Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis

Early Erythema Migrans: Do Not Count on Plasma Cells

ABSTRACT

Three hundred thousand new cases of Lyme disease are diagnosed annually in the United States. The earliest manifestation of the disease, erythema migrans, occurs earlier than serologic conversion, and skin biopsies can be very helpful in suggesting the diagnosis. Histopathologic findings vary depending on where in the lesion the specimen is taken, but typically consist of a superficial and deep perivascular and interstitial lymphocytic infiltrate with eosinophils centrally and with histiocytes and plasma cells at the periphery. Rare cases with interstitial histiocytes and rare-to-sparse plasma cells exist. We present a 67-year-old man whose skin biopsy, taken on day 2 of his eruption, demonstrated a subtle perivascular and interstitial infiltrate of histiocytes without plasma cells. Dermatopathologists need to be aware of this pattern and consider the diagnosis of erythema migrans, despite negative initial serologic testing.

The Platelet Fraction Is a Novel Reservoir to Detect Lyme Borrelia in Blood

Simple Summary

To diagnose Lyme disease, a patient’s blood is tested for antibodies that develop as part of the immune response. This can lead to cases being missed or inadequately treated. An ideal test would directly detect the Lyme disease bacteria, Borrelia, to provide better clinical guidance. In this study, we aimed to improve the methods currently used to find Borrelia in human blood, and identified two opportunities for optimization. We demonstrate that the container most commonly used to collect blood (EDTA) decreases Borrelia’s ability to grow, and we identify a superior alternative (citrate). Additionally, using experimentally infected blood, we show that Borrelia is highly concentrated in the platelet fraction, making it an ideal candidate for direct detection. These results lay the foundation for diagnostic test development, which could improve patient outcomes in Lyme disease.

Abstract

Serological diagnosis of Lyme disease suffers from considerable limitations. Yet, the technique cannot currently be replaced by direct detection methods, such as bacterial culture or molecular analysis, due to their inadequate sensitivity. The low bacterial burden in vasculature and lack of consensus around blood-based isolation of the causative pathogen, Borrelia burgdorferi, are central to this challenge. We therefore addressed methodological optimization of Borrelia recovery from blood, first by analyzing existing protocols, and then by using experimentally infected human blood to identify the processing conditions and fractions that increase Borrelia yield. In this proof-of-concept study, we now report two opportunities to improve recovery and detection of Borrelia from clinical samples. To enhance pathogen viability and cultivability during whole blood collection, citrate anticoagulant is superior to more commonly used EDTA. Despite the widespread reliance on serum and plasma as analytes, we found that the platelet fraction of blood concentrates Borrelia, providing an enriched resource for direct pathogen detection by microscopy, laboratory culture, Western blot, and PCR. The potential for platelets to serve as a reservoir for Borrelia and its diagnostic targets may transform direct clinical detection of this pathogen.

Effect of dapsone alone and in combination with intracellular antibiotics against the biofilm form of B. burgdorferi

Objective

Lyme disease is a tick-borne, multisystemic disease caused by Borrelia burgdorferi. Standard treatments for early Lyme disease include short courses of oral antibiotics but relapses often occur after discontinuation of treatment. Several studies have suggested that ongoing symptoms may be due to a highly antibiotic resistant form of B. burgdorferi called biofilms. Our recent clinical study reported the successful use of an intracellular mycobacterium persister drug used in treating leprosy, diaminodiphenyl sulfone (dapsone), in combination therapy for the treatment of Lyme disease. In this in vitro study, we evaluated the effectiveness of dapsone individually and in combination with cefuroxime and/or other antibiotics with intracellular activity including doxycycline, rifampin, and azithromycin against Borrelia biofilm forms utilizing crystal violet biofilm mass, and dimethyl methylene blue glycosaminoglycan assays combined with Live/Dead fluorescent microscopy analyses.

Results

Dapsone, alone or in various combinations with doxycycline, rifampin and azithromycin produced a significant reduction in the mass and protective glycosaminoglycan layer and overall viability of B. burgdorferi biofilm forms. This in vitro study strongly suggests that dapsone combination therapy could represent a novel and effective treatment option against the biofilm form of B. burgdorferi.

Ex Vivo Murine Skin Model for B. burgdorferi Biofilm

Borrelia burgdorferi, the causative agent of Lyme disease, has been recently shown to form biofilm structures in vitro and in vivo. Biofilms are tightly clustered microbes characterized as resistant aggregations that allow bacteria to withstand harsh environmental conditions, including the administration of antibiotics. Novel antibiotic combinations have recently been identified for B. burgdorferi in vitro, however, due to prohibiting costs, those agents have not been tested in an environment that can mimic the host tissue. Therefore, researchers cannot evaluate their true effectiveness against B. burgdorferi, especially its biofilm form. A skin ex vivo model system could be ideal for these types of experiments due to its cost effectiveness, reproducibility, and ability to investigate host-microbial interactions. Therefore, the main goal of this study was the establishment of a novel ex vivo murine skin biopsy model for B. burgdorferi biofilm research. Murine skin biopsies were inoculated with B. burgdorferi at various concentrations and cultured in different culture media. Two weeks post-infection, murine skin biopsies were analyzed utilizing immunohistochemical (IHC), reverse transcription PCR (RT-PCR), and various microscopy methods to determine B. burgdorferi presence and forms adopted as well as whether it remained live in the skin tissue explants. Our results showed that murine skin biopsies inoculated with 1 × 107 cells of B. burgdorferi and cultured in BSK-H + 6% rabbit serum media for two weeks yielded not just significant amounts of live B. burgdorferi spirochetes but biofilm forms as well. IHC combined with confocal and atomic force microscopy techniques identified specific biofilm markers and spatial distribution of B. burgdorferi aggregates in the infected skin tissues, confirming that they are indeed biofilms. In the future, this ex vivo skin model can be used to study development and antibiotic susceptibility of B. burgdorferi biofilms in efforts to treat Lyme disease effectively.

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.

Unique expression of chronic Lyme disease and Jarisch-Herxheimer reaction to doxycycline therapy in a young adult

I am a 24-year-old male who was diagnosed with chronic Lyme disease after 4 years of multiple, non-specific symptoms. I have written this case as first author with my faculty mentor listed as the coauthor. The objective of this report is to highlight the experience with doxycycline treatment. In 2007, at around age 19 years, I had an acute onset of sore throat, tonsillitis, low-grade fever, stiff upper back and neck muscles, migraines and severely stiff, cracking jaw joints. This led to >24 medical visits, multitudes of tests and examinations, and exploratory surgery over the next 3 years. In 2011, a Lyme-literate medical doctor (LLMD) diagnosed me with chronic Lyme disease. I started taking doxycycline 100 mg by mouth every 12 hours, leading to atypical sequences of events deemed a Jarisch-Herxheimer reaction by a LLMD. This case highlights the unique clinical expression of chronic Lyme disease and the Jarisch-Herxheimer response to doxycycline.

U.S. healthcare providers' experience with Lyme and other tick-borne diseases

Surveillance indicates that tick-borne diseases are a common problem in the United States. Nevertheless, little is known regarding the experience or management practices of healthcare providers who treat these conditions. The purpose of the present study was to characterize the frequency of tick-borne diseases in clinical practice and the knowledge of healthcare providers regarding their management. Four questions about tick-borne diseases were added to the 2009 Docstyles survey, a nationally representative survey of >2000 U.S. healthcare providers. Topics included diseases encountered, management of patients with early Lyme disease (LD), provision of tick-bite prophylaxis, and sources of information on tick-borne diseases. Overall, 51.3% of practitioners had treated at least one patient for a tick-borne illness in the previous year. Among these, 75.1% had treated one type of disease, 19.0% two types of disease, and 5.9% three or more diseases. LD was encountered by 936 (46.8%) providers; Rocky Mountain spotted fever was encountered by 184 (9.2%) providers. Given a scenario involving early LD, 89% of providers would prescribe antibiotics at the first visit, with or without ordering a blood test. Tick-bite prophylaxis was prescribed by 31.0% of all practitioners, including 41.1% in high-LD-incidence states and 26.0% in low-incidence states. Tick-borne diseases are encountered frequently in clinical practice. Most providers would treat early LD promptly, suggesting they are knowledgeable regarding the limitations of laboratory testing in this setting. Conversely, providers in low-LD-incidence states frequently prescribe tick-bite prophylaxis, suggesting a need for education to reduce potential misdiagnosis and overtreatment.

A prospective study among patients presenting at the general practitioner with a tick bite or erythema migrans in The Netherlands

Background

We performed a nationwide prospective study on the transmission risk for Borrelia to humans, investigating symptoms and serology at enrolment and three months after tick bites, and after standard treatment for erythema migrans (EM). Aiming to quantify the infection risk at point of care by physicians, we explored risk factors such as tick testing for Borrelia and assessment of the duration of the tick's blood meal.

Methods and Findings

Questionnaires, blood samples and ticks from patients who consulted one of 307 general practitioners for tick bites (n = 327) or EM (n = 283) in 2007 and 2008, were collected at enrolment and three months later at follow-up. Borrelia burgdorferi sensu lato DNA was detected in 29.3% of 314 ticks, using PCR/reverse line blot and real-time PCR on the OspA gene. Seroconversion in C6 ELISA, IgM or IgG immunoblots for Borrelia-specific antibodies was observed in 3.2% of tick bite cases. Fourteen tick bite cases had evidence of early Borrelia infection, of which EM developed among seven cases. The risk of developing EM after tick bites was 2.6% (95%CI: 1.1%–5.0%), and the risk of either EM or seroconversion was 5.1% (95%CI: 2.9%–8.2%). Participants with Borrelia-positive ticks had a significantly higher risk of either EM or seroconversion (odds ratio 4.8, 95%CI: 1.1–20.4), and of seroconversion alone (odds ratio 11.1, 95%CI: 1.1–108.9). A third (34%) of the cases enrolled with EM did not recall preceding tick bites. Three EM cases (1%) reported persisting symptoms, three months after standard antibiotic treatment for EM.

Conclusions

One out of forty participants developed EM within three months after tick bites. The infection risk can be assessed by tick testing for Borrelia at point of care by physicians. However, further refining is needed considering sensitivity and specificity of tick tests, accuracy of tick attachment time and engorgement.

Emerging incidence of Lyme borreliosis, babesiosis, bartonellosis, and granulocytic ehrlichiosis in Australia

Background

Borrelia burgdorferi, the causative agent of Lyme disease (LD), and Babesia, Bartonella, and Ehrlichia species (spp.) are recognized tick-borne pathogens in humans worldwide. Using serology and molecular testing, the incidence of these pathogens was investigated in symptomatic patients from Australia.

Methods

Sera were analyzed by an immunofluorescent antibody assay (IFA) followed by immunoglobulin (Ig)G and IgM Western blot (WB) assays. Both whole blood and sera were analyzed for detection of specific Borrelia spp. DNA using multiplex polymerase chain reaction (PCR) testing. Simultaneously, patients were tested for Babesia microti, Babesia duncani, Anaplasma phagocytophilum, Ehrlichia chaffeensis, and Bartonella henselae infection by IgG and IgM IFA serology, PCR, and fluorescent in situ hybridization (FISH).

Results

Most patients reported symptom onset in Australia without recent overseas travel. 28 of 51 (55%) tested positive for LD. Of 41 patients tested for tick-borne coinfections, 13 (32%) were positive for Babesia spp. and nine (22%) were positive for Bartonella spp. Twenty-five patients were tested for Ehrlichia spp. and (16%) were positive for Anaplasma phagocytophilum while none were positive for Ehrlichia chaffeensis. Among the 51 patients tested for LD, 21 (41%) had evidence of more than one tick-borne infection. Positive tests for LD, Babesia duncani, Babesia microti, and Bartonella henselae were demonstrated in an individual who had never left the state of Queensland. Positive testing for these pathogens was found in three others whose movements were restricted to the east coast of Australia.

Conclusion

The study identified a much larger tick-borne disease (TBD) burden within the Australian community than hitherto reported. In particular, the first cases of endemic human Babesia and Bartonella disease in Australia with coexisting Borrelia infection are described, thus defining current hidden and unrecognized components of TBD and demonstrating local acquisition in patients who have never been abroad.

Lyme borreliosis

Borreliosis is an infectious disease caused by spirochetes of the genus Borrelia. Lyme borreliosis, also known as Lyme disease, is a non-contagious infectious disease caused by spirochetes belonging to the complex Borrelia burgdorferi sensu lato and more often transmitted by the bite of infected ticks of the genus Ixodes.The disease is characterized by a varied clinical profile, which can trigger cutaneous, articular, neurological and cardiac manifestations.

Lyme disease and the orthopaedic implications of lyme arthritis

Lyme disease is the most common tick-borne disease in the United States and Europe. Increased awareness of the clinical manifestations of the disease is needed to improve detection and treatment. In the acute and late stages, Lyme disease may be difficult to distinguish from other disease processes. The epidemiology and pathophysiology of Lyme disease are directly related to the Borrelia burgdorferi spirochete and its effects on the integumentary, neurologic, cardiac, and musculoskeletal systems. Lyme arthritis is a common clinical manifestation of Lyme disease and should be considered in the evaluation of patients with monoarticular or pauciarticular joint complaints in a geographic area in which Lyme disease is endemic. Management of Lyme arthritis involves eradication of the spirochete with antibiotics. Generally, the prognosis is excellent. Arthroscopic synovectomy is reserved for refractory cases that do not respond to antibiotics.

Outcomes of children treated for Lyme arthritis: results of a large pediatric cohort

OBJECTIVE

Children often develop arthritis secondary to Lyme disease; however, optimal treatment of Lyme arthritis in pediatric patients remains ill-defined. We sought to characterize the outcomes of a large cohort of children with Lyme arthritis treated using the approach recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America.

METHODS

Medical records of patients with Lyme arthritis seen by rheumatologists at a tertiary care children's hospital from 1997 to 2007 were reviewed. Patients were classified with antibiotic responsive or refractory arthritis based on absence or presence of persisting joint involvement 3 months after antibiotic initiation. Treatment regimens and outcomes in patients with refractory arthritis were analyzed.

RESULTS

Of 99 children with Lyme arthritis, 76 had arthritis that responded fully to antibiotics, while 23 developed refractory arthritis. Most patients with refractory arthritis were successfully treated with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid injections (4), or disease-modifying antirheumatic drugs (DMARD) (2). Five were lost to followup. Six patients with refractory arthritis were initially treated elsewhere and received additional antibiotic therapy, with no apparent benefit. Three subsequently required DMARD, while 3 had gradual resolution of arthritis without further therapy. Antibiotic responsiveness could not be predicted from our clinical or laboratory data.

CONCLUSION

Lyme arthritis in children has an excellent prognosis. More than 75% of referred cases resolved with antibiotic therapy. Of patients with antibiotic refractory arthritis, none in whom followup data were available developed chronic arthritis, joint deformities, or recurrence of infection, supporting current treatment guidelines.