[Clinical characteristics of Lyme disease]

Clinical characteristics of Lyme disease were analysed in 22 patients. Erythema migrans was found in 20 (91%), arthralgia in 18 (81%), neuralgia in 8 (36%), encephalitis in 3 (13%), carditis in 2 (9%) and arthritis in 2 (9%) patients. The positive antibody titer was found in 14 (63%) patients. Favourable effects of antibiotic therapy was achieved in all patients. Erythema migrans has been manifested up to 12 days after tick sting and arthralgia, arthritis, neuralgia, hepatitis and chronic dermatitis within a year. Carditis and encephalitis have been developing from a month to ten years after tick sting. Lyme borreliosis is commonly manifested as a systemic disease. Together with the skin, most commonly have been involved ankle joints, heart and nervous system. The time from tick sting to the onset of first signs of the diseases varies by the involved organs.

[Lyme disease: cutaneous involvement and treatment of the initial phases]

Lyme disease is a tick-transmitted infectious disease caused by Borrelia burgdorferi. The clinical spectrum includes manifestations in the skin, heart, joints and nervous system. In Brazil no case has been reported with laboratorial confirmation. We report a suspect case with clinical and laboratorial findings in a young woman who developed cutaneous manifestations. She recovered after tetracycline treatment. The usual manifestations and the treatment of early stage of the illness are discussed.

[Erythema chronicum migrans (Lyme's disease). Clinico-epidemiologic study of 10 cases]

Migratory Chronic Erythema (MCE), which is the distinctive and diagnostic lesion of Lyme's disease, could manifest itself under different clinical manifestations. Following a clinical and a epidemiological point of view 10 cases of MCE, diagnosed during the last three years, have been studied and described. Its wide variability of the clinical manifestations is underlined, with a mean incubation period of 5.6 days between the onset of cutaneous symptoms and the tick bite. The zones mainly affected were lower limbs followed by trunk and neck. Size of lesion varied from 5 to 30 cm, with a mean of 13 cm. In two patients satellite cutaneous lesions were observed and six showed extra-cutaneous signs. Only in four patients antibodies against Borrelia burgdorferi were detected. Regarding epidemiology we did not found differences between the sexes, or by living on an urban or rural area. The tick bite was referred in half of the cases, 30% of the patients have a job related with wood, forest, farming or cattle. The season in which MCE was most frequent was spring-beginning of summer and end of summer-beginning of autumn. All patients responded to the therapy with tetracyclines and/or macrolides.

[Lyme borreliosis: how is it manifested in Spain?]

BACKGROUND

Lyme borreliosis is not usually diagnosed in Spanish patients since before 1987. The aim of this study was to know the clinical spectrum of infection by Borrelia burgdorferi in Spain by a prospective epidemiologic study.

METHODS

The period of collection of cases was from 1987 to 1989 and the follow-up period was of 2 years following diagnosis. Detection of serum antibodies was performed by indirect immunofluorescence and ELISA to patients with clinical suspicion of Lyme borreliosis established in 17 Spanish hospitals. The clinical and serologic data and the possibility of other disease which could justify the symptoms were evaluated with the doctor responsible for the patient.

RESULTS

Fifty-four patients with clinical manifestations and serologic data indicative of the disease and in whom other diagnosis were excluded were detected. Other diseases which could be the cause of the symptomatology were diagnosed in 26 patients with positive serology. Sixty-three percent of the patients had neurologic symptoms, 46% articular symptoms, 44% cutaneous symptoms and 9% cardiac symptoms.

CONCLUSIONS

Lyme borreliosis is not exceptional in Spain. Its clinical spectrum may be situated half way between American and European epidemiologic descriptions. Serology must be interpreted by the clinical manifestations.

Liver function test abnormalities in early Lyme disease

OBJECTIVE

Lyme disease is a widespread, tick-borne, spirochetal infection with multiple organ system involvement Hepatic dysfunction has not been emphasized in the literature. We report clinical findings and laboratory abnormalities in 73 patients with the pathognomonic erythema migrans rash early in the course of the illness.

DESIGN

Case series.

SETTING

Offices of family physicians in private practice and the model offices of a family practice residency program in the lower Connecticut River valley, an area to which Lyme disease is endemic.

PATIENTS

Thirty-seven female and 36 male patients with erythema migrans who had not yet been treated with antimicrobial agents.

MAIN OUTCOME MEASURE

Liver function tests.

RESULTS

Twenty patients (27%) had liver function abnormalities. Elevation of gamma-glutamyltransferase was the most common finding. Only seven patients (9%) had a positive titer in response to the enzyme-linked immunosorbent assay for Lyme disease. Other laboratory and clinical findings are described.

CONCLUSION

Subclinical hepatitis is a common finding in early Lyme disease.

Western blotting in the serodiagnosis of Lyme disease

There are currently no accepted criteria for positive Western blots in Lyme disease. In a retrospective analysis of 225 case and control subjects, the best discriminatory ability of test criteria was obtained by requiring at least 2 of the 8 most common IgM bands in early disease (18, 21, 28, 37, 41, 45, 58, and 93 kDa) and by requiring at least 5 of the 10 most frequent IgG bands after the first weeks of infection (18, 21, 28, 30, 39, 41, 45, 58, 66, and 93 kDa). When these definitions were tested in a prospective study of all 237 patients seen in a diagnostic Lyme disease clinic during a 1-year period and in 74 patients with erythema migrans or summer flu-like illnesses, the IgM blot in early disease had a sensitivity of 32% and a specificity of 100%; the IgG blot after the first weeks of infection had a sensitivity of 83% and a specificity of 95%. Among patients with indeterminate IgG responses by ELISA, 6 of 9 patients with active Lyme disease had positive blots compared with 2 of 34 patients with other illnesses (P < .001). Thus, Western blotting can be used to increase the specificity of serologic testing in Lyme disease.

Neuroborreliosis in the etiology of vestibular neuronitis

Symptoms and incidence of neuroborreliosis (NB) were studied in ambulatory patients visiting the ENT clinic in Helsinki. Especially we tried to search for possible markers indicating the connection between vestibular neuronitis and NB. A total of 350 patients were screened with the enzyme-linked immunosorbent assay (ELISA) technique for possible antibodies against Borrelia burgdorferi (BB). Twelve patients had positive serological reactions for BB with sera titer levels ranging from 640-14700 (normal < 500). In 2 additional cases, NB was clinically confirmed. In 7 cases a history of tick bite and in 4 cases erythema chronicum migrans was confirmed. In 9 cases, vertigo was the predominant symptom, and in 3 cases the symptoms were linked to facial nerve paresis. Six patients suffered from hearing loss. In 7 cases, the diagnosis was initially settled as vestibular neuronitis. NB seems to be present in about 4% of cases with apparent otologic diseases in Finland. In the majority of the cases, the disease resembles vestibular neuronitis in the acute stage. Since NB is tractable, all patients visiting the ENT clinic, especially those with vertigo, should be screened.

Erythema chronicum migrans: an electron-microscopic study

Spirochaetal organisms are found in skin specimens obtained by biopsy from a erythema chronicum migrans lesion. The histological picture shows a logical localization of a lymphohistiocytic cell infiltrate: deep dermal in the central papule and superficial in the erythematous border. The electron-microscopic characteristics of the micro-organisms in these specimens (regular waving appearance with coils every 0.8-1.2 microns, oblique striation of periplasmatic fibrils, cross-section of 0.3 micron, membranes) correspond to the spiral-like structure of Borreliae isolated from blood. The Borreliae seem to move freely through the matrix of the dermis and are not phagocytized. This brings on the typical clinical picture of the centrifugally spreading erythematous band.

Lyme disease

Lyme disease is a multisystem disorder caused by the spirochete Borrelia burgdorferi. It is transmitted to human and animal hosts primarily by ticks of the Ixodes ricinis complex. Recognition of its characteristic skin and eye manifestations facilitates diagnosis and treatment.

Antibodies to Borrelia burgdorferi in patients with carpal tunnel syndrome

In a study of 94 consecutive patients with neurophysiologically verified carpal tunnel syndrome (CTS) 7/94 had IgG and 0/94 IgM serum titers to Borrelia burgdorferi above the 98th percentile value of age and sex matched controls (n = 127). The difference in prevalence of positive IgG serum titers in patients, compared to controls, was not statistically significant. Even in patients, living in an area, highly endemic for Lyme borreliosis, routine serological screening for borrelia infection does not seem indicated in the investigation of CTS.

[Lyme disease: 4 reported cases in the Autonomous Community of Aragon]

Lyme's disease (LD) is a multisystemic infection due to Borrelia Burgdorferi transmitted through the byte of a vector arthropod of the Ixodes genre. Until now we do not know exactly which is the geographical distribution in our setting, no case have been published in the Aragon Community. We present four patients diagnosed of Lyme's disease following clinical and serological criteria (IFI) according to the recommendations of the Spanish Group for the study of Lyme's disease. A patient with Chronic Migratory Erythema (ECM); two others in stage II--one with predominant dermal lesions and other with predominant neurological symptoms--and finally, a patient in stage III with polyarticular symptoms and with antecedent of having showed a lymphocytic meningoencephalitis.

[Positive anti-Borrelia antibodies in patients with clinical manifestations compatible with neuroborreliosis]

The clinical features of 19 patients with neurological manifestations unexplained by another disease and positive serology for Borrelia burgdorferi were studied. ECM was present in only 11% of the cases and 32% referred tick bite. The characteristic features for suspicion of NB according to our series was the presence of polyneuritis in 84% of the cases specially in the form of multiple mononeuritis and involvement of the facial nerve (79%) leading to even greater suspicion with the association of V pair involvement. Seizures, sleep disorders, and higher mental dysfunction may be found in association with other more characteristic neurological features. The typical triad of NB (aseptic meningitis, facial paralysis and polyradiculoneuritis) was found in 21% of the patients and in the absence of another disease to justify the same neuroborreliosis (NB) seemed evident. In all the cases components of this triad were found. Headache, arthralgia, fever and, less frequently, arthritis are other symptoms often past with the presence of anti-BB antibodies. Patients with the shortest evolution most frequently presented antecedents of facial paralysis, sensory alterations and Romberg's sign than patients of longer evolution. CSF demonstrated the presence of pleocytosis in 24% of the cases and in only one patient a slight increase in the intrathecal activity of IgG was observed which may be of use in differential diagnosis with MS. MR showed alterations in 61% of the patients and, while not specific, the lesions present subcortical predominance.

Cultivation of Borrelia burgdorferi from erythema migrans lesions and perilesional skin

Skin biopsy specimens from the peripheral aspect of erythema migrans lesions (site 1) and from clinically normal perilesional areas (site 2) were compared as sources of Borrelia burgdorferi. This spirochete was isolated from the skin of 18 of 21 (86%) patients with untreated early Lyme disease at one or both biopsy sites. Site 1 specimens were superior to site 2 specimens for the isolation of B. burgdorferi. Site 1 specimens from 18 (86%) patients were culture positive, and site 2 specimens from 12 (57%) patients were culture positive. For patients whose site 2 specimens were culture positive, site 1 specimens were also found to be culture positive. B. burgdorferi was isolated from two patients with atypical lesions and from two patients with erythema migrans lesions that were less than 5 cm in diameter. This study demonstrates that the cultivation of B. burgdorferi from skin biopsy specimens from cutaneous lesions thought to be erythema migrans can be an efficacious procedure for confirming the diagnosis of Lyme disease and that the spirochete is present in clinically normal appearing perilesional skin.

Complications of Lyme borreliosis

Lyme borreliosis is the multisystem infectious disease caused by the spirochete Borrelia burgdorferi. Complications of this infection can involve many organ systems, especially the skin, joints, nervous system, and heart. These manifestations may be acute, or evolve slowly over months or years. Diagnosis is not always straightforward, and is currently hampered by lack of a specific serologic assay. This review discusses the syndromes associated with Lyme borreliosis and addresses issues of diagnosis and treatment.

[Incidence of skin manifestations of Lyme disease in Croatia]

In the study, the most relevant historical data concerning Lyme-borreliosis are shortly reviewed. The most frequent skin manifestations, i.e. erythema cronicum migrans (ECM), lymphocytoma cutis (LCC) and acrodermatitis chronica atrophicans (ACA) are described. The clinical course of Lyme disease and the chronologic review of the most significant data on the disease are given. The frequency of skin manifestations of Lyme-borreliosis in various areas of Croatia from 1988 to 1989 based on the reports of dermatologists throughout Croatia is presented. According to our results, it can be concluded that skin manifestations of Lyme-borreliosis are much more frequent in the central and western parts of Croatia than elsewhere. The authors hope that the use of a fluorescent method for detecting antibodies to Borrelia burgdorferi since 1989 in the Serologic Laboratory of the Department of Dermatology, Salata, Zagreb will lead to more precise results about this disorder in the future.

Ovalbumin blocking improves sensitivity and specificity of immunoglobulin M immunoblotting for serodiagnosis of patients with erythema migrans

To improve the serodiagnosis of erythema migrans, we evaluated how sensitivity and specificity of immunoblotting are influenced by antigen concentration and blocking conditions. We found that an antigen concentration of 0.5 micrograms per lane in concert with ovalbumin blocking of the nitrocellulose provided the best results. In this case, 81% of the erythema migrans had positive immunoglobulin M tests, whereas only 33% were positive in a flagellum enzyme-linked immunosorbent assay (ELISA) and 28% were positive in a sonicate ELISA.