Lyme arthritis in European children and adolescents. The Pediatric Rheumatology Collaborative Group

Differentiating Lyme arthritis: a case-based review

The incidence or prevalence of Lyme arthritis (LA) in Denmark is unknown and assumed very low. No published cases of polymerase chain reaction (PCR)-confirmed LA from Denmark exist. Clinically, LA does not differ from other rheumatic oligoarthritic disorders posing a differential diagnostic challenge. To review the incidence and prevalence of LA to our knowledge and to present a case series of PCR-confirmed LA cases from Denmark. We conducted a systematic literature review via MEDLINE and EMBASE to explore incidence and prevalence rates of LA. Additionally, we present six cases of patients diagnosed with LA in Denmark. Our literature review identified 23 studies reporting prevalence or incidence, yet only ten studies provided estimates ranging from 1.1 to 280/100.000 in the general population. Our case series identified six patients with LA from a localized region in Southern Denmark; all confirmed by Borrelia-specific real-time PCR from synovial fluid. The diagnostic delay was up to 38 months. All patients except one had a history of previous tick bites; none had erythema migrans lesions. All presented with recurrent arthritis in the knee joint, and two had arthritis in the wrist. The literature review showed an incidence of LA ranging from 1.1 to 15.8 per 100.000 in Europe. Our case series suggests a potentially higher prevalence of LA in Denmark than previously believed. Lack of tick exposure history, antibody assessments and test of Borrelia burgdorferi sensu lato DNA in synovial fluid might lead to misdiagnosed cases potentially explaining the assumed low incidence of LA in Denmark.

Chronic limping in childhood, what else other than juvenile idiopathic arthritis: a case series

BACKGROUND

Limping is a common clinical symptom in childhood; different clinical conditions may lead to limping and the diagnosis of the underlying cause may often be a challenge for the pediatrician.

CASE PRESENTATION

We describe the clinical manifestations, radiological pictures and disease course of other causes of limping in childhood, through a case series of seven cases and a brief discussion of each disease.

CONCLUSIONS

although trauma is the most common cause of acute limping, when there is no history of traumatic events and the limping has a chronic course, Juvenile Idiopathic Arthritis is usually the most likely clinical diagnosis. However, other some rare conditions should be taken into account if JIA is not confirmed or if it presents with atypical clinical picture.

Comparison of Lyme Disease in the United States and Europe

Lyme disease, or Lyme borreliosis, is the most common tickborne disease in the United States and Europe. In both locations, Ixodes species ticks transmit the Borrelia burgdorferi sensu lato bacteria species responsible for causing the infection. The diversity of Borrelia species that cause human infection is greater in Europe; the 2 B. burgdorferi s.l. species collectively responsible for most infections in Europe, B. afzelii and B. garinii, are not found in the United States, where most infections are caused by B. burgdorferi sensu stricto. Strain differences seem to explain some of the variation in the clinical manifestations of Lyme disease, which are both minor and substantive, between the United States and Europe. Future studies should attempt to delineate the specific virulence factors of the different species of B. burgdorferi s.l. responsible for these variations in clinical features.

Intraarticular Glucocorticoid Injection as Second-line Treatment for Lyme Arthritis in Children

OBJECTIVE

To determine whether second-line intraarticular glucocorticoid (IAGC) injection improves outcomes in children with persistently active Lyme arthritis after initial antibiotics.

METHODS

We conducted an observational comparative effectiveness study through chart review within 3 pediatric rheumatology centers with distinct clinical approaches to second-line treatment of Lyme arthritis. We primarily compared children receiving second-line IAGC to children receiving a second course of antibiotics alone. We evaluated the risk of developing antibiotic-refractory Lyme arthritis (ARLA) using logistic regression and the time to clinical resolution of Lyme arthritis using Cox regression.

RESULTS

Of 112 children with persistently active Lyme arthritis after first-line antibiotics, 18 children received second-line IAGC (13 with concomitant oral antibiotics). Compared to children receiving second-line oral antibiotics alone, children treated with IAGC had similar baseline characteristics but lower rates of ARLA (17% vs 44%; OR 0.3, 95% CI 0.1-0.95; p = 0.04) and faster rates of clinical resolution (HR 2.2, 95% CI 1.2-3.9; p = 0.01). Children in IAGC and oral antibiotic cohorts did not differ in treatment-associated adverse events. Among children receiving second-line IAGC, outcomes appeared similar irrespective of use of concomitant antibiotics. Outcomes were also similar between intravenous (IV) and oral antibiotic-treated cohorts, but older children seemed to respond more favorably to IV therapy. IV antibiotics were also associated with higher rates of toxicity.

CONCLUSION

IAGC injection appears to be an effective and safe second-line strategy for persistent Lyme arthritis in children, associated with rapid clinical resolution and reduced need for additional treatment.

Pediatric Antibiotic-refractory Lyme Arthritis: A Multicenter Case-control Study

OBJECTIVE

Few factors have consistently been linked to antibiotic-refractory Lyme arthritis (ARLA). We sought to identify clinical and treatment factors associated with pediatric ARLA.

METHODS

We performed a case-control study in 3 pediatric rheumatology clinics in a Lyme-endemic region (2000-2013). Eligible children were aged ≤ 18 years with arthritis and had positive testing for Lyme disease by Western blot. Cases were 49 children with persistently active arthritis despite ≥ 8 weeks of oral antibiotics or ≥ 2 weeks of parenteral antibiotics; controls were 188 children whose arthritis resolved within 3 months of starting antibiotics. We compared preselected demographic, clinical, and treatment factors between groups using logistic regression.

RESULTS

Characteristics positively associated with ARLA were age ≥ 10 years, prolonged arthritis at diagnosis, knee-only arthritis, and worsening after starting antibiotics. In contrast, children with fever, severe pain, or other signs of systemic inflammation were more likely to respond quickly to treatment. Secondarily, low-dose amoxicillin and treatment nonadherence were also linked to higher risk of ARLA. Greater antibiotic use for children with ARLA was accompanied by higher rates of treatment-associated adverse events (37% vs 15%) and resultant hospitalization (6% vs 1%).

CONCLUSION

Older children and those with prolonged arthritis, arthritis limited to the knees, or poor initial response to antibiotics are more likely to have antibiotic-refractory disease and treatment-associated toxicity. Children with severe symptoms of systemic inflammation have more favorable outcomes. For children with persistently active Lyme arthritis after 2 antibiotic courses, pediatricians should consider starting antiinflammatory treatment and referring to a pediatric rheumatologist.

Pediatric Lyme Arthritis of the Hip: The Great Imitator?

BACKGROUND

Lyme arthritis (LA) of the hip can present similarly to septic arthritis (SA) and transient synovitis (TS). The primary purpose of this study was to determine clinical and laboratory parameters differentiating LA of the hip from SA or TS among children who had undergone hip aspiration during the evaluation of hip pain.

METHODS

This was a retrospective review of all patients who underwent hip aspiration for the evaluation of hip pain at a tertiary care children's hospital in a Lyme endemic area. Clinical and laboratory data were reviewed and comparative analyses were performed between those diagnosed with LA, SA, and TS. Independent samples t test, ANOVA, and χ test were used to compare clinical and laboratory variables as appropriate. Multivariable logistic regression was used to elucidate independent predictors of LA. Statistical significance was set at P<0.05.

RESULTS

Ninety-three hip aspirations (93 patients) were included in the final analysis. Seventeen patients were diagnosed with LA, 40 with SA, and 36 with TS. Multivariable logistic regression revealed febrile history (OR=16.3; 95% CI, 2.35-113.0) and increased peripheral white blood cell (WBC) count (OR=1.26; 95% CI, 1.01-1.58) to be significantly associated with increased odds of being diagnosed with SA versus LA. Increased erythrocyte sedimentation rate (ESR) was significantly associated with increased odds of being diagnosed with LA versus TS (OR=1.06; 95% CI, 1.02-1.10), whereas febrile history (OR=0.06; 95% CI, 0.01-0.49) and increased peripheral WBC count (OR=0.8; 95% CI, 0.65-0.98) were associated with decreased odds of LA.

CONCLUSIONS

Children presenting in a Lyme endemic area with an isolated hip effusion are more likely to have LA versus SA if they have no history of fever and a decreased peripheral WBC count. Compared with TS, patients with LA are more likely to have an elevated ESR. This study adds to existing knowledge because there are few investigations examining isolated LA of the hip.

LEVEL OF EVIDENCE

Level III-retrospective case-control study.

When a patient suspected with juvenile idiopathic arthritis turns out to be diagnosed with an infectious disease - a review of Lyme arthritis in children

The Lyme arthritis is a common manifestation of infection with Borrelia burgdorferi spirochete. Despite its infectious background, the inflammation clinically and histopatologically resembles juvenile idiopathic arthritis. As it affects a considerable number of Lyme disease patients, it should be routinely considered in differential diagnosis. Development of arthritis is partially dependent on spirochetal factors, including the ribosomal spacer type and the sequence of outer surface protein C. Immunological background involves Th1-related response, but IL-17 provides an additional route of developing arthritis. Autoimmune mechanisms may lead to antibiotic-refractory arthritis. The current diagnostic standard is based on a 2-step testing: ELISA screening and immunoblot confirmation. Other suggested methods contain modified two-tier test with C6 ELISA instead of immunoblot. An initial 28-day course of oral antibiotics (doxycycline, cefuroxime axetil or amoxicillin) is a recommended treatment. Severe cases require further anti-inflammatory management. Precise investigation of new diagnostic and therapeutic approaches is advisable.

Lyme disease in children

The diagnosis and management of Lyme disease in children is similar to that in adults with a few clinically relevant exceptions. The use of doxycycline as an initial empiric choice is to be avoided for children 8 years old and younger. Children may present with insidious onset of elevated intracranial pressure during acute disseminated Lyme disease; prompt diagnosis and treatment of this condition is important to prevent loss of vision. Children who acquire Lyme disease have an excellent prognosis even when they present with the late disseminated manifestation of Lyme arthritis. Guidance on the judicious use of serologic tests is provided. Pediatricians and family practitioners should be familiar with the prevention and management of tick bites, which are common in children.

Lyme arthritis: a comparison of presentation, synovial fluid analysis, and treatment course in children and adults

OBJECTIVE

This case series examines differences in the presentation, management, and outcome of Lyme arthritis between the pediatric and adult population.

METHODS

We reviewed charts of pediatric and adult patients evaluated for Lyme arthritis by rheumatologists and pediatric infectious disease specialists in Portland, Maine between January 2002 and July 2008. Patients included for analysis had documented joint swelling and positive Lyme serology. Data on clinical presentation, synovial fluid and peripheral blood results, treatment, and clinical course were analyzed.

RESULTS

Twenty-nine adults and 52 children met case criteria for Lyme arthritis. Children were more likely than adults to present acutely (P < 0.0001) and also had higher mean peripheral blood (P = 0.05) and synovial fluid white blood cell counts (P < 0.0001). Lyme arthritis was more frequently suspected in children at presentation (P = 0.04). There was no difference between children and adults with respect to suspicion for septic arthritis, hospitalization, or surgical intervention. Adults received more antibiotic courses (P = 0.007) and were more likely to have intravenous antibiotics in subsequent treatment courses (P = 0.006). Children were more likely to have normal function within 4 weeks of initiating antibiotic treatment (P < 0.0001).

CONCLUSION

Children with Lyme arthritis were more likely to present acutely with higher synovial white cell counts than adults. We did not, however, observe a significant difference in hospitalization or surgical management. Children had more prompt resolution of their joint swelling and received less treatment overall.

Bakterielle Infektionen: Atypische Bakterien

Chlamydophila (früher Chlamydia) pneumoniae ist im Kindesalter ein seltener Erreger respiratorischer Infektionen, vor allem der Pneumonie, wenn die PCR als direkte Nachweismethode herangezogen wird. Die höhere Nachweisrate von Antikörpern gegen C. pneumoniae deutet auf eine hohe Rate asymptomatischer oder unspezifischer Infektionen durch C. pneumoniae hin.

Der Mensch ist weltweit das einzige Erregerreservoir. Kranke, seltener auch asymptomatische Ausscheider (Wochen bis 1 Jahr) sind die Ansteckungsquelle. Die Übertragung erfolgt als „Tröpfcheninfektion“ mit respiratorischen Sekreten. Eine epidemische Krankheitshäufung ist beschrieben. In feuchtem Milieu können Chlamydien bis zu 30 h auf unbelebtem Material überleben.

Im Erwachsenenalter haben 50–75 % der Bevölkerung Antikörper gegen C. pneumoniae. Die höchsten Titer werden in der Altersklasse der 5- bis 14-Jährigen gefunden – ein Indiz für das Hauptmanifestationsalter der Primärinfektion. Seroprävalenzdaten aus Deutschland decken sich mit den Angaben aus der internationalen Literatur (5 % der unter 10-Jährigen, 64 % der unter 18-Jährigen besitzen Antikörper gegen C. pneumoniae). Ambulant erworbene Pneumonien werden im Kindesalter möglicherweise in bis zu 18 % der Fälle (serologische Diagnose) durch C. pneumoniae verursacht. Untersuchungen mittels PCR hingegen weisen C. pneumoniae nur in sporadischen Fällen nach. Koinfektionen mit Mykoplasmen, aber auch Pneumokokken und Adenoviren sind keine Seltenheit.

Approach to the child with joint inflammation

Arthritis is manifested as a swollen joint having at least 2 of the following conditions: limited range of motion, pain on movement, or warmth overlying the joint. This article discusses an approach to the evaluation of a child with arthritis of one (mono) or several (poly) joints.

Primary lyme arthritis of the pediatric hip

BACKGROUND

Lyme arthritis most commonly affects the knee. It is not commonly considered in the differential diagnosis of monoarticular hip pain. There are only a few case reports describing Lyme disease presenting with isolated hip involvement. The purpose of this study is to review our experience with primary Lyme arthritis of the hip.

METHODS

Clinical records at a tertiary children's referral center in a Lyme endemic region were scanned for key words "Lyme" and "hip." Patients with isolated Lyme disease of the hip were included. Diagnosis was made based on Centers for Disease Control guidelines. Clinical presentation, laboratory evaluation, and treatment information were recorded for eligible patients.

RESULTS

Eight patients met eligibility criteria with an average age of 9.5 years (3 to 20y). All patients presented with hip pain (8), limp (3), or refusal to bear weight (5). One of 8 patients had a fever >38.5°C. Two of 8 patients had a peripheral white blood cell count >12,500/mm and 3 of 8 patients had an erythrocyte sedimentation rate>40 mm/h. Aspiration was performed on 5 patients, with a median synovial fluid white blood cell of 41,500/mm (21,500 to 73,500/mm). Three of 8 patients were treated surgically; all patients were treated with antibiotics and were asymptomatic at last follow-up. With the exception of 1 case, there was a delay before appropriate antibiotics were started.

CONCLUSIONS

Primary monoarticular Lyme arthritis of the hip is uncommon. Clinical presentation and laboratory findings are variable, and differentiating it from septic arthritis or toxic synovitis of the hip may be difficult. In areas where Lyme disease is endemic, it should be considered in the differential diagnosis of monoarticular hip pain associated with an effusion.

LEVEL OF EVIDENCE

Level IV, Case Series.

Ankle arthritis in a 6-year-old boy after a tick bite - a case report

Background:

Monoarthritis of the ankle is a rare condition in children, and is most often caused by a bacterial infection. Lyme disease is endemic in southern Scandinavia, and diagnosis remains a challenge. The clinical presentation of Lyme disease varies greatly, and often with considerable delay between exposure and presentation.

Case Presentation:

We report a case of ankle arthritis in a boy who presented one year earlier with a tick bite on the dorsum of the foot. He was suboptimally treated with oral antibiotics for one week, and developed in the following months a painless limp. Radiographs revealed a severe arthritis of the right ankle joint with necrosis of the talus and deformation of the talocrural and subtalar joints. There was no history of malaise, fever or other systemic symptoms. He remains seronegative for antibodies against B. burgdorferi.

Conclusions:

The suboptimal oral antibiotic treatment may have hindered the antibody production against B burgdorferi, while not being therapeutic, resulting in severe ankle arthritis due to seronegative Lyme disease.

[Juvenile arthritides]

Arthritis in children represents a diagnostic and therapeutic challenge. The diagnostic spectrum is broad and a very precise indication for diagnostic and therapeutic procedures, especially in small children, is important. In addition to acute arthritides - viral arthritis, reactive arthritis, Lyme arthritis and septic arthritis - secondary chronic arthritis related to an underlying disease as well as juvenile idiopathic arthritis (JIA), the most common chronic inflammatory systemic disease in children, need to be considered. This overview is a guide to the diagnosis of arthritis in childhood and to evidence-based therapy of JIA in particular. This consists of a combination of nonsteroidal anti-inflammatory drugs, systemic and intraarticular corticosteroids, traditional DMARDs such as sulfasalazine, methotrexate and leflunomide, the TNF inhibitors etanercept, adalimumab and, with restrictions, infliximab, other biopharmaceuticals such as anakinra, canakinumab and rilonacept, and tocilizumab and finally, abatacept.

Treatment of Lyme borreliosis

Borrelia burgdorferi sensu lato is the causative agent of Lyme borreliosis in humans. This inflammatory disease can affect the skin, the peripheral and central nervous system, the musculoskeletal and cardiovascular system and rarely the eyes. Early stages are directly associated with viable bacteria at the site of inflammation. The pathogen-host interaction is complex and has been elucidated only in part. B. burgdorferi is highly susceptible to antibiotic treatment and the majority of patients profit from this treatment. Some patients develop chronic persistent disease despite repeated antibiotics. Whether this is a sequel of pathogen persistence or a status of chronic auto-inflammation, auto-immunity or a form of fibromyalgia is highly debated. Since vaccination is not available, prevention of a tick bite or chemoprophylaxis is important. If the infection is manifest, then treatment strategies should target not only the pathogen by using antibiotics but also the chronic inflammation by using anti-inflammatory drugs.

Lyme arthritis presenting as transient synovitis of the hip

Transient synovitis of the hip is a common cause of hip pain in children. The etiology of transient synovitis of the hip is unknown. Lyme arthritis is characterized by brief, often recurrent episodes of oligoarthritis. Lyme arthritis most often affects a single knee, but hip involvement is uncommon. This report describes 2 children with Lyme arthritis who presented with features of transient synovitis of the hip. Lyme arthritis should be considered in the differential diagnosis of transient synovitis of the hip in children.

Lyme disease: European perspective

The main clinical features of Lyme borreliosis seem to be the same in Europe and North America; however, the course of erythema migrans is distinct, with multiple erythema migrans and hematogeneous dissemination in early Lyme borreliosis less frequently observed in Europe. Moreover, the skin manifestations borrelial lymphocytoma and acrodermatitis chronica atrophicans are apparently European phenomena. Meningoradiculoneuritis in Lyme neuroborreliosis, with its severe radicular pain, is more prominent in Europe. Similar difficulties exist on both sides of the Atlantic with the serologic diagnosis of Lyme borreliosis.

[Lyme arthritis in children and adolescents]

Lyme arthritis is one of the manifestations of Lyme disease and is caused by infection with Borrelia burgdorferi sensu lato. This article reviews the current knowledge regarding the epidemiology, etiology and pathogenesis as well as the clinical manifestations, the diagnosis, treatment and prognosis with special emphasis on children and adolescents.

Antibiotic treatment of Lyme borreliosis: what is the evidence?

Antibiotic treatment of all disease manifestations after infection with Borrelia sensu lato spp aims at resolving the presenting disease manifestation and preventing late stage disease. The goals are resolution of the preventing manifestation and prevention of the spread of bacteria to prevent late disease like arthritis. Different borrelial species prevail in Europe. The natural disease course of European borreliosis is not well defined and the effect of antibiotic treatment is unclear.

Lyme borreliosis: from infection to autoimmunity

Lyme borreliosis in humans is an inflammatory disease affecting multiple organ systems, including the nervous system, cardiovascular system, joints and muscles. The causative agent, the spirochaete Borrelia burgdorferi, is transmitted to the host by a tick bite. The pathogenesis of the disease in its early stages is associated largely with the presence of viable bacteria at the site of inflammation, whereas in the later stages of disease, autoimmune features seem to contribute significantly. In addition, it has been suggested that chronic persistence of B. burgdorferi in affected tissues is of pathogenic relevance. Long-term exposure of the host immune system to spirochaetes and/or borrelial compounds may induce chronic autoimmune disease. The study of bacterium-host interactions has revealed a variety of proinflammatory and also immunomodulatory-immunosuppressive features caused by the pathogen. Therapeutic strategies using antibiotics are generally successful, but chronic disease may require immunosuppressive treatment. Effective and safe vaccines using recombinant outer surface protein A have been developed, but have not been propagated because of fears that autoimmunity might be induced. Nevertheless, new insights into the modes of transmission of B. burgdorferi to the warm-blooded host have been generated by studying the action of these vaccines.

Phenotypes indicating cytolytic properties of Borrelia-specific interferon-gamma secreting cells in chronic Lyme neuroborreliosis

The immuno-pathogenetic mechanisms underlying chronic Lyme neuroborreliosis are mainly unknown. Human Borrelia burgdorferi (Bb) infection is associated with Bb-specific secretion of interferon-gamma (IFN-gamma), which may be important for the elimination of Bb, but this may also cause tissue injury. In order to increase the understanding of the pathogenic mechanisms in chronic neuroborreliosis, we investigated which cell types that secrete IFN-gamma. Blood mononuclear cells from 13 patients with neuroborreliosis and/or acrodermatitis chronicum atrophicans were stimulated with Bb antigen and the phenotypes of the induced IFN-gamma-secreting cells were analyzed with three different approaches. Cells expressing CD8 or TCRgammadelta, which both have cytolytic properties, were the main phenotypes of IFN-gamma-secreting cells, indicating that tissue injury in chronic neuroborreliosis may be mediated by cytotoxic cells.

Tick-borne diseases

Tick-transmitted infectious agents have assumed increased importance as causes of human disease in the United States. During the past two decades, Lyme borreliosis, ehrlichiosis, and babesiosis have emerged as newly described tick-borne infectious diseases of significance for pediatricians and pediatric neurologists. In fact, the highest rates of infection for Lyme disease and Rocky Mountain spotted fever (RMSF), by decade of age, are in childhood. As such, tick-borne infectious disease are of considerable public health concern, particularly for children residing in endemic regions. RMSF and human ehrlichioses can be life-threatening but are also eminently treatable when recognized early. Delays in diagnosis and treatment can lead to adverse outcomes. This article reviews the clinical and epidemiological features of Lyme borreliosis, RMSF, and ehrlichiosis, important causes of neurological illness among children, and summarizes current therapeutic and preventive strategies.

Ocular manifestations in children and adolescents with Lyme arthritis

BACKGROUND

Lyme arthritis is the most frequent late manifestation of Lyme borreliosis and has been associated with ocular inflammation.

METHODS

A group of 153 children and adolescents with arthritis, 84 of whom had Lyme arthritis and 69 other causes of arthritis, were followed prospectively for 22-73 (median 44) months in the course of a national study.

RESULTS

Three of 84 patients with Lyme arthritis had ocular inflammation (4%), including keratitis, anterior uveitis, and uveitis intermedia. All three had symptoms of decreased visual acuity. Whereas anterior uveitis disappeared without sequelae, a corneal scar and a permanent loss of visual acuity in the patients with keratitis and intermediate uveitis remained. Systematic examination of all patients revealed no further ocular involvement. Of 69 patients with other causes of arthritis who were followed in parallel as a control group, four of 15 patients with early onset pauciarticular juvenile rheumatoid arthritis had chronic anterior uveitis and two of 12 patients with juvenile spondyloarthropathy had acute anterior uveitis.

CONCLUSIONS

Ocular involvement with keratitis, anterior uveitis, and intermediate uveitis may occur in children and adolescents with Lyme arthritis. Visual loss appears to be symptomatic, making regular ocular screening of such patients unnecessary.

Borrelia burgdorferi downregulates ICAM-1 on human synovial cells in vitro

Lyme arthritis following infection with Borrelia burgdorferi (B. burgdorferi) is associated with the presence of bacteria in the joint, but the mechanism of persistent infection in the presence of specific antibodies and lymphocytes remains unknown. To investigate how an infection with B. burgdorferi might influence the local immune response in the joint, we examined the expression of cell adhesion molecules, human leucocyte antigens and inducible nitric oxide synthase (iNOS)-1 and -2 in human synovial cells after infection with B. burgdorferi in vitro. Synovial cells are known to influence the function of local immunologic effector cells and play a key role in the pannus formation of erosive arthritis. It has been shown previously that B. burgdorferi can persist in the cytosol of human synovial cells. The expression of the surface molecules ICAM-1, VCAM-1, HLA-class-I and -class-II and the cytosolic production of iNOS-1 and -2 in synovial cells was measured by flow cytometry for up to 5 days after infection with B. burgdorferi. A significant, lasting downregulation of surface ICAM-1 could be demonstrated on synovial cells, whereas no significant changes were seen in the expression of VCAM-1, HLA-class-I and -II, and of iNOS-1 and -2. To determine the biological significance of this downregulation an in vitro adhesion assay using peripheral blood mononuclear cells was developed. After infection with B. burgdorferi a significantly smaller number of mononuclear cells was adhering to the synovial cell monolayer. Adhesion of peripheral mononuclear cells was shown to be in part mediated by ICAM-1 by using a blocking mononuclear antibody against ICAM-1. Downregulation of ICAM-1 on synovial cells due to infection with B. burgdorferi might suppress the local immunosurveillance and might help the bacteria to persist in joint cells in vivo.

Characterization of Borrelia burgdorferi strains in Lyme arthritis

In the study presented, we investigated whether Lyme arthritis is associated with a particular Borrelia burgdorferi genospecies. Using the PCR technique, in 7/11 samples of synovial fluid of patients with Lyme arthritis a part of the ospA-gene was identified and the strains characterized by sequencing of the amplified DNA. Borrelia burgdorferi sensu stricto was found in 3 patients, B. garinii in 3, and B. afzelii in 1 patient. In conclusion, Lyme arthritis is caused by all 3 human pathogenetic genospecies which are actually known. For clinical practice PCR proved to be a rather insensitive diagnostic method, but may confirm the diagnosis of Lyme arthritis in doubtful cases.

Lyme arthritis in children: clinical epidemiology and long-term outcomes

OBJECTIVE

Although Lyme disease has become a relatively common cause of arthritis among children in areas of the country in which the disease is endemic, little information is available about the clinical epidemiology and long-term outcomes of children with Lyme arthritis. We conducted a long-term follow-up study to determine the clinical epidemiology of Lyme arthritis in children as well as their long-term outcomes.

PATIENTS AND METHODS

All children seen between 1982 and 1991 at the Pediatric Rheumatology Clinic at Newington Children's Hospital (Newington, CT) with an initial diagnosis of Lyme disease were identified. Medical records were reviewed and structured telephone interviews were conducted to obtain demographic, clinical, and follow-up data.

RESULTS

A total of 90 children (63% boys) with a mean age of 8.3 years (range, 1.8-16 years) at the time of diagnosis of Lyme arthritis were evaluated. Lyme arthritis was preceded by early Lyme disease in 23 (26%) of the children; however, only 8 (35%) of these children had been treated with appropriate antimicrobial therapy at that early stage. Ninety percent of the children had arthritis of at least one knee, while small joints were rarely involved. For the 31 children who underwent arthrocentesis, the mean white blood cell count in the synovial fluid was 38 000 cells/mm3 (range, 7000-99 000 cells/mm3) with predominantly neutrophils. For the 79 children for whom an erythrocyte sedimentation rate was determined, the highest level for 61 (77%) was >20 mm/h and for 36 (46%) was >50 mm/h. Antimicrobial therapy was initiated 2 days to 5.5 years (median, 2 months) after the onset of symptoms. However, 5 of the children were never treated with antimicrobials. Fifty-one percent of the patients had a single episode of arthritis, while 49% reported recurrent episodes of arthritis over a period of 1 week to 8 years (median, 6 months). Two children (2%) developed chronic arthritis and underwent arthroscopic synovectomy. At the time of the telephone follow-up evaluation, performed 2 to 12 years (median, 7 years) after the onset of the Lyme arthritis, 4 children had ongoing musculoskeletal complaints that resulted in mild to moderate impairment of school or sports activities, but none of the children had evidence of active arthritis.

CONCLUSION

The results of this investigation suggest that the prognosis for children with Lyme arthritis who are treated with appropriate antimicrobial therapy is excellent.

Diagnosis and treatment of Lyme arthritis

Lyme arthritis typically causes intermittent attacks of oligoarticular arthritis in a few large joints, especially the knee. A small percentage of patients may develop chronic arthritis, again affecting primarily the knee. The diagnosis is usually based on the presence of this characteristic clinical picture, exposure in an endemic area, and a positive IgG antibody response to B. burgdorferi determined by ELISA and Western blotting. In addition, spirochetal DNA can often be detected in joint fluid by PCR. Joint involvement in this infection can usually be treated successfully with a 1- or 2-month course of oral doxycycline or amoxicillin, but patients with certain genetic and immune markers may have persistent arthritis despite treatment with oral or intravenous antibiotics. If patients have persistent arthritis despite a second course of antibiotics and if the results of PCR testing are negative, the author treats such patients with anti-inflammatory agents or arthroscopic synovectomy.

Intracellular persistence of Borrelia burgdorferi in human synovial cells

To investigate if Borrelia burgdorferi can persist in resident joint cells, an infection model using cell cultures of human synovial cells was established and compared to the interaction of Borrelia burgdorferi and human macrophages. Borrelia burgdorferi were found attached to the cell surface or folded into the cell membrane of synovial cells analysed by transmission electron and confocal laser scanning microscopy. In contrast to macrophages, morphologically intact Borrelia burgdorferi were found in the cytosol of synovial cells without engulfment by cell membrane folds or phagosomes. Borrelia burgdorferi were isolated from parallel cultures. Treatment with ceftriaxone eradicated extracellular Borrelia burgdorferi, but spirochetes were reisolated after lysis of the synovial cells. Borrelia burgdorferi persisted inside synovial cells for at least 8 weeks. These data suggested that Borrelia burgdorferi might be able to persist within resident joint cells in vivo.

Lymphoproliferative responses to Borrelia burgdorferi in the diagnosis of Lyme arthritis in children and adolescents

To assess the contribution of the lymphocyte proliferation assay in response to borrelial antigens to establishing a diagnosis of Lyme arthritis (LA) the response to two strains of Borrelia burgdorferi was tested in peripheral blood lymphocytes of 103 children and adolescents with arthritis, among them 55 with LA and 48 control patients. Patients with LA had a significantly higher response to borrelial antigens than control patients. However, there were several patients with false positive and false negative test results. Specificity and sensitivity of the test were 78% and 77%. In patients with LA the test may turn positive after antibiotic therapy and remain positive for up to 19 months after the disappearance of arthritis. The test does not aid in prognosis or follow up. In one patient with seronegative LA specific lymphocyte proliferation and polymerase chain reaction for borrelial fla sequences in urine were positive.

CONCLUSION

Rarely the lymphocyte proliferation assay may aid in finding the correct diagnosis when clinical presentation and anti-borrelial serology do not match.

Dominant recognition of a Borrelia burgdorferi outer surface protein A peptide by T helper cells in patients with treatment-resistant Lyme arthritis

In an earlier study, we found that T-cell lines (TCL) from five patients with treatment-resistant Lyme arthritis preferentially recognized Borrelia burgdorferi outer surface protein A (OspA), but TCL from four patients with treatment-responsive arthritis only rarely recognized this protein. Dominant T-cell recognition of an arthritogenic OspA epitope is one way in which the immune response against OspA might be involved in the pathogenesis of treatment-resistant Lyme arthritis. In an effort to test this hypothesis, we mapped the epitopes of 31 OspA-specific TCL and five T-cell clones derived from the synovial fluid or peripheral blood samples of three patients with treatment-resistant Lyme arthritis. Although each patient's TCL recognized a broad array of OspA peptides with different individual patterns, two regions of OspA were dominantly recognized. Each patient's TCL dominantly recognized a C-terminal epitope of OspA, ranging from amino acids (aa) 214 to 233 in one patient to 244 to 263 in another, and the TCL of all three patients dominantly recognized an epitope between aa 84 and 113. These dominant regions were confirmed by clonal analysis in one patient. Thus, the region of OspA between aa 84 and 113 was the dominant T-cell epitope shared by these three patients with treatment-resistant Lyme arthritis. If the T-cell response to OspA is involved in the pathogenesis of treatment-resistant Lyme arthritis, and epitope contained within aa 84 to 113 is a potentially arthritogenic epitope.

An epidemiologic study of Lyme disease in southern Sweden

BACKGROUND

Lyme disease is the most common vector-borne infection in some temperate regions of the Northern Hemisphere. However, for most areas of endemic disease reliable epidemiologic data are sparse.

METHODS

Over a one-year period, we conducted a prospective, population-based survey of cases of Lyme disease in southern Sweden. The diagnosis was made on the basis of the presence of erythema migrans at least 5 cm in diameter or characteristic clinical manifestations such as arthritis, neuroborreliosis, and carditis.

RESULTS

We identified 1471 patients with Lyme disease, for an overall annual incidence of 69 cases per 100,000 inhabitants. The incidence varied markedly according to geographic region, and there were several areas where disease was widely prevalent. The incidence varied according to age, with the highest rates among people 5 to 9 and 60 to 74 years of age, but not according to sex. The most frequent clinical manifestation was erythema migrans (seen in 77 percent of all cases), followed by neuroborreliosis (16 percent) and arthritis (7 percent). Carditis was rare. A preceding tick bite was reported by 79 percent of the patients. Bites in the head and neck region were more common among children than among adults and were associated with an increased risk of neuroborreliosis.

CONCLUSIONS

Lyme disease is very common in southern Sweden, with a relatively high frequency of neurologic complications and arthritis. With the exception of the low incidence of carditis, the pattern of disease we found in Sweden was similar to that reported in the United States.

Diagnostic value of synovial fluid analysis in children with reactive arthritis

We report on three children with pauciarticular arthritis in whom the clinical picture and serology were compatible with both arthritis reactive to infection with Yersinia or Salmonella and with Lyme arthritis. Results of analysis of synovial fluid by polymerase chain reaction for enterobacterial or borrelial sequences were negative. Immunofluorescence with specific antibodies revealed the presence of amorphous enterobacterial antigens in synovial fluid cells. Since this staining did not reveal enterobacterial morphology, we infected synovial fluid cells of two children with juvenile rheumatoid arthritis in vitro with Yersinia or Salmonella. After 24 h typical rods were observed, but after about 1 week amorphous antigen similar to what had been found in the three patients was seen. In cases of reactive arthritis with ambiguous results of serological testing the diagnosis may be confirmed by demonstration of enterobacterial antigens in synovial fluid.