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Myszkowska-Torz A, Tomaszewski M, Kotowski M, Witczak C, Figlerowicz M, Mazur-Melewska K. Cutaneous Manifestations of Lyme Borreliosis in Children-A Case Series and Review. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010072. [PMID: 36676022 PMCID: PMC9864164 DOI: 10.3390/life13010072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
The occurrence of skin lesions is the earliest symptom of Lyme disease, and the diagnosis of these lesions and appropriate treatment may prevent complications of the disease, which are mainly neurological. The cutaneous presentation in borreliosis is heterogeneous. There are typical lesions that constitute the basis for the diagnosis of Lyme disease, and atypical ones, which cause significant diagnostic difficulties especially when the patient does not remember the tick bite. This study aims to describe the heterogeneous skin symptoms of Lyme borreliosis, as well as offer a practical approach for the recognition of the disease. Based on pediatric cases from clinical practice, rare cutaneous presentations of Lyme disease at various stages of illness and therapy are presented. Diagnostic recommendations for recognizing individual forms are discussed.
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Affiliation(s)
- Agnieszka Myszkowska-Torz
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, 61-701 Poznań, Poland
| | - Mateusz Tomaszewski
- Department of Orthodontics and Temporomanidbular Disorders, Karol Marcinkowski University of Medical Sciences, 61-701 Poznań, Poland
| | - Michał Kotowski
- Department of Pediatric Otolaryngology, Karol Marcinkowski University of Medical Sciences, 61-701 Poznań, Poland
| | - Cezary Witczak
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, 61-701 Poznań, Poland
| | - Magdalena Figlerowicz
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, 61-701 Poznań, Poland
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, 61-701 Poznań, Poland
- Correspondence:
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Podbićanin-Ziburt A, Falk TM, Metze D, Böer-Auer A. Diagnosis of Lyme Borreliosis With a Novel, Seminested Real-Time Polymerase Chain Reaction Targeting the 5S-23S Intergenic Spacer Region: Clinical Features, Histopathology, and Immunophenotype in 44 Patients. Am J Dermatopathol 2022; 44:338-347. [PMID: 34966044 DOI: 10.1097/dad.0000000000002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Lyme borreliosis (LB) is the most common tick-borne infection in Europe and North America. Polymerase chain reaction (PCR) is an important tool to confirm the diagnosis, but not always successful, especially when organisms are sparse. We developed a novel, seminested real-time PCR assay [target: 5S-23S intergenic spacer region (IGS)] and compared it with 3 well-established conventional PCR assays (IGS/OspA/real-time IGS) on 596 formalin-fixed, paraffin-embedded routine skin biopsies. The seminested real-time assay identified 46 cases of borreliosis while 25, 27, and 38 were identified by the 3 other assays, respectively (P 0.01, P 0.02, and P 0.42; significance P < 0.05). Clinicopathologic and immunophenotypic analysis of PCR-positive cases revealed 38 erythema migrans (EM), 6 Borrelia lymphocytomas, and 2 acrodermatitis chronica atrophicans (ACA). In the 44 PCR-confirmed cases, plasma cells were present in only a third of EM cases. By contrast, CD123-positive plasmacytoid dendritic cells were common (74%) and therefore are unlikely to be helpful in the differential diagnosis between EM and tumid lupus erythematosus. A loss of CD34 in a third of all LB specimens limits its diagnostic value in the differential diagnosis with morphea. Interstitial macrophages were common in cutaneous LB (42/43) forming interstitial granulomas in a third of all cases, and 3/38 EM, 3/6 Borrelia lymphocytomas, and 1/2 ACA were only identified by the new seminested real-time assay, suggesting that it is especially helpful in confirming the diagnosis of Borrelia lymphocytoma.
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Affiliation(s)
| | | | - Dieter Metze
- Department of Dermatology, University of Münster, Münster, Germany
| | - Almut Böer-Auer
- Dermatologikum Hamburg, Hamburg, Germany ; and
- Department of Dermatology, University of Münster, Münster, Germany
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3
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Torbahn G, Hofmann H, Rücker G, Bischoff K, Freitag MH, Dersch R, Fingerle V, Motschall E, Meerpohl JJ, Schmucker C. Efficacy and Safety of Antibiotic Therapy in Early Cutaneous Lyme Borreliosis: A Network Meta-analysis. JAMA Dermatol 2019; 154:1292-1303. [PMID: 30285069 DOI: 10.1001/jamadermatol.2018.3186] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Controversies about the choice of antibiotic agent and treatment modality exist in the management of erythema migrans in early cutaneous Lyme borreliosis (LB). Objective To conduct a network meta-analysis (NMA) of all randomized clinical trials on various antibiotic agents and treatment modalities in early cutaneous LB. Data Sources Electronic searches in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were conducted from inception until July 2017. The reference lists of the included studies were hand searched, authors were contacted, and ongoing trials were searched at ClinicalTrials.gov. Study Selection One reviewer screened the titles and abstracts of the 9975 reports identified by the electronic searches. Full-text copies of 161 potentially relevant articles were obtained, and 2 reviewers independently assessed those articles for inclusion. Adults with a physician-confirmed early localized skin infection who were treated with antibiotics of any dose or duration were included. Data Extraction and Synthesis Two reviewers independently extracted data on study, patient, and intervention characteristics. Network meta-analyses on treatment effects and adverse outcomes were calculated with a frequentist approach using the R package netmeta. The Grading of Recommendations Assessment, Development and Evaluation guidance for NMA was used to assess the certainty of evidence. Main Outcomes and Measures Treatment effects for response to treatment (resolution of symptoms) and treatment-related adverse events. Results Overall, 19 studies (2532 patients) were included. The mean patient age ranged between 37 and 56 years, and the percentage of female patients ranged from 36% to 60%. The antibiotics investigated were doxycycline, cefuroxime axetil, ceftriaxone, amoxicillin, azithromycin, penicillin V, and minocycline. Pooled effect sizes from NMAs did not suggest any significant differences in treatment response by antibiotic agent (eg, amoxicillin vs doxycycline odds ratio, 1.26; 95% CI, 0.41-3.87), dose, or duration (eg, doxycycline, 200 mg/d for 3 weeks, vs doxycycline, 200 mg/d for 2 weeks, odds ratio, 1.28; 95% CI, 0.49-3.34). Treatment failures were rare at both 2 months (4%; 95% CI, 2%-5%) and 12 months (2%, 95% CI, 1%-3%) after treatment initiation. There were also no differences in the effect sizes among antibiotic agents and treatment modalities for treatment-related adverse outcomes, which were generally mild to moderate. Certainty of evidence was categorized as low and very low mostly because of imprecision, indirectness, and study limitations (high risk of bias) of the included studies. Conclusions and Relevance This NMA suggests that neither the antibiotic agent nor treatment modality contributed to comparative effectiveness or drug-related adverse outcomes. This finding is relevant for physicians treating patients with LB and for patient decision making.
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Affiliation(s)
- Gabriel Torbahn
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heidelore Hofmann
- Department of Dermatology and Allergology, Technical University of Munich, München, Germany
| | - Gerta Rücker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Division of General Practice and Family Medicine, Department of Health Services Research, University of Oldenburg, Oldenburg, Germany
| | - Karin Bischoff
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael H Freitag
- Department of Neurology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Rick Dersch
- National Reference Centre for Borrelia, Bavarian Health and Food Safety Authority, Oberschleißheim, Germany
| | - Volker Fingerle
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Edith Motschall
- Division of General Practice and Family Medicine, Department of Health Services Research, University of Oldenburg, Oldenburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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4
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Böer-Auer A, Fölster-Holst R. [Skin biopsy of inflammatory skin diseases in childhood-when is it reasonable?]. Hautarzt 2018; 69:536-549. [PMID: 29869129 DOI: 10.1007/s00105-018-4205-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Compared with adulthood, inflammatory skin diseases are relatively rarely biopsied in children. Apart from the invasiveness of the procedure, the required local anesthesia, and the risks of infection and scarring, the psychological trauma of the operation has a higher impact in childhood. If a biopsy is performed, expectations towards the dermatopathology report are high. However, the evaluation of biopsies taken from children is challenging for the dermatopathologist: on the one hand, because the biopsies are often tiny or just superficial shaves and, on the other hand, because criteria for evaluation have mostly been developed from findings in adult biopsy specimens. In children, the immune system is still in the process of maturation and, therefore, infiltrates in the skin may look different from those seen in adults; however, knowledge about that is very limited to date. Moreover, numerous rare genodermatoses may manifest themselves first in childhood and need to be considered in the differential diagnosis while experience with them is often limited. Starting from the clinical presentation, this article presents histopathological features of possible differential diagnoses in order to demonstrate the value or necessity of a skin biopsy in a pediatric patient. In addition, communication with parents and child, methods of local anesthesia and biopsy techniques will be considered.
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Affiliation(s)
- A Böer-Auer
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland. .,Dermatologikum Hamburg, Stephansplatz 5, 20354, Hamburg, Deutschland.
| | - R Fölster-Holst
- Campus Kiel, Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Rosalind-Franklin-Str. 7, 24105, Kiel, Deutschland
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5
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Hofmann H, Fingerle V, Hunfeld KP, Huppertz HI, Krause A, Rauer S, Ruf B. Cutaneous Lyme borreliosis: Guideline of the German Dermatology Society. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2017; 15:Doc14. [PMID: 28943834 PMCID: PMC5588623 DOI: 10.3205/000255] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Indexed: 02/07/2023]
Abstract
This guideline of the German Dermatology Society primarily focuses on the diagnosis and treatment of cutaneous manifestations of Lyme borreliosis. It has received consensus from 22 German medical societies and 2 German patient organisations. It is the first part of an AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.) interdisciplinary guideline: “Lyme Borreliosis – Diagnosis and Treatment, development stage S3”. The guideline is directed at physicians in private practices and clinics who treat Lyme borreliosis. Objectives of this guideline are recommendations for confirming a clinical diagnosis, recommendations for a stage-related laboratory diagnosis (serological detection of IgM and IgG Borrelia antibodies using the 2-tiered ELISA/immunoblot process, sensible use of molecular diagnostic and culture procedures) and recommendations for the treatment of the localised, early-stage infection (erythema migrans, erythema chronicum migrans, and borrelial lymphocytoma), the disseminated early-stage infection (multiple erythemata migrantia, flu-like symptoms) and treatment of the late-stage infection (acrodermatitis chronica atrophicans with and without neurological manifestations). In addition, an information sheet for patients containing recommendations for the prevention of Lyme borreliosis is attached to the guideline.
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Affiliation(s)
- Heidelore Hofmann
- Klinik für Dermatologie und Allergologie der TU München, München, Germany
| | - Volker Fingerle
- Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit (LGL) Oberschleißheim, Germany
| | - Klaus-Peter Hunfeld
- Zentralinstitut für Labormedizin, Mikrobiologie & Krankenhaushygiene, Krankenhaus Nordwest, Frankfurt, Germany
| | | | | | | | - Bernhard Ruf
- Klinik für Infektiologie Klinik St Georg, Leipzig, Germany
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6
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[Lyme borreliosis after tick bite. When to consider the diagnosis Lyme borreliosis?]. MMW Fortschr Med 2017; 159:52-56. [PMID: 28656405 DOI: 10.1007/s15006-017-9850-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Torbahn G, Hofmann H, Allert R, Freitag MH, Dersch R, Fingerle V, Sommer H, Motschall E, Meerpohl JJ, Schmucker C. Efficacy and safety of pharmacological agents in the treatment of erythema migrans in early Lyme borreliosis-systematic review protocol. Syst Rev 2016; 5:73. [PMID: 27142846 PMCID: PMC4855495 DOI: 10.1186/s13643-016-0251-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/22/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Erythema migrans represents an early cutaneous and most common manifestation of Lyme borreliosis. Recommendations regarding pharmacological agents, dose and duration of treatment are subject of intense debate. This review aims to explore differences in efficacy and safety between pharmacological treatments and control treatment. METHODS To identify relevant studies, we will conduct a systematic literature search. We will include randomised controlled trials (RCTs) and non-RCTs. Eligible comparative studies need to (1) consider patients with a diagnosis of erythema migrans resulting from Lyme borreliosis and (2) compare different pharmacological agents against each other, against any other non-pharmacological treatment, placebo or no treatment. Two review authors will independently assess included studies for risk of bias according to the methods of the Cochrane Handbook for Systematic Reviews of Interventions and related to specific study designs. We will address patient-relevant outcomes including clinical remission of cutaneous symptoms, any treatment-related adverse events, quality of life and progressive symptoms such as neuroborreliosis or Lyme carditis and flu-like symptoms. Provided that the identified trials are comparable in terms of clinical issues, combined estimates will be provided. Estimations of treatment effects will be calculated based on a random effects model. Heterogeneity will be evaluated based on I (2) and chi-square test. In case of significant heterogeneity, a pooled estimate will not be provided, but heterogeneity will be investigated on the basis of methodological and clinical study aspects. We plan subgroup analysis to reveal potential differences in the effect estimates between patient populations and treatment specifications. We will consider risk of bias using sensitivity analyses to decide whether to rely on the pooled estimates. The quality of a body of evidence for individual outcomes will be assessed using the GRADE approach. DISCUSSION Benefits and harms of pharmacological treatment in erythema migrans have not yet been adequately assessed. This systematic review will evaluate and summarise available evidence addressing benefits and harms of different pharmacological treatments. In addition, this summary of clinical evidence will inform decision-making between clinicians and patients and will play an important part in patient care. PROSPERO CRD42016037932.
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Affiliation(s)
- Gabriel Torbahn
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, Freiburg, 79110, Germany.
| | - Heidelore Hofmann
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany
| | - Roman Allert
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, Freiburg, 79110, Germany.,Department of Obstetrics and Gynecology, University of Frankfurt, Frankfurt, Germany
| | - Michael H Freitag
- Department of Health Services Research, University of Oldenburg, Oldenburg, Germany
| | - Rick Dersch
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Volker Fingerle
- German National Reference Centre for Borrelia-Bavarian Health and Food Safety Authority (LGL), Oberschleißheim, Germany
| | - Harriet Sommer
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, Freiburg, 79110, Germany.,Institute for Medical Biometry and Statistics, Medical Center-University of Freiburg, Freiburg, Germany
| | - Edith Motschall
- Institute for Medical Biometry and Statistics, Medical Center-University of Freiburg, Freiburg, Germany
| | - Jörg J Meerpohl
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, Freiburg, 79110, Germany
| | - Christine Schmucker
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, Freiburg, 79110, Germany
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Wittmann D, Heppt M, Ruzicka T. [Acrodermatitis chronica atrophicans]. MMW Fortschr Med 2016; 158:64-67. [PMID: 27084166 DOI: 10.1007/s15006-016-8007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Diana Wittmann
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität, Frauenlobstr. 9-11, D-80337, München, Deutschland
| | - Markus Heppt
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität, Frauenlobstr. 9-11, D-80337, München, Deutschland
| | - Thomas Ruzicka
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität, Frauenlobstr. 9-11, D-80337, München, Deutschland
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9
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Brandt FC, Ertas B, Falk TM, Metze D, Böer-Auer A. Histopathology and immunophenotype of acrodermatitis chronica atrophicans correlated withospAandospCgenotypes ofBorreliaspecies. J Cutan Pathol 2015; 42:674-92. [DOI: 10.1111/cup.12550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/04/2015] [Accepted: 07/04/2015] [Indexed: 02/02/2023]
Affiliation(s)
| | | | | | - Dieter Metze
- Department of Dermatology; Munster University; Münster Germany
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10
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[Multiple erythema migrans and facial nerve paralysis: clinical manifestations of early disseminated Lyme borreliosis]. Hautarzt 2014; 65:268-71. [PMID: 24700023 DOI: 10.1007/s00105-014-2782-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Lyme borreliosis is a common vector-borne disease in Europe. The infection follows different stages with a broad variability of clinical symptoms and manifestations in different organs. A 49-year-old man presented with flu-like symptoms, facial nerve paralysis and multiple erythematous macular on his trunk and extremities. We diagnosed Lyme disease (stage II) with facial nerve paralysis and multiple erythema migrans. Intravenous ceftriaxone led to complete healing of hissymptoms within 2 weeks.
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Brandt FC, Ertas B, Falk TM, Metze D, Böer-Auer A. Genotyping of Borrelia from formalin-fixed paraffin-embedded skin biopsies of cutaneous borreliosis and tick bite reactions by assays targeting the intergenic spacer region, ospA and ospC genes. Br J Dermatol 2014; 171:528-43. [PMID: 24471698 DOI: 10.1111/bjd.12855] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Lyme borreliosis has a broad spectrum of clinical presentations involving the skin, joints and nervous system. The variable manifestations have been attributed to different Borrelia genospecies but genotyping required culture or fresh tissue. However, in dermatology practice, formalin-fixed paraffin-embedded biopsies are used for dermatopathological examination. Polymerase chain reaction (PCR) for Borrelia burgdorferi sensu latu has been established on such specimens, but studies attempting genotyping of subspecies or strains are lacking. OBJECTIVES To adapt PCR assays for genotyping of Borrelia using paraffin-embedded biopsies, to identify Borrelia genospecies and to compare clinicopathological features of different genospecies. METHODS Eighty-two paraffin-embedded biopsies from 68 patients, with erythema migrans, acrodermatitis chronica atrophicans, lymphocytoma cutis or tick bite reactions, were studied with assays targeting the intergenic spacer (IGS), ospA and ospC, followed by sequencing and phylogenetic analysis. Clinicopathological data were analysed comparing different Borrelia genospecies. RESULTS Genotyping by IGS, ospA and ospC was successful in 85% of patients (91% B. afzelii, 7% B. garinii, 2% B. bavariensis). ospA serotyping identified type 2 (90%), type 3 (8%) and type 4 (2%). ospC-PCR was positive in 40% of the patients revealing 12 different groups, noninvasive forms being seen only in tick bite reactions and erythema migrans. No major clinicopathological differences could be identified between the genospecies, but neural inflammation and arthralgia were seen more often in lesions caused by invasive ospC strains. CONCLUSIONS Genotyping of Borrelia can be easily implemented in a routine dermatopathology setting, especially as a fast method to confirm early cutaneous borreliosis. Genotyping could also enable earlier treatment of patients infected with invasive strains.
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Affiliation(s)
- F C Brandt
- Department of Dermatology, Münster University, Von Esmarch Strasse 58, Münster, 48149, Germany
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Abstract
Many patients present with discolouration of the legs or with non-ulcerating skin lesions, the most frequent causes being chronic venous insufficiency or other chronic or acute states of congestion. Erysipelas (cellulitis) is also a frequent example of a bacterial skin infection. A complex differential diagnosis arises from all types of immune-mediated skin lesions, opening up the broad spectrum of inflammatory systemic disease, such as vasculitis and sarcoidosis. Livedo like lesions and skin involvement in borreliosis are challenging to classify but of considerable clinical importance. The present review focuses on the description of underlying diseases as well as on diagnosis and differential diagnosis. Therapeutic considerations are discussed in less detail.
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Affiliation(s)
- L Unger
- Medizinische Klinik 1, Krankenhaus Dresden-Friedrichstadt, Städtisches Klinikum, Akademisches Lehrkrankenhaus der TU Dresden, Friedrichstr. 41, 01067, Dresden, Deutschland,
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13
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Moniuszko A, Czupryna P, Pancewicz S, Kondrusik M, Penza P, Zajkowska J. Borrelial lymphocytoma—A case report of a pregnant woman. Ticks Tick Borne Dis 2012; 3:257-8. [DOI: 10.1016/j.ttbdis.2012.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 06/12/2012] [Accepted: 06/16/2012] [Indexed: 10/28/2022]
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