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Tetens MM, Andersen NS, Dessau RB, Ellermann-Eriksen S, Jørgensen CS, Pedersen M, Bodilsen J, Søgaard KK, Bangsborg J, Nielsen ACY, Møller JK, Obel N, Lebech AM, Omland LH. Obtainment of prescribed analgesics among patients with Lyme neuroborreliosis; a nationwide, population-based matched cohort study. Ticks Tick Borne Dis 2024; 15:102371. [PMID: 38936014 DOI: 10.1016/j.ttbdis.2024.102371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/26/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Radicular pain is the most predominant symptom among adults with Lyme neuroborreliosis (LNB) but the duration preceding and following diagnosis remains unknown. We aimed to investigate whether patients with LNB have increased obtainment of analgesics before and after diagnosis and for how long. METHODS We performed a nationwide, population-based, matched cohort study (2009-2021). all Danish residents with LNB (positive Borrelia burgdorferi intrathecal antibody index test and cerebrospinal fluid pleocytosis) were included. To form a comparison cohort, individuals from the general population were randomly extracted and matched 10:1 to patients with LNB on age and sex. Outcomes were obtainment of simple analgesics, antiepileptics, tricyclic antidepressants, serotonin and noradrenaline reuptake inhibitors, tramadol, and other opioids. We calculated monthly and six-monthly proportions of individuals with obtainment of analgesics and absolute risk differences. RESULTS 1,056 patients with LNB and 10,560 comparison cohort members were included. An increased proportion of patients with LNB obtained analgesics from 3 months before study inclusion, especially simple analgesics, tramadol, and other opioids. Within the 0-1-month period after study inclusion, patients with LNB most frequently obtained simple analgesics (15 %), antiepileptics (11 %), and tramadol (10 %). Thereafter, obtainment of analgesics declined within a few months. A slightly larger proportion of patients with LNB obtained antiepileptics up to 2.5 years after diagnosis. CONCLUSIONS Up to 3 months preceding diagnosis, LNB was preceded by increased obtainment of analgesics, which suggests diagnostic delay. Importantly, most patients with LNB did not obtain analgesics after the immediate disease course, although obtainment remained more frequent up to 2.5 years after.
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Affiliation(s)
- Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Nanna S Andersen
- Clinical Centre for Emerging and Vector-borne Infections, Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark; Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Zealand University Hospital, Slagelse, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Michael Pedersen
- Department of Clinical Microbiology, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kirstine K Søgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jette Bangsborg
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev Hospital, Herlev, Denmark
| | - Alex Christian Yde Nielsen
- Department of Clinical Microbiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens Kjølseth Møller
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Clinical Microbiology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Haukali Omland
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Skarstein I, Ulvestad E, Solheim AM, Vedeler C, Ljøstad U, Mygland Å, Eikeland R, Reiso H, Lorentzen ÅR, Bos SD. Serum neurofilament light chain associates with symptom burden in Lyme neuroborreliosis patients: a longitudinal cohort study from Norway. J Neurol 2024; 271:2768-2775. [PMID: 38407594 PMCID: PMC11055709 DOI: 10.1007/s00415-024-12237-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES Serum neurofilament light chain (sNfL), an indicator of neuronal damage, is increasingly recognized as a potential biomarker for disease activity in neurodegenerative disorders. In this study, we wanted to investigate sNfL as a prognostic marker in a large, well-defined population of 90 patients with Lyme neuroborreliosis (LNB). In addition, we sought to explore associations between symptoms and sNfL levels during the acute phase of LNB. MATERIALS AND METHODS Patients diagnosed with definite or possible LNB were recruited from a double-blinded, placebo-controlled, multi-center trial, in which the participants were randomly assigned to 2 or 6 weeks of oral doxycycline treatment. The sNfL levels were measured using a single molecule array assay at both diagnosis and 6-month follow-up, and analysed against clinical parameters, variations in symptom burden and long-term complaints as assessed by a composite clinical score. RESULTS At the time of diagnosis, approximately 60% of the patients had elevated sNfL levels adjusted for age. Notably, mean sNfL levels were significantly higher at diagnosis (52 pg/ml) compared to 6 months after treatment (12 pg/ml, p < 0.001), when sNfL levels had normalized in the majority of patients. Patients with objective signs of spinal radiculitis had significantly higher baseline sNfL levels compared to patients without spinal radiculitis (p = 0.033). CONCLUSION Our findings suggest that sNfL can serve as a biomarker for peripheral nerve tissue involvement in the acute phase of LNB. As found in an earlier study, we confirm normalization of sNfL levels in blood after treatment. We found no prognostic value of acute-phase sNfL levels on patient outcome.
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Affiliation(s)
- Ingerid Skarstein
- Department of Microbiology, Haukeland University Hospital, Post Box 1400, 5021, Bergen, Norway.
- Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Elling Ulvestad
- Department of Microbiology, Haukeland University Hospital, Post Box 1400, 5021, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anne Marit Solheim
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Vedeler
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Section of Habilitation, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Randi Eikeland
- Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Hospital Trust, Kristiansand, Norway
- Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | - Harald Reiso
- Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
- Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Steffan Daniel Bos
- Department of Microbiology, Haukeland University Hospital, Post Box 1400, 5021, Bergen, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Cancer Registry of Norway, The Norwegian Institute of Public Health, Oslo, Norway
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Collignon S, Coenen F, Mols P, Chauvin C, Ngatchou W. [Bilateral facial palsy: an atypical presentation of Lyme disease (a case report)]. Pan Afr Med J 2024; 47:156. [PMID: 38974695 PMCID: PMC11226764 DOI: 10.11604/pamj.2024.47.156.43116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 07/09/2024] Open
Abstract
Lyme neuroborreliosis is a rare zoonosis which can be difficult to diagnose, in particular in low endemic areas. We here report the case of a 35-year-old man presenting with disabling back pain preceded by facial monoplegia, which was wrongly treated as Bell's palsy (paralysis a frigore) and then as post-traumatic lumbosciatica. The onset of facial diplegia allowed for a definitive diagnosis. The patient was treated with ceftriaxone and symptoms gradually improved.
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Affiliation(s)
- Sophie Collignon
- Service des Urgences, Réseau Iris Sud, Université Libre de Bruxelles, Bruxelles, Belgique
| | - François Coenen
- Service des Urgences, Réseau Iris Sud, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Pierre Mols
- Service des Urgences, Réseau Iris Sud, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Caroline Chauvin
- Service des Urgences, Réseau Iris Sud, Université Libre de Bruxelles, Bruxelles, Belgique
| | - William Ngatchou
- Service des Urgences, Réseau Iris Sud, Université Libre de Bruxelles, Bruxelles, Belgique
- Service des Urgences et de Chirurgie Cardiaque, Hôpital St Pierre de Bruxelles, Université Libre de Bruxelles, Bruxelles, Belgique
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Vrijmoeth HD, Ursinus J, Harms MG, Tulen AD, Baarsma ME, van de Schoor FR, Gauw SA, Zomer TP, Vermeeren YM, Ferreira JA, Sprong H, Kremer K, Knoop H, Joosten LAB, Kullberg BJ, Hovius JW, van den Wijngaard CC. Determinants of persistent symptoms after treatment for Lyme borreliosis: a prospective observational cohort study. EBioMedicine 2023; 98:104825. [PMID: 38016860 PMCID: PMC10755112 DOI: 10.1016/j.ebiom.2023.104825] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Patients treated for Lyme borreliosis (LB) frequently report persistent symptoms. Little is known about risk factors and etiology. METHODS In a prospective observational cohort study with a follow-up of one year, we assessed a range of microbiological, immunological, genetic, clinical, functional, epidemiological, psychosocial and cognitive-behavioral variables as determinants of persistent symptoms after treatment for LB. Between 2015 and 2018 we included 1135 physician-confirmed LB patients at initiation of antibiotic therapy, through clinical LB centers and online self-registration. Two reference cohorts of individuals without LB (n = 4000 and n = 2405) served as a control. Prediction analyses and association studies were used to identify determinants, as collected from online questionnaires (three-monthly) and laboratory tests (twice). FINDINGS Main predictors of persistent symptoms were baseline poorer physical and social functioning, higher depression and anxiety scores, more negative illness perceptions, comorbidity, as well as fatigue, cognitive impairment, and pain in 295 patients with persistent symptoms. The primary prediction model correctly indicated persistent symptoms in 71.0% of predictions (AUC 0.79). In patients with symptoms at baseline, cognitive-behavioral responses to symptoms predicted symptom persistence. Of various microbiological, immunological and genetic factors, only lower IL-10 concentrations in ex vivo stimulation experiments were associated with persistent symptoms. Clinical LB characteristics did not contribute to the prediction of persistent symptoms. INTERPRETATION Determinants of persistent symptoms after LB were mainly generic, including baseline functioning, symptoms and cognitive-behavioral responses. A potential role of host immune responses remains to be investigated. FUNDING Netherlands Organisation for Health Research and Development (ZonMw); the Dutch Ministry of Health, Welfare and Sport (VWS).
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Affiliation(s)
- Hedwig D Vrijmoeth
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Jeanine Ursinus
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Location AMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Margriet G Harms
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands
| | - Anna D Tulen
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands
| | - M E Baarsma
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Location AMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Freek R van de Schoor
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Stefanie A Gauw
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Location AMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Tizza P Zomer
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300 DS, Apeldoorn, the Netherlands
| | - Yolande M Vermeeren
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300 DS, Apeldoorn, the Netherlands
| | - José A Ferreira
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands
| | - Hein Sprong
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands
| | - Kristin Kremer
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Bart Jan Kullberg
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Joppe W Hovius
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Location AMC, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Cees C van den Wijngaard
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands.
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Lindland ES, Solheim AM, Andreassen S, Bugge R, Eikeland R, Reiso H, Lorentzen ÅR, Harbo HF, Beyer MK, Bjørnerud A. Dynamic contrast-enhanced MRI shows altered blood-brain barrier function of deep gray matter structures in neuroborreliosis: a case-control study. Eur Radiol Exp 2023; 7:52. [PMID: 37710058 PMCID: PMC10501980 DOI: 10.1186/s41747-023-00365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/22/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Main aim was assessment of regional blood-brain barrier (BBB) function by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in patients with neuroborreliosis. Secondary aim was to study the correlation of BBB function with biochemical, clinical, and cognitive parameters. METHODS Regional ethical committee approved this prospective single-center case-control study. Within 1 month after diagnosis of neuroborreliosis, 55 patients underwent DCE-MRI. The patient group consisted of 25 males and 30 females with mean age 58 years, and the controls were 8 males and 7 females with mean age 57 years. Pharmacokinetic compartment modelling with Patlak fit was applied, providing estimates for capillary leakage rate and blood volume fraction. Nine anatomical brain regions were sampled with auto-generated binary masks. Fatigue, severity of clinical symptoms and findings, and cognitive function were assessed in the acute phase and 6 months after treatment. RESULTS Leakage rates and blood volume fractions were lower in patients compared to controls in the thalamus (p = 0.027 and p = 0.018, respectively), caudate nucleus (p = 0.009 for both), and hippocampus (p = 0.054 and p = 0.009). No correlation of leakage rates with fatigue, clinical disease severity or cognitive function was found. CONCLUSIONS In neuroborreliosis, leakage rate and blood volume fraction in the thalamus, caudate nucleus, and hippocampus were lower in patients compared to controls. DCE-MRI provided new insight to pathophysiology of neuroborreliosis, and can serve as biomarker of BBB function and regulatory mechanisms of the neurovascular unit in infection and inflammation. RELEVANCE STATEMENT DCE-MRI provided new insight to pathophysiology of neuroborreliosis, and can serve as biomarker of blood-brain barrier function and regulatory mechanisms of the neurovascular unit in infection and inflammation. KEY POINTS • Neuroborreliosis is an infection with disturbed BBB function. • Microvessel leakage can be studied with DCE-MRI. • Prospective case-control study showed altered microvessel properties in thalamus, caudate, and hippocampus.
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Affiliation(s)
- Elisabeth S Lindland
- Department of Radiology, Sorlandet Hospital, Sykehusveien 1, N-4809, Arendal, Norway.
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Anne Marit Solheim
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Silje Andreassen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Sorlandet Hospital, Arendal, Norway
| | - Robin Bugge
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
| | - Randi Eikeland
- The Norwegian National Advisory Unit On Tick-Borne Diseases, Sorlandet Hospital, Kristiansand, Norway
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Harald Reiso
- The Norwegian National Advisory Unit On Tick-Borne Diseases, Sorlandet Hospital, Kristiansand, Norway
| | - Åslaug R Lorentzen
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- The Norwegian National Advisory Unit On Tick-Borne Diseases, Sorlandet Hospital, Kristiansand, Norway
| | - Hanne F Harbo
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mona K Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Atle Bjørnerud
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
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Raffetin A, Chahour A, Schemoul J, Paoletti G, He Z, Baux E, Patrat-Delon S, Nguala S, Caraux-Paz P, Puppo C, Arias P, Madec Y, Gallien S, Rivière J. Acceptance of diagnosis and management satisfaction of patients with "suspected Lyme borreliosis" after 12 months in a multidisciplinary reference center: a prospective cohort study. BMC Infect Dis 2023; 23:380. [PMID: 37280565 DOI: 10.1186/s12879-023-08352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/26/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Because patients with a "suspicion of Lyme borreliosis (LB)" may experience medical wandering and difficult care paths, often due to misinformation, multidisciplinary care centers were started all over Europe a few years ago. The aim of our study was to prospectively identify the factors associated with the acceptance of diagnosis and management satisfaction of patients, and to assess the concordance of the medical health assessment between physicians and patients 12 months after their management at our multidisciplinary center. METHODS We included all adults who were admitted to the Tick-Borne Diseases Reference Center of Paris and the Northern Region (TBD-RC) (2017-2020). A telephone satisfaction survey was conducted 12 months after their first consultation. It consisted of 5 domains and 13 items rated between 0 (lowest) and 10 (highest grade): (1)Reception; (2)Care and quality of management; (3)Information/explanations given to the patients; (4)Current medical condition and acceptance of the final diagnosis; (5)Overall appreciation. Factors associated with diagnosis acceptance and management satisfaction at 12 months were identified using logistic regression models. The concordance of the health status as assessed by doctors and patients was calculated using a Cohen's kappa test. RESULTS Of the 569 patients who consulted, 349 (61.3%) answered the questionnaire. Overall appreciation had a median rating of 9 [8;10] and 280/349 (80.2%) accepted their diagnoses. Patients who were "very satisfied" with their care paths at TBD-RC (OR = 4.64;CI95%[1.52-14.16]) had higher odds of diagnosis acceptance. Well-delivered information was strongly associated with better satisfaction with the management (OR = 23.39;CI95%[3.52-155.54]). The concordance between patients and physicians to assess their health status 12 months after their management at TBD-RC was almost perfect in the groups of those with confirmed and possible LB (κ = 0.99), and moderate in the group with other diagnoses (κ = 0.43). CONCLUSION Patients seemed to approve of this multidisciplinary care organization for suspected LB. It helped them to accept their final diagnoses and enabled a high level of satisfaction with the information given by the doctors, confirming the importance of shared medical decisions, which may help to reduce health misinformation. This type of structure may be useful for any disease with a complex and controversial diagnosis.
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Affiliation(s)
- Alice Raffetin
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France.
- EpiMAI Research Unity, Laboratory of Animal Health, Ecole Nationale Vétérinaire d'Alfort, Anses-National Veterinaty School of Alfort, Maison-Alfort, France.
- DYNAMIC Research Unity, UPEC-Anses, Créteil, France.
| | - Amal Chahour
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Julien Schemoul
- Department of Rheumatology, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Giulia Paoletti
- Department of Psychiatry, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Zhuoruo He
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
- Department of Public Health, University of Paris Saclay, Saclay, France
| | - Elisabeth Baux
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of the Eastern Region, Brabois Hospital, University Hospital of Nancy, Nancy, France
| | - Solène Patrat-Delon
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of the Western Region, University Hospital of Rennes, Rennes, France
| | - Steve Nguala
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Pauline Caraux-Paz
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Costanza Puppo
- Department of Psychology, Lumière University Lyon II, UMR 1296, Lyon, France
| | - Pauline Arias
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Yoann Madec
- Epidemiology of Emerging Diseases Unit, Institut Pasteur, University of Paris, Paris, France
| | - Sébastien Gallien
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center of Paris and the Northern Region, General Hospital of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
- DYNAMIC Research Unity, UPEC-Anses, Créteil, France
- Department of Infectious Diseases, UH Henri Mondor, Créteil, France
| | - Julie Rivière
- EpiMAI Research Unity, Laboratory of Animal Health, Ecole Nationale Vétérinaire d'Alfort, Anses-National Veterinaty School of Alfort, Maison-Alfort, France
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7
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Naudion P, Raffetin A, Zayet S, Klopfenstein T, Baux E, Martinot M, Piroth L, Caumes E, Chirouze C, Bouiller K. Positive intrathecal anti-Borrelia antibody synthesis: what are the implications for clinical practice? Clinical features and outcomes of 138 patients in a French multicenter cohort study. Eur J Clin Microbiol Infect Dis 2023; 42:441-452. [PMID: 36806057 DOI: 10.1007/s10096-023-04574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
We aimed to describe the clinical characteristics, management, and residual symptoms (RS) in patients with definite and possible Lyme neuroborreliosis (LNB). We conducted a retrospective French multicenter cohort study (2010-2020). Cases of LNB were defined as clinical manifestations attributed to LNB and a positive Borrelia-specific intrathecal antibody index (AI) ("possible" LNB) and with pleocytosis ("definite" LNB). Risk factors of RS were determined using a logistic regression model. We included 138 adult patients with a positive AI. Mean age was 59.5 years (± 14.7). The median duration of symptoms before diagnosis was 1.0 [0.5-4.0] months. The most frequent manifestation was radicular pain (n = 79, 57%). Complete cerebrospinal fluid (CSF) leukocyte analysis was available in 131 patients, of whom 72 (55%) had pleocytosis. Patients with definite LNB had a shorter duration of symptoms (median 1.0 [0.5-2.6] vs. 3.0 [0.6-7.0] months, p < 0.01) and more radicular pain (74% vs 44%, p < 0.01) than patients with possible LNB. At the last visit (median duration of follow-up: 70 [30-175] days), 74/124 patients (59.7%) reported RS, mostly radicular pain (n = 31, 25%). In multivariate analysis, definite LNB (OR = 0.21 [0.05-0.931], p = 0.039) and duration of symptoms less than 3 months (OR = 0.04 [0.01-0.37], p = 0.005) were protective factors against RS at last follow-up. Our study highlights the challenges of LNB management, especially for patients with a positive AI without pleocytosis, questioning whether LB is still ongoing or not. Early diagnosis and treatment are important to improve outcomes and to lower potential RS.
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Affiliation(s)
- Pauline Naudion
- Department of Infectious Diseases, CHU Besançon, 3 Bd Alexandre Fleming, 25030, Besançon, France
| | - Alice Raffetin
- Department of Infectious Diseases, Tick-Borne Diseases Reference Center, Paris and Northern Region, General Hospital of Villeneuve-Saint-Georges, 40 Allée de La Source, 94 190, Villeneuve-Saint-Georges, France. .,Research Unity of EpiMAI (USC Anses), Ecole Nationale Vétérinaire de Maisons-Alfort, Maisons-Alfort, France. .,European Study Group for Lyme Borreliosis (ESGBOR), Basel, Switzerland. .,EA 7380 Dynamyc, Université Paris-Est Créteil, Ecole Nationale Vétérinaire d'Alfort, USC Anses, Créteil, France.
| | - Souheil Zayet
- Department of Infectious Diseases, General Hospital of Nord Franche-Comté, Belfort, France
| | - Timothée Klopfenstein
- Department of Infectious Diseases, General Hospital of Nord Franche-Comté, Belfort, France
| | - Elisabeth Baux
- Department of Infectious Diseases, University Hospital of Nancy, Nancy, France
| | - Martin Martinot
- Department of Infectious Diseases, General Hospital of Colmar, Colmar, France
| | - Lionel Piroth
- Department of Infectious Diseases, University Hospital of Dijon, Dijon, France
| | - Eric Caumes
- Department of Infectious Diseases, University Hospital of Pitié-Salpétrière, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France.,Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie Et de Santé Publique, Paris, France
| | - Catherine Chirouze
- Department of Infectious Diseases, CHU Besançon, 3 Bd Alexandre Fleming, 25030, Besançon, France.,UMR-CNRS 6249 Chrono-Environnement, Université de Franche-Comté, 25000, Besançon, France
| | - Kevin Bouiller
- Department of Infectious Diseases, CHU Besançon, 3 Bd Alexandre Fleming, 25030, Besançon, France. .,European Study Group for Lyme Borreliosis (ESGBOR), Basel, Switzerland. .,UMR-CNRS 6249 Chrono-Environnement, Université de Franche-Comté, 25000, Besançon, France.
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8
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Ørbæk M, Gynthersen RMM, Mens H, Brandt C, Stenør C, Wiese L, Andersen ÅB, Møller HJ, Lebech AM. Cerebrospinal fluid levels of the macrophage-specific biomarker sCD163 are diagnostic for Lyme neuroborreliosis: an observational cohort study. Clin Chim Acta 2023; 543:117299. [PMID: 36931585 DOI: 10.1016/j.cca.2023.117299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES We aimed to investigate levels of the macrophage-specific marker, sCD163, in cerebrospinal fluid and plasma in patients with Lyme neuroborreliosis. We tested the diagnostic value of CSF-sCD163 and ReaScan-CXCL13 and analyzed if plasma-sCD163 could monitor treatment response. METHODS An observational cohort study: Cohort 1-Cerebrospinal fluid from adults with neuroborreliosis (n=42), bacterial meningitis (n=16), enteroviral meningitis (n=29), and controls (n=33); Cohort 2-Plasma from 23 adults with neuroborreliosis collected at diagnosis, three, and six months. sCD163 was determined using an in-house sandwich ELISA. ReaScan-CXCL13 measured semiquantitative concentrations of CXCL13, cut-off ≥250 pg/ml diagnosed neuroborreliosis. Receiver Operating Characteristics analyzed the diagnostic strength. A linear mixed model including follow-up as categorical fixed effect analyzed differences in plasma-sCD163. RESULTS CSF-sCD163 was higher in neuroborreliosis (643 µg/l) than in enteroviral meningitis (106 µg/l, p<0.0001) and controls (87 µg/l, p<0.0001), but not bacterial meningitis (669 µg/l, p=0.9). The optimal cut-off was 210 µg/l, area under the curve (AUC) 0.85. Combining ReaScan-CXCL13 with CSF-sCD163 increased AUC to 0.89. Plasma-sCD163 showed little variation and was not elevated during the 6 months of follow-up. Conclusion CSF-sCD163 is diagnostic for neuroborreliosis with an optimal cut-off of 210 µg/l. Combining ReaScan-CXCL13 with CSF-sCD163 increases AUC. Plasma-sCD163 cannot monitor treatment response.
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Affiliation(s)
- Mathilde Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Cluster for Molecular Imaging, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Helene Mens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands University Hospital, Hillerød, Denmark; Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark
| | - Christian Stenør
- Department of Neurology, Copenhagen University Hospital, Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark
| | - Åse Bengaard Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Holger J Møller
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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9
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Sigurdardottir AH, Knudtzen FC, Nymark A, Bang M. Fatigue and cognitive impairment in neuroborreliosis patients posttreatment-A neuropsychological retrospective cohort study. Brain Behav 2022; 12:e2719. [PMID: 36017773 PMCID: PMC9480899 DOI: 10.1002/brb3.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/21/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The aim of this study was to determine the prevalence of fatigue and cognitive impairment in patients with neuroborreliosis (NB) posttreatment and to determine whether delayed treatment initiation led to higher levels of fatigue and cognitive impairment. METHODS The study population consisted of 88 patients with NB included between October 10, 2014, and August 21, 2020, at the Clinical Center for Emerging and Vector-borne Infections at Odense University Hospital, Denmark. The Symbol Digit Modalities Test (SDMT) was used as a cognitive screening test, and the Modified Fatigue Impact Scale (MFIS) was used to assess the patients' level of fatigue over the course of a year. RESULTS Overall, 14.3% of patients had an SDMT score indicative of cognitive impairment, and 38.8% of patients reported experiencing fatigue 12 months posttreatment. We found no statistically significant differences in fatigue or cognitive impairment when comparing the patients who had a treatment delay of ≤14 days and those with a treatment delay of >14 days (p > .05) 12 months posttreatment. A random effects regression model showed a significant positive correlation between longer treatment delay and higher MFIS scores, indicating higher levels of fatigue. CONCLUSIONS The results of this study show that both the early and late treatment groups improved significantly over a 12-month period in terms of both cognitive symptoms and fatigue. However, it also showed that a substantial subgroup of patients with NB still suffer from fatigue and cognitive impairment 12 months posttreatment.
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Affiliation(s)
- Anna Helena Sigurdardottir
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Fredrikke Christie Knudtzen
- Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Anita Nymark
- Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Malcolm Bang
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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10
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Knudtzen FC, Jensen TG, Andersen NS, Johansen IS, Hovius JW, Skarphédinsson S. An intervention in general practice to improve the management of Lyme borreliosis in Denmark. Eur J Public Health 2022; 32:436-442. [PMID: 35323885 PMCID: PMC9159330 DOI: 10.1093/eurpub/ckac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Our objectives were to improve the following outcomes in patients with Lyme borreliosis (LB) through an educational intervention in general practice: (i) increase the number of hospital referrals on suspicion of LB, (ii) increase the number of cerebrospinal fluid (CSF) tests examined for Borrelia burgdorferi antibody index, (iii) decrease the number of serum-B. burgdorferi antibody tests ordered, (iv) shorten delay from symptom onset to hospital in Lyme neuroborreliosis (LNB) patients, (v) increase LB knowledge among general practitioners. Methods A prospective non-blinded non-randomized intervention trial on the island of Funen, Denmark. The intervention included oral and written education about LB and was carried out in areas with an LNB incidence ≥4.7/100.000 between 22 January 2019 and 7 May 2019. Results were compared between the intervention group (49 general practices) and the remaining general practices in Funen (71 practices) 2 years before and after the intervention. Results In the study period, 196 patients were referred on suspicion of LB, a 28.9% increase in the intervention group post-intervention, 59.5% increase in the control group (P = 0.47). The number of CSF-Borrelia-antibody index tests increased 20.8% in the intervention group, 18.0% in the control group (P = 0.68), while ordered serum-B. burgdorferi antibody tests declined 43.1% in the intervention group, 34.5% in the control group (P = 0.30). 25.1% had the presence of serum-B. burgdorferi antibodies. We found no difference in LNB pre-hospital delay before and after intervention or between groups (P = 0.21). The intervention group performed significantly better on a follow-up questionnaire (P = 0.02). Conclusion We found an overall improvement in LB awareness and referrals among general practitioners but could not show any effect of the intervention on clinical outcomes of LNB.
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Affiliation(s)
- Fredrikke Christie Knudtzen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Thøger Gorm Jensen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Clinical Microbiology, Odense University Hospital and Research Unit for Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Nanna Skaarup Andersen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Clinical Microbiology, Lillebaelt Hospital, Vejle, Denmark
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Joppe W Hovius
- Amsterdam UMC, Location AMC, Center for Experimental and Molecular Medicine, Amsterdam Multidisciplinary Lyme Borreliosis Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sigurdur Skarphédinsson
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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11
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Knudtzen FC, Eikeland R, Bremell D, Quist-Paulsen E, Johansen IS, Solheim AM, Skarphédinsson S. Lyme neuroborreliosis with encephalitis; a systematic literature review and a Scandinavian cohort study. Clin Microbiol Infect 2021; 28:649-656. [PMID: 34768019 DOI: 10.1016/j.cmi.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) presenting with encephalitis is rare and scarcely described. OBJECTIVES To describe the available literature on LNB encephalitis, and to characterize this patient-group through a Scandinavian retrospective cohort study. DATA-SOURCES Medline, Embase, Scopus, Cochrane library. STUDY ELIGIBILITY CRITERIA No discrimination on study-type, time of publication or language. PARTICIPANTS Review: all articles with definite LNB and confirmed/possible encephalitis. Cohort: LNB cohorts from Denmark, Sweden and Norway 1990-2019 screened for patients with encephalitis. METHODS Review: adhering to PRISMA guidelines, two authors extracted and assessed quality of studies. Cohort: data registered on demography, symptoms, CSF-findings, differentialdiagnostic examinations, treatment, residual symptoms, one-year mortality. RESULTS Review: 2330 articles screened on title/abstract, 281 full-texts, yielding 42 articles (case reports/series or cohort studies) including 45 patients from 18 countries spanning 35 years. Altered mental status ranged from personality changes and confusion to unconsciousness. Common focal symptoms were hemiparesis, ataxia and dysarthria, seven patients had seizures. Median time from symptom onset to hospital was 2 weeks (IQR 2-90 days). Of 38 patients with available follow-up after median 12 months (IQR 5-13), 32 had fully or partially recovered, 2 had died. Cohort: 35 patients (median age 67 years,IQR 48-76) were included. The encephalitis prevalence was 3.3%(95%CI 2.2-4.4%) among 1019 screened LNB-patients. Frequent encephalitis symptoms were confusion, personality-changes, aphasia, ataxia. EEGs and neuroimaging showed encephalitis in 93.8% and 20.6%, respectively. Median delay from symptom onset to hospital was 14 days(IQR 7-34), with further 7 days(IQR 3-34) delay until targeted therapy. At follow-up (median 298 days post-treatment(IQR 113-389)), 65.6% had residual symptoms. None had died. CONCLUSIONS This study shows that encephalitis is an uncommon, but likely overlooked clinical manifestation of LNB. As the high frequency of residual symptoms may be related to prolonged treatment delay, prompt LNB testing of patients with encephalitis in B.burgdorferi-endemic areas should be considered.
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Affiliation(s)
- Fredrikke Christie Knudtzen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark; Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - Randi Eikeland
- The Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Hospital, Arendal, Norway; Faculty of Health & Sport Sciences, University of Agder, Norway
| | - Daniel Bremell
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Else Quist-Paulsen
- Department of Microbiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Anne-Marit Solheim
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Sigurdur Skarphédinsson
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark; Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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12
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The Usefulness of Two CXCL13 Assays on Cerebrospinal Fluid for the Diagnosis of Lyme Neuroborreliosis: a Retrospective Study in a Routine Clinical Setting. J Clin Microbiol 2021; 59:e0025521. [PMID: 34132584 PMCID: PMC8373006 DOI: 10.1128/jcm.00255-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recent studies have shown elevated levels of the B-cell chemokine (C-X-C motif) ligand 13 (CXCL13) in the cerebrospinal fluid (CSF) of patients with early Lyme neuroborreliosis (LNB). In this retrospective study, we evaluated the diagnostic performance of the Quantikine CXCL13 enzyme-linked immunosorbent assay (ELISA) (R&D Systems, Inc., MN, USA) and the recomBead CXCL13 assay (Mikrogen, Neuried, Germany) for the detection of CXCL13 in CSF. All consecutive patients from whom a CSF and a serum sample had been collected between August 2013 and June 2016 were eligible for inclusion. Patients suspected of LNB were classified as definite, possible, or non-LNB according to the guidelines of the European Federation of Neurological Societies (EFNS). Due to the limited number of LNB patients in the predefined study period, additional LNB patients were included from outside this period. In total, 156 patients (150 consecutive patients and 6 additional LNB patients) were included. Seven (4.5%) were classified as definite, eight (5.1%) as possible, and 141 (90.4%) as non-LNB patients. Receiver operating characteristic (ROC) curve analysis comparing definite-LNB patients with non-LNB patients showed a cutoff value of 85.9 pg/ml for the Quantikine CXCL13 ELISA and 252.2 pg/ml for the recomBead CXCL13 assay. The corresponding sensitivity was 100% (95% confidence interval [CI], 100% to 100%) for both, and the corresponding specificities were 98.6% (95% CI, 96.5% to 100%) for the CXCL13 ELISA and 97.2% (95% CI, 93.6% to 100%) for the recomBead CXCL13 assay. This study showed that CXCL13 in CSF can be of additional value for the diagnosis of LNB.
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13
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Hirsch AG, Poulsen MN, Nordberg C, Moon KA, Rebman AW, Aucott JN, Heaney CD, Schwartz BS. Risk Factors and Outcomes of Treatment Delays in Lyme Disease: A Population-Based Retrospective Cohort Study. Front Med (Lausanne) 2020; 7:560018. [PMID: 33324657 PMCID: PMC7726265 DOI: 10.3389/fmed.2020.560018] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/19/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Longer time between symptom onset and treatment of Lyme disease has been associated with poor outcomes. Reducing time-to-treatment requires knowledge of risks for treatment delays. We conducted a population-based study to evaluate factors associated with delayed treatment of Lyme disease and the relation between delayed treatment and post-treatment Lyme disease syndrome (PTLDS). Methods: We mailed questionnaires to 5,314 individuals with a Lyme disease diagnosis or blood test followed by an antibiotic order in the medical record of a Pennsylvania health system from 2015 to 2017. Analyses were confined to 778 respondents who reported that they were treated for Lyme disease within the past 5 years and reported a rash and/or a positive blood test for Lyme disease. Time-to-treatment was calculated as the sum of two windows before and after seeking care for Lyme disease symptoms: time to first medical contact and time under care. We used logistic regression to evaluate factors associated with delayed time-to-treatment in each time window (>14 days vs. ≤14 days) and the association between total time-to-treatment (>30 days vs. ≤30 days) and PTLDS. We used inverse probability weighting to calculate estimates for the study's source population (5,314 individuals sent questionnaires). Results: In the source population, 25% had time to first contact >14 days, 21% had time under care >14 days, and 31% had a total time-to-treatment >30 days. Being uninsured and attributing initial symptoms to something other than Lyme disease were positively associated with delayed time to first medical contact, while seeking care at an urgent care or emergency setting (vs. primary care) was negatively associated. Diagnoses between November and April, and the absence of rash were positively associated with delays. Individuals whose treatment was delayed, defined as time-to treatment >30 days had 2.26 (95% confidence interval: 1.25, 4.05) times the odds of PTLDS as those who were treated within 30 days of symptom onset. Conclusions: In a population-based study in Pennsylvania, one-third of Lyme disease patients reported delayed treatment, which was associated with PTLDS. To improve Lyme disease outcomes, prevention efforts should aim to reduce the time before and after seeking care.
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Affiliation(s)
- Annemarie G Hirsch
- Department of Population Health Sciences, Geisinger, Danville, PA, United States
| | - Melissa N Poulsen
- Department of Population Health Sciences, Geisinger, Danville, PA, United States
| | - Cara Nordberg
- Department of Population Health Sciences, Geisinger, Danville, PA, United States
| | - Katherine A Moon
- Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Alison W Rebman
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - John N Aucott
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christopher D Heaney
- Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States.,Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Brian S Schwartz
- Department of Population Health Sciences, Geisinger, Danville, PA, United States.,Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
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14
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Zubcevik N, Mao C, Wang QM, Bose EL, Octavien RN, Crandell D, Wood LJ. Symptom Clusters and Functional Impairment in Individuals Treated for Lyme Borreliosis. Front Med (Lausanne) 2020; 7:464. [PMID: 32974369 PMCID: PMC7472530 DOI: 10.3389/fmed.2020.00464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/13/2020] [Indexed: 11/17/2022] Open
Abstract
Context: Persistent fatigue, pain, and neurocognitive impairment are common in individuals following treatment for Lyme borreliosis (LB). Poor sleep, depression, visual disturbance, and sensory neuropathies have also been reported. The cause of these symptoms is unclear, and widely accepted effective treatment strategies are lacking. Objectives: To identify symptom clusters in people with persistent symptoms previously treated for LB and to examine the relationship between symptom severity and perceived disability. Methods: This was a retrospective chart review of individuals with a history of treatment of LB referred to The Dean Center for Tick-Borne Illness at Spaulding Rehabilitation Hospital between 2015 and 2018 (n = 270) because of persistent symptoms. Symptoms and functional impairment were collected using the General Symptom Questionnaire-30 (GSQ-30), and the Sheehan Disability Scale. Clinical tests were conducted to evaluate for tick-borne co-infections and to rule out medical disorders that could mimic LB symptomatology. Exploratory factor analysis was performed to identify symptom clusters. Results: Five symptom clusters were identified. Each cluster was assigned a name to reflect the possible underlying etiology and was based on the majority of the symptoms in the cluster: the neuropathy symptom cluster, sleep-fatigue symptom cluster, migraine symptom cluster, cognitive symptom cluster, and mood symptom cluster. Symptom severity for each symptom cluster was positively associated with global functional impairment (p < 0.001). Conclusion: Identifying the interrelationship between symptoms in post-treatment LB in a cluster can aid in the identification of the etiological basis of these symptoms and could lead to more effective symptom management strategies. Key Message: This article describes symptom clusters in individuals with a history of Lyme borreliosis. Five clusters were identified: sleep-fatigue, neuropathy, migraine-like, cognition, and mood clusters. Identifying the interrelationship between symptoms in each of the identified clusters could aid in more effective symptom management through identifying triggering symptoms or an underlying etiology.
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Affiliation(s)
- Nevena Zubcevik
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Invisible International, Cambridge, MA, United States
| | - Charlotte Mao
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Massachusetts General Hospital, Department of Pediatric Infectious Diseases, Boston, MA, United States
| | - Qing Mei Wang
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Stroke Biological Recovery Laboratory, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Eliezer L Bose
- Stroke Biological Recovery Laboratory, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Rose Nadlyne Octavien
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - David Crandell
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Lisa J Wood
- Massachusetts General Hospital, Institute for Health Professions, School of Nursing, Charlestown, MA, United States.,William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, United States
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15
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Masouris I, Klein M, Ködel U. The potential for CXCL13 in CSF as a differential diagnostic tool in central nervous system infection. Expert Rev Anti Infect Ther 2020; 18:875-885. [PMID: 32479125 DOI: 10.1080/14787210.2020.1770596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Central nervous system (CNS) infections can be life-threatening and are often associated with disabling sequelae. One important factor in most CNS infections is a timely pathogen-specific treatment. The diagnostic methods available, however, do not always reach a satisfying sensitivity and specificity. In these cases, there is need for additional diagnostic biomarkers. Chemokines represent potential candidates as biomarkers, since they are an important pillar of the host immune response. The aim of this review is to discuss the diagnostic potential of cerebrospinal fluid (CSF) CXCL13 in patients with CNS infections. Areas covered: Data were obtained from a literature search in PubMed up to October 2019. This review focusses on articles on the potential of CXCL13 as a diagnostic tool. The majority of identified studies aimed to characterize its role in two diseases, namely Lyme neuroborreliosis and neurosyphilis. Expert opinion: CSF CXCL13 has a significant potential as a diagnostic and monitoring add-on marker in Lyme neuroborreliosis. Differences in study design, control groups and clinical parameters between studies, however, affect sensitivity, specificity and cutoff values, underlining the need of further studies to address these issues and pave the way for a generalized clinical practice.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, University Hospital, Ludwig Maximilian University , Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, Ludwig Maximilian University , Munich, Germany
| | - Uwe Ködel
- Department of Neurology, University Hospital, Ludwig Maximilian University , Munich, Germany
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16
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Abstract
Lyme borreliosis is the most common vectorborne disease in the northern hemisphere. It usually begins with erythema migrans; early disseminated infection particularly causes multiple erythema migrans or neurologic disease, and late manifestations predominantly include arthritis in North America, and acrodermatitis chronica atrophicans (ACA) in Europe. Diagnosis of Lyme borreliosis is based on characteristic clinical signs and symptoms, complemented by serological confirmation of infection once an antibody response has been mounted. Manifestations usually respond to appropriate antibiotic regimens, but the disease can be followed by sequelae, such as immune arthritis or residual damage to affected tissues. A subset of individuals reports persistent symptoms, including fatigue, pain, arthralgia, and neurocognitive symptoms, which in some people are severe enough to fulfil the criteria for post-treatment Lyme disease syndrome. The reported prevalence of such persistent symptoms following antimicrobial treatment varies considerably, and its pathophysiology is unclear. Persistent active infection in humans has not been identified as a cause of this syndrome, and randomized treatment trials have invariably failed to show any benefit of prolonged antibiotic treatment. For prevention of Lyme borreliosis, post-exposure prophylaxis may be indicated in specific cases, and novel vaccine strategies are under development.
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Affiliation(s)
- Bart Jan Kullberg
- Department of Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hedwig D Vrijmoeth
- Department of Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Freek van de Schoor
- Department of Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joppe W Hovius
- Amsterdam University Medical Centers, location AMC, Department of Medicine, Division of Infectious Diseases, and Amsterdam Multidisciplinary Lyme borreliosis Center, Amsterdam, Netherlands
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17
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Andreasen AM, Dehlendorff PB, Knudtzen FC, Bødker R, Kjær LJ, Skarphedinsson S. Spatial and temporal patterns of Lyme Neuroborreliosis on Funen, Denmark from 1995-2014. Sci Rep 2020; 10:7796. [PMID: 32385297 PMCID: PMC7210281 DOI: 10.1038/s41598-020-64638-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/08/2020] [Indexed: 11/18/2022] Open
Abstract
In Europe, Lyme neuroborreliosis (LNB) is the most severe manifestation of Lyme borreliosis and has recently been added to the communicable disease surveillance list for EU/EEA by the European Commission. In Northern Europe, LNB is primarily caused by the spirochete Borrelia garinii and transmitted by the tick Ixodes ricinus. This Danish observational epidemiologic case-control study includes every identified LNB patient (n = 401) on Funen, Denmark, from 1995-2014. We display spatial and temporal LNB incidence variation, seasonal distribution of cases and local spatial case clustering. Seasonal patterns show LNB symptom-onset peaking in July and a significant seasonal difference in number of cases (p < 0.01). We found no significant change in seasonality patterns over time when dividing the study period into 5-year intervals. We identified a significant local geographical hot-spot of cases with a relative risk of 2.44 (p = 0.013). Analysis revealed a significantly shorter distance to nearest forest for cases compared with controls (p < 0.001). We present a novel map of the focal geographical distribution of LNB cases in a high endemic borreliosis area. Continued studies of case clustering in the epidemiology of LNB are of key importance in guiding intervention strategies.
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Affiliation(s)
- Amalie Muus Andreasen
- Clinical Institute, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
| | | | - Fredrikke Christie Knudtzen
- Clinical Institute, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
- Department of Infectious Diseases, CCEVI, Clinical Centre of Emerging and Vector-borne Infections, Odense University Hospital, Winsloews vej 4, 5000, Odense C, Denmark
| | - Rene Bødker
- Department of Veterinary and Animals Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Lene Jung Kjær
- Department of Veterinary and Animals Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Sigurdur Skarphedinsson
- Clinical Institute, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
- Department of Infectious Diseases, CCEVI, Clinical Centre of Emerging and Vector-borne Infections, Odense University Hospital, Winsloews vej 4, 5000, Odense C, Denmark.
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18
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Eikeland R, Ljøstad U, Helgeland G, Sand G, Flemmen HØ, Bø MH, Nordaa L, Owe JF, Mygland Å, Lorentzen ÅR. Patient-reported outcome after treatment for definite Lyme neuroborreliosis. Brain Behav 2020; 10:e01595. [PMID: 32153118 PMCID: PMC7177557 DOI: 10.1002/brb3.1595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/05/2020] [Accepted: 02/13/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To chart patient-reported outcome measures (PROMs) in Norwegian patients treated for definite neuroborreliosis (NB). MATERIAL AND METHODS Adult patients treated for definite NB 1-10 years earlier supplied demographics, symptoms and treatment during NB, and answered validated questionnaires; Fatigue Severity Scale (FSS), Hospital Anxiety and Depression Scale (HADS), health-related quality of life questionnaire (RAND-36), and Patient Health Questionnaire (PHQ-15). RESULTS A higher proportion of NB-treated persons reported severe fatigue, defined as FSS score ≥ 5, than in Norwegian normative data, but when removing persons with confounding fatigue associated comorbidities (n = 69) from the analyses, there was no difference between groups. Physical health-related quality of life (RAND-36 PCS), mean FSS score, proportions of persons reporting moderate or severe somatic symptom burden (PHQ-15 score ≥ 10), anxiety (HADS-A ≥ 8), or depression (HADS-D ≥ 8) did not differ between NB-treated persons and reference scores. Mental health-related quality of life (RAND-36 MCS) was poorer than in normative data (47.1 vs. 53.3), but associated with anxiety, depression and current moderate or severe somatic symptom burden, and not with NB characteristics. CONCLUSIONS Results on validated PROM questionnaires measuring fatigue, anxiety, depression, self-reported somatic symptom burden, and physical health-related quality did not differ between persons treated for definite NB 1-10 years earlier and reference scores. NB-treated persons tended to report a slightly poorer mental health-related quality of life than found in normative data, but when adjusting for confounders the causative connection is questionable. Overall, the long-term prognosis of definite NB seems to be good.
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Affiliation(s)
- Randi Eikeland
- Department of Pediatrics, Sørlandet Hospital Trust, Arendal, Norway.,The Norwegian National Advisory Unit on Tick-borne Diseases, Arendal, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Helgeland
- Department of Neurology, Møre and Romsdal Hospital Trust, Molde, Norway
| | - Geir Sand
- Department of Infectious Diseases, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Ludmila Nordaa
- Department of Neurology, Helse Fonna Trust, Haugesund, Norway
| | - Jone Furulund Owe
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Rehabilitation, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Åslaug Rudjord Lorentzen
- The Norwegian National Advisory Unit on Tick-borne Diseases, Arendal, Norway.,Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
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19
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Rauer S, Kastenbauer S, Hofmann H, Fingerle V, Huppertz HI, Hunfeld KP, Krause A, Ruf B, Dersch R. Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc03. [PMID: 32341686 PMCID: PMC7174852 DOI: 10.3205/000279] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Volker Fingerle
- German Society for Hygiene and Microbiology (DGHM), Münster, Germany
| | - Hans-Iko Huppertz
- German Society of Paediatrics and Adolescent Medicine (DGKJ), Berlin, Germany.,German Society of Paediatric Infectology (DGPI), Berlin, Germany
| | - Klaus-Peter Hunfeld
- The German United Society of Clinical Chemistry and Laboratory Medicine (DGKL), Bonn, Germany.,INSTAND e.V., Düsseldorf, Germany
| | | | - Bernhard Ruf
- German Society of Infectious Diseases (DGI), Berlin, Germany
| | - Rick Dersch
- German Society of Neurology (DGN), Berlin, Germany.,Cochrane Germany, Faculty of Medicine, University of Freiburg, Germany
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20
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Nordberg CL, Bodilsen J, Knudtzen FC, Storgaard M, Brandt C, Wiese L, Hansen BR, Andersen ÅB, Nielsen H, Lebech AM. Lyme neuroborreliosis in adults: A nationwide prospective cohort study. Ticks Tick Borne Dis 2020; 11:101411. [PMID: 32178995 DOI: 10.1016/j.ttbdis.2020.101411] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/23/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
Abstract
The goal of this paper is to characterize the clinical presentation, serological results, current antibiotic treatment practice, including compliance with current European guidelines, and outcome in adults with Lyme neuroborreliosis (LNB) diagnosed at departments of infectious diseases in Denmark. Using a nationwide prospective cohort of patients with central nervous system infections, we identified all adults (≥ 18 years of age) treated for LNB at departments of infectious diseases in Denmark from 2015 through 2017. The database contains information on baseline demographics, history of tick bite, erythema migrans, clinical presentation, laboratory results of blood samples, and cerebrospinal (CSF) biochemistry (e.g. specific Borrelia burgdorferi sensu lato (s.l.) antibodies in serum, B. burgdorferi s.l. intrathecal antibody index) as well as antibiotic therapy. Outcome was assessed by the Glasgow Outcome Scale (GOS) and the presence of residual symptoms at follow-up one month after discharge. We included 194 LNB patients with a median age of 59 years (range 18-85 years, interquartile range [IQR] 47-69 years). The female-to-male ratio was 0.8. A total of 177 of 191 (93 %) of patients had early (second stage) LNB. A history of tick bite or erythema migrans was registered in 75 (39 %) and 49 (25 %) patients, respectively. The median duration of neurological symptoms before first hospital contact was 21 days (range 0-600 days, IQR 10-42 days). Predominant symptoms consisted of radicular pain in 135 of 194 (70 %), cranial nerve paresis in 88 of 194 (45 %), headache in 71 of 185 (38 %), and extremity paresis in 33 of 194 (17 %) patients. Serum-B. burgdorferi s.l. IgM and/or IgG antibodies were detectable in 166 of 181 (92 %) patients at the time of first CSF investigation. Median duration of antibiotic treatment was 14 days (range 10-35 days, IQR 14-21 days) and 59 (39 %) of the patients received intravenous ceftriaxone and/or benzylpenicillin G throughout treatment. At the 1-month follow-up, GOS was unfavorable (< 5) in 54 of 193 (28 %) patients. An unfavorable GOS score was more often registered in patients with ≥ 45 days of symptom duration (20 of 45 (44 %) vs. 34 of 145 (23 %); P = 0.006). In conclusion, a European cohort of adult patients with LNB diagnosed between 2015-2017 presented with classic symptoms and CSF findings. However, a substantial diagnostic delay was still observed. In disagreement with current guidelines, a substantial part of LNB patients were treated with antibiotics longer than 14 days and/or intravenously as route of administration.
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Affiliation(s)
- Cecilie Lerche Nordberg
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Fredrikke Christie Knudtzen
- Clinical Centre for Emerging and Vector-borne Infections, Department of Infectious Diseases, Odense University Hospital, Denmark.
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands University Hospital, Hillerød, Denmark.
| | - Lothar Wiese
- Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark.
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark.
| | - Åse Bengård Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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21
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Garcia-Monco JC, Benach JL. Lyme Neuroborreliosis: Clinical Outcomes, Controversy, Pathogenesis, and Polymicrobial Infections. Ann Neurol 2019; 85:21-31. [PMID: 30536421 DOI: 10.1002/ana.25389] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 12/16/2022]
Abstract
Lyme borreliosis is the object of numerous misconceptions. In this review, we revisit the fundamental manifestations of neuroborreliosis (meningitis, cranial neuritis, and radiculoneuritis), as these have withstood the test of time. We also discuss other manifestations that are less frequent. Stroke, as a manifestation of Lyme neuroborreliosis, is considered in the context of other infections. The summary of the literature regarding clinical outcomes of neuroborreliosis leads to its controversies. We also include new information on pathogenesis and on the polymicrobial nature of tick-borne diseases. In this way, we update the review that we wrote in this journal in 1995. ANN NEUROL 2019;85:21-31.
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Affiliation(s)
- Juan Carlos Garcia-Monco
- Department of Neurology, University Hospital of Basurto, Bilbao, Vizcaya, Spain.,Departments of Molecular Genetics and Microbiology, Stony Brook University School of Medicine, Stony Brook, NY
| | - Jorge L Benach
- Departments of Molecular Genetics and Microbiology, Stony Brook University School of Medicine, Stony Brook, NY.,Pathology, Stony Brook University School of Medicine, Stony Brook, NY
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22
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Turk SP, Lumbard K, Liepshutz K, Williams C, Hu L, Dardick K, Wormser GP, Norville J, Scavarda C, McKenna D, Follmann D, Marques A. Post-treatment Lyme disease symptoms score: Developing a new tool for research. PLoS One 2019; 14:e0225012. [PMID: 31710647 PMCID: PMC6844481 DOI: 10.1371/journal.pone.0225012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022] Open
Abstract
Some patients have residual non-specific symptoms after therapy for Lyme disease, referred to as post-treatment Lyme disease symptoms or syndrome, depending on whether there is functional impairment. A standardized test battery was used to characterize a diverse group of Lyme disease patients with and without residual symptoms. There was a strong correlation between sleep disturbance and certain other symptoms such as fatigue, pain, anxiety, and cognitive complaints. Results were subjected to a Logistic Regression model using the Neuro-QoL Fatigue t-score together with Short Form-36 Physical Functioning scale and Mental Health component scores; and to a Decision Tree model using only the QoL Fatigue t-score. The Logistic Regression model had an accuracy of 97% and Decision Tree model had an accuracy of 93%, when compared with clinical categorization. The Logistic Regression and Decision Tree models were then applied to a separate cohort. Both models performed with high sensitivity (90%), but moderate specificity (62%). The overall accuracy was 74%. Agreement between 2 time points, separated by a mean of 4 months, was 89% using the Decision Tree model and 87% with the Logistic Regression model. These models are simple and can help to quantitate the level of symptom severity in post-treatment Lyme disease symptoms. More research is needed to increase the specificity of the models, exploring additional approaches that could potentially strengthen an operational definition for post-treatment Lyme disease symptoms. Evaluation of how sleep disturbance, fatigue, pain and cognitive complains interrelate can potentially lead to new interventions that will improve the overall health of these patients.
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Affiliation(s)
- Siu P. Turk
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Keith Lumbard
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Kelly Liepshutz
- Leidos Biomedical Research, Inc., Clinical Services Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Carla Williams
- Leidos Biomedical Research, Inc., Clinical Services Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Linden Hu
- Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Kenneth Dardick
- Mansfield Family Practice, Storrs, Connecticut, United States of America
| | - Gary P. Wormser
- Infectious Diseases, New York Medical College, Valhalla, New York, United States of America
| | - Joshua Norville
- Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Carol Scavarda
- Infectious Diseases, New York Medical College, Valhalla, New York, United States of America
| | - Donna McKenna
- Infectious Diseases, New York Medical College, Valhalla, New York, United States of America
| | - Dean Follmann
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Adriana Marques
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
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23
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Keilp JG, Corbera K, Gorlyn M, Oquendo MA, Mann JJ, Fallon BA. Neurocognition in Post-Treatment Lyme Disease and Major Depressive Disorder. Arch Clin Neuropsychol 2019; 34:466-480. [PMID: 30418507 DOI: 10.1093/arclin/acy083] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/10/2018] [Accepted: 10/26/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Neurocognitive dysfunction in patients with residual or emergent symptoms after treatment for Lyme Disease is often attributed to comorbid depression. In this study, patients with Post-Treatment Lyme Disease Syndrome (PTLDS) were compared to patients with Major Depressive Disorder (MDD), as well as healthy comparison subjects (HC), on neurocognitive measures administered through the same laboratory, to determine if patterns of performance were similar. METHODS Two analyses were conducted. First, performance on the Wechsler Adult Intelligence Scale (WAIS-III) and on subtests from the Wechsler Memory Scale (WMS-III) was compared among the groups. Second, comparable subgroups of PTLDS and MDD patients with at least one low WMS-III score were compared on an additional set of measures assessing motor function, psychomotor performance, attention, memory, working memory, and language fluency, to determine if the overall profile of performance was similar in the two subgroups. RESULTS In the first analysis, PTLDS patients performed more poorly than both MDD and HC on tasks assessing verbal abilities, working memory, and paragraph learning. Processing speed in the two patient groups, however, was equally reduced. In the second analysis, MDD patients with low WMS-III exhibited concomitantly greater difficulties in psychomotor speed and attention, while low-WMS-III PTLDS patients exhibited greater difficulties in language fluency. CONCLUSIONS MDD and PTLDS can be confused neuropsychologically because both exhibit similar levels of psychomotor slowing. However, problems on memory-related tasks, though mild, are more pronounced in PTLDS. PTLDS patients with poorer memory also exhibit poorer language fluency, and less deficit in processing speed and attention compared to MDD.
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Affiliation(s)
- John G Keilp
- Lyme Disease Research Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
| | - Kathy Corbera
- Lyme Disease Research Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Marianne Gorlyn
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Maria A Oquendo
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J John Mann
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
| | - Brian A Fallon
- Lyme Disease Research Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
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24
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Solheim AM, Ljøstad U, Mygland Å. Six versus two weeks treatment with doxycycline in Lyme neuroborreliosis: the protocol of a multicentre, non-inferiority, double-blinded and randomised controlled trial. BMJ Open 2019; 9:e027083. [PMID: 31201188 PMCID: PMC6576128 DOI: 10.1136/bmjopen-2018-027083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Current treatment guidelines for European Lyme neuroborreliosis (LNB) recommend cephalosporins, penicillin or doxycycline for 14-28 days but evidence for optimal treatment length is poor. Treatment lengths in clinical practice tend to exceed the recommendations. Most patients experience a rapid improvement of symptoms and neurological findings within days of treatment, but some report long-term complaints. The underlying mechanisms of remaining complaints are debated, and theories as ongoing chronic infection with Borrelia burgdorferi, dysregulated immune responses, genetic predisposition, coinfection with multiple tick-borne pathogens, structural changes in CNS and personal traits have been suggested. The main purpose of our trial is to address the hypothesis of improved outcome after long-term antibiotic treatment of LNB, by comparing efficacy of treatment with 2 and 6 weeks courses of doxycycline. METHODS AND ANALYSIS The trial has a multicentre, non-inferiority, double-blinded design. One hundred and twenty patients diagnosed with LNB according to European Federation of Neurological Societies (EFNS)guidelines will be randomised to 6 or 2 weeks treatment with oral doxycycline. The patients will be followed for 12 months. The primary endpoint is improvement on a composite clinical score (CCS) from baseline to 6 months after inclusion. Secondary endpoints are improvements in the CCS 12 months after inclusion, fatigue scored on Fatigue Severity Scale, subjective symptoms on the Patient Health Questionnaire-15 scale, health-related quality of life scored on RAND 36-item short form health survey and safety as measured by side effects of the two treatment arms. Blood and cerebrospinal fluid (CSF) are collected from inclusion and throughout the follow-up and a biobank will be established. The study started including patients in November 2015 and will continue throughout December 2019. ETHICS AND DISSEMINATION The study is approved by the Norwegian regional committees for medical and health research ethics and the Norwegian Medicines Agency. Data from the study will be published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER 2015-001481-25.
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Affiliation(s)
- Anne Marit Solheim
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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25
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Jaulhac B, Saunier A, Caumes E, Bouiller K, Gehanno JF, Rabaud C, Perrot S, Eldin C, de Broucker T, Roblot F, Toubiana J, Sellal F, Vuillemet F, Sordet C, Fantin B, Lina G, Sobas C, Gocko X, Figoni J, Chirouze C, Hansmann Y, Hentgen V, Cathebras P, Dieudonné M, Picone O, Bodaghi B, Gangneux JP, Degeilh B, Partouche H, Lenormand C, Sotto A, Raffetin A, Monsuez JJ, Michel C, Boulanger N, Lemogne C, Tattevin P. Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies (II). Biological diagnosis, treatment, persistent symptoms after documented or suspected Lyme borreliosis. Med Mal Infect 2019; 49:335-346. [PMID: 31155367 DOI: 10.1016/j.medmal.2019.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/07/2019] [Indexed: 11/18/2022]
Abstract
The serodiagnosis of Lyme borreliosis is based on a two-tier strategy: a screening test using an immunoenzymatic technique (ELISA), followed if positive by a confirmatory test with a western blot technique for its better specificity. Lyme serology has poor sensitivity (30-40%) for erythema migrans and should not be performed. The seroconversion occurs after approximately 6 weeks, with IgG detection (sensitivity and specificity both>90%). Serological follow-up is not recommended as therapeutic success is defined by clinical criteria only. For neuroborreliosis, it is recommended to simultaneously perform ELISA tests in samples of blood and cerebrospinal fluid to test for intrathecal synthesis of Lyme antibodies. Given the continuum between early localized and disseminated borreliosis, and the efficacy of doxycycline for the treatment of neuroborreliosis, doxycycline is preferred as the first-line regimen of erythema migrans (duration, 14 days; alternative: amoxicillin) and neuroborreliosis (duration, 14 days if early, 21 days if late; alternative: ceftriaxone). Treatment of articular manifestations of Lyme borreliosis is based on doxycycline, ceftriaxone, or amoxicillin for 28 days. Patients with persistent symptoms after appropriate treatment of Lyme borreliosis should not be prescribed repeated or prolonged antibacterial treatment. Some patients present with persistent and pleomorphic symptoms after documented or suspected Lyme borreliosis. Another condition is eventually diagnosed in 80% of them.
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Affiliation(s)
- B Jaulhac
- Laboratoire de bactériologie et cnr des Borrelia, faculté de médecine et centre hospitalo-universitaire, 67000 Strasbourg, France
| | - A Saunier
- Médecine interne et maladies infectieuses, centre hospitalier, 24750 Périgueux, France
| | - E Caumes
- Maladies infectieuses et tropicales, hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - K Bouiller
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, UMR CNRS 6249 Université Bourgogne Franche Comté, 25000 Besançon, France
| | - J F Gehanno
- Médecine du travail, centre hospitalo-universitaire, 76000 Rouen, France
| | - C Rabaud
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 54100 Nancy, France
| | - S Perrot
- Centre d'étude et de traitement de la douleur, hôpital Cochin, 75014 Paris, France
| | - C Eldin
- Maladies infectieuses et tropicales, ihu méditerranée infection, centre hospitalo-universitaire Timone, 13000 Marseille, France
| | - T de Broucker
- Neurologie, hôpital Delafontaine, 92300 Saint-Denis, France
| | - F Roblot
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, inserm U1070, 86000 Poitiers, France
| | - J Toubiana
- Service de pédiatrie générale et maladies infectieuses, hôpital Necker-Enfants Malades, AP-HP, 75014 Paris, France
| | - F Sellal
- Département de neurologie, hôpitaux civil, 68000 Colmar, France
| | - F Vuillemet
- Département de neurologie, hôpitaux civil, 68000 Colmar, France
| | - C Sordet
- Rhumatologie, centre hospitalo-universitaire, 67000 Strasbourg, France
| | - B Fantin
- Médecine interne, hôpital Beaujon, université Paris Diderot, Inserm UMR 1137 IAME, 92110 Clichy, France
| | - G Lina
- Microbiologie, centre hospitalo-universitaire, 69000 Lyon, France
| | - C Sobas
- Microbiologie, centre hospitalo-universitaire, 69000 Lyon, France
| | - X Gocko
- Département de médecine générale, faculté de médecine, 42000 Saint-Etienne, France
| | - J Figoni
- Maladies Infectieuses et tropicales, hôpital Avicenne, 93022 Bobigny, France; Santé publique France, 94410 St Maurice, France
| | - C Chirouze
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, UMR CNRS 6249 Université Bourgogne Franche Comté, 25000 Besançon, France
| | - Y Hansmann
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 67000 Strasbourg, France
| | - V Hentgen
- Pédiatrie, centre hospitalier, 78000 Versailles, France
| | - P Cathebras
- Médecine interne, hôpital Nord, centre hospitalo-universitaire, 42000 Saint-Etienne, France
| | - M Dieudonné
- Centre Max Weber, CNRS, Université Lyon 2, 69000 Lyon, France
| | - O Picone
- Maternité Louis Mourier, 92700 Colombes, France
| | - B Bodaghi
- Ophtalmologie, hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - J P Gangneux
- Laboratoire de parasitologie-Mycologie, UMR_S 1085 Irset université Rennes1-Inserm-EHESP, centre hospitalo-universitaire, 35000 Rennes, France
| | - B Degeilh
- Laboratoire de parasitologie-Mycologie, UMR_S 1085 Irset université Rennes1-Inserm-EHESP, centre hospitalo-universitaire, 35000 Rennes, France
| | - H Partouche
- Cabinet de médecine générale, Saint-Ouen, département de médecine Générale, faculté de médecine. université Paris Descartes, 93400 Paris, France
| | - C Lenormand
- Dermatologie, hôpitaux universitaires de Strasbourg et faculté de médecine, université de Strasbourg, 67000 Strasbourg, France
| | - A Sotto
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 30000 Nîmes, France
| | - A Raffetin
- Maladies infectieuses et tropicales, centre hospitalier intercommunal, 94190 Villeneuve-St-Georges, France
| | - J J Monsuez
- Cardiologie, hôpital René Muret, 93270 Sevran, France
| | - C Michel
- Médecine générale, 67000 Strasbourg, France
| | - N Boulanger
- Médecine interne, hôpital Beaujon, université Paris Diderot, Inserm UMR 1137 IAME, 92110 Clichy, France
| | - C Lemogne
- Psychiatrie, hôpital européen Georges-Pompidou, AP-HP.5, Inserm U1266; Université Paris Descartes, 75015 Paris, France
| | - P Tattevin
- Maladies infectieuses et réanimation médicale, hôpital Pontchaillou, centre hospitalo-universitaire, 35033 Rennes, France.
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Vrijmoeth HD, Ursinus J, Harms MG, Zomer TP, Gauw SA, Tulen AD, Kremer K, Sprong H, Knoop H, Vermeeren YM, van Kooten B, Joosten LAB, Kullberg BJ, Hovius JWR, van den Wijngaard CC. Prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis: study protocol for an observational, prospective cohort study (LymeProspect). BMC Infect Dis 2019; 19:324. [PMID: 30987580 PMCID: PMC6466793 DOI: 10.1186/s12879-019-3949-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/03/2019] [Indexed: 01/23/2023] Open
Abstract
Background After antibiotic treatment of Lyme borreliosis, a subset of patients report persistent symptoms, also referred to as post-treatment Lyme disease syndrome. The reported prevalence of persistent symptoms varies considerably, and its pathophysiology is under debate. The LymeProspect study has been designed to investigate the prevalence, severity, and a wide range of hypotheses on the etiology of persistent symptoms among patients treated for Lyme borreliosis in the Netherlands. Methods LymeProspect is a prospective, observational cohort study among adults with proven or probable Lyme borreliosis, either erythema migrans or disseminated manifestations, included at the start of antibiotic treatment. During one year of follow-up, participants are subjected to questionnaires every three months and blood is collected repeatedly during the first three months. The primary outcome is the prevalence of persistent symptoms after treatment, assessed by questionnaires online focusing on fatigue (CIS, subscale fatigue severity), pain (SF-36, subscale pain) and neurocognitive dysfunction (CFQ). Potential microbiological, immunological, genetic, epidemiological and cognitive-behavioral determinants for persistent symptoms are secondary outcome measures. Control cohorts include patients with long-lasting symptoms and unconfirmed Lyme disease, population controls, and subjects having reported a tick bite not followed by Lyme borreliosis. Discussion This article describes the background and design of the LymeProspect study protocol. This study is characterized by a prospective, explorative and multifaceted design. The results of this study will provide insights into the prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis, and may provide a rationale for preventive and treatment recommendations. Trial registration NTR4998 (Netherlands Trial Register). Date of registration: 13 February 2015. Electronic supplementary material The online version of this article (10.1186/s12879-019-3949-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hedwig D Vrijmoeth
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Jeanine Ursinus
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands. .,National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands.
| | - Margriet G Harms
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Tizza P Zomer
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300, DS, Apeldoorn, the Netherlands
| | - Stefanie A Gauw
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - Anna D Tulen
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Kristin Kremer
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Hein Sprong
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - Yolande M Vermeeren
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300, DS, Apeldoorn, the Netherlands
| | - Barend van Kooten
- Lyme Center Apeldoorn, Gelre Hospital, P.O. Box 9014, 7300, DS, Apeldoorn, the Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Bart-Jan Kullberg
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Joppe W R Hovius
- Department of Internal Medicine, Division of Infectious Diseases & Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, P.O. Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - Cees C van den Wijngaard
- National Institute for Public Health and Environment (RIVM), Center for Infectious Disease Control, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands
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Knudtzen FC, Andersen NS, Jensen TG, Skarphédinsson S. Characteristics and Clinical Outcome of Lyme Neuroborreliosis in a High Endemic Area, 1995-2014: A Retrospective Cohort Study in Denmark. Clin Infect Dis 2018; 65:1489-1495. [PMID: 29048514 DOI: 10.1093/cid/cix568] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/26/2017] [Indexed: 11/12/2022] Open
Abstract
Background Despite a well-described symptomatology, treatment delay and sequelae are common in patients with Lyme neuroborreliosis (LNB). The aim of this study was to contribute to the knowledge about the symptomatology and epidemiology of LNB. Methods We conducted a retrospective study of all LNB cases verified by a positive Borrelia intrathecal antibody index test performed at the Department of Microbiology, Odense University Hospital, Denmark, from 1995 through 2014. Results The study included 431 patients; 126 were children. The mean incidence was 4.7 per 100 000 inhabitants per year. The median delay from neurological symptom debut to first hospital contact was 20 days and significantly longer for patients with symptom debut in the winter/early spring. The most common clinical symptoms were painful radiculitis (65.9%), cranial nerve palsy (43.4%), and headache (28.3%). A total of 30.6% were seen in >1 hospital department, and 85.6% were admitted during their course of treatment. Serum Borrelia immunoglobulin M and immunoglobulin G at the time of positive Borrelia intrathecal antibody index test were negative in 67 patients (15.5%). We found a median treatment delay of 24 days, with no improvement in our 20-year study period. Residual symptoms following treatment were found in 28.1% of patients, and risk of residual symptoms was significantly associated with delay from symptom debut to initiation of treatment. Conclusions The association between treatment delay and residual symptoms and the lack of improvement in treatment delay during the study period highlight the need for standardized diagnostic routines and a better follow-up for LNB patients. Our findings disprove that all patients with LNB develop positive serum Borrelia antibodies within 6 weeks after infection.
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Affiliation(s)
- Fredrikke Christie Knudtzen
- Department of Infectious Diseases, Clinical Center of Emerging and Vectorborne Infections (CCEVI), Odense University Hospital
| | | | - Thøger Gorm Jensen
- Department of Clinical Microbiology, CCEVI, Odense University Hospital, Denmark
| | - Sigurdur Skarphédinsson
- Department of Infectious Diseases, Clinical Center of Emerging and Vectorborne Infections (CCEVI), Odense University Hospital
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Cerebrospinal Fluid B-lymphocyte Chemoattractant CXCL13 in the Diagnosis of Acute Lyme Neuroborreliosis in Children. Pediatr Infect Dis J 2017; 36:e286-e292. [PMID: 28661964 DOI: 10.1097/inf.0000000000001669] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current markers of Lyme neuroborreliosis (LNB) in children have insufficient sensitivity in the early stage of disease. The B-lymphocyte chemoattractant CXCL13 in the cerebrospinal fluid (CSF) may be useful in diagnosing LNB, but its specificity has not been evaluated in studies including children with clinically relevant differential diagnoses. The aim of this study was to elucidate the diagnostic value of CSF CXCL13 in children with symptoms suggestive of LNB. METHODS Children with symptoms suggestive of LNB were included prospectively into predefined groups with a high or low likelihood of LNB based on CSF pleocytosis and the detection of Borrelia antibodies or other causative agents. CSF CXCL13 levels were compared between the groups, and receiver-operating characteristic analyses were performed to indicate optimal cutoff levels to discriminate LNB from non-LNB conditions. RESULTS Two hundred and ten children were included. Children with confirmed LNB (n=59) and probable LNB (n=18) had higher CSF CXCL13 levels than children with possible LNB (n=7), possible peripheral LNB (n=7), non-Lyme aseptic meningitis (n=12), non-meningitis (n=91) and negative controls (n=16). Using 18 pg/mL as a cutoff level, both the sensitivity and specificity of CSF CXCL13 for LNB (confirmed and probable) were 97%. Comparing only children with LNB and non-Lyme aseptic meningitis, the sensitivity and specificity with the same cutoff level were 97% and 83%, respectively. CONCLUSION CSF CXCL13 is a sensitive marker of LNB in children. The specificity to discriminate LNB from non-Lyme aseptic meningitis may be more moderate, suggesting that CSF CXCL13 should be used together with other variables in diagnosing LNB in children.
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Geebelen L, Lernout T, Kabamba-Mukadi B, Saegeman V, Sprong H, Van Gucht S, Beutels P, Speybroeck N, Tersago K. The HUMTICK study: protocol for a prospective cohort study on post-treatment Lyme disease syndrome and the disease and cost burden of Lyme borreliosis in Belgium. ACTA ACUST UNITED AC 2017; 75:42. [PMID: 28794875 PMCID: PMC5545865 DOI: 10.1186/s13690-017-0202-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 06/05/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND In Belgium, different routine surveillance systems are in place to follow-up Lyme borreliosis trends. However, accurate data on the disease and monetary burden for the different clinical manifestations are lacking. Despite recommended antibiotic treatment, a proportion of Lyme patients report persisting aspecific symptoms for six months or more (e.g. fatigue, widespread musculoskeletal pain, cognitive difficulties), a syndrome now named "post-treatment Lyme disease syndrome" (PTLDS). Controversy exists on the cause, incidence and severity of PTLDS. This study aims to estimate the incidence of PTLDS in patients with Lyme borreliosis and to quantify the disease burden and economic costs associated with the different clinical manifestations of Lyme borreliosis in Belgium. METHODS The project is a prospective cohort study in which about 600 patients with an erythema migrans and 100 patients with disseminated Lyme borreliosis will be followed up. Questionnaires, including the SF-36 vitality and pain subscale, the Cognitive Failure Questionnaire and the EQ-5D-5L, will be used to collect information on acute and persisting symptoms and the impact on quality of life. Symptom frequency and severity will be compared with self-reported pre-Lyme health status, a control group and existing Belgian population norms. Additionally, information on the associated costs and possible risk factors for the development of PTLDS will be collected. DISCUSSION A study of the health burden will allow evaluation of the relative importance of Lyme borreliosis in Belgium and information on the economic cost will help to formulate cost-effective measures. There are only few prospective studies conducted estimating the incidence of PTLDS and even though discussion exists about the prevalence of subjective symptoms in the general population, a control group of non-Lyme borreliosis participants has often not been included.
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Affiliation(s)
- Laurence Geebelen
- Epidemiology of Infectious Diseases, Scientific Institute of Public Health (WIV-ISP), Rue Juliette Wytsmanstraat 14, 1050 Brussels, Belgium
| | - Tinne Lernout
- Epidemiology of Infectious Diseases, Scientific Institute of Public Health (WIV-ISP), Rue Juliette Wytsmanstraat 14, 1050 Brussels, Belgium
| | - Benoît Kabamba-Mukadi
- Laboratory of Medical Microbiology, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Veroniek Saegeman
- Department of Microbiology, University Hospitals Leuven, Leuven, Belgium
| | - Hein Sprong
- Laboratory for Zoonoses and Environmental Microbiology, National Institute for Public Health and Environment (RIVM), Bilthoven, The Netherlands
| | - Steven Van Gucht
- Viral Diseases, Scientific Institute of Public Health (WIV-ISP), Brussels, Belgium
| | - Philippe Beutels
- Centre for Health Economics Research & Modelling Infectious Diseases (CHERMID), Vaccine & Infectious Disease Institute, Faculty of Medicine & Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Katrien Tersago
- Epidemiology of Infectious Diseases, Scientific Institute of Public Health (WIV-ISP), Rue Juliette Wytsmanstraat 14, 1050 Brussels, Belgium
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Abstract
Lyme borreliosis is a tick-borne disease that predominantly occurs in temperate regions of the northern hemisphere and is primarily caused by the bacterium Borrelia burgdorferi in North America and Borrelia afzelii or Borrelia garinii in Europe and Asia. Infection usually begins with an expanding skin lesion, known as erythema migrans (referred to as stage 1), which, if untreated, can be followed by early disseminated infection, particularly neurological abnormalities (stage 2), and by late infection, especially arthritis in North America or acrodermatitis chronica atrophicans in Europe (stage 3). However, the disease can present with any of these manifestations. During infection, the bacteria migrate through the host tissues, adhere to certain cells and can evade immune clearance. Yet, these organisms are eventually killed by both innate and adaptive immune responses and most inflammatory manifestations of the infection resolve. Except for patients with erythema migrans, Lyme borreliosis is diagnosed based on a characteristic clinical constellation of signs and symptoms with serological confirmation of infection. All manifestations of the infection can usually be treated with appropriate antibiotic regimens, but the disease can be followed by post-infectious sequelae in some patients. Prevention of Lyme borreliosis primarily involves the avoidance of tick bites by personal protective measures.
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Affiliation(s)
- Allen C Steere
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Franc Strle
- Department of Infectious Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gary P Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla, New York, USA
| | - Linden T Hu
- Department of Molecular Biology and Microbiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joppe W R Hovius
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Xin Li
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paul S Mead
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
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Abstract
Appropriate, critical application of evidence-based diagnostic criteria enables both a clear definition of what constitutes neuroborreliosis-nervous system infection with Borrelia burgdorferi sensu stricto in the US, B garinii and less commonly B. afzelii and other species in Europe-and recognition that this disorder is quite similar in Europe and the US. Most commonly evidenced by lymphocytic meningitis and/or multifocal inflammation of the peripheral (common; cranial neuropathy, radiculopathy, mononeuropathy multiplex) or central (rare) nervous system, it is readily diagnosed and highly antibiotic responsive. Encephalopathy-altered cognition or memory-can occur as part of the systemic infection and inflammatory state, but is not evidence of neuroborreliosis. Post treatment Lyme disease syndrome-persistent neurobehavioral symptoms 6 months or more after usually curative antibiotic treatment-if real and not simply an example of anchoring bias-is unrelated to neuroborreliosis. The pathophysiology of neuroborreliosis remains unclear, but appears to involve both a requirement for viable micro-organisms and significant immune amplification.
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Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, Summit, NJ, USA. .,Neurology and Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, USA.
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Halperin JJ. Editorial Commentary: Neuroborreliosis: What Is It, What Isn't It? Clin Infect Dis 2016; 63:354-5. [PMID: 27161776 DOI: 10.1093/cid/ciw303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, Summit, New Jersey
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Wills AB, Spaulding AB, Adjemian J, Prevots DR, Turk SP, Williams C, Marques A. Long-term Follow-up of Patients With Lyme Disease: Longitudinal Analysis of Clinical and Quality-of-life Measures. Clin Infect Dis 2016; 62:1546-1551. [PMID: 27025825 PMCID: PMC4885655 DOI: 10.1093/cid/ciw189] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/19/2016] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Aprielle B Wills
- Epidemiology Unit
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | - Alicen B Spaulding
- Epidemiology Unit
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | - Jennifer Adjemian
- Epidemiology Unit
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
- US Public Health Service, Commissioned Corps, Rockville
| | - D Rebecca Prevots
- Epidemiology Unit
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | - Siu-Ping Turk
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | - Carla Williams
- Clinical Monitoring Research Program, Leidos Biomedical Research Inc., National Cancer Institute, Frederick, Maryland
| | - Adriana Marques
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
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Ogrinc K, Lusa L, Lotrič-Furlan S, Bogovič P, Stupica D, Cerar T, Ružić-Sabljić E, Strle F. Course and Outcome of Early European Lyme Neuroborreliosis (Bannwarth Syndrome): Clinical and Laboratory Findings. Clin Infect Dis 2016; 63:346-53. [PMID: 27161773 DOI: 10.1093/cid/ciw299] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 04/06/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Information on the course and outcome of early European Lyme neuroborreliosis is limited. METHODS The study comprised 77 patients (38 males, 39 females; median age, 58 years) diagnosed with painful meningoradiculitis (Bannwarth syndrome) who were followed up for 1 year at a single center. RESULTS Duration of neurological symptoms before diagnosis was 30 (interquartile range, 14-50) days. The most frequent symptoms/signs were radicular pain (100%), sleep disturbances (75.3%), erythema migrans (59.7%), headache (46.8%), fatigue (44.2%), malaise (39%), paresthesias (32.5%), peripheral facial palsy (PFP) (36.4%), meningeal signs (19.5%), and pareses (7.8%). Cerebrospinal fluid (CSF) analysis revealed lymphocytic/monocytic pleocytosis, elevated protein concentration, and intrathecal synthesis of borrelial immunoglobulin M and immunoglobulin G antibody in 100%, 81.1%, 63%, and 88.7% of patients, respectively. Borreliae (predominantly Borrelia garinii) were isolated from CSF, skin, and blood in 15.6%, 40.6%, and 2.7% of patients, respectively. The outcome after 14-day treatment with ceftriaxone was favorable in 87.8% of patients. Control CSF examination at 3 months showed decreased leukocyte counts in all patients; however, 23.3% still had pleocytosis (>10 × 10(6) cells/L). A model based on pretreatment data and the findings at the end of 14-day antibiotic treatment accurately predicted which patients would have an unfavorable outcome 6 or 12 months after treatment. CONCLUSIONS Our patients had fewer pretreatment neurological complications (PFP, pareses) than reported for Bannwarth syndrome decades ago, probably as the result of earlier recognition and prompt antibiotic treatment. Unfavorable outcome was rare and was predicted by the continued presence of symptoms 14 days after commencement of treatment.
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Affiliation(s)
- Katarina Ogrinc
- Department of Infectious Diseases, University Medical Center Ljubljana
| | - Lara Lusa
- Institute for Biostatistics and Medical Informatics
| | | | - Petra Bogovič
- Department of Infectious Diseases, University Medical Center Ljubljana
| | - Daša Stupica
- Department of Infectious Diseases, University Medical Center Ljubljana
| | - Tjaša Cerar
- Institute for Microbiology and Immunology, Medical Faculty, University of Ljubljana, Slovenia
| | - Eva Ružić-Sabljić
- Institute for Microbiology and Immunology, Medical Faculty, University of Ljubljana, Slovenia
| | - Franc Strle
- Department of Infectious Diseases, University Medical Center Ljubljana
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Prevalence and spectrum of residual symptoms in Lyme neuroborreliosis after pharmacological treatment: a systematic review. J Neurol 2015; 263:17-24. [DOI: 10.1007/s00415-015-7923-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 10/23/2022]
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Abstract
Lyme disease, caused by the Borrelia burgdorferi bacterium, is the most common vector-borne disease in the northern hemisphere. The clinical presentation varies with disease stage, and neurological manifestations (often referred to as Lyme neuroborreliosis) are reported in up to 12% of patients with Lyme disease. Most aspects of the epidemiology, clinical manifestation and treatment of Lyme neuroborreliosis are well known and accepted; only the management of so-called chronic Lyme disease is surrounded by considerable controversy. This term is used for disparate patient groups, including those who have untreated late-stage infection (for example, late neuroborreliosis), those with subjective symptoms that persist after treatment (termed 'post-treatment Lyme disease syndrome' [PTLDS]), and those with unexplained subjective complaints that may or may not be accompanied by positive test results for B. burgdorferi infection in serum (here called 'chronic Lyme disease'). The incidence of PTLDS is still a matter of debate, and its pathogenesis is unclear, but there is evidence that these patients do not have ongoing B. burgdorferi infection and, thus, do not benefit from additional antibiotic therapy. Chronic Lyme disease lacks an accepted clinical definition, and most patients who receive this diagnosis have other illnesses. Thus, a careful diagnostic work-up is needed to ensure proper treatment.
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Affiliation(s)
- Uwe Koedel
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
| | - Volker Fingerle
- Bavarian Health and Food Safety Authority &German National Reference Centre for Borrelia, Veterinärstrasse 2, 85764 Oberschleissheim, Germany
| | - Hans-Walter Pfister
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
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Morris G, Berk M, Walder K, Maes M. The Putative Role of Viruses, Bacteria, and Chronic Fungal Biotoxin Exposure in the Genesis of Intractable Fatigue Accompanied by Cognitive and Physical Disability. Mol Neurobiol 2015; 53:2550-71. [PMID: 26081141 DOI: 10.1007/s12035-015-9262-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/28/2015] [Indexed: 01/08/2023]
Abstract
Patients who present with severe intractable apparently idiopathic fatigue accompanied by profound physical and or cognitive disability present a significant therapeutic challenge. The effect of psychological counseling is limited, with significant but very slight improvements in psychometric measures of fatigue and disability but no improvement on scientific measures of physical impairment compared to controls. Similarly, exercise regimes either produce significant, but practically unimportant, benefit or provoke symptom exacerbation. Many such patients are afforded the exclusionary, non-specific diagnosis of chronic fatigue syndrome if rudimentary testing fails to discover the cause of their symptoms. More sophisticated investigations often reveal the presence of a range of pathogens capable of establishing life-long infections with sophisticated immune evasion strategies, including Parvoviruses, HHV6, variants of Epstein-Barr, Cytomegalovirus, Mycoplasma, and Borrelia burgdorferi. Other patients have a history of chronic fungal or other biotoxin exposure. Herein, we explain the epigenetic factors that may render such individuals susceptible to the chronic pathology induced by such agents, how such agents induce pathology, and, indeed, how such pathology can persist and even amplify even when infections have cleared or when biotoxin exposure has ceased. The presence of active, reactivated, or even latent Herpes virus could be a potential source of intractable fatigue accompanied by profound physical and or cognitive disability in some patients, and the same may be true of persistent Parvovirus B12 and mycoplasma infection. A history of chronic mold exposure is a feasible explanation for such symptoms, as is the presence of B. burgdorferi. The complex tropism, life cycles, genetic variability, and low titer of many of these pathogens makes their detection in blood a challenge. Examination of lymphoid tissue or CSF in such circumstances may be warranted.
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Affiliation(s)
- Gerwyn Morris
- Tir Na Nog, Bryn Road seaside 87, Llanelli, SA15 2LW, Wales, UK
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, Department of Psychiatry and The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - Ken Walder
- Centre for Molecular and Medical Research, School of Medicine, Deakin University, Geelong, Australia
| | - Michael Maes
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia. .,Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Diplégie faciale révélatrice d’une maladie de Lyme. Rev Med Interne 2015; 36:352-5. [DOI: 10.1016/j.revmed.2014.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/09/2014] [Accepted: 05/07/2014] [Indexed: 11/18/2022]
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Lyme disease: A rigorous review of diagnostic criteria and treatment. J Autoimmun 2015; 57:82-115. [DOI: 10.1016/j.jaut.2014.09.004] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 01/07/2023]
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Abstract
Lyme disease, a multisystem spirochetal infection, continues to be the subject of considerable debate, but not controversy. Recent years have seen improvements in diagnostic tools, better understanding of pathophysiology, and increasing evidence of efficacy of standard treatment regimens. Nervous system involvement is particularly confusing to patients and many physicians. A rational approach based on objective findings can clarify the cause and dictate the best treatment of patients' difficulties. Diagnosis for all but the earliest cases rests on the combination of likely contact with infected Ixodes ticks and laboratory confirmation of exposure to the causative organism, Borrelia burgdorferi (two-tier serology, combining ELISA with a confirmatory Western blot). Treatment is generally with oral antimicrobials such as doxycycline. Parenteral regimens are usually necessary only for the most severe cases.
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Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center & Atlantic Neurosciences Institute, Icahn School of Medicine at Mount Sinai, 99 Beauvoir Avenue, Summit, NJ, 07902, USA,
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Chandra AM, Keilp JG, Fallon BA. Correlates of perceived health-related quality of life in post-treatment Lyme encephalopathy. PSYCHOSOMATICS 2013; 54:552-9. [PMID: 23845316 DOI: 10.1016/j.psym.2013.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/21/2013] [Accepted: 04/22/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Marked functional impairment has been reported by patients with post-treatment Lyme disease syndrome (PTLDS). OBJECTIVE We sought to identify the clinical features that contribute most strongly to the impaired health status associated with PTLDS. METHODS Enrolled patients had a well-documented history of Lyme disease, prior treatment with at least 3 weeks with intravenous ceftriaxone, a positive IgG Western blot, and objective problems with memory. An index score to capture aggregate cognitive functioning, Short-Form 36 physical and mental component summary scores, and scores on other clinical and demographic measures were examined. Multiple linear regressions were performed to determine significant predictors of perceptions of impaired life functioning as delineated by the Short-Form 36. RESULTS Fatigue was the most important contributor to perceived impairments in overall physical functioning, and fatigue and depression significantly predicted perceived impairments in overall mental functioning. CONCLUSIONS Because fatigue and depression contribute prominently to reports of impaired physical functioning and mental functioning among patients with PTLDS, clinicians should assess patients for these symptoms and consider targeting these symptoms in the selection of treatment interventions. Future controlled studies should examine the effectiveness of such agents for patients with PTLDS.
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Veauthier C. Younger age, female sex, and high number of awakenings and arousals predict fatigue in patients with sleep disorders: a retrospective polysomnographic observational study. Neuropsychiatr Dis Treat 2013; 9:1483-94. [PMID: 24109185 PMCID: PMC3792952 DOI: 10.2147/ndt.s50763] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The Fatigue Severity Scale (FSS) is widely used to assess fatigue, not only in the context of multiple sclerosis-related fatigue, but also in many other medical conditions. Some polysomnographic studies have shown high FSS values in sleep-disordered patients without multiple sclerosis. The Modified Fatigue Impact Scale (MFIS) has increasingly been used in order to assess fatigue, but polysomnographic data investigating sleep-disordered patients are thus far unavailable. Moreover, the pathophysiological link between sleep architecture and fatigue measured with the MFIS and the FSS has not been previously investigated. METHODS This was a retrospective observational study (n = 410) with subgroups classified according to sleep diagnosis. The statistical analysis included nonparametric correlation between questionnaire results and polysomnographic data, age and sex, and univariate and multiple logistic regression. RESULTS The multiple logistic regression showed a significant relationship between FSS/MFIS values and younger age and female sex. Moreover, there was a significant relationship between FSS values and number of arousals and between MFIS values and number of awakenings. CONCLUSION Younger age, female sex, and high number of awakenings and arousals are predictive of fatigue in sleep-disordered patients. Further investigations are needed to find the pathophysiological explanation for these relationships.
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Affiliation(s)
- Christian Veauthier
- Department of Neurology, Hanse-Klinikum, Stralsund, Germany ; Department of Neurology, Centre Hospitalier de Belfort-Montbéliard (CHBM), Montbéliard, France
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