Le lymphocytome borrélien du lobe de l’oreille

Case presentation and management of Lyme disease patients: a 9-year retrospective analysis in France

Introduction

Lyme borreliosis (LB) is the most common vector disease in temperate countries of the northern hemisphere. It is caused by Borrelia burgdorferi sensu lato complex.

Methods

To study the case presentation of LB in France, we contacted about 700 physicians every year between 2003 and 2011. An anonymous questionnaire was established allowing the collection of 3,509 cases. The information collected was imported or directly entered into databases and allowed identifying variables that were validated in a multiple correspondence analysis (MCA).

Results

Sixty percent of the cases were confirmed, 10% were probable, 13.5% doubtful, 10.2% asymptomatic seropositive and 6.3% were negative. The clinical manifestations reported were cutaneous (63%), neurological (26%), articular (7%), ocular (1.9%) and cardiac (1.3%). Almost all patients were treated. When focusing more particularly on confirmed cases, our studies confirm that children have a distinct clinical presentation from adults. There is a gender effect on clinical presentation, with females presenting more often with erythema migrans or acrodermatitis chronica atrophicans than males, while males present more often with neurological signs or arthritis than females.

Discussion

This is the first time that a comprehensive study of suspected Lyme borreliosis cases has been conducted over several years in France. Although we were not able to follow the clinical course of patients after treatment, these results suggest the interest of refining the questionnaire and of following up a cohort of patients over a sufficiently long period to obtain more information on their fate according to different parameters.

Borrelial lymphocytoma

Borrelial lymphocytoma is a rare cutaneous manifestation of early localized European Lyme borreliosis. It manifests as a nodule or plaque with a diameter of up to a few centimeters. The lesion is, as a rule, solitary. It is more common in children than in adults and, in contrast to erythema migrans and acrodermatitis chronica atrophicans, has male predominance. A tick bite has been reported in approximately one half of patients; the tick bite is usually at the site or in the vicinity of the later borrelial lymphocytoma. The predilection site for the development of lesions is the breast in adults and the ear lobe in children. Borrelial lymphocytoma is frequently associated with erythema migrans, but rarely with other manifestations of Lyme borreliosis, and is predominantly caused by Borrelia afzelii. At presentation, approximately half of the patients with borrelial lymphocytoma have measurable serum borrelial antibodies and, in about one third, spirochetes can be cultivated from the skin lesion. A 14-day antibiotic therapy, as recommended for patients with erythema migrans, is highly successful. Posttreatment duration of a borrelial lymphocytoma is positively associated with the pretreatment duration of the lesion and with patient age, while treatment failure is associated with the clinical signs of disseminated Lyme borreliosis at presentation. Substantial improvements in knowledge on borrelial lymphocytoma and laboratory diagnostics in recent decades have contributed to earlier diagnosis and treatment. Consequently, borrelial lymphocytoma is usually a mild disease with a good prognosis.

Borrelial Lymphocytoma in Adult Patients

BACKGROUND

Information on the course and outcome of borrelial lymphocytoma (BL) is limited.

METHODS

The study comprised 144 adult patients (75 female, 69 male; median age, 49 years) who had BL diagnosed at a single center between 1986 and 2014 and were followed up for 1 year.

RESULTS

BL was located on the breast in 106 patients (73.6%), on the ear lobe in 27 (18.8%), and elsewhere in 11 (7.6%). The median duration of BL before diagnosis was 27 days (interquartile range [IQR], 9-68 days). Concomitant erythema migrans was registered in 104 of 144 patients (72.2%); other objective manifestations of Lyme borreliosis (LB) were present in 11 (7.6%). Immunoglobulin M and/or G borrelial serum antibodies were present in 72 patients (50%). Borreliae were isolated from BL lesions in 14 of 42 patients (33.3%) who had not received antibiotics before skin biopsy. Of 13 typed Borrelia strains, 11 were B. afzelii, 1 was B. garinii, and 1 was B. bissettii The median duration of BL after starting antibiotic treatment was 21 days ([IQR], 10-30 days); the average duration was longer in patients who were older, had longer BL duration before treatment, or had signs of disseminated LB. Treatment failure occurred in 14 of 144 patients (9.7%). Patients with signs or symptoms of disseminated LB before treatment had nearly 4 times higher odds of treatment failure (95% confidence interval, 1.22-13.07) than those without such symptoms. All patients with treatment failure had uneventful outcome after retreatment.

CONCLUSIONS

BL is a rare manifestation of early localized LB. Fourteen-day antibiotic treatment, as used for erythema migrans, is effective.

Extrafacial indolent CD8-positive cutaneous lymphoid proliferation with unusual symmetrical presentation involving both feet

Indolent CD8+ cutaneous lymphoid proliferation represents a recently described entity among cutaneous T-cell lymphomas that typically presents with solitary skin lesions on the face or at acral sites and usually follows an indolent clinical course. Histopathologically, this entity is characterized by a dense dermal infiltrate of non-epidermotropic, small- to medium-sized pleomorphic CD8+ T-cells of the non-activated cytotoxic phenotype showing a clear-cut grenz zone and a low proliferation index. Distinction from otherwise aggressive T-cell lymphomas bearing a cytotoxic CD8+ phenotype is fundamental. We herein present an unusual case of indolent CD8+ cutaneous lymphoid proliferation presenting in bilateral symmetrical distribution on both feet and lacking the otherwise described grenz zone. Our case widens the spectrum of possible clinical and histomorphological variations of this entity. Taking into account the distinctive and unique clinical and microscopic features of all hitherto published cases of indolent CD8+ cutaneous lymphoid proliferation we suppose that this lymphoma subtype has to be included as a new and distinct entity in the World Health Organisation (WHO)-/European Organisation for Research and Treatment of Cancer (EORTC)-classification of cutaneous lymphomas.