The impact of immunosuppression on erythema migrans. A retrospective study of clinical presentation, response to treatment and production of Borrelia antibodies in 33 patients

Early Lyme Disease (Erythema Migrans) and Its Mimics (Southern Tick-Associated Rash Illness and Tick-Associated Rash Illness)

Erythema migrans, an expanding erythematous skin lesion that develops days to weeks following an Ixodes species tick bite, is the most common clinical manifestation of Lyme disease. Presentations in the United States differ somewhat from that in Europe, presumably because of the different etiologic agents. Diagnosis is based on the appearance of the skin lesion, rather than on laboratory testing. After treatment with an appropriate oral antibiotic for 10 to 14 days, the prognosis is excellent. Two conditions that cause a similar skin lesion following a tick bite, but are of unknown cause, are Southern tick-associated rash illness in the United States and tick-associated rash illness in Japan.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

Early Lyme Borreliosis in Patients Treated with Tumour Necrosis Factor-Alfa Inhibitors

The study evaluated the course and outcome of erythema migrans in patients receiving tumour necrosis factor-alpha (TNF-α) inhibitors. Among 4157 adults diagnosed with erythema migrans in the period 2009–2018, 16 (2.6%) patients were receiving TNF-α inhibitors (adalimumab, infliximab, etarnecept, golimumab), often in combination with other immunosuppressants, for rheumatic (13 patients) or inflammatory bowel (three patients) disease. Findings in this group were compared with those in 32 sex- and age-matched immunocompetent patients diagnosed with erythema migrans in the same years. In comparison with the control group, the immunocompromised patients had a shorter incubation period (7 vs. 14 days; p = 0.0153), smaller diameter of erythema migrans (10.5 vs. 15.5 cm; p = 0.0014), and more frequent comorbidities other than immune-mediated diseases (62.5% vs. 25%, p = 0.0269), symptoms/signs of disseminated Lyme borreliosis (18.8% vs. 0%, p = 0.0324), and treatment failure (25% vs. 0%, p = 0.0094). After retreatment with an antibiotic, the clinical course of Lyme borreliosis resolved. Continuing TNF inhibitor treatment during concomitant borrelial infection while using identical approaches for antibiotic treatment as in immunocompetent patients resulted in more frequent failure of erythema migrans treatment in patients receiving TNF inhibitors. However, the majority of treatment failures were mild, and the course and outcome of Lyme borreliosis after retreatment with antibiotics was favourable.

Lyme borreliosis-from tick bite to diagnosis and treatment

Lyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixodes. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves even without antibiotic treatment. The infecting pathogens can spread to other tissues and organs, resulting in manifestations that can involve the nervous system, joints, heart and skin. Fatal outcome is extremely rare and is due to severe heart involvement; fetal involvement is not reliably ascertained. Laboratory support-mainly by serology-is essential for diagnosis, except in the case of typical erythema migrans. Treatment is usually with antibiotics for 2 to 4 weeks; most patients recover uneventfully. There is no convincing evidence for antibiotic treatment longer than 4 weeks and there is no reliable evidence for survival of borreliae in adequately treated patients. European Lyme borreliosis is a frequent disease with increasing incidence. However, numerous scientifically questionable ideas on its clinical presentation, diagnosis and treatment may confuse physicians and lay people. Since diagnosis of Lyme borreliosis should be based on appropriate clinical signs, solid knowledge of clinical manifestations is essential.

Smear Campaign: Misattribution of Pancytopenia to a Tick-Borne Illness

We report the case of a 51-year-old woman presenting with a targetoid rash and pancytopenia after a tick bite. Initial evaluation was notable for severe neutropenia on the complete blood cell count differential, a positive Lyme IgM antibody, and a peripheral blood smear demonstrating atypical lymphocytes. While her pancytopenia was initially attributed to tick-borne illness, peripheral flow cytometry showed 7% myeloblasts, and a bone marrow biopsy confirmed 60% blasts. The patient was ultimately diagnosed with acute myelogenous leukemia, in addition to early, localized Lyme disease. This case highlights the differential diagnosis for pancytopenia, cytopenia patterns for different tick-borne illnesses, the risk of premature closure in internal medicine, and management of Lyme disease in hosts with altered immunity.

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.

Erythema migrans

Erythema migrans (EM) is the most common objective manifestation of Borrelia burgdorferi infection. Systemic symptoms are usually present. Most patients do not recall a preceding tick bite. Despite a characteristic appearance, EM is not pathognomonic for Lyme disease and must be distinguished from other similar appearing skin lesions. EM is a clinical diagnosis; serologic and PCR assays are unnecessary. Leukopenia and thrombocytopenia are indicative of either an alternative diagnosis, or coinfection with another tick-borne pathogen. When EM is promptly treated with appropriate antimicrobial agents, the prognosis is excellent. Persons in endemic areas should take measures to prevent tick bites.

Course and outcome of Early Lyme borreliosis in patients with hematological malignancies

Patients with erythema migrans and underlying hematological malignancy more often had signs of disseminated Lyme borreliosis and more frequently needed antibiotic retreatment than sex-, age-, and antibiotic treatment-matched immunocompetent persons with erythema migrans. However, the outcome was excellent in both groups.

Lyme neuroborreliosis in a patient treated with TNF-alpha inhibitor

A 57-year-old woman, receiving TNF-alpha inhibitor adalimumab for psoriasis, presented with early Lyme neuroborreliosis (Bannwarth's syndrome). Discontinuation of adalimumab and 14-day therapy with ceftriaxone resulted in a smooth course and favorable outcome of Lyme borreliosis. This is the first report on Lyme neuroborreliosis in a patient treated with TNF-alpha inhibitor.

Lyme carditis in an immunocompromised patient

We present a case of a 68-year-old man with a history of liver transplant and of chronic immunosuppression therapy who presented to the emergency department (ED) for fevers and worsening fatigue for two days. On further investigation, the patient was found to have a new first-degree heart block on his electrocardiograph. Coupled with the history of a recent tick bite, the patient was diagnosed with vector-borne carditis. Although the patient's titers for various vectors remained negative, due to a long history of immunosuppression, he was treated for Lyme disease and his heart block completely resolved with antibiotic treatment. We describe details of the case as well as discuss the impacts of immunosuppression on vector-borne disease. Immunosuppressed patients represent a special population and can present with chief complaints made even more complicated by their medical history, and this case illustrates the importance of being mindful of how immunosuppression can affect a patient's presentation. As the efficacy of antirejection medications improved, the ED may see an increasing number of patients with solid organ transplants. A greater understanding of this special patient population is key to formulating optimal treatment plans.

Seronegative lyme neuroborreliosis in a patient using rituximab

A 66-year-old woman presented with severe shooting pains throughout her back and legs, followed by progressive deafness, weight loss and headache. She had a history of marginal zone B-cell lymphoma stage IV-B, for which she was successfully treated with immunochemotherapy and rituximab maintenance therapy. A relapse was suspected, but chemotherapy was not administered, since, despite elaborate investigations, malignancy could not be proven. Because of a history of tick bites she was tested for antibodies against Borrelia burgdorferi in serum and cerebrospinal fluid (CSF), which were negative. However, a B burgdorferi PCR on CSF came back positive. The patient was treated for seronegative Lyme neuroborreliosis with ceftriaxone intravenously and dramatically improved. This case presentation demonstrates that, in immunocompromised patients, it is important not to solely rely on antibody testing and to use additional diagnostic tests to avoid missing or delaying the diagnosis.

[Lyme disease with hepatitis and corticosteroids: a case report]

INTRODUCTION

Abnormalities of liver function tests have been occasionally described in large series of Lyme disease, but only one case of hepatitis directly related to infection have been described in literature.

CASE REPORT

A 78-year-old-man, with a past medical history of polymyalgia rheumatica (PMR) who had discontinued corticosteroids two years before, presented a transient acute fever and liver cholestasis and cytolysis after an exposure to tick bites. A few days later, cervical pain occurred and corticosteroids were resumed as a PMR relapse was suspected. Hematogenous dissemination with acute meningoradiculitis and multiple erythema migrans led to conclude to a stage 2 Lyme disease.

CONCLUSION

Although hepatitis complicating the course of Lyme disease has been described in literature, the marked inflammation in our patient led us to investigate the possibility of a co-infection. Also, we discuss the responsibility of corticosteroids in clinical worsening of Lyme disease if they are prescribed without concomitant antibiotics.

Lyme disease: Part I. Advances and perspectives

Lyme disease (LD) is an increasingly recognized multisystem, insect-borne zoonosis. Prevalent worldwide, it has a variety of presentations at different stages of infection. The characteristic rash with central clearing known as erythema chronicum migrans, or simply erythema migrans, appears in its first stage. Typical features may be absent, and important variations are evident among cases seen in different parts of the world. LD may be difficult to diagnose clinically; knowledge about its epidemiology and transmission may be of assistance when the diagnosis is unclear. Based upon our experience with LD and a comprehensive literature review, we provide an update of LD epidemiology, pathophysiology, and management. We also cover the three clinical stages of LD that parallel those of syphilis, another spirochetal disease.

Severe course of Lyme neuroborreliosis in an HIV-1 positive patient; case report and review of the literature

Background

Lyme Neuroborreliosis (LNB) in a human immunodeficiency virus (HIV) positive patient is a rare co-infection and has only been reported four times in literature. No case of an HIV patient with a meningoencephalitis due to LNB in combination with HIV has been described to date.

Case presentation

A 51 year old woman previously diagnosed with HIV presented with an atypical and severe LNB. Diagnosis was made evident by several microbiological techniques. Biochemical and microbiological recovery during treatment was rapid, however after treatment the patient suffered from severe and persistent sequelae.

Conclusions

A clinician should consider LNB when being confronted with an HIV patient with focal encephalitis, without any history of Lyme disease or tick bites, in an endemic area. Rapid diagnosis and treatment is necessary in order to minimize severe sequelae.

Erythema migrans

Erythema migrans (EM) is the most common objective manifestation of Lyme disease, accounting for about 90% of cases. Establishing the diagnosis of EM is important because appropriate treatment with oral antibiotics at an early stage of infection with Borrelia burgdorferi results in excellent outcomes. This article includes a discussion of the epidemiology of EM and its clinical, differential, and laboratory diagnosis. The treatment of EM and the prevention of Lyme disease are also discussed.

Antigen biochips verify and extend the scope of antibody detection in Lyme borreliosis

The antibody response of serum IgM and IgG of patients with neuroborreliosis and erythema migrans of Lyme borreliosis (LB) was examined against a 41-kDa flagellar antigen and an 8-mer synthetic OspC8 peptide (VAESPKKP) derived from the C-terminus of outer surface protein C (OspC) from Borrelia garinii. We developed a streptavidin-modified biochip-based immunodiagnosis and compared it with conventional methods such as enzyme-linked immunosorbent assay (ELISA) and Western blot (WB). The diagnostic sensitivity of the coated biochips was demonstrated to be identical, and the results of conventional assays such as ELISA and WB were confirmed. Flagellar antigens lead to better diagnosis because of a higher discriminative value. By contrast, OspC8, a peptide derived from the outer surface antigen, is less sensitive to identify immunity in LB. The inferior antigenicity of OspC8 may be due to epitope masking. Overall, this system is open to simultaneously analyze a larger family of peptides differing in length. Thus, an array approach is generally more advantageous to extend the pattern of antigens to be tested for antigenicity in LB. Serial analysis during ongoing disease may be valuable to learn more about the course of the disease and intermittent reactivation of infection. Protein biochip as a potential substitution of ELISA and WB method offers the opportunity to study serum immunity in a multiplicity of patients simultaneously.