Laboratory testing for suspected Lyme disease

Diagnosis and treatment of Lyme disease in children

Lyme disease is a zoonotic infection caused by the spirochete Borrelia burgdorferi sensu lato which is transmitted to humans mainly by tick bites. The global incidence of Lyme disease is rising, and children are more frequently affected. The disease can manifest in various organs causing non-specific symptoms. The lack of sensitive and specific diagnostic tests makes the management of Lyme disease challenging. This article offers up-to-date clinical algorithms for the management of children with suspected or diagnosed Lyme disease.

Lyme borreliosis diagnosis: state of the art of improvements and innovations

With almost 700 000 estimated cases each year in the United States and Europe, Lyme borreliosis (LB), also called Lyme disease, is the most common tick-borne illness in the world. Transmitted by ticks of the genus Ixodes and caused by bacteria Borrelia burgdorferi sensu lato, LB occurs with various symptoms, such as erythema migrans, which is characteristic, whereas others involve blurred clinical features such as fatigue, headaches, arthralgia, and myalgia. The diagnosis of Lyme borreliosis, based on a standard two-tiered serology, is the subject of many debates and controversies, since it relies on an indirect approach which suffers from a low sensitivity depending on the stage of the disease. Above all, early detection of the disease raises some issues. Inappropriate diagnosis of Lyme borreliosis leads to therapeutic wandering, inducing potential chronic infection with a strong antibody response that fails to clear the infection. Early and proper detection of Lyme disease is essential to propose an adequate treatment to patients and avoid the persistence of the pathogen. This review presents the available tests, with an emphasis on the improvements of the current diagnosis, the innovative methods and ideas which, ultimately, will allow more precise detection of LB.

Positive Tests for Lyme Disease and Emergency Department Visits for Bell's Palsy Patients

BACKGROUND

Etiologies for Bell's palsy include herpes viruses and Lyme disease, with highest incidence in the colder and warmer months, respectively. In New Jersey, a Lyme-endemic area, the months with the most Lyme disease (80% of cases) are May through October ("Lyme months").

OBJECTIVE

Our aim was to determine whether positive tests for Lyme disease and visits are greater in the Lyme months than the rest of the year for patients with Bell's palsy in New Jersey emergency departments (EDs).

METHODS

We conducted a retrospective chart review from two New Jersey suburban EDs with consecutive patients from February 1, 2013 to January 31, 2018.We identified patients having Bell's palsy using the emergency physician diagnosis. We tabulated positive Lyme tests and visits for Bell's palsy by month of year. We calculated the ratio of positive tests and visits between the Lyme months and the rest of the year along with 95% confidence intervals (CIs).

RESULTS

There were 442 visits for Bell's palsy, 359 (81%) of these patients were tested for Lyme disease and 57 (16%) of the tests were positive. The Lyme months had 7.1 (95% CI 3.5-14.4) times more positive tests and 1.3 (95% CI 1.1-1.4) times more Bell's palsy visits than the rest of the year. Both measures peaked in July.

CONCLUSIONS

In a Lyme-endemic area, positive Lyme tests and ED visits for Bell's palsy are greatest in the Lyme months, peaking in July. This finding can help guide testing and treatment for patients in the ED with Bell's palsy during various months of the year.

Recent strategies for the diagnosis of early Lyme disease

Lyme disease (LD) is the most common tick-borne disease in the Northern Hemisphere. As the most prevalent vector-borne disease in the USA, LD affects 300,000 human cases each year. LD is caused by inoculation of the bacterial spirochete, Borrelia burgdorferi sensu lato, from an infected tick. If not treated quickly and completely, the bacteria disseminate from the tick's biting site into multiple organs including the joints, heart, and brain. Thus, the best outcome from medical intervention can be expected with early detection and treatment with antibiotics, prior to multi-organ dissemination. In the absence of a characteristic rash, LD is diagnosed using serological testing involving enzyme-linked immunosorbent assay (ELISA) followed by western blotting, which is collectively known as the two-tier algorithm. These assays detect host antibodies against the bacteria, but are hampered by low sensitivity, which can miss early LD cases. This review discusses the application of some current assays for diagnosing LD clinically, thus providing a foundation for exploring newer techniques being developed in the laboratory for more sensitive detection of early LD.

Cutaneous Lyme borreliosis: Guideline of the German Dermatology Society

This guideline of the German Dermatology Society primarily focuses on the diagnosis and treatment of cutaneous manifestations of Lyme borreliosis. It has received consensus from 22 German medical societies and 2 German patient organisations. It is the first part of an AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.) interdisciplinary guideline: “Lyme Borreliosis – Diagnosis and Treatment, development stage S3”.

The guideline is directed at physicians in private practices and clinics who treat Lyme borreliosis. Objectives of this guideline are recommendations for confirming a clinical diagnosis, recommendations for a stage-related laboratory diagnosis (serological detection of IgM and IgG Borrelia antibodies using the 2-tiered ELISA/immunoblot process, sensible use of molecular diagnostic and culture procedures) and recommendations for the treatment of the localised, early-stage infection (erythema migrans, erythema chronicum migrans, and borrelial lymphocytoma), the disseminated early-stage infection (multiple erythemata migrantia, flu-like symptoms) and treatment of the late-stage infection (acrodermatitis chronica atrophicans with and without neurological manifestations). In addition, an information sheet for patients containing recommendations for the prevention of Lyme borreliosis is attached to the guideline.

To test or not to test? Laboratory support for the diagnosis of Lyme borreliosis: a position paper of ESGBOR, the ESCMID study group for Lyme borreliosis

BACKGROUND

Lyme borreliosis (LB) is a tick-borne infection caused by Borrelia burgdorferi sensu lato. The most frequent clinical manifestations are erythema migrans and Lyme neuroborreliosis. Currently, a large volume of diagnostic testing for LB is reported, whereas the incidence of clinically relevant disease manifestations is low. This indicates overuse of diagnostic testing for LB with implications for patient care and cost-effective health management.

AIM

The recommendations provided in this review are intended to support both the clinical diagnosis and initiatives for a more rational use of laboratory testing in patients with clinically suspected LB.

SOURCES

This is a narrative review combining various aspects of the clinical and laboratory diagnosis with an educational purpose. The literature search was based on existing systematic reviews, national and international guidelines and supplemented with specific citations.

IMPLICATIONS

The main recommendations according to current European case definitions for LB are as follows. Typical erythema migrans should be diagnosed clinically and does not require laboratory testing. The diagnosis of Lyme neuroborreliosis requires laboratory investigation of the spinal fluid including intrathecal antibody production, and the remaining disease manifestations require testing for serum antibodies to B. burgdorferi. Testing individuals with non-specific subjective symptoms is not recommended, because of a low positive predictive value.

Practices of Lyme disease diagnosis and treatment by general practitioners in Quebec, 2008-2015

BACKGROUND

Lyme disease (LD), a multisystem infection caused by the spirochete Borrelia burgdorferi sensu stricto (B. burgdorferi), is the most reported vector-borne disease in North America, and by 2020, 80% of the population in central and eastern Canada could live in LD risk areas. Among the key factors for minimising the impact of LD are the accurate diagnosis and appropriate management of patients bitten by ticks. In this study, the practices of Quebec general practitioners (GPs) on LD diagnosis and management of patients bitten by infected ticks are described.

METHODS

Eight years (2008 to 2015) of retrospective demographic and clinical data on patients bitten by infected Ixodes scapularis (I. scapularis) ticks and on the management of suspected and confirmed LD cases by Quebec GPs were analysed.

RESULTS

Among 50 patients, all the antimicrobial treatments of LD clinical cases were appropriate according to current guidelines. However, more than half (62.8%) of erythema migrans (EM) were possibly misdiagnosed, 55.6%, (n = 27) of requested serologic tests were possibly unnecessary and the majority (96.5%, n = 57) of prophylactic antimicrobial treatments were not justified according to current guidelines.

CONCLUSIONS

These observations underline the importance for public health to enhance the knowledge of GPs where LD is emerging, to minimise the impact of the disease on patients and the financial burden on the health system.

Seroprevalence of Borrelia burgdorferi antibodies in white-tailed deer from Texas

Lyme Disease is caused by the bacterial pathogen Borrelia burgdorferi, and is transmitted by the tick-vector Ixodes scapularis. It is the most prevalent arthropod-borne disease in the United States. To determine the seroprevalence of B. burgdorferi antibodies in white-tailed deer (Odocoileus virginianus) from Texas, we analyzed serum samples (n = 1493) collected during the 2001–2015 hunting seasons, using indirect ELISA. Samples with higher sero-reactivity (0.803 and above) than the negative control group (0.662) were further tested using a more specific standardized western immunoblot assay to rule out false positives. Using ELISA, 4.7% of the samples were sero-reactive against B. burgdorferi, and these originated in two eco-regions in Texas (Edwards Plateau and South Texas Plains). However, only 0.5% of the total samples were sero-reactive by standardized western immunoblot assay. Additionally, both ELISA and standardized western immunoblot assay results correlated with an increased incidence in human Lyme Disease cases reported in Texas. This is the first longitudinal study to demonstrate fluctuation in sero-reactivity of white-tailed deer to B. burgdorferi sensu stricto antigens in southern United States. Future ecological and geographical studies are needed to assess the environmental factors governing the prevalence of Lyme Disease in non-endemic areas of the southern United States.

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White-tailed deer serum samples were analyzed for anti Borrelia burgdorferi IgG.

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This is the first 15-year longitudinal study reported in Texas, and provides data previously unavailable within the study of Lyme disease ecology.

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White-tailed deer population density might be critical to sero-prevalence.

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Further pathogenic landscape studies on Lyme disease in Texas are recommended.

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Databased Lyme disease ecology models in Texas can be developed.

Diagnostic impact of routine Lyme serology in recent-onset arthritis: results from the ESPOIR cohort

Objectives

Lyme disease may be considered by rheumatologists in patients with recent-onset arthritis, even in the absence of suggestive symptoms. The aim of this study was to determine the diagnostic impact of routine Lyme serology in a French cohort of patients with recent-onset arthritis affecting at least 2 joints.

Methods

We performed an ancillary study of a French prospective multicentre cohort established to monitor clinical, biological and radiographic data in patients with inflammatory arthritis in at least 2 joints, lasting for 6 weeks to 6 months. Borrelia IgM and IgG antibodies were sought routinely at baseline, using ELISA tests, independently from the physician's strategy for detecting a spirochetal infection. We recorded the proportion of patients with a final diagnosis of Lyme arthritis and evaluated the diagnostic performance of Lyme serology in this particular context. The clinical and biological characteristics of patients according to the Lyme serology results were analysed.

Results

Of 810 patients, 657 (81.1%) were negative for IgM and IgG antibodies, 91 (11.2%) had only IgM antibodies, 49 (6%) had only IgG antibodies, and 13 (1.6%) had IgG and IgM antibodies. Thus, 7.6% had IgG positivity, consistent with exposure to Borrelia infection. IgG positivity was significantly more prevalent in the North and North-East regions of France (χ²=14.6, p<0.001). No patients received a definite diagnosis of Lyme arthritis.

Conclusions

This study does not support routine Lyme serological testing in patients with recent-onset inflammatory arthritis affecting more than 1 joint.

Nonrheumatoid Inflammatory Arthroses of the Hand and Wrist

Various inflammatory and autoimmune conditions affecting joints of the hand and wrist can present with symptoms similar to those of rheumatoid arthritis. The most common of these nonrheumatoid arthroses are psoriatic arthritis, systemic lupus erythematosus, and systemic sclerosis. Management of these and several other conditions is typically medical in nature and continues to evolve with the development of biologically targeted medications. Surgical treatment is not frequently used but can be efficacious for severe cases to alleviate symptoms and correct deformities.

Lyme Disease Presenting as a Spontaneous Knee Effusion

Musculoskeletal complaints, which are frequently associated with Lyme disease, often prompt patients to see a physician. In particular, transient episodes of spontaneous knee effusion are common early in the progression of Lyme disease, and, if left untreated, 60% of patients diagnosed with the disease develop Lyme arthritis. This disease is easily treated with antibiotics; therefore, inclusion of Lyme disease in the differential diagnosis as a potential cause of a spontaneous knee effusion can prevent the development of more severe symptoms associated with the disease. However, the time required to receive test results and the inconsistencies between serum and synovial tests can complicate diagnosis of the disease.

Comparison of detection of Borrelia burgdorferi DNA and anti-Borrelia burgdorferi antibodies in patients with erythema migrans in north-eastern Poland

Introduction

Diagnostic methods in erythema migrans are still not standardized.

Aim

To evaluate the frequency of Borrelia burgdorferi s.l. DNA presence in patients with erythema migrans (EM); to assess the polymerase chain reaction (PCR) procedure for detecting B. burgdorferi s.l. DNA in patients with the skin form of Lyme borreliosis; and to compare the results of the PCR-based method with the traditional ELISA method.

Material and methods

Skin biopsy and blood samples from 93 patients with EM were examined for B. burgdorferi s.l. DNA detection (PCR). Seventy-one of these patients were examined for the presence of anti-B. burgdorferi s.l. antibodies (ELISA).

Results

Borrelia burgdorferi s.l. DNA was detected in 48% of the skin biopsy specimens and in 2% of blood samples. Only 1 patient was PCR positive in both blood and skin samples. Seventy percent of patients whose PCR results were positive were bitten by a tick less than 14 days before. IgM anti-B. burgdorferi s.l – specific antibodies were present in the serum of 35% of patients and IgG antibodies – in 30% of patients. Seventeen percent were positive in both IgM and IgG.

Conclusions

Polymerase chain reaction of skin biopsy specimens seems to be currently the most sensitive and specific test for the diagnosis of patients with EM, especially in patients with a short duration of the disease (< 14 days) but still its effectiveness is much lower than expected. Polymerase chain reaction of blood samples cannot be recommended at the present time for the routine diagnostic of patients with EM.

A concise critical analysis of serologic testing for the diagnosis of lyme disease

Diagnostic testing for Lyme disease in the clinical setting primarily relies on assessment of serologic responses to infection, with the exception of the early localized phase of disease, in which the diagnosis must be made clinically, due to the recognized insensitivity of serologic testing at this phase of disease. For the diagnosis of early disseminated and late disease, the Centers for Disease Control and Prevention (CDC) recommends a two-tiered approach to testing consisting of initial IgM and IgG quantitative enzyme-linked immunosorbent assay (ELISA), followed by confirmation of all indeterminate or positive ELISA tests with separate IgG and IgM Western blots. This critical analysis addresses the sensitivity, specificity, and predictive value of serologic testing for Lyme disease in early localized, early disseminated, and late disease. Other testing modalities currently under evaluation are also discussed, including IgG vlsE C6 peptide ELISA, other two-tiered testing strategies, rapid diagnostics, and PCR. An understanding of the strengths and limitations of currently available testing for Lyme disease is critical for appropriate diagnosis.

Lyme disease testing by large commercial laboratories in the United States

BACKGROUND

Laboratory testing is helpful when evaluating patients with suspected Lyme disease (LD). A 2-tiered antibody testing approach is recommended, but single-tier and nonvalidated tests are also used. We conducted a survey of large commercial laboratories in the United States to assess laboratory practices. We used these data to estimate the cost of testing and number of infections among patients from whom specimens were submitted.

METHODS

Large commercial laboratories were asked to report the type and volume of testing conducted nationwide in 2008, as well as the percentage of positive tests for 4 LD-endemic states. The total direct cost of testing was calculated for each test type. These data and test-specific performance parameters available in published literature were used to estimate the number of infections among source patients.

RESULTS

Seven participating laboratories performed approximately 3.4 million LD tests on approximately 2.4 million specimens nationwide at an estimated cost of $492 million. Two-tiered testing accounted for at least 62% of assays performed; alternative testing accounted for <3% of assays. The estimated frequency of infection among patients from whom specimens were submitted ranged from 10% to 18.5%. Applied to the total numbers of specimens, this yielded an estimated 240 000 to 444 000 infected source patients in 2008.

DISCUSSION

LD testing is common and costly, with most testing in accordance with diagnostic recommendations. These results highlight the importance of considering clinical and exposure history when interpreting laboratory results for diagnostic and surveillance purposes.

Use of immunoassays in neurological diagnosis and research

OBJECTIVES

To review the use of immunoassays in the diagnosis and research of disorders affecting the nervous system.

METHODS

Systematic review of the English literature.

RESULTS

Immunoassays have demonstrated utility for: (1) the detection of antigen (molecules, genes, gene products, peptides, hormones and drug metabolites) and (2) the detection of an immune response (antigen-antibody complexes and specific and non-specific populations of antibodies) in serum, cerebrospinal fluid, and central nervous system tissue.

DISCUSSION

The specificity of the antibody-antigen interaction makes immunoassays an ideal diagnostic and research tool for the investigation of neurological disease. A number of immunoassays are available for this purpose, and the choice of a particular methodology generally depends upon whether one is detecting antigen, antibody or antigen-antibody complexes, and the nature of the biologic sample that is being tested. Ease of testing, sensitivity, specificity and cost are other important considerations.

Improved culture conditions for the growth and detection of Borrelia from human serum

In this report we present a method to cultivate Borrelia spirochetes from human serum samples with high efficiency. This method incorporates improved sample collection, optimization of culture media and use of matrix protein. The method was first optimized utilizing Borrelia laboratory strains, and later by demonstrating growth of Borrelia from sera from fifty seropositive Lyme disease patients followed by another cohort of 72 Lyme disease patients, all of whom satisfied the strict CDC surveillance case definition for Lyme disease. The procedure resulted in positive cultures in 47% at 6 days and 94% at week 16. Negative controls included 48 cases. The positive identification of Borrelia was performed by immunostaining, PCR, and direct DNA sequencing.

Application of medical and analytical methods in Lyme borreliosis monitoring

Lyme borreliosis (LB) is one of the most common tick-borne diseases in the northern hemisphere. It is a chronic inflammatory disease caused by the spirochaete Borrelia burgdorferi. In its early stages, pathological skin lesions, namely erythema chronicum migrans, appear. The lesions, usually localised at the site of the bite, may become visible from a few weeks up to 3 months after the infection. Predominant clinical symptoms of the disease also involve joint malfunctions and neurological or cardiac disorders. Lyme disease, in all its stages, may be successfully treated with antibiotics. The best results, however, are obtained in its early stages. In order to diagnose the disease, numerous medical or laboratory techniques have been developed. They are applied to confirm the presence of intact spirochaetes or spirochaete components such as DNA or proteins in tick vectors, reservoir hosts or patients. The methods used for the determination of LB biomarkers have also been reviewed. These biomarkers are formed during the lipid peroxidation process. The formation of peroxidation products generated by human organisms is directly associated with oxidative stress. Apart from aldehydes (malondialdehyde and 4-hydroxy-2-nonenal), many other unsaturated components such as isoprostenes and neuroprostane are obtained. The fast determination of these compounds in encephalic fluid, urine or plasma, especially in early stages of the disease, enables its treatment. Various analytical techniques which allow the determination of the aforementioned biomarkers have been reported. These include spectrophotometry as well as liquid and gas chromatography. The analytical procedure also requires the application of a derivatization step by the use of selected reagents.

Primary lyme arthritis of the pediatric hip

BACKGROUND

Lyme arthritis most commonly affects the knee. It is not commonly considered in the differential diagnosis of monoarticular hip pain. There are only a few case reports describing Lyme disease presenting with isolated hip involvement. The purpose of this study is to review our experience with primary Lyme arthritis of the hip.

METHODS

Clinical records at a tertiary children's referral center in a Lyme endemic region were scanned for key words "Lyme" and "hip." Patients with isolated Lyme disease of the hip were included. Diagnosis was made based on Centers for Disease Control guidelines. Clinical presentation, laboratory evaluation, and treatment information were recorded for eligible patients.

RESULTS

Eight patients met eligibility criteria with an average age of 9.5 years (3 to 20y). All patients presented with hip pain (8), limp (3), or refusal to bear weight (5). One of 8 patients had a fever >38.5°C. Two of 8 patients had a peripheral white blood cell count >12,500/mm and 3 of 8 patients had an erythrocyte sedimentation rate>40 mm/h. Aspiration was performed on 5 patients, with a median synovial fluid white blood cell of 41,500/mm (21,500 to 73,500/mm). Three of 8 patients were treated surgically; all patients were treated with antibiotics and were asymptomatic at last follow-up. With the exception of 1 case, there was a delay before appropriate antibiotics were started.

CONCLUSIONS

Primary monoarticular Lyme arthritis of the hip is uncommon. Clinical presentation and laboratory findings are variable, and differentiating it from septic arthritis or toxic synovitis of the hip may be difficult. In areas where Lyme disease is endemic, it should be considered in the differential diagnosis of monoarticular hip pain associated with an effusion.

LEVEL OF EVIDENCE

Level IV, Case Series.

Lyme borreliosis

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

The laboratory diagnosis of Lyme borreliosis: Guidelines from the Canadian Public Health Laboratory Network

Lyme borreliosis is uncommonly seen in Canada. Most cases have occurred in close proximity to small geographical areas where infected ticks have become established. Although few cases are seen, thousands of patients are tested yearly. Unless patients are carefully selected and an appropriately sensitive and specific testing algorithm is applied, large numbers of patients without Lyme borreliosis will be incorrectly diagnosed. The Canadian Public Health Laboratory Network has developed the present guidelines to assist physicians in assessing patients for Lyme borreliosis, and to help guide the choice and interpretation of laboratory testing.

How big is the Lyme problem? Using novel methods to estimate the true number of Lyme disease cases in British Columbia residents from 1997 to 2008

Lyme disease (LD) is rare in British Columbia (BC) and, despite being a reportable condition since 1994, may be underreported. Here we review all provincial laboratory and clinical databases to determine the number of LD cases reported in BC from 1997 to 2008. We analyzed demographic characteristics of LD cases and used capture-recapture methodology to estimate the true number of cases in BC for this period. From 1997 to 2008, 93 confirmed cases of LD were reported in BC. Conservative capture-recapture estimates place the true number of LD cases in BC during this period at 142 (95% confidence interval: 111-224), indicating up to 40% underreporting of this rare disease. Despite this underreporting, BC continues to have low endemic risk of LD. Strategies are needed to increase both physician awareness and the use of preventive measures in the BC population, including for those traveling to other endemic areas.

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.

Entzündliche Erkrankungen

Unter einer Meningitis versteht man eine Entzündung von Pia mater und Arachnoidea. Das Erregerspektrum ist weit und reicht von Bakterien, die hämatogen-metastatisch, fortgeleitet oder durch offene Hirnverletzung zur eitrigen Meningitis führen, über Viren zu Pilzen und Parasiten. Insbesondere bei den unbehandelt häufig letal verlaufenden eitrigen Meningitiden ist eine rasche Diagnose mit Erregernachweis notwendig. Unverzüglich ist daraufhin eine spezifische, der regionalen Resistenzentwicklung angepasste Therapie einzuleiten. Die meningeale Affektion im Rahmen einer Listeriose oder Tuberkulose verdient aufgrund des klinischen Bildes, des Verlaufs und der spezifischen Therapie besondere Beachtung. Die fungalen Infektionen werden, da klinisch häufig als Meningoenzephalitis imponierend, in Abschn. 33.3 abgehandelt.

[Neuroborreliosis]

Neuroborreliosis is easily diagnosed by means of clinical symptoms and laboratory findings. Guiding symptoms are radicular pain and pareses of the extremities and the facial nerve. There is a great number of further less frequently occurring neurological symptoms, which can be attributed to a borrelial infection only by appropriate investigations of the CSF. Radiculitis is cured adequately by oral doxycycline while symptoms of the central nervous system are probably better treated intravenously by ceftriaxone, cefotaxime or penicillin G. Post-Lyme syndrome is a diffuse description of non-specific complaints, which are not the explicit result of a former infection with B. burgdorferi. As further antibiotics do not help and the CSF is unremarkable in most patients, a persistent infection with B. burgdorferi s.l. in all probability can be excluded.

Lyme neuroborreliosis in children: a prospective study of clinical features, prognosis, and outcome

BACKGROUND

Evaluation of children with clinically suspected neuroborreliosis (NB) is difficult. With a prospective study design we wanted to characterize children with signs and symptoms indicative for NB, investigate clinical outcome and, if possible, identify factors of importance for recovery.

MATERIAL/METHODS

Children being evaluated for NB (n = 177) in southeast Sweden were categorized into 3 groups: "confirmed neuroborreliosis" (41%) with Borrelia antibodies in the cerebrospinal fluid, "possible neuroborreliosis" (26%) with pleocytosis but no Borrelia antibodies in the cerebrospinal fluid, and "not determined" (33%) with no pleocytosis and no Borrelia antibodies in the cerebrospinal fluid. Antibiotic treatment was given to 69% of children. Patients were followed during 6 months and compared with a matched control group (n = 174).

RESULTS

Clinical recovery at the 6-month follow-up (n = 177) was generally good and no patient was found to have recurrent or progressive neurologic symptoms. However, persistent facial nerve palsy caused dysfunctional and cosmetic problems in 11% of patients. Persistent nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls. Influence on daily life was reported to the same extent in patients and controls. Consequently, persistent headache and fatigue at follow-up should not be considered as attributable to NB. No prognostic factors could be identified.

CONCLUSIONS

Clinical recovery was satisfactory in children being evaluated for NB although persistent symptoms from facial nerve palsy occurred. Persistent nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls.

A genome-wide proteome array reveals a limited set of immunogens in natural infections of humans and white-footed mice with Borrelia burgdorferi

Humans and other animals with Lyme borreliosis produce antibodies to a number of components of the agent Borrelia burgdorferi, but a full accounting of the immunogens during natural infections has not been achieved. Employing a protein array produced in vitro from 1,292 DNA fragments representing approximately 80% of the genome, we compared the antibody reactivities of sera from patients with early or later Lyme borreliosis to the antibody reactivities of sera from controls. Overall, approximately 15% of the open reading frame (ORF) products (Orfs) of B. burgdorferi in the array detectably elicited an antibody response in humans with natural infections. Among the immunogens, 103 stood out on the basis of statistical criteria. The majority of these Orfs were also immunogenic with sera obtained from naturally infected Peromyscus leucopus mice, a major reservoir. The high-ranking set included several B. burgdorferi proteins hitherto unrecognized as immunogens, as well as several proteins that have been established as antigens. The high-ranking immunogens were more likely than nonreactive Orfs to have the following characteristics: (i) plasmid-encoded rather than chromosome-encoded proteins, (ii) a predicted lipoprotein, and (iii) a member of a paralogous family of proteins, notably the Bdr and Erp proteins. The newly discovered antigens included Orfs encoded by several ORFs of the lp36 linear plasmid, such as BBK07 and BBK19, and proteins of the flagellar apparatus, such as FliL. These results indicate that the majority of deduced proteins of B. burgdorferi do not elicit antibody responses during infection and that the limited sets of immunogens are similar for two different host species.

Evaluation of two commercial systems for automated processing, reading, and interpretation of Lyme borreliosis Western blots

The diagnosis of Lyme borreliosis (LB) is commonly made by serologic testing with Western blot (WB) analysis serving as an important supplemental assay. Although specific, the interpretation of WBs for diagnosis of LB (i.e., Lyme WBs) is subjective, with considerable variability in results. In addition, the processing, reading, and interpretation of Lyme WBs are laborious and time-consuming procedures. With the need for rapid processing and more objective interpretation of Lyme WBs, we evaluated the performances of two automated interpretive systems, TrinBlot/BLOTrix (Trinity Biotech, Carlsbad, CA) and BeeBlot/ViraScan (Viramed Biotech AG, Munich, Germany), using 518 serum specimens submitted to our laboratory for Lyme WB analysis. The results of routine testing with visual interpretation were compared to those obtained by BLOTrix analysis of MarBlot immunoglobulin M (IgM) and IgG and by ViraScan analysis of ViraBlot and ViraStripe IgM and IgG assays. BLOTrix analysis demonstrated an agreement of 84.7% for IgM and 87.3% for IgG compared to visual reading and interpretation. ViraScan analysis of the ViraBlot assays demonstrated agreements of 85.7% for IgM and 94.2% for IgG, while ViraScan analysis of the ViraStripe IgM and IgG assays showed agreements of 87.1 and 93.1%, respectively. Testing by the automated systems yielded an average time savings of 64 min/run compared to processing, reading, and interpretation by our current procedure. Our findings demonstrated that automated processing and interpretive systems yield results comparable to those of visual interpretation, while reducing the subjectivity and time required for Lyme WB analysis.

Diagnosis and treatment of Lyme disease

Lyme disease is the most common tick-borne disease in the United States. This review details the risk factors, clinical presentation, treatment, and prophylaxis for the disease. Information was obtained from a search of the PubMed and MEDLINE databases (keyword: Lyme disease) for articles published from August 31, 1997, through September 1, 2007. Approximately 20,000 cases of Lyme disease are reported annually. Residents of the coastal Northeast, northwest California, and the Great Lakes region are at highest risk. Children and those spending extended time outdoors in wooded areas are also at increased risk. The disease is transmitted to humans through the bite of the Ixodes tick (Ixodes scapularis and Ixodes pacificus). Typically, the tick must feed for at least 36 hours for transmission of the causative bacterium, Borrelia burgdorferi, to occur. Each of the 3 stages of the disease is associated with specific clinical features: early localized infection, with erythema migrans, fever, malaise, fatigue, headache, myalgias, and arthralgias; early disseminated infection (occurring days to weeks later), with neurologic, musculoskeletal, or cardiovascular symptoms and multiple erythema migrans lesions; and late disseminated infection, with intermittent swelling and pain of 1 or more joints (especially knees). Neurologic manifestations (neuropathy or encephalopathy) may occur. Diagnosis is usually made clinically. Treatment is accomplished with doxycycline or amoxicillin; cefuroxime axetil or erythromycin can be used as an alternative. Late or severe disease requires intravenous ceftriaxone or penicillin G. Single-dose doxycycline (200 mg orally) can be used as prophylaxis in selected patients. Preventive measures should be emphasized to patients to help reduce risk.

Seronegative Lyme arthritis

We present a 10-year-old girl who had been diagnosed with juvenile idiopathic arthritis 5 years before and who experienced a flare of arthritis affecting one knee while she was off medication for almost 3 years. Seronegative Lyme arthritis had to be diagnosed based on the detection of Borrelia burgdorferi DNA in synovial fluid. No humoral immune response to Borrelia burgdorferi was detectable before, at the time of diagnosis and up to 3 years later.

Function and evolution of plasmid-borne genes for pyrimidine biosynthesis in Borrelia spp

The thyX gene for thymidylate synthase of the Lyme borreliosis (LB) agent Borrelia burgdorferi is located in a 54-kb linear plasmid. In the present study, we identified an orthologous thymidylate synthase gene in the relapsing fever (RF) agent Borrelia hermsii, located it in a 180-kb linear plasmid, and demonstrated its expression. The functions of the B. hermsii and B. burgdorferi thyX gene products were evaluated both in vivo, by complementation of a thymidylate synthase-deficient Escherichia coli mutant, and in vitro, by testing their activities after purification. The B. hermsii thyX gene complemented the thyA mutation in E. coli, and purified B. hermsii ThyX protein catalyzed the conversion of dTMP from dUMP. In contrast, the B. burgdorferi ThyX protein had only weakly detectable activity in vitro, and the B. burgdorferi thyX gene did not provide complementation in vivo. The lack of activity of B. burgdorferi's ThyX protein was associated with the substitution of a cysteine for a highly conserved arginine at position 91. The B. hermsii thyX locus was further distinguished by the downstream presence in the plasmid of orthologues of nrdI, nrdE, and nrdF, which encode the subunits of ribonucleoside diphosphate reductase and which are not present in the LB agents B. burgdorferi and Borrelia garinii. Phylogenetic analysis suggested that the nrdIEF cluster of B. hermsii was acquired by horizontal gene transfer. These findings indicate that Borrelia spp. causing RF have a greater capability for de novo pyrimidine synthesis than those causing LB, thus providing a basis for some of the biological differences between the two groups of pathogens.

A Qualitative Approach to Understanding Patients' Diagnosis of Lyme Disease

OBJECTIVES

The purpose of this study was to explore the lived experience of becoming diagnosed with Lyme disease.

DESIGN

A qualitative, phenomenological study was conducted to investigate the experience of becoming diagnosed with Lyme disease.

SAMPLE

A purposive sample of 10 participants diagnosed with Lyme disease were interviewed and tape-recorded. Data saturation guided the size of the sample.

METHODS

The interviews were transcribed verbatim. Key words or phrases were extracted and clustered; clusters were interpreted into themes. Analyzed data were confirmed with the participants for trustworthiness and reliability.

RESULTS

Six themes emerged from the interviews. Participants expressed feelings of frustration during the long road to diagnosis. They endured multiple diagnostic tests and were seen by numerous health care providers. Participants voiced financial stress. They expressed the need for self-advocacy and felt validation when a diagnosis was made. Despite the chronicity of their illness, the participants voiced a sense of hopefulness for their future.

CONCLUSION

A deep understanding of the lived experience of becoming diagnosed with Lyme disease allows for nurses to prioritize health care interventions and strategize ways to implement quality improvement systems as clients enter the health care environment.

MRI features of Lyme arthritis in children

OBJECTIVE

Oligoarthritis is the most common manifestation of late Lyme disease in children. Considerable overlap can occur in the clinical presentation of Lyme arthritis and acute septic arthritis. Early differentiation is critical, given the disparate therapeutic implications; Lyme arthritis is treated with outpatient oral antibiotics, while septic arthritis requires hospitalization, IV antibiotics, and, often, surgical drainage. We wanted to identify MRI features that may distinguish Lyme arthritis from septic arthritis in children.

MATERIALS AND METHODS

Knee MR images in 11 children with Lyme arthritis and 7 with septic arthritis, with a mean age 10.6 years old and 11.7 years old, respectively, were reviewed by a radiologist blinded to the final diagnosis. Joint effusion size, synovial thickness, adenopathy, subcutaneous, marrow, and muscle edema on MRI; and clinical parameters including age, sex, fever, WBC, erythrocyte sedimentation rate, C-reactive protein, and joint fluid WBC in the two patient groups were compared using univariate and multivariate analyses.

RESULTS

Subcutaneous edema was seen in all septic arthritis patients but in only one of 11 patients with Lyme arthritis (p < 0.01). Myositis and adenopathy were present in all Lyme arthritis patients and two of seven patients with septic arthritis (both p < 0.01). No significant difference was present in synovial thickness, marrow edema, or joint fluid size. There were no statistically significant differences in the clinical parameters assessed.

CONCLUSION

Our results identified three MRI features, specifically, myositis, adenopathy, and lack of subcutaneous edema, that strongly suggest the diagnosis of Lyme arthritis rather than septic arthritis in children with acute inflammation of the knee. Awareness of these characteristic MRI features may avoid unnecessary invasive procedures and cost.

Diagnosis of lyme borreliosis

A large amount of knowledge has been acquired since the original descriptions of Lyme borreliosis (LB) and of its causative agent, Borrelia burgdorferi sensu stricto. The complexity of the organism and the variations in the clinical manifestations of LB caused by the different B. burgdorferi sensu lato species were not then anticipated. Considerable improvement has been achieved in detection of B. burgdorferi sensu lato by culture, particularly of blood specimens during early stages of disease. Culturing plasma and increasing the volume of material cultured have accomplished this. Further improvements might be obtained if molecular methods are used for detection of growth in culture and if culture methods are automated. Unfortunately, culture is insensitive in extracutaneous manifestations of LB. PCR and culture have high sensitivity on skin samples of patients with EM whose diagnosis is based mostly on clinical recognition of the lesion. PCR on material obtained from extracutaneous sites is in general of low sensitivity, with the exception of synovial fluid. PCR on synovial fluid has shown a sensitivity of up to >90% (when using four different primer sets) in patients with untreated or partially treated Lyme arthritis, making it a helpful confirmatory test in these patients. Currently, the best use of PCR is for confirmation of the clinical diagnosis of suspected Lyme arthritis in patients who are IgG immunoblot positive. PCR should not be used as the sole laboratory modality to support a clinical diagnosis of extracutaneous LB. PCR positivity in seronegative patients suspected of having late manifestations of LB most likely represents a false-positive result. Because of difficulties in direct methods of detection, laboratory tests currently in use are mainly those detecting antibodies to B. burgdorferi sensu lato. Tests used to detect antibodies to B. burgdorferi sensu lato have evolved from the initial formats as more knowledge on the immunodominant antigens has been collected. The recommendation for two-tier testing was an attempt to standardize testing and improve specificity in the United States. First-tier assays using whole-cell sonicates of B. burgdorferi sensu lato need to be standardized in terms of antigen composition and detection threshold of specific immunoglobulin classes. The search for improved serologic tests has stimulated the development of recombinant protein antigens and the synthesis of specific peptides from immunodominant antigens. The use of these materials alone or in combination as the source of antigen in a single-tier immunoassay may someday replace the currently recommended two-tier testing strategy. Evaluation of these assays is currently being done, and there is evidence that certain of these antigens may be broadly cross-reactive with the B. burgdorferi sensu lato species causing LB in Europe.

Molecular methods for diagnosis of viral encephalitis

Hundreds of viruses cause central nervous system (CNS) disease, including meningoencephalitis and postinfectious encephalomyelitis, in humans. The cerebrospinal fluid (CSF) is abnormal in >90% of cases; however, routine CSF studies only rarely lead to identification of a specific etiologic agent. Diagnosis of viral infections of the CNS has been revolutionized by the advent of new molecular diagnostic technologies to amplify viral nucleic acid from CSF, including PCR, nucleic acid sequence-based amplification, and branched-DNA assay. PCR is ideally suited for identifying fastidious organisms that may be difficult or impossible to culture and has been widely applied for detection of both DNA and RNA viruses in CSF. The technique can be performed rapidly and inexpensively and has become an integral component of diagnostic medical practice in the United States and other developed countries. In addition to its use for identification of etiologic agents of CNS disease in the clinical setting, PCR has also been used to quantitate viral load and monitor duration and adequacy of antiviral drug therapy. PCR has also been applied in the research setting to help discriminate active versus postinfectious immune-mediate disease, identify determinants of drug resistance, and investigate the etiology of neurologic disease of uncertain cause. This review discusses general principles of PCR and reverse transcription-PCR, including qualitative, quantitative, and multiplex techniques, with comment on issues of sensitivity, specificity, and positive and negative predictive values. The application of molecular diagnostic methods for diagnosis of specific infectious entities is reviewed in detail, including viruses for which PCR is of proven efficacy and is widely available, viruses for which PCR is less widely available or for which PCR has unproven sensitivity and specificity, and nonviral entities which can mimic viral CNS disease.

Appropriateness of Lyme disease serologic testing

BACKGROUND

Although rapid diagnosis of Lyme disease is essential for effective treatment, there is concern about inappropriate testing. We conducted a prospective, cross-sectional survey of clinicians to assess the use and appropriateness of Lyme disease serologic tests (LDSTs).

METHODS

LDSTs performed at 2 large Wisconsin reference laboratories were systematically sampled for 12 consecutive months. A standardized questionnaire was used to gather data about the submitting clinician and the patient tested. Tests were categorized as appropriate, inappropriate, or discretionary, and associations were assessed using logistic regression analysis. A test was defined as inappropriate if the patient was asymptomatic, had erythema migrans, or was treated empirically, or if the test was ordered as a test of cure.

RESULTS

We surveyed 303 clinicians regarding 356 LDSTs: 72 tests (20%) were appropriate, 95 (27%) were inappropriate, and 189 (53%) were discretionary. Tests were more likely to be inappropriate if they were ordered by an emergency or urgent care physician compared with other specialists (adjusted odds ratio [AOR] 5.2, 95% confidence interval [CI], 1.3-20.6), or if preceded by a known tick bite (AOR 6.8, 95% CI, 2.6-17.6). The patient rather than the clinician requested 26% of tests, which were more likely to be inappropriate than clinician-requested tests (crude odds ratio [COR] 5.8, 95% CI, 2.5-13.6). Tests were more likely to be patient-requested if they were ordered by an internist (AOR 2.6, 95% CI, 1.4-4.8) or if the patient was > or =40 years old (AOR 2.2, 95% CI, 1.3-3.9).

CONCLUSIONS

Many LDSTs are ordered inappropriately, often influenced by patient demand. Education of clinicians and patients about testing indications and contraindications is needed to reduce the number of inappropriate LDSTs.