivity (91%) by a nested PCR in urine of patients with Lyme borreliosis. In addition, this test can be a reliable marker for the efficacy of treatment.