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Yıldız AB, Çetin E, Pınarlık F, Keske Ş, Can F, Ergönül Ö. Discrepancy between IDSA and ESGBOR in Lyme disease: Individual participant meta-analysis in Türkiye. Zoonoses Public Health 2024; 71:337-348. [PMID: 38413371 DOI: 10.1111/zph.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 01/28/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The evidence on the prevalence of Lyme borreliosis (LB) is limited, but there is a suspicion of overdiagnosis of LB in recent years. We reviewed the LB diagnosis and treatment-related data in Türkiye, based on the Infectious Diseases Society of America (IDSA) 2020 and European Society of Clinical Microbiology and Infectious Diseases Study Group for Lyme Borreliosis (ESGBOR) 2018 guidelines. By detecting the disagreements between these two, we outlined the areas to be improved for future guidelines. METHODS We performed a literature search according to the PRISMA guidelines in PubMed, Ovid-Medline, Web of Science, Turkish Medline, Scopus, CINAHL, ULAKBIM TR Index, Google Scholar and Cochrane Library databases. We included the published cases in a database and evaluated according to IDSA and ESGBOR guidelines. We outlined the reasons for misdiagnoses and inappropriate uses of antibiotics. RESULTS We included 42 relevant studies with 84 LB cases reported from Türkiye between 1990 and December 2022. Among 84 cases, the most common clinical findings were nervous system findings (n = 37, 44.0%), erythema migrans (n = 29, 34.5%) and ophthalmologic findings (n = 15, 17.9%). The IDSA 2020 and ESGBOR 2018 guidelines agreed on the diagnosis of 71 (84.5%) cases; there was an agreement that 31 cases (36.9%) were misdiagnosed and 40 cases (47.6%) were correctly diagnosed, and there was disagreement for 13 cases (15.5%). Serum immunoglobulin M (IgM), IgG measurements by ELISA and western blot were widely performed, and they were effective in definitive diagnosis merely when used according to guidelines. Inappropriate use of antibiotics was detected in 42 (50.0%) of cases which were classified in the following categories: incorrect LB diagnosis, inappropriate choice of antibiotic, inappropriate route of drug administration and prolonged antibiotic treatment. CONCLUSION Overdiagnosis and non-adherence to guidelines is a common problem. The discordance between seroprevalence and clinical studies necessitates a consensus over the best clinical approach.
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Affiliation(s)
| | - Ecesu Çetin
- Koç University School of Medicine, Istanbul, Turkey
| | - Fatihan Pınarlık
- Graduate School of Health Sciences, Koc University, Istanbul, Turkey
- Koç University-Isbank Center for Infectious Diseases, Istanbul, Turkey
| | - Şiran Keske
- Koç University-Isbank Center for Infectious Diseases, Istanbul, Turkey
- Department of Infectious Diseases and Clinical Microbiology, Koç University School of Medicine, Istanbul, Turkey
| | - Füsun Can
- Koç University-Isbank Center for Infectious Diseases, Istanbul, Turkey
- Department of Clinical Microbiology, Koç University School of Medicine, Istanbul, Turkey
| | - Önder Ergönül
- Koç University-Isbank Center for Infectious Diseases, Istanbul, Turkey
- Department of Infectious Diseases and Clinical Microbiology, Koç University School of Medicine, Istanbul, Turkey
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2
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Watts J, Taylor K. Gentrification increases risk of tick-borne disease for communities of colour. Nat Microbiol 2024; 9:312-313. [PMID: 38316921 DOI: 10.1038/s41564-023-01590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
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3
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Sanders S, Barratt A, Buchbinder R, Doust J, Kazda L, Jones M, Glasziou P, Bell K. Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework. J Clin Epidemiol 2024; 165:111215. [PMID: 37952702 DOI: 10.1016/j.jclinepi.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions. STUDY DESIGN AND SETTING We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis. RESULTS Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy. CONCLUSION Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.
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Affiliation(s)
- Sharon Sanders
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia.
| | - Alexandra Barratt
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3800, Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Herston, Queensland 4006, Australia
| | - Luise Kazda
- NHMRC Healthy Environments And Lives (HEAL) National Research Network, National Centre for Epidemiology and Population Health, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory 2601, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Katy Bell
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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4
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Grąźlewska W, Sołowińska K, Holec-Gąsior L. In silico epitope prediction of Borrelia burgdorferi sensu lato antigens for the detection of specific antibodies. J Immunol Methods 2024; 524:113596. [PMID: 38070727 DOI: 10.1016/j.jim.2023.113596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 11/22/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023]
Abstract
Despite many years of research, serodiagnosis of Lyme disease still faces many obstacles. Difficulties arise mainly due to the low degree of amino acid sequence conservation of the most immunogenic antigens among B. burgdorferi s.l. genospecies, as well as differences in protein production depending on the environment in which the spirochete is located. Mapping B-cell epitopes located on antigens allows for a better understanding of antibody-pathogen interactions which is essential for the development of new and more effective diagnostic tools. In this study, in silico B-cell epitope mapping was performed to determine the theoretical diagnostic potential of selected B. burgdorferi s.l. proteins (BB0108, BB0126, BB0298, BB0689, BB0323, FliL, PstS, SecD, EF-Tu). Bioinformatics software predicted 35 conserved linear and 31 conformational epitopes with the degree of identity among B. burgdorferi s.l. of at least 85%, which may prove to be useful in the development of a new tool for the diagnosis of Lyme disease.
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Affiliation(s)
- Weronika Grąźlewska
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland
| | - Karolina Sołowińska
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland
| | - Lucyna Holec-Gąsior
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland.
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5
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Grąźlewska W, Holec-Gąsior L, Sołowińska K, Chmielewski T, Fiecek B, Contreras M. Epitope Mapping of BmpA and BBK32 Borrelia burgdorferi Sensu Stricto Antigens for the Design of Chimeric Proteins with Potential Diagnostic Value. ACS Infect Dis 2023; 9:2160-2172. [PMID: 37803965 PMCID: PMC10722512 DOI: 10.1021/acsinfecdis.3c00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Indexed: 10/08/2023]
Abstract
Lyme disease is a tick-borne zoonosis caused by Gram-negative bacteria belonging to the Borrelia burgdorferi sensu lato (s.l.) group. In this study, IgM- and IgG-specific linear epitopes of two B. burgdorferi sensu stricto (s.s.) antigens BmpA and BBK32 were mapped using a polypeptide array. Subsequently, two chimeric proteins BmpA-BBK32-M and BmpA-BBK32-G were designed to validate the construction of chimeras using the identified epitopes for the detection of IgM and IgG, respectively, by ELISA. IgG-ELISA based on the BmpA-BBK32-G antigen showed 71% sensitivity and 95% specificity, whereas a slightly lower diagnostic utility was obtained for IgM-ELISA based on BmpA-BBK32-M, where the sensitivity was also 71% but the specificity decreased to 89%. The reactivity of chimeric proteins with nondedicated antibodies was much lower. These results suggest that the identified epitopes may be useful in the design of new forms of antigens to increase the effectiveness of Lyme disease serodiagnosis. It has also been proven that appropriate selection of epitopes enables the construction of chimeric proteins exhibiting reactivity with a specific antibody isotype.
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Affiliation(s)
- Weronika Grąźlewska
- Department
of Molecular Biotechnology and Microbiology, Faculty of Chemistry, University of Gdańsk Technology, 80-233 Gdańsk, Poland
- SaBio,
Instituto de Investigación en Recursos Cinegéticos IREC−CSIC-UCLM-JCCM, 13005 Ciudad Real, Spain
| | - Lucyna Holec-Gąsior
- Department
of Molecular Biotechnology and Microbiology, Faculty of Chemistry, University of Gdańsk Technology, 80-233 Gdańsk, Poland
| | - Karolina Sołowińska
- Department
of Molecular Biotechnology and Microbiology, Faculty of Chemistry, University of Gdańsk Technology, 80-233 Gdańsk, Poland
| | - Tomasz Chmielewski
- Department
of Parasitology and Diseases Transmitted by Vectors, National Institute of Public Health NIH - National Research Institute, 00-791 Warsaw, Poland
| | - Beata Fiecek
- Department
of Parasitology and Diseases Transmitted by Vectors, National Institute of Public Health NIH - National Research Institute, 00-791 Warsaw, Poland
| | - Marinela Contreras
- SaBio,
Instituto de Investigación en Recursos Cinegéticos IREC−CSIC-UCLM-JCCM, 13005 Ciudad Real, Spain
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Porwancher R, Levin A, Trevejo R. Immunoblot Criteria for Diagnosis of Lyme Disease: A Comparison of CDC Criteria to Alternative Interpretive Approaches. Pathogens 2023; 12:1282. [PMID: 38003747 PMCID: PMC10674374 DOI: 10.3390/pathogens12111282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/26/2023] Open
Abstract
The current Centers for Disease Control and Prevention (CDC) interpretive criteria for serodiagnosis of Lyme disease (LD) involve a two-tiered approach, consisting of a first-tier EIA, IFA, or chemiluminescent assay, followed by confirmation of positive or equivocal results by either immunoblot or a second-tier EIA. To increase overall sensitivity, single-tier alternative immunoblot assays have been proposed, often utilizing antigens from multiple Borrelia burgdorferi strains or genospecies in a single immunoblot; including OspA and OspB in their antigen panel; requiring fewer positive bands than permitted by current CDC criteria; and reporting equivocal results. Published reports concerning alternative immunoblot assays have used relatively small numbers of LD patients and controls to evaluate novel multi-antigen assays and interpretive criteria. We compared the two most commonly used alternative immunoblot interpretive criteria (labeled A and B) to CDC criteria using data from multiple FDA-cleared IgG and IgM immunoblot test kits. These single-tier alternative interpretive criteria, applied to both IgG and IgM immunoblots, demonstrated significantly more false-positive or equivocal results in healthy controls than two-tiered CDC criteria (12.4% and 35.0% for Criteria A and B, respectively, versus 1.0% for CDC criteria). Due to limited standardization and high false-positive rates, the presently evaluated single-tier alternative immunoblot interpretive criteria appear inferior to CDC two-tiered criteria.
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Affiliation(s)
- Richard Porwancher
- Section of Allergy, Immunology, and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
- Princeton Infectious Diseases Associates, LLC, Plainsboro, NJ 08536, USA
| | - Andrew Levin
- Kephera Diagnostics, LLC, Framingham, MA 01702, USA;
| | - Rosalie Trevejo
- Epidemiologist, Acute and Communicable Disease Prevention, Oregon Health Authority, Portland, OR 97232, USA;
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Rowan S, Mohseni N, Chang M, Burger H, Peters M, Mir S. From Tick to Test: A Comprehensive Review of Tick-Borne Disease Diagnostics and Surveillance Methods in the United States. Life (Basel) 2023; 13:2048. [PMID: 37895430 PMCID: PMC10608558 DOI: 10.3390/life13102048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/08/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Tick-borne diseases (TBDs) have become a significant public health concern in the United States over the past few decades. The increasing incidence and geographical spread of these diseases have prompted the implementation of robust surveillance systems to monitor their prevalence, distribution, and impact on human health. This comprehensive review describes key disease features with the geographical distribution of all known tick-borne pathogens in the United States, along with examining disease surveillance efforts, focusing on strategies, challenges, and advancements. Surveillance methods include passive and active surveillance, laboratory-based surveillance, sentinel surveillance, and a One Health approach. Key surveillance systems, such as the National Notifiable Diseases Surveillance System (NNDSS), TickNET, and the Tick-Borne Disease Laboratory Network (TBDLN), are discussed. Data collection and reporting challenges, such as underreporting and misdiagnosis, are highlighted. The review addresses challenges, including lack of standardization, surveillance in non-human hosts, and data integration. Innovations encompass molecular techniques, syndromic surveillance, and tick surveillance programs. Implications for public health cover prevention strategies, early detection, treatment, and public education. Future directions emphasize enhanced surveillance networks, integrated vector management, research priorities, and policy implications. This review enhances understanding of TBD surveillance, aiding in informed decision-making for effective disease prevention and control. By understanding the current surveillance landscape, public health officials, researchers, and policymakers can make informed decisions to mitigate the burden of (TBDs).
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Affiliation(s)
| | | | | | | | | | - Sheema Mir
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, CA 91766, USA; (S.R.)
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8
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Sébastien P, Jacques D, Catherine P, Xavier G. Diagnosis and treatment of "chronic Lyme": primum non nocere. BMC Infect Dis 2023; 23:642. [PMID: 37784031 PMCID: PMC10544220 DOI: 10.1186/s12879-023-08618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Approximately 10% of patients experience prolonged symptoms after Lyme disease. PTLDS (post treatment Lyme disease syndrome) is a controversial topic. It has been described as a source of overdiagnosis and off-label treatment. This review aims to describe the diagnostic errors and adverse events associated with the diagnosis and treatment of PTLDS. METHODS systematic review of the literature in the Medline and Cochrane Library databases, according to PRISMA criteria, including randomized clinical trials (RCT), observational studies, and case reports addressing diagnostic errors and adverse events published between January 2010 and November 2020 in English or French. Selection used a quadruple reading process on the basis of the titles and abstracts of the different articles, followed by a full reading. RESULTS 17 studies were included: 1 RCT, 6 observational studies and 10 case reports. In the 6 observational studies, overdiagnosis rates were very high, ranging from 80 to 100%. The new diagnoses were often psychiatric, rheumatological and neurological. Disorders with somatic symptoms were often cited. Diagnostic delays were identified for cancers and frontoparietal dementia. In the RCT and observational studies, prolonged anti-infective treatments were also responsible for adverse events, with emergency room visits and/or hospitalization. The most common adverse events were diarrhea, sometimes with Clostridium difficile colitis, electrolyte abnormalities, sepsis, bacterial and fungal infections, and anaphylactic reactions. CONCLUSION This review highlights the risks of prolonged anti-infective treatments that have not been proven to be beneficial in PTLDS. It emphasizes the ethical imperative of the "primum non nocere" principle, which underscores the importance of not causing harm to patients. Physicians should exercise caution in diagnosing PTLDS and consider the potential risks associated with off-label treatments.
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Affiliation(s)
| | | | - Plotton Catherine
- Campus Santé Innovations, SAINT-PRIEST-EN-JAREZ, Jean-Monnet University, 10 RUE de la Marandière, 42270, Saint-Étienne, France
| | - Gocko Xavier
- Campus Santé Innovations, SAINT-PRIEST-EN-JAREZ, Jean-Monnet University, 10 RUE de la Marandière, 42270, Saint-Étienne, France.
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9
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Shafquat M, Angulo FJ, Pilz A, Moïsi JC, Stark JH. The Incidence of Lyme Borreliosis Among Children. Pediatr Infect Dis J 2023; 42:867-874. [PMID: 37406218 PMCID: PMC10501351 DOI: 10.1097/inf.0000000000004040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND First recognized in children in the United States, Lyme borreliosis (LB) is the most prevalent tickborne illness in North America and Europe. However, the incidence of LB in children, including geographic variation and difference from that in adults, is incompletely described. METHODS We compiled surveillance data from public health agency websites reporting age-stratified LB case data, which was combined with census data to derive incidence estimates. Additional incidence estimates were obtained through a systematic literature review. RESULTS We identified 18 surveillance systems and 15 published studies for derivation of LB incidence in children. National incidence of >10 cases in children per 100,000 per year were estimated for the United States and parts of Eastern, Western and Northern Europe. However, there was substantial variation in incidence among countries in some European regions. National incidence estimates from the literature largely aligned with estimates from surveillance. Surveillance-reported pediatric incidence was lower than adult incidence in adults in 8 countries, similar to adult incidence in 3 countries, and higher than adult incidence in 1 country. Among all pediatric age strata, the 5-9 years of age stratum had the highest proportion of pediatric cases in most countries. CONCLUSIONS As pediatric LB represents a substantial proportion of overall LB incidence across countries in Europe and North America, LB prevention and control efforts should target pediatric as well as adult populations. However, better data are needed to fully characterize the difference in incidence across geographic regions.
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Affiliation(s)
- Madiha Shafquat
- From the Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Collegeville, Pennsylvania
| | - Frederick J. Angulo
- From the Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Collegeville, Pennsylvania
| | - Andreas Pilz
- Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Vienna, Austria
| | - Jennifer C. Moïsi
- Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Paris, France
| | - James H. Stark
- From the Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Collegeville, Pennsylvania
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10
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Forrest IS, O’Neal AJ, Pedra JHF, Do R. Cholesterol Contributes to Risk, Severity, and Machine Learning-Driven Diagnosis of Lyme Disease. Clin Infect Dis 2023; 77:839-847. [PMID: 37227948 PMCID: PMC10506776 DOI: 10.1093/cid/ciad307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Lyme disease is the most prevalent vector-borne disease in the US, yet its host factors are poorly understood and diagnostic tests are limited. We evaluated patients in a large health system to uncover cholesterol's role in the susceptibility, severity, and machine learning-based diagnosis of Lyme disease. METHODS A longitudinal health system cohort comprised 1 019 175 individuals with electronic health record data and 50 329 with linked genetic data. Associations of blood cholesterol level, cholesterol genetic scores comprising common genetic variants, and burden of rare loss-of-function (LoF) variants in cholesterol metabolism genes with Lyme disease were investigated. A portable machine learning model was constructed and tested to predict Lyme disease using routine lipid and clinical measurements. RESULTS There were 3832 cases of Lyme disease. Increasing cholesterol was associated with greater risk of Lyme disease and hypercholesterolemia was more prevalent in Lyme disease cases than in controls. Cholesterol genetic scores and rare LoF variants in CD36 and LDLR were associated with Lyme disease risk. Serological profiling of cases revealed parallel trajectories of rising cholesterol and immunoglobulin levels over the disease course, including marked increases in individuals with LoF variants and high cholesterol genetic scores. The machine learning model predicted Lyme disease solely using routine lipid panel, blood count, and metabolic measurements. CONCLUSIONS These results demonstrate the value of large-scale genetic and clinical data to reveal host factors underlying infectious disease biology, risk, and prognosis and the potential for their clinical translation to machine learning diagnostics that do not need specialized assays.
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Affiliation(s)
- Iain S Forrest
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Medical Scientist Training Program, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anya J O’Neal
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joao H F Pedra
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ron Do
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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11
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Bonnet C, Figoni J, Souty C, Septfons A, de Martino S, de Valk H, Fournier L, Hanslik T, Jaulhac B, Blanchon T. Prevalence and factors associated with a prescription of a Lyme borreliosis serology for erythema migrans diagnosis in general practice: a study from the French sentinel network, 2009-2020. BMC PRIMARY CARE 2023; 24:163. [PMID: 37620763 PMCID: PMC10464237 DOI: 10.1186/s12875-023-02108-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/18/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Serological testing of patients consulting for typical erythema migrans (EM) is not recommended in European recommendations for diagnosis of Lyme borreliosis (LB). Little is known on the level of adherence of French general practitioners to these recommendations. The objectives were to estimate the proportion of Lyme borreliosis serological test prescription in patients with erythema migrans seen in general practice consultations in France, and to study the factors associated with this prescription. METHODS LB cases with an EM reported by the French general practitioners (GPs) of the Sentinelles network between January 2009 and December 2020 were included. To assess the associations with a prescription of a serological test, multilevel logistic regression models were used. RESULTS Among the 1,831 EM cases included, a prescription for a LB serological test was requested in 24.0% of cases. This proportion decreased significantly over the study period, from 46.8% in 2009 to 15.8% in 2020. A LB serological prescription was associated with patients with no reported tick bite (Odds Ratio (OR): 1.95; 95% confidence interval [1.23-3.09]), multiple EM (OR: 3.82 [1.63-8.92]), EM of five centimeters or more (OR: 4.34 [2.33-8.08]), and GPs having diagnosed less than one EM case per year during the study period (OR: 5.28 [1.73-16.11]). CONCLUSIONS Serological testing of patients consulting for EM is not recommended in European recommendations for diagnosis of Lyme borreliosis. Therefore, the significant decrease in the rate of LB serological test for EM over the study period is encouraging. The factors identified in this study can be used to improve messaging to GPs and patients. Further efforts are needed to continue to disseminate diagnostic recommendations for LB to GPs, especially those who rarely see patients with EM.
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Affiliation(s)
- Camille Bonnet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France.
| | - Julie Figoni
- Santé publique France, Saint-Maurice, F94410, France
| | - Cécile Souty
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
| | | | - Sylvie de Martino
- CNR des Borrelia et Institut de Bactériologie, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, CHRU Strasbourg, UR7290, ITI InnoVec, Strasbourg, 67000, France
| | | | - Lucie Fournier
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
| | - Thomas Hanslik
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
- Service de Médecine Interne, APHP, Hôpital Ambroise Paré, Assistance Publique - Hôpitaux de Paris, Boulogne-Billancourt, France
- Université Versailles Saint-Quentin-en-Yvelines, UVSQ, UFR de Médecine Simone Veil, Versailles, France
| | - Benoît Jaulhac
- CNR des Borrelia et Institut de Bactériologie, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, CHRU Strasbourg, UR7290, ITI InnoVec, Strasbourg, 67000, France
| | - Thierry Blanchon
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
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Brummitt SI, Harvey DJ, Smith WA, Barker CM, Kjemtrup AM. Assessment of Physician Knowledge, Attitudes, and Practice for Lyme Disease in a Low-Incidence State. JOURNAL OF MEDICAL ENTOMOLOGY 2022; 59:2182-2188. [PMID: 36130173 DOI: 10.1093/jme/tjac137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 06/15/2023]
Abstract
Lyme disease (LD), caused by the bacterium Borrelia burgdorferi, is transmitted to humans in California through the bite of infected blacklegged ticks (Ixodes pacificus). Overall, the incidence of LD in California is low: approximately 0.2 confirmed cases per 100,000 population. However, California's unique ecological diversity results in wide variation in local risk, including regions with local foci at elevated risk of human disease. The diagnosis of LD can be challenging in California because the prior probability of infection for individual patients is generally low. Combined with nonspecific symptoms and complicated laboratory testing, California physicians need a high level of awareness of LD in California to recognize and diagnose LD efficiently. This research addresses an under-studied area of physicians' knowledge and practice of the testing and treatment of LD in a low-incidence state. We assessed knowledge and practices related to LD diagnosis using an electronic survey distributed to physicians practicing in California through mixed sampling methods. Overall, responding physicians in California had a general awareness of Lyme disease and were knowledgeable regarding diagnosis and treatment. However, we found that physicians in California could benefit from further education to improve test-ordering practices, test interpretation, and awareness of California's disease ecology with elevated levels of focal endemicity, to improve recognition, diagnosis, and treatment of LD in California patients.
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Affiliation(s)
- Sharon I Brummitt
- Department of Medicine and Epidemiology, School of Veterinary Medicine, One Shields Avenue, University of California Davis, Davis, CA 95616, USA
| | - Danielle J Harvey
- Department of Public Health Sciences, School of Medicine, Medical Sciences 1C, One Shields Avenue, University of California Davis, Davis, CA 95616, USA
| | - Woutrina A Smith
- Department of Medicine and Epidemiology, School of Veterinary Medicine, One Shields Avenue, University of California Davis, Davis, CA 95616, USA
| | - Christopher M Barker
- Department of Pathology, Microbiology, and Immunology, School of Veterinary Medicine, One Shields Avenue, University of California Davis, Davis, CA 95616, USA
| | - Anne M Kjemtrup
- California Department of Public Health, Vector-Borne Disease Section, 1616 Capitol Avenue, MS 7307, P.O. Box 997377, Sacramento, CA 95899, USA
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Healthcare claims-based Lyme disease case-finding algorithms in the United States: A systematic literature review. PLoS One 2022; 17:e0276299. [PMID: 36301959 PMCID: PMC9612517 DOI: 10.1371/journal.pone.0276299] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 10/05/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Lyme disease (LD) is the fifth most commonly reported notifiable infectious disease in the United States (US) with approximately 35,000 cases reported in 2019 via public health surveillance. However, healthcare claims-based studies estimate that the number of LD cases is >10 times larger than reported through surveillance. To assess the burden of LD using healthcare claims data and the effectiveness of interventions for LD prevention and treatment, it is important to use validated well-performing LD case-finding algorithms ("LD algorithms"). We conducted a systematic literature review to identify LD algorithms used with US healthcare claims data and their validation status. METHODS We searched PubMed and Embase for articles published in English since January 1, 2000 (search date: February 20, 2021), using the following search terms: (1) "Lyme disease"; and (2) "claim*" or "administrative* data"; and (3) "United States" or "the US*". We then reviewed the titles, abstracts, full texts, and bibliographies of the articles to select eligible articles, i.e., those describing LD algorithms used with US healthcare claims data. RESULTS We identified 15 eligible articles. Of these, seven studies used LD algorithms with LD diagnosis codes only, four studies used LD diagnosis codes and antibiotic dispensing records, and the remaining four studies used serologic test order codes in combination with LD diagnosis codes and antibiotics records. Only one of the studies that provided data on algorithm performance: sensitivity 50% and positive predictive value 5%, and this was based on Lyme disease diagnosis code only. CONCLUSIONS US claims-based LD case-finding algorithms have used diverse strategies. Only one algorithm was validated, and its performance was poor. Further studies are warranted to assess performance for different algorithm designs and inform efforts to better assess the true burden of LD.
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Lutaud R, Verger P, Peretti-Watel P, Eldin C. When the patient is making the (wrong?) diagnosis: a biographical approach to patients consulting for presumed Lyme disease. Fam Pract 2022:cmac116. [PMID: 36267023 PMCID: PMC9619758 DOI: 10.1093/fampra/cmac116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Media coverage of Lyme disease (LD) has led to an increase in consultations for presumed LD in Europe. However, LD is confirmed in only 10%-20% of patients, with a significant number remaining in a diagnostic dead-end. OBJECTIVES To reach a deeper understanding of how patients themselves contribute to the diagnostic process. To describe the genesis of the LD hypothesis in care pathways. METHODS In 2019, 30 patients from a prospective cohort consulting in the infectious diseases department at University Hospital in Marseille for presumed LD were recruited for semistructured interviews. The inclusion criteria were: suffering from subjective symptoms for 6 months, no clinical or paraclinical argument suggesting current LD. The patients' medical trajectories were collected using a biographical approach. RESULTS The diagnosis of LD was primarily triggered by identification with personal testimonies found on the Internet. Most of patients were leading their own diagnostic investigation. The majority of participants were convinced they had LD despite the lack of medical evidence and the scepticism of their referring GP. CONCLUSION GPs should first systematically explore patients' aetiologic representations in order to improve adherence to the diagnosis especially in the management of medically unexplained symptoms. Long COVID-19 syndrome challenge offers an opportunity to promote active patient involvement in diagnosis.
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Affiliation(s)
- Romain Lutaud
- Department of General Practice, Aix Marseille University, Marseille, France
- UMR UMR 7268 ADES, EFS, CNRS, Aix-Marseille University, Marseille, France
- ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d’Azur, Marseille, France
| | - Pierre Verger
- ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d’Azur, Marseille, France
| | | | - Carole Eldin
- UMR UVE, Aix Marseille University, IRD, Inserm, Marseille, France
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15
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Alcon-Chino MET, De-Simone SG. Recent Advances in the Immunologic Method Applied to Tick-Borne Diseases in Brazil. Pathogens 2022; 11:pathogens11080870. [PMID: 36014992 PMCID: PMC9414916 DOI: 10.3390/pathogens11080870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 12/10/2022] Open
Abstract
Zoonotic-origin infectious diseases are one of the major concerns of human and veterinary health systems. Ticks, as vectors of several zoonotic diseases, are ranked second only to mosquitoes as vectors. Many ticks’ transmitted infections are still endemic in the Americas, Europe, and Africa and represent approximately 17% of their infectious diseases population. Although our scientific capacity to identify and diagnose diseases is increasing, it remains a challenge in the case of tick-borne conditions. For example, in 2017, 160 cases of the Brazilian Spotted Fever (BSF, a tick-borne illness) were confirmed, alarming the notifiable diseases information system. Conversely, Brazilian borreliosis and ehrlichiosis do not require notification. Still, an increasing number of cases in humans and dogs have been reported in southeast and northeastern Brazil. Immunological methods applied to human and dog tick-borne diseases (TBD) show low sensitivity and specificity, cross-reactions, and false IgM positivity. Thus, the diagnosis and management of TBD are hampered by the personal tools and indirect markers used. Therefore, specific and rapid methods urgently need to be developed to diagnose the various types of tick-borne bacterial diseases. This review presents a brief historical perspective on the evolution of serological assays and recent advances in diagnostic tests for TBD (ehrlichiosis, BSF, and borreliosis) in humans and dogs, mainly applied in Brazil. Additionally, this review covers the emerging technologies available in diagnosing TBD, including biosensors, and discusses their potential for future use as gold standards in diagnosing these diseases.
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Affiliation(s)
- Mônica E. T. Alcon-Chino
- Center for Technological Development in Health (CDTS), National Institute of Science and Technology for Innovation in Neglected Population Diseases (INCT-IDPN), FIOCRUZ, Rio de Janeiro 21040-900, Brazil;
- Post-Graduation Program in Science and Biotechnology, Department of Molecular and Cellular Biology, Biology Institute, Federal Fluminense University, Niterói 22040-036, Brazil
| | - Salvatore G. De-Simone
- Center for Technological Development in Health (CDTS), National Institute of Science and Technology for Innovation in Neglected Population Diseases (INCT-IDPN), FIOCRUZ, Rio de Janeiro 21040-900, Brazil;
- Post-Graduation Program in Science and Biotechnology, Department of Molecular and Cellular Biology, Biology Institute, Federal Fluminense University, Niterói 22040-036, Brazil
- Laboratory of Epidemiology and Molecular Systematics, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-900, Brazil
- Correspondence: ; Tel.: +55-21-38658183
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Brown Marusiak A, Hollingsworth BD, Abernathy H, Alejo A, Arahirwa V, Mansour O, Giandomenico D, Schmitz J, Williams C, Barbarin AM, Boyce RM. Patterns Testing for Tick-Borne Diseases and Implications for Surveillance in the Southeastern US. JAMA Netw Open 2022; 5:e2212334. [PMID: 35576005 PMCID: PMC9112065 DOI: 10.1001/jamanetworkopen.2022.12334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
IMPORTANCE Tick-borne diseases (TBD), including spotted fever group rickettsiosis (SFGR), ehrlichiosis, and, increasingly, Lyme disease, represent a substantial public health concern throughout much of the southeastern United States. Yet, there is uncertainty about the epidemiology of these diseases because of pitfalls in existing diagnostic test methods. OBJECTIVE To examine patterns of diagnostic testing and incidence of TBD in a large, academic health care system. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included diagnostic test results for TBD at UNC Health, a large academic health care system with inpatient and outpatient facilities, from January 1, 2017, to November 30, 2020. Participants included all individuals seeking routine care at UNC Health facilities who had testing for SFGR, ehrlichiosis, or Lyme disease performed during the study period. MAIN OUTCOMES AND MEASURES Rates of test positivity, testing completeness, and incidence of TBD. RESULTS During the 4-year study period, 11 367 individuals (6633 [58.4%] female; 10 793 [95%] non-Hispanic individuals and 8850 [77.9%] White individuals; median [IQR] age, 53 [37-66] years) were tested for TBD. Among the 20 528 diagnostic tests performed, 47 laboratory-confirmed, incident cases of SFGR, 27 cases of ehrlichiosis, and 76 cases of Lyme were confirmed, representing incidence rates of 4.7%, 7.1%, and 0.7%, respectively. However, 3984 of SFGR tests (79.3%) and 3606 of Ehrlichia tests (74.3%) lacked a paired convalescent sample. Of 20 528 tests, there were 11 977 tests (58.3%) for Lyme disease from 10 208 individuals, 5448 tests (26.5%) for SFGR from 4520 individuals, and 3103 tests (15.1%) for ehrlichiosis from 2507 individuals. Most striking, testing for ehrlichiosis was performed in only 55% of patients in whom SFGR was ordered, suggesting that ehrlichiosis remains underrecognized. An estimated 187 incident cases of SFGR and 309 of ehrlichiosis were potentially unidentified because of incomplete testing. CONCLUSIONS AND RELEVANCE In this cross-sectional study, most of the patients suspected of having TBD did not have testing performed in accordance with established guidelines, which substantially limits understanding of TBD epidemiology. Furthermore, the data revealed a large discrepancy between the local burden of disease and the testing performed. These findings underscore the need to pursue more robust, active surveillance strategies to estimate the burden of TBD and distribution of causative pathogens.
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Affiliation(s)
- Amanda Brown Marusiak
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brandon D. Hollingsworth
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Haley Abernathy
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Aidin Alejo
- Department of Pathology and Laboratory Medicine, McLendon Clinical Laboratories, UNC Health, Chapel Hill, North Carolina
| | - Victor Arahirwa
- Department of Pathology and Laboratory Medicine, McLendon Clinical Laboratories, UNC Health, Chapel Hill, North Carolina
| | - Odai Mansour
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dana Giandomenico
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John Schmitz
- Department of Pathology and Laboratory Medicine, McLendon Clinical Laboratories, UNC Health, Chapel Hill, North Carolina
| | - Carl Williams
- Division of Public Health, Communicable Disease Branch, Raleigh, North Carolina
| | - Alexis M. Barbarin
- Division of Public Health, Communicable Disease Branch, Raleigh, North Carolina
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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17
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Knudtzen FC, Jensen TG, Andersen NS, Johansen IS, Hovius JW, Skarphédinsson S. An intervention in general practice to improve the management of Lyme borreliosis in Denmark. Eur J Public Health 2022; 32:436-442. [PMID: 35323885 PMCID: PMC9159330 DOI: 10.1093/eurpub/ckac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Our objectives were to improve the following outcomes in patients with Lyme borreliosis (LB) through an educational intervention in general practice: (i) increase the number of hospital referrals on suspicion of LB, (ii) increase the number of cerebrospinal fluid (CSF) tests examined for Borrelia burgdorferi antibody index, (iii) decrease the number of serum-B. burgdorferi antibody tests ordered, (iv) shorten delay from symptom onset to hospital in Lyme neuroborreliosis (LNB) patients, (v) increase LB knowledge among general practitioners. Methods A prospective non-blinded non-randomized intervention trial on the island of Funen, Denmark. The intervention included oral and written education about LB and was carried out in areas with an LNB incidence ≥4.7/100.000 between 22 January 2019 and 7 May 2019. Results were compared between the intervention group (49 general practices) and the remaining general practices in Funen (71 practices) 2 years before and after the intervention. Results In the study period, 196 patients were referred on suspicion of LB, a 28.9% increase in the intervention group post-intervention, 59.5% increase in the control group (P = 0.47). The number of CSF-Borrelia-antibody index tests increased 20.8% in the intervention group, 18.0% in the control group (P = 0.68), while ordered serum-B. burgdorferi antibody tests declined 43.1% in the intervention group, 34.5% in the control group (P = 0.30). 25.1% had the presence of serum-B. burgdorferi antibodies. We found no difference in LNB pre-hospital delay before and after intervention or between groups (P = 0.21). The intervention group performed significantly better on a follow-up questionnaire (P = 0.02). Conclusion We found an overall improvement in LB awareness and referrals among general practitioners but could not show any effect of the intervention on clinical outcomes of LNB.
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Affiliation(s)
- Fredrikke Christie Knudtzen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Thøger Gorm Jensen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Clinical Microbiology, Odense University Hospital and Research Unit for Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Nanna Skaarup Andersen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Clinical Microbiology, Lillebaelt Hospital, Vejle, Denmark
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Joppe W Hovius
- Amsterdam UMC, Location AMC, Center for Experimental and Molecular Medicine, Amsterdam Multidisciplinary Lyme Borreliosis Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sigurdur Skarphédinsson
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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18
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Joyner G, Mavin S, Milner R, Lim C. Introduction of IgM testing for the diagnosis of acute Lyme borreliosis: a study of the benefits, limitations and costs. Eur J Clin Microbiol Infect Dis 2022; 41:671-675. [PMID: 35089441 PMCID: PMC8934319 DOI: 10.1007/s10096-021-04366-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
Testing for IgM antibodies to Borrelia burgdorferi in Scottish patients with suspected Lyme borreliosis was introduced in 2018 to supplement the IgG testing already in situ. Results from 2018 to 2020 were assessed alongside available clinical data to evaluate the utility of IgM testing in serum. An estimated false positive rate of 25.5% was observed with IgM immunoblot vs 80.1% for IgM chemiluminescent immunoassay (CLIA). IgM testing can aid earlier diagnoses if used within a selective two-tier testing protocol: only patients with acute onset of symptoms should be tested for IgM CLIA but confirmation by immunoblot and consideration of clinical picture is necessary.
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Affiliation(s)
- Greg Joyner
- Scottish Lyme Disease and Tick-Borne Infections Reference Laboratory (SLDTRL), Raigmore Hospital, Inverness, IV2 3UJ, UK
| | - Sally Mavin
- Scottish Lyme Disease and Tick-Borne Infections Reference Laboratory (SLDTRL), Raigmore Hospital, Inverness, IV2 3UJ, UK.
| | - Rachel Milner
- Scottish Lyme Disease and Tick-Borne Infections Reference Laboratory (SLDTRL), Raigmore Hospital, Inverness, IV2 3UJ, UK
| | - Chin Lim
- Scottish Lyme Disease and Tick-Borne Infections Reference Laboratory (SLDTRL), Raigmore Hospital, Inverness, IV2 3UJ, UK
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19
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Willis SJ, Cocoros NM, Callahan M, Herrick B, Brown CM, Kruskal BA, Klompas M. Assessment of Antibiotic Prescriptions for Lyme Disease After Modification of Reporting Language for Positive Screening Test Results. JAMA Netw Open 2022; 5:e2144928. [PMID: 35076704 PMCID: PMC8790673 DOI: 10.1001/jamanetworkopen.2021.44928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This quality improvement study assesses whether revision of positive Lyme disease test result text was associated with decreases in the frequency of antibiotic prescriptions for patients without confirmatory results.
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Affiliation(s)
- Sarah J Willis
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | | | - Catherine M Brown
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Benjamin A Kruskal
- Atrius Health, Boston, Massachusetts
- New England Quality Care Alliance, Braintree, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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20
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Kalmár Z, Briciu V, Coroian M, Flonta M, Rădulescu AL, Topan A, Mihalca AD, Lupșe M. Seroprevalence of antibodies against Borrelia burgdorferi sensu lato in healthy blood donors in Romania: an update. Parasit Vectors 2021; 14:596. [PMID: 34863277 PMCID: PMC8645117 DOI: 10.1186/s13071-021-05099-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Borrelia burgdorferi sensu lato (s.l.) genogroup is the causative agent responsible for Lyme borreliosis, a common tick-borne infectious disease in some temperate regions of the Northern Hemisphere. In humans, the clinical manifestations of Lyme borreliosis vary from dermatological infection to severe systemic manifestations. In Romania, data on the seroprevalence of Lyme borreliosis and associated risk factors are scarce and outdated, as the only seroprevalence study with a large dataset was published more than 20 years ago. Therefore, the aim of the present study was to evaluate the seroprevalence for Borrelia burgdorferi s.l. in healthy blood donors from six Romanian counties and identify the associated risk factors. METHODS The study was conducted among 1200 healthy blood donors aged between 18 and 65 years during November 2019 and September 2020 from six counties in the northwestern and central parts of Romania. A two-tiered testing strategy was applied. Positive and equivocal immunoenzymatic test results for IgG and IgM antibodies were further confirmed by Western blot. RESULTS Serum samples from 20% of the blood donors had positive or equivocal IgG and IgM ELISA index values. In total, 2.3% of the serum samples for IgG and 1.8% for IgM were positive by Western blot. The seroprevalence for both antibodies varied between 1.5% (Satu-Mare) and 6.5% (Bistrița-Năsăud) in the six counties investigated. The highest seroprevalence was observed in men (4.7%), in blood donors performing their professional activities outdoors (4.2%), and in those aged ≥ 56 years (8%). CONCLUSIONS These findings confirm the presence of specific IgG and IgM antibodies to B. burgdorferi s.l. among healthy blood donors from Romania. Furthermore, potential risk factors, such as gender, age, and behavior, associated with the presence of positive B. burgdorferi s.l. antibodies among healthy blood donors were identified.
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Affiliation(s)
- Zsuzsa Kalmár
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Violeta Briciu
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania. .,Hospital for Infectious Diseases, Cluj-Napoca, Romania.
| | - Mircea Coroian
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania.,University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, Cluj-Napoca, Romania
| | - Mirela Flonta
- Hospital for Infectious Diseases, Cluj-Napoca, Romania
| | | | - Adriana Topan
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Andrei Daniel Mihalca
- University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, Cluj-Napoca, Romania
| | - Mihaela Lupșe
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania.,Hospital for Infectious Diseases, Cluj-Napoca, Romania
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Abstract
PURPOSE OF REVIEW Lyme disease is an important, vector-borne infection found throughout the temperate Northern hemisphere. The disease causes rash, acute systemic illness, and in some untreated patients, inflammatory arthritis. This review examines the emergence, clinical features and management of early Lyme disease and Lyme arthritis. RECENT FINDINGS There has been continuing progress in characterizing the clinical manifestations, diagnostic testing and treatment of Lyme disease. Almost all patients with early Lyme disease can be cured with antibiotic treatment. In most cases, Lyme arthritis also responds to antibiotics, but some patients require additional treatment approaches. SUMMARY The diagnosis of Lyme disease is based on clinical manifestations and adjunctive laboratory testing. For the rheumatologist, Lyme arthritis should be recognized by a pattern of attacks of asymmetric, oligo-arthritis, recognizable by clinical manifestations in the same way that other rheumatic diseases, such as gout or rheumatoid arthritis, are diagnosed.
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Reifert J, Kamath K, Bozekowski J, Lis E, Horn EJ, Granger D, Theel ES, Shon J, Sawyer JR, Daugherty PS. Serum Epitope Repertoire Analysis Enables Early Detection of Lyme Disease with Improved Sensitivity in an Expandable Multiplex Format. J Clin Microbiol 2021; 59:e01836-20. [PMID: 33148704 PMCID: PMC8111119 DOI: 10.1128/jcm.01836-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/27/2020] [Indexed: 12/25/2022] Open
Abstract
Widely employed diagnostic antibody serology for Lyme disease, known as standard two-tier testing (STTT), exhibits insufficient sensitivity in early Lyme disease, yielding many thousands of false-negative test results each year. Given this problem, we applied serum antibody repertoire analysis (SERA), or next-generation sequencing (NGS)-based serology, to discover IgG and IgM antibody epitope motifs capable of detecting Lyme disease-specific antibodies with high sensitivity and specificity. Iterative motif discovery and bioinformatic analysis of epitope repertoires from subjects with Lyme disease (n = 264) and controls (n = 391) yielded a set of 28 epitope motifs representing 20 distinct IgG antibody epitopes and a set of 38 epitope motifs representing 21 distinct IgM epitopes, which performed equivalently in a large validation cohort of STTT-positive samples. In a second validation set from subjects with clinically defined early Lyme disease (n = 119) and controls (n = 257), the SERA Lyme IgG and IgM assay exhibited significantly improved sensitivity relative to STTT (77% versus 62%; Z-test; P = 0.013) and improved specificity (99% versus 97%). Early Lyme disease subjects exhibited significantly fewer reactive epitopes (Mann-Whitney U test; P < 0.0001) relative to subjects with Lyme arthritis. Thus, SERA Lyme IgG and M panels provided increased accuracy in early Lyme disease in a readily expandable multiplex assay format.
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Affiliation(s)
| | | | | | - Ewa Lis
- Serimmune Inc., Goleta, California, USA
| | | | - Dane Granger
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester Minnesota, USA
| | - Elitza S Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester Minnesota, USA
| | - John Shon
- Serimmune Inc., Goleta, California, USA
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23
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Srećković B, Knežević S, Đorđević S. Chronic Lyme neuroborreliosis. ABC - CASOPIS URGENTNE MEDICINE 2021. [DOI: 10.5937/abc2102024s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction. Lyme neuroborreliosis is an infectious disorder of the central and/or peripheral nervous system caused by the tick stump of the genus Ixodes rici, infected with species Borrelia burgdorferi sensu lato (in Europe). The disease manifests as meningitis, encephalitis, meningoradiculitis, vasculitis, paresthesia of the facial nerve and painful radiculopathy. Case report. A 44-year-old patient reports fatigue, forgetfulness, headache, confusion, depression, drowsiness, irritability, instability, her undercooks are crushed, sheeps of a bride and does not recall being called an object. Muscular reflexes of the undergrowth are reduced. Plantar response flexion, Lazarevic sign is positive at 45 degrees from the surface. No weakness of the dorsal and plantar flexion of the fingers of the feet. Relieves sensitivity in the region of inertia nerv peroneus and tibialis. Sphincters were fine. The patient had a diagnosed Lyme disease, five months prior to the exacerbation of anxiety. Due to erythema migrans and subfebrility, diagnosis and seropositivity to Borrelia burgdorferi were established in both classes of the enzymelinked immunosorbent assay antibodies and a confirmed Western blot test. She took doxycycline 200 milligrams/day, three weeks. The analysis of cerebrospinal fluid revealed proteinhorn (0.42 g/L), normal glycorrhachia, pleocytosis, and positive intrathecal IgG antibodies. Electromyography pointed to axonal degeneration of the lower extremities. The magnetic resonance is neat. The therapy includes ceftriaxone, 2 grams/day, vitamins and analgesic therapy. Neuroborreliois was maintained by the laboratory during one-year follow-up. Mental disorders, headaches, confusion and irritability, neurological signs have significantly regressed. Conclusion. The gold standard in diagnostics of neuroborelliosis is the determination of intrathecal antibodies. For the definitive diagnosis, clinical signs of disease, pleocytosis and positive antibodies are necessary. Intrathecal antibodies remain long positive and they are not recommended for monitoring for the effects of therapy.
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Moriyama Y, Kutsuna S, Toda Y, Kawabata H, Sato K, Ohmagari N. Three cases diagnosed not Lyme disease but "tick-associated rash illness (TARI)" in Japan. J Infect Chemother 2020; 27:650-652. [PMID: 33309106 DOI: 10.1016/j.jiac.2020.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/23/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
We report three cases of tick-associated rash illness (TARI) in Japan that presented with erythema migrans (EM) after a tick bite. Although EM is considered to be a characteristic finding of Lyme disease, EM can occur even if patient is not affected by Lyme disease and if it is bitten by a tick. In Japan, the vector of Lyme disease pathogens are not distributed in most areas, and patients with EM are unlikely to have Lyme disease. We aim to raise TARI awareness among physicians.
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Affiliation(s)
- Yuki Moriyama
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Satoshi Kutsuna
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan.
| | - Yuta Toda
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Hiroki Kawabata
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Kozue Sato
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Norio Ohmagari
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
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Gynthersen RMM, Tetens MM, Ørbæk M, Haahr R, Fana V, Hansen K, Mens H, Andersen ÅB, Lebech AM. Classification of patients referred under suspicion of tick-borne diseases, Copenhagen, Denmark. Ticks Tick Borne Dis 2020; 12:101591. [PMID: 33126203 DOI: 10.1016/j.ttbdis.2020.101591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/31/2023]
Abstract
To provide better care for patients suspected of having a tick-transmitted infection, the Clinic for Tick-borne Diseases at Rigshospitalet, Copenhagen, Denmark was established. The aim of this prospective cohort study was to evaluate diagnostic outcome and to characterize demographics and clinical presentations of patients referred between the 1st of September 2017 to 31st of August 2019. A diagnosis of Lyme borreliosis was based on medical history, symptoms, serology and cerebrospinal fluid analysis. The patients were classified as definite Lyme borreliosis, possible Lyme borreliosis or post-treatment Lyme disease syndrome. Antibiotic treatment of Lyme borreliosis manifestations was initiated in accordance with the national guidelines. Patients not fulfilling the criteria of Lyme borreliosis were further investigated and discussed with an interdisciplinary team consisting of specialists from relevant specialties, according to individual clinical presentation and symptoms. Clinical information and demographics were registered and managed in a database. A total of 215 patients were included in the study period. Median age was 51 years (range 17-83 years), and 56 % were female. Definite Lyme borreliosis was diagnosed in 45 patients, of which 20 patients had erythema migrans, 14 patients had definite Lyme neuroborreliosis, six had acrodermatitis chronica atrophicans, four had multiple erythema migrans and one had Lyme carditis. Furthermore, 12 patients were classified as possible Lyme borreliosis and 12 patients as post-treatment Lyme disease syndrome. A total of 146 patients (68 %) did not fulfil the diagnostic criteria of Lyme borreliosis. Half of these patients (73 patients, 34 %) were diagnosed with an alternative diagnosis including inflammatory diseases, cancer diseases and two patients with a tick-associated disease other than Lyme borreliosis. A total of 73 patients (34 %) were discharged without sign of somatic disease. Lyme borreliosis patients had a shorter duration of symptoms prior to the first hospital encounter compared to patients discharged without a specific diagnosis (p<0.001). When comparing symptoms at presentation, patients discharged without a specific diagnosis suffered more often from general fatigue and cognitive dysfunction. In conclusion, 66 % of all referred patients were given a specific diagnosis after ended outpatient course. A total of 32 % was diagnosed with either definite Lyme borreliosis, possible Lyme borreliosis or post-treatment Lyme disease syndrome; 34 % was diagnosed with a non-tick-associated diagnosis. Our findings underscore the complexity in diagnosing Lyme borreliosis and the importance of ruling out other diseases through careful examination.
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Affiliation(s)
- Rosa M M Gynthersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mathilde Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rasmus Haahr
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Viktoria Fana
- Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Helene Mens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Åse Bengård Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Mast Cell Biology and Linkages for Non-clonal Mast Cell Activation and Autoimmune/Inflammatory Syndrome Induced by Adjuvants. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s42399-020-00494-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kortela E, Kanerva M, Kurkela S, Oksi J, Järvinen A. Suspicion of Lyme borreliosis in patients referred to an infectious diseases clinic: what did the patients really have? Clin Microbiol Infect 2020; 27:1022-1028. [PMID: 32979573 DOI: 10.1016/j.cmi.2020.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/31/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the conditions behind the symptoms in patients with suspected Lyme borreliosis (LB) who were referred to an infectious diseases clinic. METHODS In this retrospective, population-based study, we collected data from the medical records of all patients referred for infectious disease consultations in 2013 due to presumed LB from a population of 1.58 million. The patients were classified according to the certainty of LB on the basis of their symptoms, signs and laboratory results. Data on the outcomes and subsequent alternative diagnoses during the 4-year follow-up period were reviewed from all of the available patient records from public, private and occupational healthcare providers. RESULTS A total of 256 patients (16/100 000) were referred as a result of suspicion of LB; 30 (12%) of 256 were classified with definite, 36 (14%) with probable and 65 (25%) with possible LB. LB was unlikely in 121 (47%) patients. A novel diagnosis was discovered in the background symptoms in 73 (29%) of patients. Previously diagnosed comorbidities caused at least some of the symptoms in 48 (19%) patients. Other explanations for symptoms were found in 81 (67%) of 121 of unlikely and 22 (34%) of 65 of possible LB patients. The spectrum of conditions behind the symptoms was quite broad and most often were musculoskeletal, neurological, psychological or functional disorders. CONCLUSIONS LB was unlikely in half of the patients with presumed LB. In most cases the patients had other conditions that explained their symptoms.
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Affiliation(s)
- Elisa Kortela
- Division of Infectious Diseases, Inflammation Centre, Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Medicine, University of Turku, Finland.
| | - Mari Kanerva
- Division of Infectious Diseases, Inflammation Centre, Helsinki University Hospital and University of Helsinki, Finland
| | - Satu Kurkela
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jarmo Oksi
- Department of Infectious Diseases, Turku University Hospital and University of Turku, Turku, Finland
| | - Asko Järvinen
- Division of Infectious Diseases, Inflammation Centre, Helsinki University Hospital and University of Helsinki, Finland
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Kip MMA, Oonk MLJ, Levin MD, Schop A, Bindels PJE, Kusters R, Koffijberg H. Preventing overuse of laboratory diagnostics: a case study into diagnosing anaemia in Dutch general practice. BMC Med Inform Decis Mak 2020; 20:178. [PMID: 32736551 PMCID: PMC7395377 DOI: 10.1186/s12911-020-01198-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background More information is often thought to improve medical decision-making, which may lead to test overuse. This study assesses which out of 15 laboratory tests contribute to diagnosing the underlying cause of anaemia by general practitioners (GPs) and determines a potentially more efficient subset of tests for setting the correct diagnosis. Methods Logistic regression was performed to determine the impact of individual tests on the (correct) diagnosis. The statistically optimal test subset for diagnosing a (correct) underlying cause of anaemia by GPs was determined using data from a previous survey including cases of real-world anaemia patients. Results Only 9 (60%) of the laboratory tests, and patient age, contributed significantly to the GPs’ ability to diagnose an underlying cause of anaemia (CRP, ESR, ferritin, folic acid, haemoglobin, leukocytes, eGFR/MDRD, reticulocytes and serum iron). Diagnosing the correct underlying cause may require just five (33%) tests (CRP, ferritin, folic acid, MCV and transferrin), and patient age. Conclusions In diagnosing the underlying cause of anaemia a subset of five tests has most added value. The real-world impact of using only this subset should be further investigated. As illustrated in this case study, a statistical approach to assessing the added value of tests may reduce test overuse.
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Affiliation(s)
- Michelle M A Kip
- Department of Health Technology and Services Research, University of Twente, Technical Medical Center, Faculty of Behavioural, Management and Social Sciences, Enschede, the Netherlands.
| | - Martijn L J Oonk
- Department of Health Technology and Services Research, University of Twente, Technical Medical Center, Faculty of Behavioural, Management and Social Sciences, Enschede, the Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Annemarie Schop
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Ron Kusters
- Department of Health Technology and Services Research, University of Twente, Technical Medical Center, Faculty of Behavioural, Management and Social Sciences, Enschede, the Netherlands.,Laboratory for Clinical Chemistry and Haematology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Hendrik Koffijberg
- Department of Health Technology and Services Research, University of Twente, Technical Medical Center, Faculty of Behavioural, Management and Social Sciences, Enschede, the Netherlands
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Performance of a Modified Two-Tiered Testing Enzyme Immunoassay Algorithm for Serologic Diagnosis of Lyme Disease in Nova Scotia. J Clin Microbiol 2020; 58:JCM.01841-19. [PMID: 32321781 DOI: 10.1128/jcm.01841-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/07/2020] [Indexed: 12/25/2022] Open
Abstract
Compared to the standard two-tiered testing (STTT) algorithm for Lyme disease serology using an enzyme immunoassay (EIA) followed by Western blotting, data from the United States suggest that a modified two-tiered testing (MTTT) algorithm employing two EIAs has improved sensitivity to detect early localized Borrelia burgdorferi infections without compromising specificity. From 2011 to 2014, in the Canadian province of Nova Scotia, where Lyme disease is hyperendemic, sera submitted for Lyme disease testing were subjected to a whole-cell EIA, followed by C6 EIA and subsequently IgM and/or IgG immunoblots on sera with EIA-positive or equivocal results. Here, we evaluate the effectiveness of the MTTT algorithm compared to the STTT approach in a Nova Scotian population. Retrospective chart reviews were performed on patients testing positive with the whole-cell and C6 EIAs (i.e., the MTTT algorithm). Patients were classified as having Lyme disease if they had a positive STTT result, a negative STTT result but symptoms consistent with Lyme disease, or evidence of seroconversion on paired specimens. Of the 10,253 specimens tested for Lyme disease serology, 9,806 (95.6%) were negative. Of 447 patients who tested positive, 271 charts were available for review, and 227 were classified as patients with Lyme disease. The MTTT algorithm detected 25% more early infections with a specificity of 99.56% (99.41 to 99.68%) compared to the STTT. These are the first Canadian data to show that serology using a whole-cell sonicate EIA followed by a C6 EIA (MTTT) had improved sensitivity for detecting early B. burgdorferi infection with specificity similar to that of two-tiered testing using Western blots.
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Talagrand-Reboul E, Raffetin A, Zachary P, Jaulhac B, Eldin C. Immunoserological Diagnosis of Human Borrelioses: Current Knowledge and Perspectives. Front Cell Infect Microbiol 2020; 10:241. [PMID: 32509603 PMCID: PMC7248299 DOI: 10.3389/fcimb.2020.00241] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/27/2020] [Indexed: 01/11/2023] Open
Abstract
Spirochetes of the genus Borrelia are divided into relapsing fever borreliae and Lyme disease borreliae. Immunoserological assays have been poorly developed for relapsing fever borreliae, where direct detection methods are more adapted to the pathophysiology of these infections presenting with massive bacteraemia. However, emergence of the novel agent of relapsing fever B. miyamotoi has renewed interest in serology in this context. In Lyme disease, because direct detection methods show low sensitivity, serology plays a central role in the diagnostic strategy. This diagnostic strategy is based on a two-tier methodology involving a first test (ELISA) with high sensitivity and acceptable specificity and a second, more specific test (western blot) for diagnostic confirmation. The most frequent limitations and pitfalls of serology are cross reactions, false IgM positivity, a seronegative window period at the early time of the infection, and serologic scars with a suspicion of reinfection. International guidelines have thus been proposed to avoid these difficulties with interpretation. Finally, unconventional diagnostic tests have been developed recently in the context of a highly publicized disease, with widely varying results, some of which have no available evidence-based data. New two-tier testing strategies using two ELISA tests (C6 and WCS for example) to replace immunoblot are currently proposed by some authors and guidelines, and promising new tests such as CXCL-13 in CSF are promising tools for the improvement of the diagnosis of Lyme borreliosis.
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Affiliation(s)
- Emilie Talagrand-Reboul
- UR 7290 Virulence Bactérienne Précoce, Université de Strasbourg, Centre Hospitalier Régional Universitaire de Strasbourg, Fédération de Médecine Translationnelle, Groupe Borréliose de Strasbourg, Strasbourg, France.,National Reference Center for Borrelia, CHRU Strasbourg, Strasbourg, France
| | - Alice Raffetin
- Department of Infectious Diseases, Centre Hospitalier Lucie-et-Raymond-Aubrac, Villeneuve-Saint-Georges, France
| | - Pierre Zachary
- UR 7290 Virulence Bactérienne Précoce, Université de Strasbourg, Centre Hospitalier Régional Universitaire de Strasbourg, Fédération de Médecine Translationnelle, Groupe Borréliose de Strasbourg, Strasbourg, France.,National Reference Center for Borrelia, CHRU Strasbourg, Strasbourg, France
| | - Benoît Jaulhac
- UR 7290 Virulence Bactérienne Précoce, Université de Strasbourg, Centre Hospitalier Régional Universitaire de Strasbourg, Fédération de Médecine Translationnelle, Groupe Borréliose de Strasbourg, Strasbourg, France.,National Reference Center for Borrelia, CHRU Strasbourg, Strasbourg, France
| | - Carole Eldin
- Aix Marseille Univ, IRD, SSA, VITROME, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
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Modified two-tiered testing algorithm for Lyme disease serology: the Canadian context. Can Commun Dis Rep 2020; 46:125-131. [PMID: 32558809 DOI: 10.14745/ccdr.v46i05a05] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lyme disease (LD) is emerging in many parts of central and eastern Canada. Serological testing is most commonly used to support laboratory diagnosis of LD. Standard two-tiered testing (STTT) for LD involves detection of Borrelia burgdorferi antibodies using an enzyme immunoassay (EIA) followed by IgM and/or IgG immunoblots. However, improved sensitivity has been demonstrated using a modified two-tiered testing (MTTT) approach, in which a second EIA instead of the traditional immunoblot is used. This article summarises the evidence supporting the MTTT versus STTT for laboratory diagnosis of LD in Canada. METHODS Peer reviewed literature on the sensitivity and specificity of different EIAs were compared by Canadian experts in LD diagnostic for MTTT vs STTT in patients with clinical history of LD residing in LD endemic areas or in samples from the LD serum repository. RESULTS The MTTT approach consistently demonstrated improved sensitivity to detect early infections with B. burgdorferi and also maintained high specificity vs STTT. CONCLUSION Diagnostic improvements in sensitivity of LD testing without significant loss of specificity have been consistently reported when MTTT is compared with STTT in studies conducted in highly LD endemic regions. Our working group agrees with the recommendation by the United States Centers for Disease Control that serological testing for LD using MTTT is an acceptable alternative to STTT. This recommendation is contingent on development and implementation of comprehensive validation studies on the performance of MTTT vs STTT within the Canadian context, including evaluation of the test performance in areas of low endemicity for LD.
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Zannoli S, Fantini M, Semprini S, Marchini B, Ceccarelli B, Sparacino M, Schiavone P, Belgrano A, Ruscio M, Gobbetti M, Nicoletti M, Robatscher E, Pagani E, Sambri V. Multicenter Evaluation of the C6 Lyme ELISA Kit for the Diagnosis of Lyme Disease. Microorganisms 2020; 8:microorganisms8030457. [PMID: 32213811 PMCID: PMC7143974 DOI: 10.3390/microorganisms8030457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/23/2020] [Accepted: 03/20/2020] [Indexed: 11/19/2022] Open
Abstract
Lyme disease (LD), caused by infection with Borrelia burgdorferi, is the most common tick-borne infection in many regions of Eurasia. Antibody detection is the most frequently used laboratory test, favoring a two-step serodiagnostic algorithm; immunoenzymatic detection of antibodies to C6 has been shown to perform similarly to a standard two-step workflow. The aim of this study was the performance evaluation of the C6 Lyme ELISA kit compared to a standard two-step algorithm in three laboratories located in the northeastern region of Italy which cater to areas with different LD epidemiology. A total of 804 samples were tested, of which 695 gave concordant results between C6 testing and routine workflow (564 negative, 131 positive). Wherever available, clinical presentation and additional laboratory tests were analyzed to solve discrepancies. The C6 based method showed a good concordance with the standard two-step algorithm (Cohen’s κ = 0.619), however, the distribution of discrepancies seems to point towards a slightly lower specificity of C6 testing, which is supported by literature and could impact on patient management. The C6 ELISA, therefore, is not an ideal stand-alone test; however, if integrated into a two-step algorithm, it might play a part in achieving a sensitive, specific laboratory diagnosis of LD.
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Affiliation(s)
- Silvia Zannoli
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
- Correspondence:
| | - Michela Fantini
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
| | - Simona Semprini
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
| | - Barbara Marchini
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
| | - Barbara Ceccarelli
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
| | - Monica Sparacino
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
| | - Pasqua Schiavone
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
| | - Anna Belgrano
- Azienda Sanitaria Universitaria Integrata - Trieste (ASUIT) Laboratory, 34149 Trieste, Italy; (A.B.); (M.R.)
| | - Maurizio Ruscio
- Azienda Sanitaria Universitaria Integrata - Trieste (ASUIT) Laboratory, 34149 Trieste, Italy; (A.B.); (M.R.)
| | - Martina Gobbetti
- Azienda Sanitaria Alto Adige-Bolzano Microbiology Laboratory, 39100 Bolzano, Italy; (M.G.); (M.N.); (E.R.); (E.P.)
| | - Maira Nicoletti
- Azienda Sanitaria Alto Adige-Bolzano Microbiology Laboratory, 39100 Bolzano, Italy; (M.G.); (M.N.); (E.R.); (E.P.)
| | - Eva Robatscher
- Azienda Sanitaria Alto Adige-Bolzano Microbiology Laboratory, 39100 Bolzano, Italy; (M.G.); (M.N.); (E.R.); (E.P.)
| | - Elisabetta Pagani
- Azienda Sanitaria Alto Adige-Bolzano Microbiology Laboratory, 39100 Bolzano, Italy; (M.G.); (M.N.); (E.R.); (E.P.)
| | - Vittorio Sambri
- Unit of Microbiology, The Great Romagna Area Hub Laboratory, 47522 Pievesestina di Cesena (FC), Italy; (M.F.); (S.S.); (B.M.); (B.C.); (M.S.); (P.S.); (V.S.)
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy
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Abstract
PURPOSE OF REVIEW Since recognition in 1975, Lyme disease has become the most common vector-borne illness in North America and Europe. The clinical features are well-characterized and treatment is usually curative, but misperceptions about morbidity persist. The purpose of this review is to examine advances in the diagnosis and treatment of Lyme disease, as well as ongoing management challenges. RECENT FINDINGS It is useful to recognize that Lyme disease occurs in stages, with early- and late-stage disease. Clinical expression is in part determined by Borrelial variability. For example, some strains of Borrelia burgdorferi, the causative organism in North America, are particularly arthritogenic. Most patients with early Lyme disease can be cured with a single course of oral antibiotic therapy, in contrast to some patients with Lyme arthritis, a late-stage manifestation, who are more antibiotic refractory and require other treatment strategies. Successful treatment of Lyme disease begins with successful diagnosis and with an understanding of the emergence, clinical features, and impact of Lyme disease over the past half century.
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Affiliation(s)
- Robert T Schoen
- Section of Rheumatology, Allergy and Clinical Immunology, Yale University School of Medicine, 60 Temple Street, Suite 6A, New Haven, CT, 06510, USA.
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Abstract
This review discusses considerations related to laboratory diagnostic testing purchased directly by consumers without the care and oversight of a medical doctor. There are necessary tensions between the patient, physician, laboratory medical professional (physician or scientist), laboratory as a corporate entity (where applicable), and manufacturers of diagnostic equipment. When the physician, in particular, the primary care physician, is removed from this relationship, there is a significant opportunity of exploitation of the patient. All downstream investigations following direct-to-consumer testing, including attendant risk, are offloaded onto the traditional medical system, caring physician(s), and patients themselves. This process places patients at risk of iatrogenic harm.
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Kobayashi T, Higgins Y, Samuels R, Moaven A, Sanyal A, Yenokyan G, Lantos PM, Melia MT, Auwaerter PG. Misdiagnosis of Lyme Disease With Unnecessary Antimicrobial Treatment Characterizes Patients Referred to an Academic Infectious Diseases Clinic. Open Forum Infect Dis 2019; 6:5527068. [PMID: 31363774 PMCID: PMC6663506 DOI: 10.1093/ofid/ofz299] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/25/2019] [Indexed: 12/05/2022] Open
Abstract
Background Although Lyme disease is the most common vector-borne infection in the United States, diagnostic accuracy within community settings is not well characterized. Methods A retrospective observational cohort study of patients referred to an academic center with a presumed diagnosis or concern for Lyme disease between 2000 and 2013 was performed to analyze diagnoses and treatments. Characteristics of those with Lyme disease and those misdiagnosed as having Lyme disease were compared. Results Of 1261 patients, 911 (72.2%) did not have Lyme disease, 184 (14.6%) had active or recent Lyme disease, 150 (11.9%) had a remote history of Lyme disease, and 16 (1.3%) were identified as having possible Lyme disease. Patients without current Lyme disease were more likely to be female (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.08–2.45), to have had symptoms for >3 months (OR, 8.78; 95% CI, 5.87–13.1), to have higher symptom counts (OR per additional symptom, 1.08; 95% CI, 1.02–1.13), to have had more Lyme-related laboratory testing (OR per additional laboratory test, 1.17; 95% CI, 1.03–1.32), and to have been diagnosed with what were regarded as coinfections (OR, 3.13; 95% CI, 1.14–8.57). Of the 911 patients without Lyme disease, 764 (83.9%) had received antimicrobials to treat Lyme disease or their coinfections. The percentage of patients established to have Lyme disease was lower than in earlier studies of referred populations. Conclusions Among patients referred to an academic Infectious Diseases practice for Lyme disease, incorrect diagnoses and unnecessary antibiotic treatment were common, both for Lyme disease and for coinfections.
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Affiliation(s)
- Takaaki Kobayashi
- Infectious Disease, University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yvonne Higgins
- Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roger Samuels
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aurasch Moaven
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Abanti Sanyal
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul M Lantos
- Medicine and Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Michael T Melia
- Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul G Auwaerter
- Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
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36
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Jaulhac B, Saunier A, Caumes E, Bouiller K, Gehanno JF, Rabaud C, Perrot S, Eldin C, de Broucker T, Roblot F, Toubiana J, Sellal F, Vuillemet F, Sordet C, Fantin B, Lina G, Sobas C, Gocko X, Figoni J, Chirouze C, Hansmann Y, Hentgen V, Cathebras P, Dieudonné M, Picone O, Bodaghi B, Gangneux JP, Degeilh B, Partouche H, Lenormand C, Sotto A, Raffetin A, Monsuez JJ, Michel C, Boulanger N, Lemogne C, Tattevin P. Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies (II). Biological diagnosis, treatment, persistent symptoms after documented or suspected Lyme borreliosis. Med Mal Infect 2019; 49:335-346. [PMID: 31155367 DOI: 10.1016/j.medmal.2019.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/07/2019] [Indexed: 11/18/2022]
Abstract
The serodiagnosis of Lyme borreliosis is based on a two-tier strategy: a screening test using an immunoenzymatic technique (ELISA), followed if positive by a confirmatory test with a western blot technique for its better specificity. Lyme serology has poor sensitivity (30-40%) for erythema migrans and should not be performed. The seroconversion occurs after approximately 6 weeks, with IgG detection (sensitivity and specificity both>90%). Serological follow-up is not recommended as therapeutic success is defined by clinical criteria only. For neuroborreliosis, it is recommended to simultaneously perform ELISA tests in samples of blood and cerebrospinal fluid to test for intrathecal synthesis of Lyme antibodies. Given the continuum between early localized and disseminated borreliosis, and the efficacy of doxycycline for the treatment of neuroborreliosis, doxycycline is preferred as the first-line regimen of erythema migrans (duration, 14 days; alternative: amoxicillin) and neuroborreliosis (duration, 14 days if early, 21 days if late; alternative: ceftriaxone). Treatment of articular manifestations of Lyme borreliosis is based on doxycycline, ceftriaxone, or amoxicillin for 28 days. Patients with persistent symptoms after appropriate treatment of Lyme borreliosis should not be prescribed repeated or prolonged antibacterial treatment. Some patients present with persistent and pleomorphic symptoms after documented or suspected Lyme borreliosis. Another condition is eventually diagnosed in 80% of them.
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Affiliation(s)
- B Jaulhac
- Laboratoire de bactériologie et cnr des Borrelia, faculté de médecine et centre hospitalo-universitaire, 67000 Strasbourg, France
| | - A Saunier
- Médecine interne et maladies infectieuses, centre hospitalier, 24750 Périgueux, France
| | - E Caumes
- Maladies infectieuses et tropicales, hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - K Bouiller
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, UMR CNRS 6249 Université Bourgogne Franche Comté, 25000 Besançon, France
| | - J F Gehanno
- Médecine du travail, centre hospitalo-universitaire, 76000 Rouen, France
| | - C Rabaud
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 54100 Nancy, France
| | - S Perrot
- Centre d'étude et de traitement de la douleur, hôpital Cochin, 75014 Paris, France
| | - C Eldin
- Maladies infectieuses et tropicales, ihu méditerranée infection, centre hospitalo-universitaire Timone, 13000 Marseille, France
| | - T de Broucker
- Neurologie, hôpital Delafontaine, 92300 Saint-Denis, France
| | - F Roblot
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, inserm U1070, 86000 Poitiers, France
| | - J Toubiana
- Service de pédiatrie générale et maladies infectieuses, hôpital Necker-Enfants Malades, AP-HP, 75014 Paris, France
| | - F Sellal
- Département de neurologie, hôpitaux civil, 68000 Colmar, France
| | - F Vuillemet
- Département de neurologie, hôpitaux civil, 68000 Colmar, France
| | - C Sordet
- Rhumatologie, centre hospitalo-universitaire, 67000 Strasbourg, France
| | - B Fantin
- Médecine interne, hôpital Beaujon, université Paris Diderot, Inserm UMR 1137 IAME, 92110 Clichy, France
| | - G Lina
- Microbiologie, centre hospitalo-universitaire, 69000 Lyon, France
| | - C Sobas
- Microbiologie, centre hospitalo-universitaire, 69000 Lyon, France
| | - X Gocko
- Département de médecine générale, faculté de médecine, 42000 Saint-Etienne, France
| | - J Figoni
- Maladies Infectieuses et tropicales, hôpital Avicenne, 93022 Bobigny, France; Santé publique France, 94410 St Maurice, France
| | - C Chirouze
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, UMR CNRS 6249 Université Bourgogne Franche Comté, 25000 Besançon, France
| | - Y Hansmann
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 67000 Strasbourg, France
| | - V Hentgen
- Pédiatrie, centre hospitalier, 78000 Versailles, France
| | - P Cathebras
- Médecine interne, hôpital Nord, centre hospitalo-universitaire, 42000 Saint-Etienne, France
| | - M Dieudonné
- Centre Max Weber, CNRS, Université Lyon 2, 69000 Lyon, France
| | - O Picone
- Maternité Louis Mourier, 92700 Colombes, France
| | - B Bodaghi
- Ophtalmologie, hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - J P Gangneux
- Laboratoire de parasitologie-Mycologie, UMR_S 1085 Irset université Rennes1-Inserm-EHESP, centre hospitalo-universitaire, 35000 Rennes, France
| | - B Degeilh
- Laboratoire de parasitologie-Mycologie, UMR_S 1085 Irset université Rennes1-Inserm-EHESP, centre hospitalo-universitaire, 35000 Rennes, France
| | - H Partouche
- Cabinet de médecine générale, Saint-Ouen, département de médecine Générale, faculté de médecine. université Paris Descartes, 93400 Paris, France
| | - C Lenormand
- Dermatologie, hôpitaux universitaires de Strasbourg et faculté de médecine, université de Strasbourg, 67000 Strasbourg, France
| | - A Sotto
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 30000 Nîmes, France
| | - A Raffetin
- Maladies infectieuses et tropicales, centre hospitalier intercommunal, 94190 Villeneuve-St-Georges, France
| | - J J Monsuez
- Cardiologie, hôpital René Muret, 93270 Sevran, France
| | - C Michel
- Médecine générale, 67000 Strasbourg, France
| | - N Boulanger
- Médecine interne, hôpital Beaujon, université Paris Diderot, Inserm UMR 1137 IAME, 92110 Clichy, France
| | - C Lemogne
- Psychiatrie, hôpital européen Georges-Pompidou, AP-HP.5, Inserm U1266; Université Paris Descartes, 75015 Paris, France
| | - P Tattevin
- Maladies infectieuses et réanimation médicale, hôpital Pontchaillou, centre hospitalo-universitaire, 35033 Rennes, France.
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