Lyme Arthritis

The year that shaped the outcome of the OspA vaccine for human Lyme disease

The expansion of Lyme borreliosis endemic areas and the corresponding increase of disease incidence have opened the possibility for greater acceptance of a vaccine. In this perspective article, we discuss the discovery of outer surface protein A (OspA) of B. burgdorferi, and the subsequent pre-clinical testing and clinical trials of a recombinant OspA vaccine for human Lyme disease. We also discuss in detail the open public hearings of the FDA Lyme disease vaccine advisory panel held in 1998 where concerns of molecular mimicry induced autoimmunity to native OspA were raised, the limitations of those studies, and the current modifications of recombinant OspA to develop a multivalent subunit vaccine for Lyme disease.

Borrelia burgdorferi basic membrane protein A stimulates murine macrophage to secrete specific chemokines

In this study, we investigated the mechanisms that lead to the production of proinflammatory mediators by the murine macrophage cell line, RAW264.7, when these cells are exposed in vitro to recombinant Borrelia burgdorferi basic membrane protein A (rBmpA). Using antibody protein microarray technology with high-throughput detection ability for detecting 25 chemokines in culture supernatant the RAW264.7 cell culture supernatants at 12 and 24 h post-stimulation with rBmpA, we identified two chemokines, a monocyte chemoattractant protein-5 (MCP-5/CCL12) and a macrophage inflammatory protein-2 (MIP-2/CXCL2), both of which increased significantly after stimulation. We then chose these two chemokines for further study. Enzyme-linked immunosorbent assay and real-time polymerase chain reaction revealed that with the increase of rBmpA concentration, MCP-5/CCL12 and MIP-2/CXCL2 showed concentration-dependent increases (p <0.01).Our results indicate that the rBmpA could stimulate the secretion of several specific chemokines and induce Lyme arthritis.

Isoforskolin downregulates proinflammatory responses induced by Borrelia burgdorferi basic membrane protein A

The plant Coleus forskohlii is distributed primarily in India, Thailand, China, Egypt and Brazil and has a history of use in the treatment of multiple diseases. Isoforskolin (ISOF) is the principle active component of C. forskohlii native to China and has previously been studied for its biological effects. The aim of the present study was to evaluate the effect of ISOF on the proinflammatory responses induced by recombinant Borrelia burgdorferi basic membrane protein A (rBmpA). In in vitro experiments, the proinflammatory effects of rBmpA and the anti-inflammatory function of ISOF were evaluated in murine macrophages, human macrophages and dendritic cells by detecting the transcription and expression of tumor necrosis factor (TNF)-α and interleukin (IL)-6. In in vivo experiments, mean arthritis index and X-ray and histopathological examinations were used to verify the role of ISOF in experimental Lyme arthritis in mice. The results indicated that rBmpA, which induced the transcription and expression of TNF-α and IL-6, activated proinflammatory responses in murine macrophages, human macrophages and dendritic cells. In turn, ISOF downregulated the transcription and expression of TNF-α and IL-6 induced by rBmpA. Additionally, the in vivo experiments demonstrated that ISOF could also inhibit the symptoms of experimental Lyme arthritis. These results suggest that ISOF may have a potential application as an anti-inflammatory agent for the treatment of Lyme arthritis.

Arthropod-borne bacterial diseases in pregnancy

Arthropod-borne bacterial diseases affect more than 25,000 Americans every year and thousands more around the world. These infections present a diagnostic dilemma for clinicians because they mimic many other pathologic conditions and are often low on or absent from the differential diagnosis list. Diagnosis is particularly challenging during pregnancy, as these infections may mimic common pregnancy-specific conditions, such as typical and atypical preeclampsia, or symptoms of pregnancy itself. Concerns regarding the safety in pregnancy of some indicated antibiotics add a therapeutic challenge for the prescriber, requiring knowledge of alternative therapeutic options for many arthropod-borne bacterial diseases. Physicians, especially those in endemic areas, must keep this class of infections in mind, particularly when the presentation does not appear classic for more commonly seen conditions. This article discusses presentation, diagnosis, and treatment of the most common of these arthropod-borne bacterial diseases, including Lyme disease, Rocky Mountain spotted fever, tick-borne relapsing fever, typhus, plague, cat-scratch disease, and Carrión disease.

Evaluating the child with acute hip pain ("irritable hip") in a Lyme endemic region

OBJECTIVES

To estimate the prevalence of Lyme infection among children presenting with acute, nontraumatic hip pain in a Lyme endemic region and to investigate predictors of Lyme disease among children with suspected transient synovitis.

STUDY DESIGN

Retrospective cross-sectional study of children with unilateral hip pain who were brought to an academic pediatric emergency department. Cases were identified by specific discharge diagnoses or radiologic imaging. Lyme infection was determined by serologic criteria, and a minimum prevalence was estimated for the entire study population; maximum estimate was determined for those who had Lyme testing. Multivariate regression was used to identify discriminating clinical findings for Lyme disease among those with nonseptic arthritis.

RESULTS

Three hundred eighty-five children with a median age of 5.4 years were studied; 15% of children had fever ≥38.0°C and 40% had pain for less than 24 hours at evaluation. Lyme infection was identified in 5.2% (95% CI 3.2%-7.9%). A maximum estimate of Lyme disease was calculated to be 8.0% (95% CI 4.9%-12.0%). Regression analysis did not identify any practical clinical predictors of Lyme infection.

CONCLUSIONS

Lyme infection occurred in approximately 5% of children with acute, nontraumatic hip pain who were evaluated in a pediatric emergency department in a Lyme endemic region. Based on this estimate, we do not recommend routine Lyme testing when transient synovitis is suspected; however, Lyme testing should be considered in children having laboratory studies obtained for alternative diagnoses such as septic/pyogenic arthritis and for those with an atypical clinical course for transient synovitis.

Clinical management of septic arthritis

Septic arthritis is a rheumatologic emergency as joint destruction occurs rapidly and can lead to significant morbidity and mortality. Accurate diagnosis can be particularly challenging in patients with underlying inflammatory joint disease. This review outlines the risk factors for septic arthritis and summarizes the causative bacterial organisms. We highlight advances in antibiotic management with a focus on new drugs for methicillin-resistant Staphylococcus aureus (MRSA) and discuss the use of adjunctive therapies for treatment of septic arthritis in adults.

Distinguishing Lyme from septic knee monoarthritis in Lyme disease-endemic areas

OBJECTIVE

Because Lyme and septic arthritis may present similarly, we sought to identify children with knee monoarthritis at low risk for septic arthritis who may not require arthrocentesis.

METHODS

We performed a retrospective study of children with knee monoarthritis presenting to 1 of 2 pediatric centers, both located in Lyme disease-endemic areas. Septic arthritis was defined by a positive result on synovial fluid culture or synovial fluid pleocytosis with a positive blood culture result. Lyme arthritis was defined as a positive Lyme serologic result or physician-documented erythema migrans rash. All other children were considered to have other inflammatory arthritis. A clinical prediction model was derived by using recursive partitioning to identify children at low risk for septic arthritis, and the model was then externally validated.

RESULTS

We identified 673 patients with knee monoarthritis; 19 (3%) had septic arthritis, 341 (51%) had Lyme arthritis, and 313 (46%) had other inflammatory arthritis. The following predictors of knee septic arthritis were identified: peripheral blood absolute neutrophil count ≥10 × 10(3) cells per mm(3) and an erythrocyte sedimentation rate ≥40 mm/hour. In the validation population, no child with a absolute neutrophil count <10 × 10(3) cells per mm(3) and an erythrocyte sedimentation rate <40 mm/hour had septic arthritis (sensitivity: 6 of 6 [100%], 95% confidence interval [CI]: 54-100; specificity: 87 of 160 [54%], 95% CI: 46-62). Overall, none of the 19 children with septic arthritis were classified as low risk (10%, 95% CI: 0-17).

CONCLUSIONS

Laboratory criteria can be used to identify children with knee monoarthritis at low risk for septic arthritis who may not require diagnostic arthrocentesis.

Lyme disease and the orthopaedic implications of lyme arthritis

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

Emergence of chronic Lyme arthritis: putting the breaks on CD28 costimulation

Lyme disease is a debilitating infection that is caused upon a bite of Borrelia burgdorferi (Bb)-infected ticks. One of the most prominent clinical manifestations is the development of chronic Lyme arthritis. Months after Bb infection, approximately 60% of untreated Lyme patients experience intermittent arthritic attacks that may last for years. The use of the CD28(-/-) mouse in Bb infection has helped to shed light into the mechanisms that govern this inflammatory process, which seems to be tightly regulated. In this current review, the effect of immunoregulation, as well as CD28 deficiency in the development of chronic Lyme arthritis is discussed.

Approach to knee effusions

The presence of an intra-articular knee effusion requires an extensive differential diagnosis and a systematic diagnostic approach. Pediatric knee effusions occur most commonly as acute hemarthroses after traumatic injury. However, the knee joint is susceptible to effusions secondary to a wide variety of atraumatic causes. Special attention is required in the atraumatic effusion to distinguish features of infectious, postinfectious, rheumatologic, hematologic, vasculitic, and malignant disease. This review discusses the various etiologies of both traumatic and atraumatic pediatric knee effusions highlighting the historical, physical examination, and laboratory characteristics to aid the emergency provider in diagnosis and initial management.

The immunobiology of viral arthritides

A large range of human viruses are associated with the development of arthritis or arthralgia. Although there are many parallels with autoimmune arthritides, there is little evidence that viral arthritides lead to autoimmune disease. In humans viral arthritides usually last from weeks to months, can be debilitating, and are usually treated with non-steroidal anti-inflammatory drugs, but with variable success. Viral arthritides likely arise from immunopathological inflammatory responses directed at viruses and/or their products residing and/or replicating within joint tissues. Macrophages recruited by monocyte chemoattractant protein-1 (MCP-1/CCL2) and activated by interferon, and proinflammatory mediators like tumour necrosis factor alpha, interferon gamma, interleukin-6 and interleukin-1beta appear to be common elements in this group of diseases. The challenge for new treatments is to target excessive inflammation without compromising anti-viral immunity. Recent evidence from mouse models suggests targeting MCP-1 or complement may emerge as viable new treatment options for viral arthritides.

Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies

OBJECTIVE

Identify clinical predictors of Lyme arthritis among patients with acute monoarticular arthritis.

METHODS

A medical chart review was conducted of children </=18 years of age with monoarticular arthritis who underwent arthrocentesis in a pediatric emergency department located in the northeast United States. Patients were classified into 3 categories of arthritis: septic, Lyme, or nonseptic non-Lyme arthritis. Historical, clinical, and laboratory data were compared to identify distinguishing features of Lyme arthritis.

RESULTS

One hundred seventy-nine patients were studied: 46 (26%) patients with septic arthritis, 55 (31%) patients with Lyme arthritis, and 78 (43%) patients with nonseptic non-Lyme arthritis. Compared with those with septic arthritis, patients with Lyme disease were more likely to have a tick-bite history, knee involvement, and less likely to have a history of fever or elevated temperature at triage. Erythrocyte sedimentation rate, C-reactive protein, joint white blood cell count, and joint neutrophil percentage were also statistically lower. In comparison to nonseptic non-Lyme arthritis, knee involvement and tick-bite history were predictors of Lyme. Erythrocyte sedimentation rate, joint white blood cell count, and joint neutrophil percentage were also statistically different. Multivariate analysis comparing Lyme to septic arthritis demonstrated fever history and elevated C-reactive protein level to be negative predictors of Lyme arthritis and knee involvement to be a positive predictor (model sensitivity: 88%; specificity: 82%).

CONCLUSIONS

Lyme arthritis shares features with both septic and nonseptic non-Lyme arthritis. This overlap prevents the creation of a clinically useful predictive model for Lyme arthritis. In endemic areas, Lyme testing should be performed on all patients presenting with acute monoarticular arthritis.

Le diagnostic clinique des manifestations articulaires et musculaires de la borréliose de Lyme

The diagnosis of Lyme borreliosis in case of joint and muscular presentations is generally suggested by epidemiological factors. However, as a rule, laboratory testing is required to confirm the diagnosis. When considering the epidemiology of Lyme borreliosis in France, the only areas free of ticks infected by Borrelia burgdorgeri sl, are those close to the Mediterranean sea or at high altitude. The risk is greatest in the Alsace region. Exposure is particularly high among forest workers and people who use the countryside for their leisure activities. The likelihood of infection following a tick bite is difficult to assess; indeed, the bite site may remain unnoticed. A medical history of erythema migrans, if untreated, is a major diagnostic clue, although the association appears to be less consistent in France than in the US. Lyme arthritis generally arises apparently spontaneously. It is characteristically mono- or oligo-articular, asymmetrical, predominantly affects the knee, and has an intermittent course. Synovial cysts and enthesitis are common. Myositis is rare, polymorphic, and has been linked to other symptoms in the same localizations. Minor arthralgia and myalgia frequently occur, principally early in the course of the infection. It was suggested that sequels of the disease include so-called fibromyalgic syndromes. The principal differential diagnosis as far as arthritis is concerned, is made on spondylarthropathy and chronic juvenile arthritis. Rheumatoid arthritis is another pathology, although Lyme arthritis does sometimes evolve to chronicity.

Lyme borreliosis

Lyme borreliosis is a tick-borne infectious disease caused by the spirochaetes Borrelia burgdorferi, B. garinii and B. afzelii. It comprises a wide spectrum of symptoms affecting skin, musculoskeletal system, heart, eyes, central and peripheral nervous system. The diagnosis is based on clinical findings in combination with detection of specific IgM and/or IgG antibodies. Diagnostic problems arise from patients with non-specific symptoms and positive IgG antibody detection. Adequate antibiotic therapy cures more than 90% of the patients. However, in some patients repeated therapy is necessary and a small number of patients develop chronic arthritis or other features. While there is currently no vaccine available, prevention of tick bite is the most effective prophylaxis.