1
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Lorentzen ÅR, Berg KK, Ljøstad U. Rituximab leading to an atypical presentation of neuroborreliosis and false negative serology. Pract Neurol 2024; 24:215-218. [PMID: 38135497 DOI: 10.1136/pn-2023-003976] [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] [Accepted: 11/02/2023] [Indexed: 12/24/2023]
Abstract
Two patients, recently treated with the B-cell-depleting monoclonal antibody, rituximab, had 2-3 months of progressive systemic symptoms; comprehensive investigations did not clarify the diagnosis. Transient radicular pain at disease onset had suggested neuroborreliosis, but seronegativity and an atypical clinical course made this unlikely. However, PCR identified Borrelia burgdorferi DNA in cerebrospinal fluid, establishing the diagnosis of neuroborreliosis. Both the clinical picture and the laboratory findings can be atypical in people with neuroborreliosis who have recently been treated with rituximab. In B-cell depleted patients living in endemic areas, one should suspect neuroborreliosis even when the typical symptoms are drowned out by more atypical symptoms; PCR should be used as a diagnostic supplement when the serological response is uncertain or absent.
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Affiliation(s)
- Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway
- Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Sykehus HF, Kristiansand, Norway
| | | | - Unn Ljøstad
- Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
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2
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Abstract
Acute myelopathies are spinal cord disorders characterized by a rapidly progressive course reaching nadir within hours to a few weeks that may result in severe disability. The multitude of underlying etiologies, complexities in confirming the diagnosis, and often unforgiving nature of spinal cord damage have always represented a challenge. Moreover, certain slowly progressive myelopathies may present acutely or show abrupt worsening in specific settings and thus further complicate the diagnostic workup. Awareness of the clinical and magnetic resonance imaging characteristics of different myelopathies and the specific settings where they occur is fundamental for a correct diagnosis. Neuroimaging helps distinguish compressive etiologies that may require urgent surgery from intrinsic etiologies that generally require medical treatment. Differentiation between various myelopathies is essential to establish timely and appropriate treatment and avoid harm from unnecessary procedures. This article reviews the contemporary spectrum of acute myelopathy etiologies and provides guidance for diagnosis and management.
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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3
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Abstract
Lyme borreliosis is caused by a growing list of related, yet distinct, spirochetes with complex biology and sophisticated immune evasion mechanisms. It may result in a range of clinical manifestations involving different organ systems, and can lead to persistent sequelae in a subset of cases. The pathogenesis of Lyme borreliosis is incompletely understood, and laboratory diagnosis, the focus of this review, requires considerable understanding to interpret the results correctly. Direct detection of the infectious agent is usually not possible or practical, necessitating a continued reliance on serologic testing. Still, some important advances have been made in the area of diagnostics, and there are many promising ideas for future assay development. This review summarizes the state of the art in laboratory diagnostics for Lyme borreliosis, provides guidance in test selection and interpretation, and highlights future directions.
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Quarsten H, Salte T, Lorentzen ÅR, Hansen IJW, Hamre R, Forselv KJN, Øines Ø, Wennerås C, Noraas S. Tick-Borne Pathogens Detected in the Blood of Immunosuppressed Norwegian Patients Living in a Tick-Endemic Area. Clin Infect Dis 2020; 73:e2364-e2371. [PMID: 32662513 DOI: 10.1093/cid/ciaa971] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/08/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The knowledge regarding the occurrence and the clinical implications of tick-borne infections in immunosuppressed patients living in tick-endemic areas is limited. METHODS Adult patients with autoimmune conditions requiring immunosuppressive treatment such as infliximab and rituximab, were invited to participate in the study when they attended the hospital for treatment and/or control of the disease. Whole blood samples were analysed by real-time PCR for Borrelia burgdorferi s.l., Borrelia miyamotoi, Anaplasma phagocytophilum, Rickettsia spp., Candidatus Neoehrlichia mikurensis and Babesia spp. RESULTS The occurrence of tick-borne pathogens in the blood of patients (n=163) with autoimmune conditions requiring immunosuppressive treatment were evaluated. Pathogen DNA was detected in 8.6% (14/163) of the patients. The predominant pathogen was Candidatus Neoehrlichia mikurensis (12/14), which was carried in the blood of infected patients for 10-59 days until treatment with doxycycline. Borrelia burgdorferi sensu lato and Rickettsia spp. were detected in one patient each. The B. burgdorferi-infected patient presented with fever, whereas the remaining patients were judged to have subclinical infections. Borrelia miyamotoi, Anaplasma phagocytophilum, and Babesia spp. were not detected in any patient. CONCLUSIONS Patients treated with biologicals and living in a tick-endemic area seem to have a high risk of contracting Ca. Neoehrlichia mikurensis infection which if left untreated could result in thromboembolic complications.
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Affiliation(s)
- Hanne Quarsten
- Department of Medical Microbiology, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
| | - Tore Salte
- Department of Clinical Medicine, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
| | - Åslaug R Lorentzen
- Department of Neurology, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
- The Norwegian National Advisory Unit on Tick-Borne Diseases, Arendal, Norway
| | - Inger J W Hansen
- Department of Clinical Medicine, Section of Rheumatology, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
| | - Runar Hamre
- Department of Clinical Medicine, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
| | - Kristine J N Forselv
- Department of Neurology, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
| | - Øivind Øines
- Department of Food Safety, Animal Welfare, and Animal Health, Oslo Norwegian Veterinary Institute, Oslo, Norway
| | - Christine Wennerås
- Department of Infectious Diseases, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Sølvi Noraas
- Department of Medical Microbiology, Sørlandet Hospital Health Enterprise, Kristiansand, Norway
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Khan S, Bhattal GK, Shah NH, Lascano J, Karki A. Neuroborreliosis with Unusual Presentation: A Case Report. Cureus 2019; 11:e5758. [PMID: 31723517 PMCID: PMC6825459 DOI: 10.7759/cureus.5758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Lyme disease is the most common vector-borne disease in the northern hemisphere. Neurological complications usually manifest in patients who do not receive treatment for Lyme disease. Neurological involvement may be early or late, depending on the duration of the symptoms. Early neuroborreliosis presents with symptoms such as headache and meningism; late neuroborreliosis can present with signs and symptoms of encephalopathy and stroke-like symptoms. The diagnosis is based on clinical manifestations and lumbar puncture finding. Treatment consists of intravenous antibiotics for a period of three to four weeks. Patients who receive early treatment usually have an excellent prognosis, with very few patients developing post-treatment Lyme disease syndrome. Here, we report an unusual case of Lyme disease with extremely high cerebrospinal fluid protein level and devastating neurological sequelae. The diagnosis of neuroborreliosis is based on neurological symptoms and lumbar puncture findings.
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Affiliation(s)
- Salman Khan
- Internal Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, USA
| | | | | | - Jorge Lascano
- Internal Medicine, University of Florida, Gainesville, USA
| | - Apurwa Karki
- Internal Medicine - Critical Care, Guthrie Clinic/Robert Packer Hospital, Sayre, USA
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Maraspin V, Bogovič P, Rojko T, Ružić-Sabljić E, Strle F. Erythema Migrans: Course and Outcome in Patients Treated With Rituximab. Open Forum Infect Dis 2019; 6:ofz292. [PMID: 31334301 PMCID: PMC6634433 DOI: 10.1093/ofid/ofz292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/18/2019] [Indexed: 01/22/2023] Open
Abstract
Background Information on Lyme borreliosis (LB) in patients treated with rituximab is limited to individual case reports. Methods We reviewed data on adult patients diagnosed with typical erythema migrans (EM) at the LB outpatient clinic of the University Medical Center Ljubljana, Slovenia, in the 10-year period 2008–2017. For all patients, clinical and laboratory information was acquired prospectively using a standardized questionnaire. Results Among 4230 adult patients with a diagnosis of EM, 7 patients (0.17%), 5 women and 2 men with a median age of 65 years (range, 55–66 years), were receiving rituximab for an underlying medical condition. In these 7 patients, signs of disseminated LB (43%) and the isolation rates of borreliae from blood before antibiotic treatment (40%) were unusually high compared with corresponding findings in immunocompetent patients who had EM diagnosed at the same institution (8% vs <2%, respectively). The rates of LB-associated constitutional symptoms and borrelial antibodies in serum were lower than expected (14% and 29%, respectively, in patients receiving rituximab vs 25% and 65% in immunocompetent patients). One of the 7 patients (14%) experienced treatment failure; nevertheless, the outcome of early LB 1 year after antibiotic treatment, as used for immunocompetent patients with EM, was excellent in all 7 patients. Conclusions Findings in 7 patients with EM who were receiving rituximab for underlying disease suggest that although early LB in these patients is more often disseminated than in immunocompetent patients, the outcome 1 year after antibiotic treatment, as used for immunocompetent patients, is excellent.
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Affiliation(s)
- Vera Maraspin
- Department of Infectious Diseases, University Medical Center Ljubljana, Slovenia
| | - Petra Bogovič
- Department of Infectious Diseases, University Medical Center Ljubljana, Slovenia
| | - Tereza Rojko
- Department of Infectious Diseases, University Medical Center 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, Slovenia
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Wagemakers A, Visser MC, de Wever B, Hovius JW, van de Donk NWCJ, Hendriks EJ, Peferoen L, Muller FF, Ang CW. Case report: persistently seronegative neuroborreliosis in an immunocompromised patient. BMC Infect Dis 2018; 18:362. [PMID: 30071836 PMCID: PMC6090844 DOI: 10.1186/s12879-018-3273-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/25/2018] [Indexed: 12/01/2022] Open
Abstract
Background Infection with Borrelia burgdorferi sensu lato complex (B. b. sl) spirochetes can cause Lyme borreliosis, manifesting as localized infection (e.g. erythema migrans) or disseminated disease (e.g. Lyme neuroborreliosis). Generally, patients with disseminated Lyme borreliosis will produce an antibody response several weeks post-infection. So far, no case of neuroborreliosis has been described with persistently negative serology one month after infection. Case presentation We present a patient with a history of Mantle cell lymphoma and treatment with R-CHOP (rituximab, doxorubicine, vincristine, cyclofosfamide, prednisone), with a meningo-encephalitis, who was treated for a suspected lymphoma relapse. However, no malignant cells or other signs of malignancy were found, and microbial tests did not reveal any clues, including Borrelia serology. He did not recall being bitten by ticks, and a Borrelia PCR on CSF was negative. After spontaneous improvement of symptoms, he was discharged without definite diagnosis. Several weeks later, he was readmitted with a relapse of symptoms of meningo-encephalitis. This time however, a Borrelia PCR on CSF was positive, confirmed by two independent laboratories, and the patient received ceftriaxone upon which he partially recovered. Interestingly, during the diagnostic process of this exceptionally difficult case, a variety of different serological assays for Borrelia antibodies remained negative. Only P41 (flagellin) IgG was detected by blot and the Liaison IgG became equivocal 2 months after initial testing. Conclusions To the best of our knowledge this is the first case of neuroborreliosis that is seronegative on repeated sera and multiple test modalities. This unique case demonstrates the difficulty to diagnose neuroborreliosis in severely immunocompromised patients. In this case, a delay in diagnosis was caused by broad differential diagnosis, an absent known history of tick bites, negative serology and the low sensitivity of PCR on CSF. Therefore, awareness of the diagnostic limitations to detect Borrelia infection in this specific patient category is warranted. Electronic supplementary material The online version of this article (10.1186/s12879-018-3273-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Wagemakers
- Department of medical microbiology, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands.
| | - M C Visser
- Department of neurology, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands
| | - B de Wever
- Department of medical microbiology, Academic medical center, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands
| | - J W Hovius
- Department of internal medicine/Amsterdam multidisciplinary Lyme center, Academic medical center, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands
| | - N W C J van de Donk
- Department of hematology, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands
| | - E J Hendriks
- Department of radiology and nuclear medicine, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands
| | - L Peferoen
- Department of pathology, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands
| | - F F Muller
- Department of neurology, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands
| | - C W Ang
- Department of medical microbiology, VU medical center, De Boelelaan 1117, Amsterdam, 1081, HV, The Netherlands
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Dessau RB, van Dam AP, Fingerle V, Gray J, Hovius JW, Hunfeld KP, Jaulhac B, Kahl O, Kristoferitsch W, Lindgren PE, Markowicz M, Mavin S, Ornstein K, Rupprecht T, Stanek G, Strle F. To test or not to test? Laboratory support for the diagnosis of Lyme borreliosis: a position paper of ESGBOR, the ESCMID study group for Lyme borreliosis. Clin Microbiol Infect 2017; 24:118-124. [PMID: 28887186 DOI: 10.1016/j.cmi.2017.08.025] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/26/2017] [Accepted: 08/29/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lyme borreliosis (LB) is a tick-borne infection caused by Borrelia burgdorferi sensu lato. The most frequent clinical manifestations are erythema migrans and Lyme neuroborreliosis. Currently, a large volume of diagnostic testing for LB is reported, whereas the incidence of clinically relevant disease manifestations is low. This indicates overuse of diagnostic testing for LB with implications for patient care and cost-effective health management. AIM The recommendations provided in this review are intended to support both the clinical diagnosis and initiatives for a more rational use of laboratory testing in patients with clinically suspected LB. SOURCES This is a narrative review combining various aspects of the clinical and laboratory diagnosis with an educational purpose. The literature search was based on existing systematic reviews, national and international guidelines and supplemented with specific citations. IMPLICATIONS The main recommendations according to current European case definitions for LB are as follows. Typical erythema migrans should be diagnosed clinically and does not require laboratory testing. The diagnosis of Lyme neuroborreliosis requires laboratory investigation of the spinal fluid including intrathecal antibody production, and the remaining disease manifestations require testing for serum antibodies to B. burgdorferi. Testing individuals with non-specific subjective symptoms is not recommended, because of a low positive predictive value.
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Affiliation(s)
- R B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Region Sjælland, Denmark.
| | - A P van Dam
- OLVG General Hospital and Public Health Laboratory, Amsterdam, The Netherlands
| | - V Fingerle
- National Reference Centre for Borrelia, Munich, Oberschleissheim, Germany
| | - J Gray
- UCD School of Biology and Environmental Science, University College Dublin, Dublin, Ireland
| | - J W Hovius
- Centre for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - K-P Hunfeld
- Northwest Medical Centre, Academic Teaching Hospital, Medical Faculty, Goethe-University, Frankfurt/Main and INSTAND e.V., Düsseldorf, Germany
| | - B Jaulhac
- National Reference Centre for Borrelia, Hôpitaux Universitaires de Strasbourg, France
| | - O Kahl
- Tick-radar GmbH, Berlin, Germany
| | - W Kristoferitsch
- Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Vienna, Austria
| | | | - M Markowicz
- Institute for Hygiene and Applied Immunology, Medical University of Vienna, Vienna, Austria
| | - S Mavin
- National Lyme Borreliosis Testing Laboratory, Raigmore Hospital, Inverness, UK
| | - K Ornstein
- Division of Medicine, Skånevård Kryh, Region Skåne, Sweden
| | - T Rupprecht
- Department of Neurology, HELIOS Klinikum München West, Munich, Germany
| | - G Stanek
- Institute for Hygiene and Applied Immunology, Medical University of Vienna, Vienna, Austria
| | - F Strle
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Seronegative Lyme neuroborreliosis in a patient treated by rituximab. Rev Neurol (Paris) 2015; 172:166-7. [PMID: 26318890 DOI: 10.1016/j.neurol.2015.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/03/2015] [Accepted: 06/05/2015] [Indexed: 11/24/2022]
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10
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Ang CW, Brandenburg AH, van Burgel ND, Bijlmer HA, Herremans T, Stelma F, Lunel FV, van Dam AP. A Dutch nationwide evaluation of serological assays for detection of Borrelia antibodies in clinically well-defined patients. Diagn Microbiol Infect Dis 2015; 83:222-8. [PMID: 26286381 DOI: 10.1016/j.diagmicrobio.2015.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/10/2015] [Accepted: 07/14/2015] [Indexed: 11/29/2022]
Abstract
Numerous tests for the detection of antibodies against Borrelia burgdorferi are commercially available. Manufacturer-derived data invariably report a high sensitivity and specificity, but comparative studies demonstrate large differences in clinical practice, especially with regard to specificity. We retrospectively collected data from validation studies for B. burgdorferi antibody assays from 8 laboratories in the Netherlands. The total number of samples was 809. Samples were selected based on clinical and laboratory parameters. We included samples from patients with erythema migrans, acrodermatitis chronicum atrophicans, and neuroborreliosis; cross-reactivity controls; and healthy controls. Data are presented from 10 enzyme-linked immunosorbent assays and 5 immunoblots. For manifestations of B. burgdorferi infection with short disease duration, the positivity rate of the assays varied significantly. In patients with long disease duration, the positivity rate differed only marginally. In cross-reactivity controls, there was significant variation in the reactivity rate. The majority of false-positive reactions are of the IgM isotype.
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Affiliation(s)
- C W Ang
- Department of Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, The Netherlands.
| | - A H Brandenburg
- Center for Infectious Diseases, Izore, Leeuwarden, The Netherlands
| | - N D van Burgel
- Department of Medical Microbiology, Centre of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - H A Bijlmer
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - T Herremans
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - F Stelma
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F Verduyn Lunel
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A P van Dam
- OLVG/Public Health Laboratory, Amsterdam, The Netherlands
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Maraspin V, Ružić-Sabljić E, Lusa L, Strle F. Course and outcome of Early Lyme borreliosis in patients with hematological malignancies. Clin Infect Dis 2015; 61:427-31. [PMID: 25956890 DOI: 10.1093/cid/civ341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/20/2015] [Indexed: 11/12/2022] Open
Abstract
Patients with erythema migrans and underlying hematological malignancy more often had signs of disseminated Lyme borreliosis and more frequently needed antibiotic retreatment than sex-, age-, and antibiotic treatment-matched immunocompetent persons with erythema migrans. However, the outcome was excellent in both groups.
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Affiliation(s)
- Vera Maraspin
- Department of Infectious Diseases, University Medical Center Ljubljana
| | | | - Lara Lusa
- Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Slovenia
| | - Franc Strle
- Department of Infectious Diseases, University Medical Center Ljubljana
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12
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Merkac MI, Tomazic J, Strle F. Lyme neuroborreliosis in a patient treated with TNF-alpha inhibitor. Infection 2015; 43:759-62. [PMID: 25922085 DOI: 10.1007/s15010-015-0779-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/07/2015] [Indexed: 11/28/2022]
Abstract
A 57-year-old woman, receiving TNF-alpha inhibitor adalimumab for psoriasis, presented with early Lyme neuroborreliosis (Bannwarth's syndrome). Discontinuation of adalimumab and 14-day therapy with ceftriaxone resulted in a smooth course and favorable outcome of Lyme borreliosis. This is the first report on Lyme neuroborreliosis in a patient treated with TNF-alpha inhibitor.
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Affiliation(s)
| | - Janez Tomazic
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525, Ljubljana, Slovenia
| | - Franc Strle
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525, Ljubljana, Slovenia.
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