Lyme disease during pregnancy

Borrelia spirochetes in European exotic farm animals

Ticks transmit a broad spectrum of pathogens, threatening both animal and human health. Tick survival and proliferation are strongly dependent on host selection and suitability. The hard tick Ixodes ricinus, which is widespread throughout most of Europe, is a host generalist capable of feeding on many different vertebrate species. Pasture-kept exotic farm animals may be at a high risk for tick and tick-borne pathogens infestations but research characterizing this is currently lacking. This study focused on the detection of Borrelia spirochetes (including Borrelia miyamotoi) in exotic farm animals. Using nested-PCR with Borrelia-specific primers, 121 serum samples from 54 exotic farm animals of several species bred in four different farms in Bohemia and Moravia (Czechia) were tested. Positive samples were sequenced for the identification of Borrelia species. The prevalence of Borrelia DNA in the samples ranged from 13 to 67%, depending on the sampling site. The sequencing results confirmed the DNA presence of multiple spirochete species from the Borrelia burgdorferi sensu lato complex. Only one sample from an ostrich (Struthio camelus) was found to be positive for Borrelia myiamotoi. The results show that exotic farm animals can serve as hosts for hard ticks and can be infected by Borrelia spirochetes, transmitted by hard ticks. Therefore, these animals could play a relevant role in maintaining Borrelia spirochetes in nature.

Recurrent bilateral chorioretinitis with positive Lyme serology: a case report

Background

It has been disputed whether Lyme is a true causative agent in posterior uveitis or an incidental finding.

Case presentation

This report presents a case of a 33-year-old Caucasian female with a remote history of Lyme disease who presented with blurry vision in the right eye. Exam and imaging revealed a right active chorioretinitis and positive Lyme serology. The patient was systemically treated with prednisone and antibiotics. Symptoms initially improved, but she later developed a localized choriocapillaritis in the left eye. Steroids and antibiotics were restarted many times with fluctuating course of the disease. The patient was then started on chronic steroid-sparing immunosuppression, which has controlled the condition without recurrence.

Conclusions

The current report presents a unique case of recurrent bilateral chorioretinitis with positive Lyme serology and raises the question of the existence of true Lyme-associated uveitis.

Management of Lyme Disease in European Children: a Review for Practical Purpose

PURPOSE OF REVIEW

Lyme disease is a tick-borne zoonosis transmitted through a bite of a tick carrying a spirochete belonging to Borrelia species. In the last 20 years, the reported incidence of Lyme disease is increased by three times in Europe. Clinically, the illness develops through a primary stage with a typical skin rash (erythema marginatum), then a secondary stage with possible neurologic or cardiac involvement. The last stage (chronic Lyme disease) is mainly represented by arthritis or late neurological complications but nowadays is rarely seen due to precocious antibiotic use.

RECENT FINDINGS

The diagnosis of Lyme disease is essentially based on history in agreement with tick exposure (living/recent traveling in endemic area or tick bite) and clinical findings compatible with the disease. At present, no laboratory diagnostic tool available can neither establish nor exclude the diagnosis of Lyme disease. The management of Lyme disease should comprise a prophylactic administration of antibiotic in selected population (patients exposed to a tick bite in endemic regions) in which the typical signs of Lyme disease are not yet appeared; conversely, patients with current signs of Lyme disease should undergo a standard therapeutic course. First-line therapy should be oral tetracycline or oral penicillin/cephalosporin (in pediatric populations, beta-lactamic drugs are preferred). In severe courses, intravenous route should be preferred. The aim of this review is to provide an updated guide to the management of pediatric Lyme patients, from prophylaxis to first- and second-line therapy in European setting.

Congenital Tick Borne Diseases: Is This An Alternative Route of Transmission of Tick-Borne Pathogens In Mammals?

Tick-borne diseases (TBDs) have become a popular topic in many medical journals. Besides the obvious participation of ticks in the transmission of pathogens that cause TBD, little is written about alternative methods of their spread. An important role is played in this process by mammals, which serve as reservoirs. Transplacental transfer also plays important role in the spread of some TBD etiological agents. Reservoir species take part in the spread of pathogens, a phenomenon that has extreme importance in synanthropic environments. Animals that accompany humans and animals migrating from wild lands to urban areas increase the probability of pathogen infections by ticks This article provides an overview of TBDs, such as tick-borne encephalitis virus (TBEV), and TBDs caused by spirochetes, α-proteobacteria, γ-proteobacteria, and Apicomplexa, with particular attention to reports about their potential to cross the maternal placenta. For each disease, the method of propagation, symptoms of acute and chronic phase, and complications of their course in adults, children, and animals are described in detail. Additional information about transplacental transfer of these pathogens, effects of congenital diseases caused by them, and the possible effects of maternal infection to the fetus are also discussed. The problem of vertical transmission of pathogens presents a new challenge for medicine. Transfer of pathogens through the placenta may lead not only to propagation of diseases in the population, but also constitute a direct threat to health and fetal development. For this reason, the problem of vertical transmission requires more attention and an estimation of the impact of placental transfer for each of listed pathogens.

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.

Lyme disease

Lyme disease, caused by the spirochete Borrelia burgdorferi, is the most common vector-borne disease in the United States. The clinical presentation varies depending on the stage of the illness: early disease includes erthyma migrans, early disseminated disease includes multiple erythema migrans, meningitis, cranial nerve palsies, and carditis; late disease is primarily arthritis. The symptoms and signs of infection resolve in most patients after treatment with appropriate antimicrobials for 2 to 4 weeks. Serologic testing should be used judiciously as it often results in misdiagnosis when performed on blood from patients with a low prior probability of disease and those with only nonspecific symptoms such as fatigue or arthralgia without objective signs of infection.

[Lyme disease: prophylaxis after tick bite]

Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by infected ticks. The transmission depends on several factors, especially on the duration of the tick's presence in the host body (the nymph which is smaller than the adults and thus less visible, is in this case the most frequently involved) and on whether the tick is infected or not. The interpretation of results in the few available studies is made difficult by the lack of information obtained (due to difficulty to collect information and examination costs). The comparison is made even more difficult by the difference between Borrelia ticks species in various regions. Today, the best methods are preventive: protective clothing, tick repellents, checking and removal of ticks after a journey in an endemic zone, and in case of tick bite, regular examination of the bite site during the following weeks in order to initiate an early curative treatment if ECM is diagnosed. The currently available data seems to be insufficient to suggest systematic antimicrobial prophylaxis in case of tick bite.

Lyme Disease in Pregnancy: Case Report and Review of the Literature

Lyme disease is the most common vector-borne disease in the United States. A number of other spirochetal diseases, if contracted in pregnancy, have been shown to cause fetal harm and there is concern over a similar effect with gestational borreliosis. Previously published individual case reports have suggested a possible association between gestational borreliosis and adverse pregnancy outcome; however, no specific pattern of teratogenicity has been shown, and a causal relationship has never been proven. In addition, larger epidemiological and serological series have consistently failed to demonstrate an increased risk to pregnant women who develop Lyme disease if they receive appropriate antimicrobial therapy. We describe a favorable outcome in a 42-year-old woman who developed Lyme disease in the third trimester and was treated with a full course of oral amoxicillin. In addition, we offer a review of the relevant literature regarding Lyme disease and pregnancy. The appropriate investigation and management of a woman with gestational borreliosis are discussed.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that Lyme disease is not an uncommon disease during pregnancy and can occur in states outside of the Northeast, explain that the diagnosis is made clinically and may be confirmed by laboratory tests, state that treatment is recommended during pregnancy, and summarize that there is no consistent data of adverse fetal effects even though the placenta is infected.

Breast milk and infection

Three viruses (CMV, HIV, and HTLV-I) frequently cause infection or disease as a result of breast-milk transmission. Reasonable guidelines have been pro-posed for when and how to avoid breast milk in the case of maternal infection. For other viruses, prophylactic immune therapy to protect the infant against all modes of transmission are indicated (VZV, varicella-zoster immunoglobulin, HAV and immunoglobulin, HBV, and HBIg + HBV vaccine). In most maternal viral infections, breast milk is not an important mode of transmission, and continuation of breastfeeding is in the best interest of the infant and mother (see Tables 2 and 3). Maternal bacterial infections rarely are complicated by transmission of infection to their infants through breast milk. In a few situations, temporary cessation of breastfeeding or the avoidance of breast milk is appropriate for a limited time (24 hours for N gonorrheae, H infiuenzae, Group B streptococci, and staphylococci and longer for others including B burgdorferi, T pallidum, and M tuberculosis). In certain situations, prophylactic or empiric therapy may be advised for the infant (eg, T pallidum, M tuberculosis, H influenzae) (see Table 1). Antimicrobial use by the mother should not be a reason not to breastfeed. Alternative regimens that are compatible with breastfeeding can be chosen to treat the mother effectively. In most cases of suspected infection in the breastfeeding mother, the delay in seeking medical care and making the diagnosis means the infant has been ex-posed already. Stopping breastfeeding at this time only deprives the infant of the nutritional and potential immunologic benefits. Breastfeeding or the use of expressed breast milk, even if temporarily suspended, should be encouraged and supported. Decisions about breast milk and infection should balance the potential risk compared with the innumerable benefits of breast milk.

Lyme disease

Lyme disease is due to infection with a tick-borne spirochete, Borrelia burgdorferi. Risk for infection is confined to regions that contain the Ixodid tick vector. Characteristic skin, musculoskeletal, cardiac, ocular, and neurologic disorders are associated with the local, early dissemination and late stages of infection. Neurologic involvement can be seen at all stages, and involves both central and peripheral nervous system syndromes. The inability to easily culture B. burgdorferi and the lack of a reliable active infection assay have contributed to controversies in diagnosis and management. Because the vast majority of patients are seropositive, however, antibody testing is helpful to support the diagnosis of Lyme disease. With appropriate antibiotics, most patients do well. This infection provides an important model system to understand how interactions between an organism, vector, and host lead to disease. It also provides a model to study how infectious agents lead to neurologic disease.

Neurologic aspects of Lyme disease

Lyme disease has emerged as a major infection with frequent neurologic manifestations. These manifestations probably reflect several predominantly indirect pathogenetic mechanisms and involve host, vector, and organism factors. With early diagnosis and appropriate antibiotic treatment, patients do well. Because culture is not reliable, diagnosis has relied on positive serology to document exposure. Serology should improve as second-generation assays become available. Although there is a preventive vaccine based on the lipoprotein OspA, newer vaccines in development may prove more desirable. Lyme disease provides a valuable model to study how infectious pathogens cause neurologic disease.

Current and future treatment of Lyme disease

Lyme borreliosis, a tick-transmitted spirochetal disease, may begin with a characteristic expanding skin lesion at the site of the tick bite. Within several days to weeks, the infection can spread haematogenously to involve the heart, nervous system or the joints. After months to years, the spirochete may persist in these organs causing a chronic form of illness. All stages of this disease can be treatable with antimicrobial agents.

Lyme disease

Lyme disease, which is caused by Borrelia burgdorferi and transmitted in the United States primarily by Ixodes scapularis (the deer tick), is the most common vector borne disease in the United States. Its most frequent manifestation, a characteristic, expanding annular rash (erythema migrans), sometimes accompanied by myalgia, arthralgia, and malaise, occurs in nearly 90% of persons with symptomatic infection. Other manifestations of Lyme disease include seventh cranial nerve palsy, aseptic meningitis, and arthritis. Extensive coverage in the press about the serious effects of Lyme disease has led to widespread anxiety about this illness that is far out of proportion to the actual morbidity that it causes. This problem is exacerbated by the frequent use of serological tests to eliminate the possible diagnosis of Lyme disease in persons with only nonspecific symptoms (such as arthralgia or fatigue) who have a very low probability that Lyme disease is the cause of their symptoms. Consequently, misdiagnosis is frequent and is the most common cause of failure of treatment. The prognosis for most persons with Lyme disease is excellent.

Lyme borreliosis

Lyme borreliosis (Lyme disease) is often said to be associated with "protean" manifestations, a reference to the ancient god Proteus, who could assume many forms and thus elude his pursuers. This legendary quality has clouded our understanding of Lyme borreliosis by giving Borrelia burgdorferi infection a mythical aura of its own. This review shows that this illness, while incompletely understood, is far more palpable than Proteus and is (in most cases) much more readily subdued. The clinical presentations of Lyme borreliosis do differ in North America and Eurasia, possibly due to the differing pathogenicity of distinct genospecies of Borrelia burgdorferi. The most common manifestation, however, in both continents is erythema migrans. Diagnosis should rest on a careful history and objective clinical findings, supported by appropriately chosen laboratory tests. Reports of coinfection with other tick-borne diseases should prompt a fresh look at Lyme borreliosis. Assertions about "protean manifestations" of B burgdorferi infection should be reappraised. Advances in laboratory techniques are welcome but culture remains the gold standard for the diagnosis--and no laboratory test result should substitute for careful clinical observation and critical analysis.