Peripheral neuropathy in acrodermatitis chronica atrophicans - a late Borrelia manifestation

Infectious Neuropathies

OBJECTIVE

This article discusses the clinical manifestations and management of infectious peripheral neuropathies.

LATEST DEVELOPMENTS

Several infectious etiologies of peripheral neuropathy are well-recognized and their treatments are firmly established. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with several central and peripheral nervous system manifestations, including peripheral neuropathies. Additionally, some COVID-19 vaccines have been associated with Guillain-Barré syndrome. These disorders are an active area of surveillance and research. Recent evidence-based guidelines have provided updated recommendations for the diagnosis and treatment of Lyme disease.

ESSENTIAL POINTS

Infectious agents of many types (primarily bacteria and viruses) can affect the peripheral nerves, resulting in various clinical syndromes such as mononeuropathy or mononeuropathy multiplex, distal symmetric polyneuropathy, radiculopathy, inflammatory demyelinating polyradiculoneuropathy, and motor neuronopathy. Knowledge of these infections and the spectrum of peripheral nervous system disorders associated with them is essential because many have curative treatments. Furthermore, understanding the neuropathic presentations of these disorders may assist in diagnosing the underlying infection.

Acrodermatitis chronica atrophicans: clinical and microbiological characteristics of a cohort of 693 Slovenian patients

BACKGROUND

Information on large groups of patients with acrodermatitis chronica atrophicans (ACA) is limited.

METHODS

We assessed clinical and microbiological characteristics of patients with ACA diagnosed at a single medical centre and compared findings in periods 1991-2004 vs. 2005-2018. The cohort is representative of Slovenian ACA patients.

RESULTS

We assessed 693 patients: 461 females and 232 males, with median age of 64 years. Median duration of ACA before diagnosis was 12 months. In all but 2 patients, the skin lesions were located on extremities, more often on the lower (70.0%) than the upper (45.2%), bilaterally in 42.4%. Reddish-blue discoloration, swelling, thinning and wrinkling of skin were present in 95.2%, 28.1%, 46.4% and 20.5% of patients, respectively. Overall, 64.4% of patients reported constitutional symptoms, 23.1% had local symptoms, and 20.8% had symptoms/signs of peripheral neuropathy. Nodules, arthritis, joint deformity, muscle atrophy and paresis were rare (<3%). Borreliae were isolated from 200/664 (30.1%) skin samples; 92.8% were Borrelia afzelii. B. garinii and B. burgdorferi s.s. were more often isolated from the skin of male patients (OR = 4.17) and from those with arthropathy (OR = 11.74). Patients included in the more recent period were older, complained less often of constitutional symptoms but more often of local symptoms, and more often had local swelling but less often skin atrophy and bilateral involvement, probably as a consequence of earlier diagnosis.

CONCLUSIONS

ACA, typically caused by B. afzelii, usually affects older women. Clinical presentation depends on the duration of illness and probably on the Borrelia species causing the disease.

Comparison of Lyme Disease in the United States and Europe

Lyme disease, or Lyme borreliosis, is the most common tickborne disease in the United States and Europe. In both locations, Ixodes species ticks transmit the Borrelia burgdorferi sensu lato bacteria species responsible for causing the infection. The diversity of Borrelia species that cause human infection is greater in Europe; the 2 B. burgdorferi s.l. species collectively responsible for most infections in Europe, B. afzelii and B. garinii, are not found in the United States, where most infections are caused by B. burgdorferi sensu stricto. Strain differences seem to explain some of the variation in the clinical manifestations of Lyme disease, which are both minor and substantive, between the United States and Europe. Future studies should attempt to delineate the specific virulence factors of the different species of B. burgdorferi s.l. responsible for these variations in clinical features.

Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis

Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis.

This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults.

Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany).

The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.

[Epidemiology of Lyme borreliosis in France - both certainties and uncertainties]

Epidemiological evidence for tick-borne infections, particularly those related to Lyme borreliosis, is heterogeneous. Lyme borreliosis is a tick-born zoonosis transmitted by ticks of the genus Ixodes ricinus. After tick bite, the risk of transmission of an infectious agent remains low, most often represented by Borrelia burgdorferi sensu lato; co-infections in Humans by several different infectious agents (bacterial, viral or parasitic) are possible but a priori rare. In addition, besides well-known tick-borne pathogens, new species or gender of micro-organisms are regularly described in ticks but their pathogenicity in human pathology is not described or not yet established. The clinical presentation of Lyme borreliosis is varied, with localized and disseminated forms occurring long ago after tick bite, making diagnosis sometimes difficult. The natural course of Lyme borreliosis is insufficiently known because of recommendations of antibiotherapy in case of illness; however, some historical studies seem reassuring with possible spontaneous healing and seemingly minor sequelae. The diagnosis of disseminated forms requires paraclinical examinations, in first place serology, whose sensitivity increases with time of evolution of borreliosis; this is all the more interesting as the disseminated forms are of more difficult clinical diagnosis. After antibiotherapy, the clinical course is good, the sequelae remain possible especially in case of late diagnosis or late disseminated form; however, their frequency remains unknown.

Lyme Neuroborreliosis

BACKGROUND

The new German S3 guideline on Lyme neuroborreliosis is intended to provide physicians with scientifically based information and recommendations on the diagnosis and treatment of this disease.

METHODS

The scientific literature was systematically searched and the retrieved publications were assessed at the German Cochrane Center (Deutsches Cochrane Zentrum) in Freiburg in the 12 months beginning in March 2014. In addition to the main search terms "Lyme disease," "neuroborreliosis," "Borrelia," and "Bannwarth," 28 further terms relating to neurological manifestations of the disease were used for the search in the Medline and Embase databases and in the Cochrane Central Register of Controlled Trials.

RESULTS

In the treatment of early Lyme neuroborreliosis, orally administered doxycycline is well tolerated, and its efficacy is equivalent to that of intravenously administered beta-lactam antibiotics (penicillin G, ceftriaxone, and cefotaxime) (relative risk [RR]: 0.98, 95% confidence interval [CI]: [0.68; 1.42], P = 0.93). 14 days of treatment suffice for early Lyme neuroborreliosis, and 14-21 days of treatment usually suffice for late (chronic) Lyme neuroborreliosis.

CONCLUSION

Lyme neuroborreliosis has a favorable prognosis if treated early. The long-term administration of antibiotics over many weeks or even months for putative chronic Lyme neuroborreliosis with nonspecific symptoms yields no additional benefit and carries the risk of serious adverse effects.

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.

A critical appraisal of the mild axonal peripheral neuropathy of late neurologic Lyme disease

In older studies, a chronic distal symmetric sensory neuropathy was reported as a relatively common manifestation of late Lyme disease in the United States. However, the original papers describing this entity had notable inconsistencies and certain inexplicable findings, such as reports that this condition developed in patients despite prior antibiotic treatment known to be highly effective for other manifestations of Lyme disease. More recent literature suggests that this entity is seen rarely, if at all. A chronic distal symmetric sensory neuropathy as a manifestation of late Lyme disease in North America should be regarded as controversial and in need of rigorous validation studies before acceptance as a documented clinical entity.

Lyme Neuroborreliosis

PURPOSE OF REVIEW

Lyme disease, caused by the spirochete Borrelia burgdorferi, is the most common tick-borne illness in the United States and Europe. Lyme disease usually begins with the characteristic skin lesion, erythema migrans, at the site of the tick bite. Following hematogenous dissemination, neurologic, cardiac, and/or rheumatologic involvement may occur. Neurologic involvement occurs in up to 15% of untreated B. burgdorferi infection and neurologists should be familiar with its diagnosis and management.

RECENT FINDINGS

The most common early neurologic manifestations of Lyme disease are cranial neuropathy (particularly facial palsy), lymphocytic meningitis, and radiculoneuritis, which often occur in combination. Late neuroborreliosis occurs much less frequently than early disease. A combination of clinical and laboratory findings is recommended for the diagnosis of Lyme neuroborreliosis. Treatment with recommended antibiotic regimens is effective in Lyme neuroborreliosis, and patients with early disease usually have excellent outcomes. Recovery is slower and may be incomplete in patients with late disease.

SUMMARY

Nervous system involvement occurs in up to 15% of patients with untreated B. burgdorferi infection. This article reviews clinical aspects of the diagnosis and treatment of Lyme neuroborreliosis, with focus on the United States.

Long-term Follow-up of Patients With Lyme Disease: Longitudinal Analysis of Clinical and Quality-of-life Measures

BACKGROUND

Lyme disease is the most common vector-borne disease in the United States. Some patients report persistent or intermittent subjective symptoms of mild to moderate intensity after antibiotic treatment for Lyme disease. We sought to evaluate trends in clinical and quality-of-life (QOL) measures in a cohort of patients with Lyme disease enrolled in a natural history study at the National Institutes of Health from 2001-2014.

METHODS

QOL was measured using the self-administered 36-item Short Form Health Survey (SF-36) during study follow-up. Primary outcomes included mean physical (PCS) and mental (MCS) health QOL composite scores and reporting long-term (≥2 years) symptoms, adjusted for Lyme disease stage and severity at diagnosis.

RESULTS

Overall, 101 patients with an average follow-up time of 3.9 years (range, 0.5-11.3 years) were included. At first visit, overall mean QOL scores were below the US population mean for both PCS (45.6 ± 10.4) and MCS (47.3 ± 11.5) but increased to just above the national average after 3 years of follow-up for both PCS (50.7 ± 9.6) and MCS (50.1 ± 10.0). Baseline QOL scores were lowest in those with late disease (P < 0.01) but also increased by the end of follow-up to national averages. In multivariate analysis, the only factors significantly associated with long-term symptoms or lower QOL scores were other comorbidities unrelated to Lyme disease.

CONCLUSIONS

Comorbid conditions can play a role in the reporting of long-term symptoms and overall QOL of Lyme disease patients and should be considered in the evaluation of these patients.

CLINICAL TRIALS REGISTRATION

NCT00028080.

Laboratory diagnosis of Lyme disease: advances and challenges

The majority of laboratory tests performed for the diagnosis of Lyme disease are based on detection of the antibody responses against B burgdorferi in serum. The sensitivity of antibody-based tests increases with the duration of the infection. Patients early in their illness are more likely to have a negative result. There is a need to simplify the testing algorithm for Lyme disease, improving sensitivity in early disease while still maintaining high specificity and providing information about the stage of infection. The development of a point of care assay and biomarkers for active infection would be major advances for the field.

Management approaches for suspected and established Lyme disease used at the Lyme disease diagnostic center

2015 marks the 27th year that the Lyme Disease Diagnostic Center, located in New York State in the United States, has provided care for patients with suspected or established deer tick-transmitted infections. There are five deer tick-transmitted infectious in this geographic area of which Lyme disease is the most common.For patients with erythema migrans, we do not obtain any laboratory testing. However, if the patient is febrile at the time of the visit or reports rigors and high-grade fevers, we consider the possibility of a co-infection and order pertinent laboratory tests.Our preferred management for Lyme disease-related facial palsy and/or radiculopathy is a 2-week course of doxycycline. Patients who are hospitalized for Lyme meningitis are usually treated at least initially with ceftriaxone. We have not seen convincing cases of encephalitis or myelitis solely due to Borrelia burgdorferi infection in the absence of laboratory evidence of concomitant deer tick virus infection (Powassan virus). We have also never seen Lyme encephalopathy or a diffuse axonal peripheral neuropathy and suggest that these entities are either very rare or nonexistent.We have found that Lyme disease rarely presents with fever without other objective clinical manifestations. Prior cases attributed to Lyme disease may have overlooked an asymptomatic erythema migrans skin lesion or the diagnosis may have been based on nonspecific IgM seroreactivity. More research is needed on the appropriate management and significance of IgG seropositivity in asymptomatic patients who have no history of Lyme disease.

Chronic Lyme; diagnostic and therapeutic challenges

In this review, we aim to discuss the definition, clinical and laboratory features, diagnostics, and management of chronic Lyme. Chronic Lyme is a rare condition caused by long-lasting and ongoing infection with the spirochete Borrelia burgdorferi (Bb). The most common manifestations are progressive encephalitis, myelitis, acrodermatitis chronica atrophicans with or without neuropathy, and arthritis. Chronic Lyme is not considered to present with isolated subjective symptoms. Direct detection of Bb has low yield in most manifestations of chronic Lyme, while almost 100% of the cases are seropositive, that is, have detectable Bb IgG antibodies in serum. Detection of Bb antibodies only with Western blot technique and not with ELISA and detection of Bb IgM antibodies without simultaneous detection of Bb IgG antibodies should be considered as seronegativity in patients with long-lasting symptoms. Patients with chronic Lyme in the nervous system (neuroborreliosis) have, with few exceptions, pleocytosis and production of Bb antibodies in their cerebrospinal fluid. Strict guidelines should be applied in diagnostics of chronic Lyme, and several differential diagnoses, including neurological disease, rheumatologic disease, post-Lyme disease syndrome, chronic fatigue syndrome, and psychiatric disease, should be considered in the diagnostic workup. Antibiotic treatment with administration route and dosages according to current guidelines are recommended. Combination antimicrobial therapy or antibiotic courses longer than 4 weeks are not recommended. Patients who attribute their symptoms to chronic Lyme on doubtful basis should be offered a thorough and systematic diagnostic approach, and an open and respectful dialogue.

Lyme neuroborreliosis

Lyme neuroborreliosis (LNB) designates the nervous system disorders caused by the tick-borne spirochete Borrelia burgdorferi (Bb). The clinical syndromes are usually distinct and are classified as early and the rare late or chronic LNB. Early LNB occurs 3-6 weeks after infection most frequently as a lymphocytic meningoradiculoneuritis (LMR). Symptoms are mainly due to a painful sensory radiculitis and a multifocal motor radiculo-neuritis. Fifty percent have cranial nerve involvement predominantly uni- or bilateral facial nerve palsies. Meningitic symptoms occur primarily in children. Nerve biopsies, autopsies, animal models, and nerve conduction studies showed that the pathology is a lymphocytic perineuritis leading to multisegmental axonal injury of nerve roots, spinal ganglia, and distal nerve segments. Due to meningeal and root inflammation cerebrospinal fluid (CSF) shows lymphocytic inflammation. The only evidence that Bb causes peripheral neuropathy without CSF inflammation is seen in patients with acrodermatitis chronica atrophicans (ACA), a chronic dermatoborreliosis. In the rare chronic or late LNB the pathology and thus the clinical presentation is primarily due to chronic meningitis and meningovascular CNS involvement, whereas the peripheral nervous system is not primarily affected. In early and late LNB the diagnosis is based on a characteristic clinical appearance and CSF inflammation with Bb-specific intrathecal antibody production. Both conditions, but not the ACA-associated neuropathy, respond to antibiotic therapy.

Peripheral nervous system manifestations of lyme borreliosis

Lyme disease is a tick-borne illness that has protean neurologic manifestations involving both the central and peripheral nervous system. The peripheral nervous system manifestations of Lyme borreliosis can be divided chronologically into acute and chronic forms. Within weeks after disease onset, approximately 15% of untreated patients develop an acute Lyme meningoradiculoneuritis with headache, fever, radicular pain, weakness, and sensory loss, often associated with cranial neuropathy, usually facial palsy. Cerebrospinal fluid typically shows lymphocytic pleocytosis, high protein, and normal glucose. Diagnosis is made by recognition of characteristic clinical features with a history of preceding exposure and confirmed by serologic evidence of exposure to B. burgdorferi or by antibody or PCR evidence of cerebrospinal fluid infection. Months to years after onset, rare patients may develop chronic polyradiculoneuropathy presenting with sensory symptoms or radicular pain. Diagnosis is confirmed by a history of exposure, previous systemic or acute neurologic manifestations of Lyme borreliosis, and serologic evidence of infection. Pathology of acute or chronic Lyme radiculoneuropathy reveals axonal degeneration with perivascular mononuclear infiltration. Eradication of the organism can be achieved with 2 to 4 weeks of ceftriaxone for both acute and chronic Lyme neuroborreliosis. Isolated facial palsy without evidence of cerebrospinal fluid infection can be treated with oral antibiotics such as doxycycline. Prognosis after therapy is good, but neurologic recovery is slower for chronic than acute Lyme radiculoneuropathy.

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.

Neuroborreliosis: pathogenesis, symptoms, diagnosis and treatment

Lyme disease is the most common human tick-borne disease in the northern hemisphere. This article describes the current knowledge of several aspects of Lyme neuroborreliosis. The epidemiology is reviewed first, with special respect to the difference between European and American disease. Then, the current knowledge about the pathogenesis of Lyme neuroborreliosis is presented, with emphasis on immune evasion strategies. Furthermore, the clinical picture of acute Lyme neuroborreliosis and the frequently discussed post-Lyme disease syndrome are critically discussed. The commonly used diagnostic strategies, as well as the relevance of the lymphocyte transformation test, CD57+/CD3- cell count and CXCL13, are presented. Finally, the therapeutic options are described to give a balanced overview of all aspects of this disease.

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.

Skin manifestations of lyme borreliosis: diagnosis and management

Lyme borreliosis is a multisystem infectious disease caused by tick-transmitted spirochetes of the Borrelia burgdorferi sensu lato complex. The three characteristic cutaneous manifestations are erythema migrans, borrelial lymphocytoma, and acrodermatitis chronica atrophicans. Erythema migrans occurs in acute Lyme borreliosis, lymphocytoma is a subacute lesion, and acrodermatitis is the typical manifestation of late Lyme borreliosis. Clinical appearances of erythema migrans and lymphocytoma (when located on the ear or breast) are characteristic, whereas acrodermatitis is often confused with vascular conditions. The diagnosis of erythema migrans is made clinically. Serologic analyses often yield false-negative results and are not required for the diagnosis. However, serologic proof of the diagnosis in lymphocytoma (approximately 90% positive) and acrodermatitis (100% positive) is mandatory. Histopathologic examination often adds substantial information in patients with skin manifestations of Lyme borreliosis and is recommended in clinically (and serologically) undecided cases of erythema migrans or lymphocytoma and is obligatory in acrodermatitis. Polymerase chain reaction for Borrelia-specific DNA (rather than culture of the spirochete) and immunohistochemical investigations (lymphocytoma) are sometimes necessary adjuncts for the diagnosis. Antibacterial treatment is necessary in all patients to eliminate the spirochete, cure current disease, and prevent late sequelae. Oral doxycycline, also effective against coinfection with Anaplasma phagocytophilum, is the mainstay of therapy of cutaneous manifestations of Lyme borreliosis. Other first-line antibacterials are amoxicillin and cefuroxime axetil. Erythema migrans is treated for 2 weeks, lymphocytoma for 3-4 weeks, and acrodermatitis for at least 4 weeks.

Sur quels éléments cliniques et épidémiologiques faut-il évoquer le diagnostic de la borréliose de Lyme? Aspects neurologiques et psychiatriques au cours de la maladie de Lyme

Lyme disease is associated with various systemic and neurological manifestations. The neurological and psychiatric manifestations of Lyme disease are more frequently observed during its secondary phase (stage 2) than during its late tertiary phase (stage 3). In stage 2, cerebrospinal fluid and bacterial tests are consistent with the ongoing infection. Painful meningoradiculitis, encephalomyelitis and encephalitis, and symptoms of depression are the most characteristic at this stage. The diagnosis should be based on the association of clinical, epidemiological, and biological features. Adequate treatment usually leads to recovery. In stage 3 of the disease, the link between neurological manifestations and initial infection is uncertain. Distal axonal polyneuropathy and chronic encephalopathy are the most frequently reported presentations.

Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis

Most patients with erythema migrans, the pathognomonic rash of Lyme disease, do not recall a deer tick bite. The rash is classically 5 to 68 cm of annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%). Serologic testing is not indicated for patients with erythema migrans, because initially, the result is usually negative. Successful treatment of a patient with erythema migrans can be accomplished with 20 days of oral doxycycline, amoxicillin, or cefuroxime axetil. Patients with Lyme arthritis usually present with a mildly painful swollen knee. Patients with Lyme arthritis have markedly positive serology and can usually be successfully treated with 28 days of oral doxycycline or amoxicillin. Some patients may have persistent effusion despite 4 to 8 weeks of antibiotics and may need synovectomy. Persistent effusion is not due to persistent infection. Antibiotic therapy for more than 8 weeks for patients with Lyme disease is not indicated. Chronic Lyme disease due to antibiotic resistant infection has not been demonstrated.

The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis were prepared by an expert panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 31[Suppl 1]:1-14). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. For each of these Ixodes tickborne infections, information is provided about prevention, epidemiology, clinical manifestations, diagnosis, and treatment. Tables list the doses and durations of antimicrobial therapy recommended for treatment and prevention of Lyme disease and provide a partial list of therapies to be avoided. A definition of post-Lyme disease syndrome is proposed.

Acrodermatitis chronica atrophicans in a 15-year-old girl misdiagnosed as venous insufficiency for 6 years

Acrodermatitis chronica atrophicans, the characteristic cutaneous manifestation of late Lyme borreliosis, typically occurs in elderly women. To our knowledge, only 4 cases of acrodermatitis chronica atrophicans in children have been described. Prompt diagnosis and treatment are important to prevent progression of disease and extracutaneous complications. We describe a 15-year-old girl with acrodermatitis chronica atrophicans of the left leg that had been misdiagnosed as chronic venous insufficiency for 6 years. Because of the long-standing disease course, skin changes expanded and progressed to marked atrophy. The correct diagnosis was finally based on clinical, histopathologic, and serologic findings. The girl was treated with oral doxycycline for 6 weeks, but her skin changes did not fully normalize. This case illustrates the possibility of acrodermatitis chronica atrophicans appearing in childhood and the difficulties in differentiating vascular disorders from acrodermatitis chronica atrophicans on the basis of the clinical appearance alone.

Central nervous system Lyme disease

Lyme disease is a disease caused by the spirochete, Borrelia burgdorferi. It is transmitted to humans via a bite from an infected tick. It has several classic stages or categories of illness, including early localized disease, early disseminated disease, and late disease. The focus of this article is on the manifestations, diagnosis, and treatment of Lyme disease of the central nervous system.

Peripheral neuropathy in acrodermatitis chronica atrophicans - effect of treatment

Forty-seven patients with the late borrelial manifestation acrodermatitis chronica atrophicans (ACA) and with objective neurological and/or neurophysiological findings were followed up after antibiotic treatment with dermatological, serological, neurological and neurophysiological controls. Despite a good therapeutic effect on ACA lesions, specific antibody values and symptoms of irritative nerve lesions, the objective neurological and neurophysiological findings of nerve deficit remained unchanged. There was no progress of neuropathy findings during the follow-up time. Our interpretation of the results is that the remaining neuropathy signs after treatment of ACA are neurological sequelae and not manifestations of persisting Borrelia infection.

Lyme neuroborreliosis

A broad variability in the clinical manifestations is observed in the European and North American borrelioses. This is dependent on bacterial strain differences in virulence and organotropism, and on different immune responses to Borrelia burgdorferi of the host in these areas. Experimental neuroborreliosis has given insights into mediators and molecular mechanisms of inflammation induced by B. burgdorferi. Histopathological investigations have described the different patterns of injury in the peripheral and central nervous systems. The classic symptoms of neuroborreliosis have been supplemented by new clinical syndromes and neuropsychological investigations. In clinical trials, the efficacy and cost effectiveness of recommended oral and intravenous antibiotic therapies have been compared in early Lyme disease, arthritis and acute disseminated Lyme disease.