Detection of Borrelia burgdorferi DNA and complement membrane attack complex deposits in the sural nerve of a patient with chronic polyneuropathy and tertiary Lyme disease

Chronic Lyme Disease: An Evidence-Based Definition by the ILADS Working Group

Objective: Chronic Lyme disease has been a poorly defined term and often dismissed as a fictitious entity. In this paper, the International Lyme and Associated Diseases Society (ILADS) provides its evidence-based definition of chronic Lyme disease. Definition: ILADS defines chronic Lyme disease (CLD) as a multisystem illness with a wide range of symptoms and/or signs that are either continuously or intermittently present for a minimum of six months. The illness is the result of an active and ongoing infection by any of several pathogenic members of the Borrelia burgdorferi sensu lato complex (Bbsl). The infection has variable latency periods and signs and symptoms may wax, wane and migrate. CLD has two subcategories, CLD, untreated (CLD-U) and CLD, previously treated (CLD-PT). The latter requires that CLD manifestations persist or recur following treatment and are present continuously or in a relapsing/remitting pattern for a duration of six months or more. Methods: Systematic review of over 250 peer reviewed papers in the international literature to characterize the clinical spectrum of CLD-U and CLD-PT. Conclusion: This evidence-based definition of chronic Lyme disease clarifies the term's meaning and the literature review validates that chronic and ongoing Bbsl infections can result in chronic disease. Use of this CLD definition will promote a better understanding of the infection and facilitate future research of this infection.

Femoral mononeuropathy in Lyme disease: a case report

Background

Peripheral neuropathy is a common complication of Lyme disease. Cranial mononeuropathy, particularly that affecting the facial nerve, can be a presenting symptom, and at times, it can be associated with polyradiculopathies or plexopathies. However, isolated femoral neuropathy has not yet been reported in Lyme disease; therefore, we felt the need to present this case.

Case presentation

Laboratory investigations were performed on a 67-year-old man living in a region at high risk for Lyme disease after he developed erythema migrans on his chest, accompanied by the swelling of his left knee joint. A Western blot immunoglobulin assay was performed, including a screening for connective tissue disorders. Positive serological test results led to the administration of oral doxycycline therapy at a dosage of 100 mg twice daily. Shortly afterwards, he developed gait difficulties and frequent falls. The clinical examination and electrodiagnostic studies were consistent with femoral neuropathy. To look for etiologies other than Lyme disease, radiographic studies of his lumbar spine, pelvic cavity, retroperitoneal compartment, and hips were conducted. In addition, he was screened for diabetes. However, no other etiologies were found to explain the femoral neuropathy. Eventually, he recovered, and he was able to return to work.

Conclusion

We firmly believe that the femoral neuropathy and Lyme disease seen in this patient were causally related.

[A Japanese case of neuroborreliosis with papillitis]

A 53-year-old Japanese female developed a fever about two months after a tick bite. She also exhibited blurred vision, central scotoma in the left eye, left facial paresis and mild ataxia. A fundus examination revealed left disc swelling in the left eye. An ophthalmological examination showed decreased visual acuity with central scotoma in the left eye. We suspected neuroborreliosis because of the presence of pleocytosis and an elevated level of IL-6 in the cerebrospinal fluid (CSF), in addition to the characteristic neurological findings. She was positive for serum IgG antibodies against Borrelia by a Western blot of her serum. Therefore, we diagnosed her to have neuroborreliosis with papillitis. After the combined administration of antibiotics and steroids, her symptoms gradually improved, but not all of her eye manifestations resolved. Although ocular involvement is rare in neuroborreliosis, this case highlights the fact that neuroborreliosis shoud be considered as a differential diagnosis for patients presenting with papillitis. The diagnosis of neuroborreliosis is important since improvement of the visual acuity is possible with specific antibiotheraphy. In cases with papillitis of unknown etiology, it might be better to consider the possibility of neuroborreliosis should be considered when there are signs of Lyme borreliosis, such as facial nerve palsy, arthritis or radiculoneuritis.

Lumbosacral multiradiculopathy responsive to antibiotic therapy: description of four patients with lumbar spondylosis and a superimposed Lyme disease

Lyme disease is a diffuse zoonosis caused by spirochaetes of the Borrelia burgdorferi species complex. Neurological manifestations of the disease, involving central or peripheral nervous system, are common. This study describes four consecutive patients with an MRI-proven lumbosacral spondylosis, who complained of progressive worsening of symptoms in the last months in which serological evaluation suggested a superimposed B. Burgdorferi infection. Four patients, all from the Lazio region, were admitted to the Department of Neurology. Extensive laboratory studies and clinical, anamnestic and neurophysiological evaluation were performed in all cases. In all cases, anamnesis revealed a previous diagnosis of lumbosacral foraminal stenosis. Clinical and neurophysiological findings were consistent with a lumbosacral multiradiculopathy. Considering serological evaluation suggestive of a superimposed B. burgdorferi infection a proper antibiotic therapy was started. All cases showed a marked improvement of symptoms. Clinicians should be aware that in all cases of lumbosacral multiradiculopathy, even if a mechanical cause is documented, B. burgdorferi may be a simply treatable condition.

Peripheral nervous system manifestations of lyme borreliosis

Lyme disease is a tick-borne illness that has protean neurologic manifestations involving both the central and peripheral nervous system. The peripheral nervous system manifestations of Lyme borreliosis can be divided chronologically into acute and chronic forms. Within weeks after disease onset, approximately 15% of untreated patients develop an acute Lyme meningoradiculoneuritis with headache, fever, radicular pain, weakness, and sensory loss, often associated with cranial neuropathy, usually facial palsy. Cerebrospinal fluid typically shows lymphocytic pleocytosis, high protein, and normal glucose. Diagnosis is made by recognition of characteristic clinical features with a history of preceding exposure and confirmed by serologic evidence of exposure to B. burgdorferi or by antibody or PCR evidence of cerebrospinal fluid infection. Months to years after onset, rare patients may develop chronic polyradiculoneuropathy presenting with sensory symptoms or radicular pain. Diagnosis is confirmed by a history of exposure, previous systemic or acute neurologic manifestations of Lyme borreliosis, and serologic evidence of infection. Pathology of acute or chronic Lyme radiculoneuropathy reveals axonal degeneration with perivascular mononuclear infiltration. Eradication of the organism can be achieved with 2 to 4 weeks of ceftriaxone for both acute and chronic Lyme neuroborreliosis. Isolated facial palsy without evidence of cerebrospinal fluid infection can be treated with oral antibiotics such as doxycycline. Prognosis after therapy is good, but neurologic recovery is slower for chronic than acute Lyme radiculoneuropathy.

[Successful treatment of neuroborreliosis with combined administration of antibiotics and steroids: a case report]

A 66-year-old woman developed bilateral facial paralysis as well as sensory and motor disturbances of extremities. Two months after the onset of paralysis, she also developed sensory disturbance of her trunk and vesicorectal disturbance, and her symptoms worsened gradually. Because the interferon-γ level in the cerebrospinal fluid was elevated, we suspected that her symptoms were caused by polyneuropathy and myelitis associated with infection. Her serum IgM and IgG antibodies against Borrelia garinii and B. afzelli were positive. Therefore, we diagnosed her as having neuroborreliosis. Her symptoms gradually improved after the combined administration of antibiotics and steroids. The present case report showed that it might be better to consider the possibility of neuroborreliosis when there are increasing concentrations of cytokine and chemokine, and that combination treatment with antibiotics and steroids can be used for the treatment of this disease.

Autoimmune-mediated polyneuropathy triggered by borrelial infection?

A patient with proven borrelial infection of the central nervous system (CNS) and progressive weakness of the arms was treated with antibiotics. Although the initially elevated CXCL13 concentration in the cerebrospinal fluid decreased, indicating effective treatment of the infection, weakness progressed. Investigation revealed multiple nerve conduction blocks and the presence of GM1 antibodies, suggesting a multifocal motor neuropathy; the patient improved on treatment with intravenous immunoglobulins. This report of an autoimmune-mediated polyneuropathy in a patient with borrelial CNS infection indicates that such patients might respond to immunomodulatory therapy if antibiotic treatment is not effective.

Sur quels éléments cliniques et épidémiologiques faut-il évoquer le diagnostic de la borréliose de Lyme? Aspects neurologiques et psychiatriques au cours de la maladie de Lyme

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.

Lyme disease and the peripheral nervous system

Lyme disease, the multisystem infectious disease caused by the tick-borne spirochete Borrelia burgdorferi, causes a broad variety of peripheral nerve disorders, including single or multiple cranial neuropathies, painful radiculopathies, and diffuse polyneuropathies. Virtually all appear to be varying manifestations of a mononeuropathy multiplex. Diagnosis requires that the patient should have had possible exposure to the only known vectors, Ixodes ticks, and also have either other pathognomonic clinical manifestations or laboratory evidence of exposure. Treatment with antimicrobial regimens is highly effective. The mechanism underlying these neuropathies remains unclear, although interactions between anti-Borrelia antibodies and several peripheral nerve constituent molecules raise intriguing possibilities.

Lyme disease

Lyme disease is due to infection with a tick-borne spirochete, Borrelia burgdorferi. Risk for infection is confined to regions that contain the Ixodid tick vector. Characteristic skin, musculoskeletal, cardiac, ocular, and neurologic disorders are associated with the local, early dissemination and late stages of infection. Neurologic involvement can be seen at all stages, and involves both central and peripheral nervous system syndromes. The inability to easily culture B. burgdorferi and the lack of a reliable active infection assay have contributed to controversies in diagnosis and management. Because the vast majority of patients are seropositive, however, antibody testing is helpful to support the diagnosis of Lyme disease. With appropriate antibiotics, most patients do well. This infection provides an important model system to understand how interactions between an organism, vector, and host lead to disease. It also provides a model to study how infectious agents lead to neurologic disease.

Neurologic aspects of Lyme disease

Lyme disease has emerged as a major infection with frequent neurologic manifestations. These manifestations probably reflect several predominantly indirect pathogenetic mechanisms and involve host, vector, and organism factors. With early diagnosis and appropriate antibiotic treatment, patients do well. Because culture is not reliable, diagnosis has relied on positive serology to document exposure. Serology should improve as second-generation assays become available. Although there is a preventive vaccine based on the lipoprotein OspA, newer vaccines in development may prove more desirable. Lyme disease provides a valuable model to study how infectious pathogens cause neurologic disease.

H9724, a monoclonal antibody to Borrelia burgdorferi's flagellin, binds to heat shock protein 60 (HSP60) within live neuroblastoma cells: a potential role for HSP60 in peptide hormone signaling and in an autoimmune pathogenesis of the neuropathy of Lyme disease

Although Borrelia burgdorferi, the causative agent of Lyme disease, is found at the site of many disease manifestations, local infection may not explain all its features. B. burgdorferi's flagellin cross-reacts with a component of human peripheral nerve axon, previously identified as heat shock protein 60 (HSP60). The cross-reacting epitopes are bound by a monoclonal antibody to B. burgdorferi's flagellin, H9724. Addition of H9724 to neuroblastoma cell cultures blocks in vitro spontaneous and peptide growth-factor-stimulated neuritogenesis. Withdrawal of H9724 allows return to normal growth and differentiation. Using electron microscopy, immunoprecipitation and immunoblotting, and FACS analysis we sought to identify the site of binding of H9724, with the starting hypotheses that the binding was intracellular and not identical to the binding site of II-13, a monoclonal anti-HSP60 antibody. The current studies show that H9724 binds to an intracellular target in cultured cells with negligible, if any, surface binding. We previously showed that sera from patients with neurological manifestations of Lyme disease bound to human axons in a pattern identical to H9724's binding; these same sera also bind to an intracellular neuroblastoma cell target. II-13 binds to a different HSP60 epitope than H9724: II-13 does not modify cellular function in vitro. As predicted, II-13 bound to mitochondria, in a pattern of cellular binding very different from H9724, which bound in a scattered cytoplasmic, nonorganelle-related pattern. H9724's effect is the first evidence that HSP60 may play a role in peptide-hormone-receptor function and demonstrates the modulatory potential of a monoclonal antibody on living cells.

Lyme neuroborreliosis

A broad variability in the clinical manifestations is observed in the European and North American borrelioses. This is dependent on bacterial strain differences in virulence and organotropism, and on different immune responses to Borrelia burgdorferi of the host in these areas. Experimental neuroborreliosis has given insights into mediators and molecular mechanisms of inflammation induced by B. burgdorferi. Histopathological investigations have described the different patterns of injury in the peripheral and central nervous systems. The classic symptoms of neuroborreliosis have been supplemented by new clinical syndromes and neuropsychological investigations. In clinical trials, the efficacy and cost effectiveness of recommended oral and intravenous antibiotic therapies have been compared in early Lyme disease, arthritis and acute disseminated Lyme disease.

Isolated neuritis of the sciatic nerve in a case of Lyme disease

Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi. The course of the disease is divided into three stages, the second of which may include various types of peripheral nervous system disturbances. We report the case of a patient with persistent deficits caused by the prevalent involvement of the sciatic nerve, confirmed by electrophysiological and neuropathological findings. The most significant bioptic results were axonal degeneration and perivascular inflammation. Damage to a single peripheral nerve as the dominant clinical expression during the course of Lyme disease is an unusual finding that has been rarely described in the literature.