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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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Monaghan M, Norman S, Gierdalski M, Marques A, Bost JE, DeBiasi RL. Pediatric Lyme disease: systematic assessment of post-treatment symptoms and quality of life. Pediatr Res 2024; 95:174-181. [PMID: 36997691 DOI: 10.1038/s41390-023-02577-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Lyme disease is common among children and adolescents. Antibiotic treatment is effective, yet some patients report persistent symptoms following treatment, with or without functional impairment. This study characterized long-term outcome of pediatric patients with Lyme disease and evaluated the case definition of post-treatment Lyme disease (PTLD) syndrome. METHODS The sample included 102 children with confirmed Lyme disease diagnosed 6 months-10 years prior to enrollment (M = 2.0 years). Lyme diagnosis and treatment information was extracted from the electronic health record; parent report identified presence, duration, and impact of symptoms after treatment. Participants completed validated questionnaires assessing health-related quality of life, physical mobility, fatigue, pain, and cognitive impact. RESULTS Most parents reported their child's symptoms resolved completely, although time to full resolution varied. Twenty-two parents (22%) indicated their child had at least one persistent symptom >6 months post-treatment, 13 without functional impairment (PTLD symptoms) and 9 with functional impairment (PTLD syndrome). Children with PTLD syndrome had lower parent-reported Physical Summary scores and greater likelihood of elevated fatigue. CONCLUSIONS In the current study, most children with Lyme disease experienced full resolution of symptoms, including those who initially met PTLD syndrome criteria. Effective communication about recovery rates and common symptoms that may persist post-treatment is needed. IMPACT The majority of pediatric patients treated for all stages of Lyme disease reported full resolution of symptoms within 6 months. 22% of pediatric patients reported one or more symptom persisting >6 months, 9% with and 13% without accompanying functional impairment. Effective communication with families about recovery rates and common symptoms that may persist post-treatment of Lyme disease is needed.
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Affiliation(s)
- Maureen Monaghan
- Divisions of Psychology and Behavioral Health, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Stephanie Norman
- Center for Translational Research, Children's Research Institute, Washington, DC, USA
| | - Marcin Gierdalski
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Center for Translational Research, Children's Research Institute, Washington, DC, USA
- Division of Biostatistics and Study Methodology, Childrens National Research Institute, Washington, DC, USA
| | - Adriana Marques
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - James E Bost
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Center for Translational Research, Children's Research Institute, Washington, DC, USA
- Division of Biostatistics and Study Methodology, Childrens National Research Institute, Washington, DC, USA
| | - Roberta L DeBiasi
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
- Center for Translational Research, Children's Research Institute, Washington, DC, USA.
- Division of Pediatric Infectious Diseases, Children's National Hospital, Washington, DC, USA.
- Department of Microbiology, Immunology and Tropical Medicine, The George Washington University School of Medicine, Washington, DC, USA.
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Greenberg R. Correspondence re: M Monaghan et al. Pediatric Lyme disease: systematic assessment of post-treatment symptoms and quality of life. Pediatr Res 2024; 95:2. [PMID: 37422496 DOI: 10.1038/s41390-023-02720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/21/2023] [Indexed: 07/09/2023]
Affiliation(s)
- Rosalie Greenberg
- Medical Arts Psychotherapy Assoc. PA, 33 Overlook Road Suite 406, New Jersey, 07901, Summit, USA.
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Gagliardi TA, Agarwalla A, Johnson PK, Leong J, DelBello DA. Bilateral Knee Lyme Arthritis in Children: A Report of 3 Cases. JBJS Case Connect 2023; 13:01709767-202306000-00026. [PMID: 37172117 DOI: 10.2106/jbjs.cc.22.00719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
CASES Three patients presented with bilateral knee pain, effusion, decreased range of motion, and difficulty ambulating. Synovial analysis demonstrated leukocytosis in bilateral knees with positive serum enzyme-linked immunosorbent assay. All cases were managed with antibiotics and anti-inflammatories. One patient developed chronic Lyme arthritis and underwent arthroscopic synovectomy. CONCLUSION Bilateral knee arthritis is a possible presentation of Lyme disease in children. Accurate diagnosis and treatment with antibiotics and anti-inflammatories can lead to satisfactory outcomes. Arthroscopic synovectomy may be indicated if conservative treatment fails.
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Affiliation(s)
- Thomas A Gagliardi
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, New York
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Abstract
Lyme disease is now the most frequently reported vector-borne disease in the United States. The highest incidence is in children aged 5 to 9 years with a male predominance. The most common manifestation, erythema migrans, is sometimes not recognized, leading to risk of complications. Testing for Lyme disease should only be done if there is a consistent clinical syndrome with exposure in a Lyme-endemic area. Most forms of Lyme disease are successfully treated with short courses of oral therapy. Prevention and management of tick bites is important.
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Affiliation(s)
- Carol A McCarthy
- Department of Pediatrics, Division of Pediatric Infectious Disease, Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA; Maine Medical Partners Pediatric Specialty Care, 887 Congress Street, Suite 310, Portland, ME 04102, USA.
| | - Jason A Helis
- Tufts University School of Medicine, Boston, MA, USA; Department of Pediatrics, Division of Pediatric Neurology, Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, USA; Maine Medical Partners Neurology, 92 Campus Drive Suite B, Scarborough, ME 04074, USA
| | - Brian E Daikh
- Tufts University School of Medicine, Boston, MA, USA; Department of Medicine, Maine Medical Center; Rheumatology Associates, 51 Sewall Street, Portland, ME, USA
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Musonera JB, Valiquette L, Baron G, Milord F, Marcoux D, Thivierge K, Bedard-Dallaire S, Pelletier AA, Lachance R, Bourget J, Simard C, Cantin E, Abbasi F, Haraoui LP, Carignan A. Management and clinical outcomes of Lyme disease in acute care facilities in 2 endemic regions of Quebec, Canada: a multicentre retrospective cohort study. CMAJ Open 2022; 10:E570-E576. [PMID: 35764331 PMCID: PMC9241544 DOI: 10.9778/cmajo.20210063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite increases in cases of Lyme disease, little is known about the management and clinical course of the disease in Canada. We aimed to describe the management and clinical course of Lyme disease in patients treated in acute care facilities in Quebec and to assess adherence to the 2006 Infectious Diseases Society of America (IDSA) guideline. METHODS This retrospective multicentre cohort study included pediatric and adult patients with serologically confirmed Lyme disease treated in acute care facilities (12 community hospitals and 2 tertiary care centres) of 2 endemic regions of Quebec (Estrie and Montérégie), from 2004 to 2017. We considered drug choice, prescribed dose and treatment duration in assessing adherence of prescriptions to the 2006 IDSA guideline. The main outcome was complete resolution of symptoms at 3 months after the initiation of treatment. RESULTS We included 272 patients from 14 institutions (age range 3-87 yr). Early disseminated Lyme disease (140 patients [51%]) was predominant. Adherence to the IDSA guideline was observed in 235 (90%) of the 261 cases with complete information, and adherence was stable over time (2004-2013: 57/64 [89%]; 2014-2015: 64/71 [90%]; 2016-2017: 114/126 [90%]; p = 0.8). Non-adherence to the guideline (n = 26) was predominantly due to longer-than-recommended treatment duration (16/26 [62%]). Resolution of objective signs at 3 months after treatment initiation occurred in 265 (99%) of 267 patients, whereas post-treatment Lyme disease syndrome was observed in 27 patients (10%) with increasing incidence over time (2004-2013: 3/65 [5%]; 2014-2015: 4/73 [5%]; 2016-2017: 20/129 [16%]; p = 0.02). INTERPRETATION We observed clinical resolution of Lyme disease in 99% of the patients, and most treatments (90%) complied with the 2006 IDSA guideline. The incidence of post-treatment Lyme disease syndrome increased over the study period, warranting further prospective studies.
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Affiliation(s)
- Jean B Musonera
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Geneviève Baron
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - François Milord
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Dominique Marcoux
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Karine Thivierge
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Samuel Bedard-Dallaire
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Andrée A Pelletier
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Raphaël Lachance
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Jeremy Bourget
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Catherine Simard
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Emmanuelle Cantin
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Farhad Abbasi
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Louis-Patrick Haraoui
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases (Musonera, Valiquette, Marcoux, Bedard-Dallaire, Pelletier, Haraoui, Carignan), Department of Community Health Sciences (Baron, Milord) and Faculté de médecine et des Sciences de la santé (Lachance, Bourget, Cantin, Abbasi), Université de Sherbrooke, Sherbrooke, Que.; Laboratoire de santé publique du Québec (Thivierge), Montréal, Que.; Université Laval (Simard), Québec, Que.
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Clark IA. Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic. Pharmacol Res Perspect 2022; 10:e00926. [PMID: 35174650 PMCID: PMC8850677 DOI: 10.1002/prp2.926] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
The chronic neurological aspects of traumatic brain injury, post‐stroke syndromes, long COVID‐19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen‐associated molecular patterns or damage‐associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non‐infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF‐maintained, microglial activation. While too large to negotiate the blood‐brain barrier effectively, the specific anti‐TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.
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Affiliation(s)
- Ian Albert Clark
- Research School of Biology, Australian National University, Canberra, ACT, Australia
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A Review of Post-treatment Lyme Disease Syndrome and Chronic Lyme Disease for the Practicing Immunologist. Clin Rev Allergy Immunol 2021; 62:264-271. [PMID: 34687445 DOI: 10.1007/s12016-021-08906-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 12/22/2022]
Abstract
Lyme disease is an infection caused by Borrelia burgdorferi sensu lato, which is transmitted to humans through the bite of an infected Ixodes tick. The majority of patients recover without complications with antibiotic therapy. However, for a minority of patients, accompanying non-specific symptoms can persist for months following completion of therapy. The constellation of symptoms such as fatigue, cognitive dysfunction, and musculoskeletal pain that persist beyond 6 months and are associated with disability have been termed post-treatment Lyme disease syndrome (PTLDS), a subset of a broader term "chronic Lyme disease." Chronic Lyme disease is a broad, vaguely defined term that is used to describe patients with non-specific symptoms that are attributed to a presumed persistent Borrelia burgdorferi infection in patients who may or may not have evidence of either previous or current Lyme disease. The diagnoses of chronic Lyme disease and of PTLDS have become increasingly relevant to the practice of immunologists due to referrals for consultation or for intravenous immunoglobulin (IVIG) treatment. This review aims to explore the relationship between chronic Lyme disease, post-treatment Lyme disease syndrome, and the immune system. Here, we review the current literature on (1) issues in conventional and alternative diagnostic testing for Lyme disease, (2) the hypothesis that B. burgdorferi infection can persist despite appropriate use of recommended antibiotics, (3) current theories regarding B. burgdorferi's role in causing both immune dysregulation and protracted symptoms, and (4) the use of IVIG for the treatment of Lyme disease.
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Corre C, Coiffier G, Le Goff B, Ferreyra M, Guennic X, Patrat-Delon S, Degeilh B, Albert JD, Tattevin P. Lyme arthritis in Western Europe: a multicentre retrospective study. Eur J Clin Microbiol Infect Dis 2021; 41:21-27. [PMID: 34417687 DOI: 10.1007/s10096-021-04334-y] [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: 06/03/2021] [Accepted: 08/04/2021] [Indexed: 11/25/2022]
Abstract
To characterize Lyme arthritis, with a focus on management, and outcome. Observational retrospective multicentre study in Western France, of all consecutive cases of Lyme arthritis, documented by Borrelia burgdorferi IgG on ELISA serological testing, confirmed by Western blot, with or without positive Borrelia PCR in synovial fluid, with no alternative diagnosis. We enrolled 52 patients (29 males), with a mean age of 43 ± 19.4 years. Most patients had monoarthritis (n = 43, 82.7%), involving the knee (n = 51, 98.1%), with a median delay between symptoms onset and Lyme arthritis diagnosis of 5 months (interquartile range, 1.5-8). Synovial fluid analysis yielded median white cell count of 16,000/mm3 (9230-40,500), and positive PCR in 16 cases (39%), for B. burgdorferi sensu stricto (n = 5), B. garinii (n = 5), B. afzelii (n = 3), and undetermined (n = 3). All patients received antibiotics, for a median duration of 28 days (21-30), with doxycycline (n = 44, 84.6%), ceftriaxone (n = 6, 11.5%), or amoxicillin (n = 2). Twelve patients (23.1%) also received intra-articular injection of glucocorticoids as first-line treatment. Of 47 patients with follow-up, 35 (74.5%) had complete resolution of Lyme arthritis. Lyme arthritis in Western Europe may be due to B. burgdorferi ss, B. afzelii, or B. garinii. Clinical presentation is similar to Lyme arthritis in North America (i.e. chronic knee monoarthritis), with low sensitivity of synovial fluid PCR (39%).
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Affiliation(s)
- Clémence Corre
- Rheumatology Department, Bretagne-Atlantique Hospital Center, Hôpital CHUBERT, Vannes, France
| | - Guillaume Coiffier
- Reference Centre for Tick-Borne Diseases in Western France, Rennes, France
- Rheumatology Department, University Hospital, Rennes, France
- Rheumatology Department, GHT Rance-Emeraude, René Pléven Hospital, Dinan, France
| | - Benoit Le Goff
- Rheumatology Department, University Hospital, Nantes, France
| | - Marine Ferreyra
- Rheumatology Department, Bretagne-Atlantique Hospital Center, Hôpital CHUBERT, Vannes, France
| | - Xavier Guennic
- Rheumatology Department, Yves Le Foll Hospital, Saint-Brieuc, France
| | - Solène Patrat-Delon
- Reference Centre for Tick-Borne Diseases in Western France, Rennes, France
- Infectious Diseases Department, University Hospital, Rennes, France
| | - Brigitte Degeilh
- Reference Centre for Tick-Borne Diseases in Western France, Rennes, France
- Rheumatology Department, Yves Le Foll Hospital, Saint-Brieuc, France
| | - Jean-David Albert
- Reference Centre for Tick-Borne Diseases in Western France, Rennes, France
- Rheumatology Department, University Hospital, Rennes, France
| | - Pierre Tattevin
- Reference Centre for Tick-Borne Diseases in Western France, Rennes, France.
- Rheumatology Department, Yves Le Foll Hospital, Saint-Brieuc, France.
- Parasitology and Applied Zoology Laboratory, Rennes University Hospital, Rennes, France.
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, 2, rue Henri Le Guilloux, 35033 Cedex 9, Rennes, France.
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Methodological Quality Assessment with the AGREE II Scale and a Comparison of European and American Guidelines for the Treatment of Lyme Borreliosis: A Systematic Review. Pathogens 2021; 10:pathogens10080972. [PMID: 34451436 PMCID: PMC8399315 DOI: 10.3390/pathogens10080972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Most European and American countries recently updated their guidelines on Lyme borreliosis (LB). The aim of this study was to provide a comparative overview of existing guidelines on the treatment of LB in Europe and America and to assess the methodological quality of their elaboration. METHODS A systematic search was carried out in MEDLINE, Google Scholar, and the national databases of scientific societies from 2014 to 2020. Quality was assessed by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. RESULTS Twelve guidelines were included. The scores for the AGREE II domains (median ± IQR) were: overall assessment 100 ± 22, scope and purpose 85 ± 46, stakeholder involvement 88 ± 48, rigour of development 67 ± 35, clarity of presentation 81 ± 36, applicability 73 ± 52 and editorial independence 79% ± 54%. Cohen's weighted kappa showed a high agreement (K = 0.90, 95%CI 0.84-0.96). Guidelines were quite homogeneous regarding the recommended molecules (mostly doxycycline in the first intention and ceftriaxone in the second intention), their duration (10 to 28 days), and their dosage. The differences were due to the lack of well-conducted comparative trials. The International Lyme and Associated Diseases Society (ILADS) guidelines were the only ones to suggest longer antibiotics based on an expert consensus. CONCLUSION European and American guidelines for the treatment of LB were quite homogeneous but based on moderate- to low-evidence studies. Well-conducted comparative trials are needed to assess the best molecules, the optimal duration and the most effective doses.
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Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1-e48. [PMID: 33417672 DOI: 10.1093/cid/ciaa1215] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
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Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
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Abstract
Lyme borreliosis is a tick-borne disease that is widespread throughout the northern hemisphere. Ixodes ricinus is present throughout metropolitan France, except for the Mediterranean region. The debate revolves around whether or not a chronic form of Lyme disease exists. This controversy is not limited to France but has been reported worldwide. In France, in 2019, 24 scientific societies representing the medical disciplines most involved in Lyme disease, including the Société Française de Rhumatologie (French Rheumatology Society [SFR]) and the Société de Pathologie Infectieuse de la Langue Française (French Infectious Disease Society-SPILF), published recommendations on the management of Lyme borreliosis following a submission to the Director General of Health. These recommendations conflict with those of the Haute Autorité de Santé (HAS), a multi-specialties independent group of physician, on a key point: whether to add a new nosological entity labeled as "persistent polymorphous signs and symptoms (or syndrome) possibly due to tick bite." The creation of this new syndrome risks should increase anchoring bias, leading to the attribution of all symptoms to a possible tick bite, without considering differential diagnoses. Lyme disease has been extensively studied. Erythema migrans is the primary clinical manifestation. In the presence of nonmetabolic, nonseptic monoarthritis involving the knee or radiculitis of a lower limb during the summer, Lyme disease should be suspected. Serologic testing for Lyme disease is reliable in the case of late forms such as chronic arthritis, while the detection of Borrelia DNA in synovial fluid by PCR is inconsistent. Sometimes, the serology can be misleading in early forms such as radiculitis. Treatment is based on doxycycline for 14 days in early forms (radiculitis), or 28 days in late forms (arthritis). Arthritis can persist or recur after antibiotic therapy. The prevalence of a diffuse polyalgia syndrome (fibromyalgia) following Lyme disease does not seem to differ much from that in the general population. It is not improved by prolonged antibiotic therapy, which is therefore not recommended.
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Affiliation(s)
- Guillaume Coiffier
- Service de Rhumatologie, GHT Rance-Émeraude, CH Dinan, 74 boulevard Chateaubriand, 22100 Dinan, France; Centre de Référence des Maladies Vectorielles à Tiques (MVT), Pontchaillou, CHU Rennes, 33 boulevard Louis Guilloux, 35000 Rennes, France; Groupe de travail sur les Infections Ostéo-articulaires, Société Française de Rhumatologie (SFR), Paris, France.
| | - Pierre Tattevin
- Service de Maladies Infectieuses & Réanimation Médicale, Pontchaillou, CHU Rennes, 33 boulevard Louis Guilloux, 35000 Rennes, France; Centre de Référence des Maladies Vectorielles à Tiques (MVT), Pontchaillou, CHU Rennes, 33 boulevard Louis Guilloux, 35000 Rennes, France
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Brouwer MAE, van de Schoor FR, Vrijmoeth HD, Netea MG, Joosten LAB. A joint effort: The interplay between the innate and the adaptive immune system in Lyme arthritis. Immunol Rev 2020; 294:63-79. [PMID: 31930745 PMCID: PMC7065069 DOI: 10.1111/imr.12837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/07/2019] [Indexed: 12/20/2022]
Abstract
Articular joints are a major target of Borrelia burgdorferi, the causative agent of Lyme arthritis. Despite antibiotic treatment, recurrent or persistent Lyme arthritis is observed in a significant number of patients. The host immune response plays a crucial role in this chronic arthritic joint complication of Borrelia infections. During the early stages of B. burgdorferi infection, a major hinder in generating a proper host immune response is the lack of induction of a strong adaptive immune response. This may lead to a delayed hyperinflammatory reaction later in the disease. Several mechanisms have been suggested that might be pivotal for the development of Lyme arthritis and will be highlighted in this review, from molecular mimicry of matrix metallopeptidases and glycosaminoglycans, to autoimmune responses to live bacteria, or remnants of Borrelia spirochetes in joints. Murine studies have suggested that the inflammatory responses are initiated by innate immune cells, but this does not exclude the involvement of the adaptive immune system in this dysregulated immune profile. Genetic predisposition, via human leukocyte antigen-DR isotype and microRNA expression, has been associated with the development of antibiotic-refractory Lyme arthritis. Yet the ultimate cause for (antibiotic-refractory) Lyme arthritis remains unknown. Complex processes of different immune cells and signaling cascades are involved in the development of Lyme arthritis. When these various mechanisms are fully been unraveled, new treatment strategies can be developed to target (antibiotic-refractory) Lyme arthritis more effectively.
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Affiliation(s)
- Michelle A. E. Brouwer
- Department of Internal MedicineRadboud Center for Infectious Diseases (RCI)Radboud Institute of Molecular Life Sciences (RIMLS)Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Freek R. van de Schoor
- Department of Internal MedicineRadboud Center for Infectious Diseases (RCI)Radboud Institute of Molecular Life Sciences (RIMLS)Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Hedwig D. Vrijmoeth
- Department of Internal MedicineRadboud Center for Infectious Diseases (RCI)Radboud Institute of Molecular Life Sciences (RIMLS)Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Mihai G. Netea
- Department of Internal MedicineRadboud Center for Infectious Diseases (RCI)Radboud Institute of Molecular Life Sciences (RIMLS)Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
- Department for Genomics & ImmunoregulationLife and Medical Sciences Institute (LIMES)University of BonnBonnGermany
| | - Leo A. B. Joosten
- Department of Internal MedicineRadboud Center for Infectious Diseases (RCI)Radboud Institute of Molecular Life Sciences (RIMLS)Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
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14
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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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15
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Horton DB, Taxter AJ, Davidow AL, Groh B, Sherry DD, Rose CD. Pediatric Antibiotic-refractory Lyme Arthritis: A Multicenter Case-control Study. J Rheumatol 2019; 46:943-951. [PMID: 30824653 DOI: 10.3899/jrheum.180775] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Few factors have consistently been linked to antibiotic-refractory Lyme arthritis (ARLA). We sought to identify clinical and treatment factors associated with pediatric ARLA. METHODS We performed a case-control study in 3 pediatric rheumatology clinics in a Lyme-endemic region (2000-2013). Eligible children were aged ≤ 18 years with arthritis and had positive testing for Lyme disease by Western blot. Cases were 49 children with persistently active arthritis despite ≥ 8 weeks of oral antibiotics or ≥ 2 weeks of parenteral antibiotics; controls were 188 children whose arthritis resolved within 3 months of starting antibiotics. We compared preselected demographic, clinical, and treatment factors between groups using logistic regression. RESULTS Characteristics positively associated with ARLA were age ≥ 10 years, prolonged arthritis at diagnosis, knee-only arthritis, and worsening after starting antibiotics. In contrast, children with fever, severe pain, or other signs of systemic inflammation were more likely to respond quickly to treatment. Secondarily, low-dose amoxicillin and treatment nonadherence were also linked to higher risk of ARLA. Greater antibiotic use for children with ARLA was accompanied by higher rates of treatment-associated adverse events (37% vs 15%) and resultant hospitalization (6% vs 1%). CONCLUSION Older children and those with prolonged arthritis, arthritis limited to the knees, or poor initial response to antibiotics are more likely to have antibiotic-refractory disease and treatment-associated toxicity. Children with severe symptoms of systemic inflammation have more favorable outcomes. For children with persistently active Lyme arthritis after 2 antibiotic courses, pediatricians should consider starting antiinflammatory treatment and referring to a pediatric rheumatologist.
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Affiliation(s)
- Daniel B Horton
- From the Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey; Department of Biostatistics - Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware. .,D.B. Horton, MD, MSCE, Division of Pediatric Rheumatology, Rutgers Robert Wood Johnson Medical School, and Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, and Rutgers School of Public Health; A.J. Taxter, MD, MSCE, Brenner Children's Hospital, Wake Forest Baptist Medical Center; A.L. Davidow, PhD, Rutgers School of Public Health; B. Groh, MD, Penn State Milton S. Hershey Medical Center; D.D. Sherry, MD, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania; C.D. Rose, MD, Division of Rheumatology, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University.
| | - Alysha J Taxter
- From the Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey; Department of Biostatistics - Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware.,D.B. Horton, MD, MSCE, Division of Pediatric Rheumatology, Rutgers Robert Wood Johnson Medical School, and Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, and Rutgers School of Public Health; A.J. Taxter, MD, MSCE, Brenner Children's Hospital, Wake Forest Baptist Medical Center; A.L. Davidow, PhD, Rutgers School of Public Health; B. Groh, MD, Penn State Milton S. Hershey Medical Center; D.D. Sherry, MD, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania; C.D. Rose, MD, Division of Rheumatology, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University
| | - Amy L Davidow
- From the Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey; Department of Biostatistics - Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware.,D.B. Horton, MD, MSCE, Division of Pediatric Rheumatology, Rutgers Robert Wood Johnson Medical School, and Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, and Rutgers School of Public Health; A.J. Taxter, MD, MSCE, Brenner Children's Hospital, Wake Forest Baptist Medical Center; A.L. Davidow, PhD, Rutgers School of Public Health; B. Groh, MD, Penn State Milton S. Hershey Medical Center; D.D. Sherry, MD, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania; C.D. Rose, MD, Division of Rheumatology, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University
| | - Brandt Groh
- From the Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey; Department of Biostatistics - Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware.,D.B. Horton, MD, MSCE, Division of Pediatric Rheumatology, Rutgers Robert Wood Johnson Medical School, and Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, and Rutgers School of Public Health; A.J. Taxter, MD, MSCE, Brenner Children's Hospital, Wake Forest Baptist Medical Center; A.L. Davidow, PhD, Rutgers School of Public Health; B. Groh, MD, Penn State Milton S. Hershey Medical Center; D.D. Sherry, MD, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania; C.D. Rose, MD, Division of Rheumatology, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University
| | - David D Sherry
- From the Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey; Department of Biostatistics - Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware.,D.B. Horton, MD, MSCE, Division of Pediatric Rheumatology, Rutgers Robert Wood Johnson Medical School, and Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, and Rutgers School of Public Health; A.J. Taxter, MD, MSCE, Brenner Children's Hospital, Wake Forest Baptist Medical Center; A.L. Davidow, PhD, Rutgers School of Public Health; B. Groh, MD, Penn State Milton S. Hershey Medical Center; D.D. Sherry, MD, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania; C.D. Rose, MD, Division of Rheumatology, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University
| | - Carlos D Rose
- From the Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey; Department of Biostatistics - Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware.,D.B. Horton, MD, MSCE, Division of Pediatric Rheumatology, Rutgers Robert Wood Johnson Medical School, and Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, and Rutgers School of Public Health; A.J. Taxter, MD, MSCE, Brenner Children's Hospital, Wake Forest Baptist Medical Center; A.L. Davidow, PhD, Rutgers School of Public Health; B. Groh, MD, Penn State Milton S. Hershey Medical Center; D.D. Sherry, MD, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania; C.D. Rose, MD, Division of Rheumatology, Nemours/A.I. duPont Hospital for Children, Thomas Jefferson University
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Jarosz AC, Badawi A. Metabolites of prostaglandin synthases as potential biomarkers of Lyme disease severity and symptom resolution. Inflamm Res 2018; 68:7-17. [PMID: 30121835 PMCID: PMC6314976 DOI: 10.1007/s00011-018-1180-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/08/2018] [Indexed: 01/09/2023] Open
Abstract
Background Lyme disease or Lyme borreliosis (LB) is the commonest vector-borne disease in the North America. It is an inflammatory disease caused by the bacterium Borrelia burgdorferi. The role of the inflammatory processes mediated by prostaglandins (PGs), thromboxanes and leukotrienes (LTs) in LB severity and symptoms resolution is yet to be elucidated. Objectives We aim to systematically review and evaluate the role of PGs and related lipid mediators in the induction and resolution of inflammation in LB. Methods We conducted a comprehensive search in PubMed, Ovid MEDLINE(R), Embase and Embase Classic to identify cell-culture, animal and human studies reporting the changes in PGs and related lipid mediators of inflammation during the course of LB. Results We identified 18 studies to be included into this systematic review. The selected reports consisted of seven cell-culture studies, seven animal studies, and four human studies (from three patient populations). Results from cell-culture and animal studies suggest that PGs and other lipid mediators of inflammation are elevated in LB and may contribute to disease development. The limited number of human studies showed that subjects with Lyme meningitis, Lyme arthritis (LA) and antibiotic-refractory LA had increased levels of an array of PGs and lipid mediators (e.g., LTB4, 8-isoPGF2α, and phospholipases A2 activity). Levels of these markers were significantly reduced following the treatment with antibiotics or non-steroidal anti-inflammatory drugs. Conclusion Dysregulation of prostaglandins and related lipid mediators may play a role in the etiology of LB and persistence of inflammation that may lead to long-term complications. Further investigation into the precise levels of a wide range of PGs and related factors is critical as it may propose novel markers that can be used for early diagnosis. Electronic supplementary material The online version of this article (10.1007/s00011-018-1180-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alicia Caroline Jarosz
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, FitzGerald Building, 150 College Street, Toronto, ON, M5S3E2, Canada
| | - Alaa Badawi
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, FitzGerald Building, 150 College Street, Toronto, ON, M5S3E2, Canada.
- Public Health Risk Sciences Division, Public Health Agency of Canada, 180 Queen Street West, Toronto, ON, M5V 3L7, Canada.
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Entzündliche Gelenkerkrankungen. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0511-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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18
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Ali A. Lyme Disease. Integr Med (Encinitas) 2018. [DOI: 10.1016/b978-0-323-35868-2.00023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Orczyk K, Świdrowska-Jaros J, Smolewska E. When a patient suspected with juvenile idiopathic arthritis turns out to be diagnosed with an infectious disease - a review of Lyme arthritis in children. Pediatr Rheumatol Online J 2017; 15:35. [PMID: 28482848 PMCID: PMC5422956 DOI: 10.1186/s12969-017-0166-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/01/2017] [Indexed: 12/26/2022] Open
Abstract
The Lyme arthritis is a common manifestation of infection with Borrelia burgdorferi spirochete. Despite its infectious background, the inflammation clinically and histopatologically resembles juvenile idiopathic arthritis. As it affects a considerable number of Lyme disease patients, it should be routinely considered in differential diagnosis. Development of arthritis is partially dependent on spirochetal factors, including the ribosomal spacer type and the sequence of outer surface protein C. Immunological background involves Th1-related response, but IL-17 provides an additional route of developing arthritis. Autoimmune mechanisms may lead to antibiotic-refractory arthritis. The current diagnostic standard is based on a 2-step testing: ELISA screening and immunoblot confirmation. Other suggested methods contain modified two-tier test with C6 ELISA instead of immunoblot. An initial 28-day course of oral antibiotics (doxycycline, cefuroxime axetil or amoxicillin) is a recommended treatment. Severe cases require further anti-inflammatory management. Precise investigation of new diagnostic and therapeutic approaches is advisable.
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Affiliation(s)
- Krzysztof Orczyk
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
| | - Joanna Świdrowska-Jaros
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
| | - Elżbieta Smolewska
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
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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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Hatchette TF, Johnston BL, Schleihauf E, Mask A, Haldane D, Drebot M, Baikie M, Cole TJ, Fleming S, Gould R, Lindsay R. Epidemiology of Lyme Disease, Nova Scotia, Canada, 2002-2013. Emerg Infect Dis 2016; 21:1751-8. [PMID: 26401788 PMCID: PMC4593424 DOI: 10.3201/eid2110.141640] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Nova Scotia has the highest reported incidence in Canada, but risk is localized to identified disease-endemic regions. Ixodes scapularis ticks, which transmit Borreliaburgdorferi, the causative agent of Lyme disease (LD), are endemic to at least 6 regions of Nova Scotia, Canada. To assess the epidemiology and prevalence of LD in Nova Scotia, we analyzed data from 329 persons with LD reported in Nova Scotia during 2002–2013. Most patients reported symptoms of early localized infection with rash (89.7%), influenza-like illness (69.6%), or both; clinician-diagnosed erythema migrans was documented for 53.2%. In a separate serosurvey, of 1,855 serum samples screened for antibodies to B.burgdorferi, 2 were borderline positive (both with an indeterminate IgG on Western blot), resulting in an estimated seroprevalence of 0.14% (95% CI 0.02%–0.51%). Although LD incidence in Nova Scotia has risen sharply since 2002 and is the highest in Canada (16/100,000 population in 2013), the estimated number of residents with evidence of infection is low, and risk is localized to currently identified LD-endemic regions.
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Abstract
In the United States, Lyme arthritis is the most common feature of late-stage Borrelia burgdorferi infection, usually beginning months after the initial bite. In some, earlier phases are asymptomatic and arthritis is the presenting manifestation. Patients with Lyme arthritis have intermittent or persistent attacks of joint swelling and pain in 1 or a few large joints. Serologic testing is the mainstay of diagnosis. Synovial fluid polymerase chain reaction for B burgdorferi DNA is often positive before treatment, but is not a reliable marker of spirochetal eradication after therapy. This article reviews the clinical manifestations, diagnosis, and management of Lyme arthritis.
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Affiliation(s)
- Sheila L Arvikar
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Allen C Steere
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Abstract
The diagnosis and management of Lyme disease in children is similar to that in adults with a few clinically relevant exceptions. The use of doxycycline as an initial empiric choice is to be avoided for children 8 years old and younger. Children may present with insidious onset of elevated intracranial pressure during acute disseminated Lyme disease; prompt diagnosis and treatment of this condition is important to prevent loss of vision. Children who acquire Lyme disease have an excellent prognosis even when they present with the late disseminated manifestation of Lyme arthritis. Guidance on the judicious use of serologic tests is provided. Pediatricians and family practitioners should be familiar with the prevention and management of tick bites, which are common in children.
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Affiliation(s)
- Sunil K Sood
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY 11549, USA; Department of Pediatrics, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706, USA; Pediatric Infectious Diseases, Cohen Children's Medical Center, New Hyde Park, NY 11040, USA.
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Glaude PD, Huber AM, Mailman T, Ramsey S, Lang B, Stringer E. Clinical characteristics, treatment and outcome of children with Lyme arthritis in Nova Scotia. Paediatr Child Health 2015; 20:377-80. [PMID: 26526378 DOI: 10.1093/pch/20.7.377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Lyme disease is an emerging problem in Nova Scotia. Lyme arthritis is a late manifestation of Lyme disease. OBJECTIVE To describe the demographic characteristics, referral patterns and clinical course of children diagnosed with Lyme arthritis in a tertiary care pediatric rheumatology clinic in Nova Scotia. METHODS In the present retrospective chart review, subjects diagnosed with Lyme arthritis between 2006 and 2013 were identified through the clinic database. Demographic variables, referral patterns, clinical presentation and information regarding treatment course and outcome were collected. RESULTS Seventeen patients were identified; 76% presented in 2012 and 2013. In 37.5% of cases, the referring physician suspected Lyme disease. Most patients presented with one or more painful and/or swollen joints; 94% had knee involvement. Only three of 17 patients had a history of erythema migrans and four of 17 recalled a tick bite. Five patients had a history of neurological manifestations consistent with Lyme disease, although, none had a diagnosis made at the time. Arthritis usually resolved after treatment with standard antibiotics; however, at last follow-up, two patients had antibiotic refractory Lyme arthritis, with one having joint damage despite aggressive arthritis treatment. CONCLUSION A significant increase in cases of Lyme arthritis has recently been recognized in a pediatric rheumatology clinic in Nova Scotia. A history of a tick bite or erythema migrans were not sensitive markers of Lyme arthritis, and this diagnosis was often not considered by the referring physician. Educational initiatives should be undertaken to increase local awareness of this treatable cause of arthritis in children.
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Affiliation(s)
- Pier Diane Glaude
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
| | - Adam M Huber
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
| | - Timothy Mailman
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
| | - Suzanne Ramsey
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
| | - Bianca Lang
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
| | - Elizabeth Stringer
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
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[Diagnosis and treatment of Lyme arthritis. Recommendations of the Pharmacotherapy Commission of the Deutsche Gesellschaft für Rheumatologie (German Society for Rheumatology)]. Z Rheumatol 2015; 73:469-74. [PMID: 24924733 DOI: 10.1007/s00393-014-1370-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
These guidelines summarize the current evidence for diagnosis and treatment of Lyme arthritis and the most frequent skin manifestations of Borrelia burgdorferi infections. Lyme arthritis is a monoarticular or oligoarticular form of arthritis that typically involves the knee. A positive enzyme-linked immunosorbent assay (ELISA) for IgG antibodies should be followed by an IgG immunoblot. A positive PCR test from synovial fluid adds increased diagnostic certainty. Serum positivity for antibodies to Borrelia burgdorferi without typical symptoms does not justify antibiotic treatment. Oral antibiotic treatment for erythema migrans is recommended using doxycycline, 200 mg once per day for 10-21 days, alternative choices are amoxicillin, cefuroxime and azithromycin. For children below 8 years of age, amoxicillin is recommended.Lyme arthritis can usually be successfully treated with orally administered antimicrobial agents. Doxycycline, 1 × 200 or 2 × 100 mg for 30 days is the antibiotic agent of choice. Amoxicillin (3 × 500-1000 mg) can be alternatively chosen. Patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy should be treated intravenously. In this situation, ceftriaxone at 2 g per day for 14-21 days is recommended. There is no evidence to recommend long-term and combined treatments.
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Bachur RG, Adams CM, Monuteaux MC. Evaluating the child with acute hip pain ("irritable hip") in a Lyme endemic region. J Pediatr 2015; 166:407-11.e1. [PMID: 25444013 DOI: 10.1016/j.jpeds.2014.09.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 08/18/2014] [Accepted: 09/19/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To estimate the prevalence of Lyme infection among children presenting with acute, nontraumatic hip pain in a Lyme endemic region and to investigate predictors of Lyme disease among children with suspected transient synovitis. STUDY DESIGN Retrospective cross-sectional study of children with unilateral hip pain who were brought to an academic pediatric emergency department. Cases were identified by specific discharge diagnoses or radiologic imaging. Lyme infection was determined by serologic criteria, and a minimum prevalence was estimated for the entire study population; maximum estimate was determined for those who had Lyme testing. Multivariate regression was used to identify discriminating clinical findings for Lyme disease among those with nonseptic arthritis. RESULTS Three hundred eighty-five children with a median age of 5.4 years were studied; 15% of children had fever ≥38.0°C and 40% had pain for less than 24 hours at evaluation. Lyme infection was identified in 5.2% (95% CI 3.2%-7.9%). A maximum estimate of Lyme disease was calculated to be 8.0% (95% CI 4.9%-12.0%). Regression analysis did not identify any practical clinical predictors of Lyme infection. CONCLUSIONS Lyme infection occurred in approximately 5% of children with acute, nontraumatic hip pain who were evaluated in a pediatric emergency department in a Lyme endemic region. Based on this estimate, we do not recommend routine Lyme testing when transient synovitis is suspected; however, Lyme testing should be considered in children having laboratory studies obtained for alternative diagnoses such as septic/pyogenic arthritis and for those with an atypical clinical course for transient synovitis.
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Affiliation(s)
- Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Cynthia M Adams
- Division of Emergency Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
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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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Aiyer A, Walrath J, Hennrikus W. Lyme arthritis of the pediatric ankle. Orthopedics 2014; 37:e952-5. [PMID: 25275987 DOI: 10.3928/01477447-20140924-94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/25/2014] [Indexed: 02/03/2023]
Abstract
Lyme arthritis results from acute inflammation caused by the spirochete Borrelia burgdorferi. The number of cases per year has been rising since 2006, with a majority of patients being affected in the northeastern United States. Development of Lyme arthritis is of particular importance to the orthopedic surgeon because Lyme arthritis often presents as an acute episode of joint swelling and tenderness and may be confused with bacterial septic arthritis. Considering the vast difference in treatment management between these 2 pathologies, differentiating between them is of critical importance. Septic arthritis often needs to be addressed surgically, whereas Lyme arthritis can be treated with oral antibiotics alone. Laboratory testing for Lyme disease often results in a delay in diagnosis because many laboratories batch-test Lyme specimens only a few times per week because of increased expense. The authors present a case of Lyme arthritis in the pediatric ankle in an endemic region. No clear algorithm exists to delineate between septic arthritis and Lyme arthritis of the joint. Improved clinical guidelines for the identification and diagnosis of Lyme arthritis of the ankle are important so that appropriate antibiotics can be used and surgery can be avoided.
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Abstract
Background Lyme disease is an emerging zoonotic infection in Canada. As the Ixodes tick expands its range, more Canadians will be exposed to Borrelia burgdorferi, the bacterium that causes Lyme disease. Objective To review the clinical diagnosis and treatment of Lyme disease for front-line clinicians. Methods A literature search using PubMed and restricted to articles published in English between 1977 and 2014. Results Individuals in Lyme-endemic areas are at greatest risk, but not all tick bites transmit Lyme disease. The diagnosis is predominantly clinical. Patients with Lyme disease may present with early disease that is characterized by a "bull's eye rash", fever and myalgias or with early disseminated disease that can manifest with arthralgias, cardiac conduction abnormalities or neurologic symptoms. Late Lyme disease in North America typically manifests with oligoarticular arthritis but can present with a subacute encephalopathy. Antibiotic treatment is effective against Lyme disease and works best when given early in the infection. Prophylaxis with doxycyline may be indicated in certain circumstances. While a minority of patients may have persistent symptoms, evidence does not demonstrate that prolonged courses of antibiotics improve outcome. Conclusion Clinicians need to be aware of the signs and symptoms of Lyme disease. Knowing the regions where Borrelia infection is endemic in North America is important for recognizing patients at risk and informing the need for treatment.
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Daikh BE, Emerson FE, Smith RP, Lucas FL, McCarthy CA. Lyme arthritis: a comparison of presentation, synovial fluid analysis, and treatment course in children and adults. Arthritis Care Res (Hoboken) 2014; 65:1986-90. [PMID: 23925915 DOI: 10.1002/acr.22086] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 07/03/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This case series examines differences in the presentation, management, and outcome of Lyme arthritis between the pediatric and adult population. METHODS We reviewed charts of pediatric and adult patients evaluated for Lyme arthritis by rheumatologists and pediatric infectious disease specialists in Portland, Maine between January 2002 and July 2008. Patients included for analysis had documented joint swelling and positive Lyme serology. Data on clinical presentation, synovial fluid and peripheral blood results, treatment, and clinical course were analyzed. RESULTS Twenty-nine adults and 52 children met case criteria for Lyme arthritis. Children were more likely than adults to present acutely (P < 0.0001) and also had higher mean peripheral blood (P = 0.05) and synovial fluid white blood cell counts (P < 0.0001). Lyme arthritis was more frequently suspected in children at presentation (P = 0.04). There was no difference between children and adults with respect to suspicion for septic arthritis, hospitalization, or surgical intervention. Adults received more antibiotic courses (P = 0.007) and were more likely to have intravenous antibiotics in subsequent treatment courses (P = 0.006). Children were more likely to have normal function within 4 weeks of initiating antibiotic treatment (P < 0.0001). CONCLUSION Children with Lyme arthritis were more likely to present acutely with higher synovial white cell counts than adults. We did not, however, observe a significant difference in hospitalization or surgical management. Children had more prompt resolution of their joint swelling and received less treatment overall.
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Wormser GP, O’Connell S. Treatment of infection caused byBorrelia burgdorferisensu lato. Expert Rev Anti Infect Ther 2014; 9:245-60. [DOI: 10.1586/eri.10.174] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nimmrich S, Becker I, Horneff G. Intraarticular corticosteroids in refractory childhood Lyme arthritis. Rheumatol Int 2014; 34:987-94. [PMID: 24390634 DOI: 10.1007/s00296-013-2923-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 12/14/2013] [Indexed: 01/26/2023]
Abstract
Lyme arthritis caused by infection with Borrelia burgdorferi is a common late manifestation of Lyme borreliosis. Current treatment recommendations include at least one oral or intravenous antibiotic course, followed by antirheumatic therapy in case of refractory arthritis. We reviewed the course of 31 children with Lyme arthritis who had received antibiotic treatment and assessed outcome and requirement of antirheumatic therapy. Of a total of 31 patients, 23 (74%) showed complete resolution of arthritis after one or two courses of antibiotics, whereas in 8 patients (28%), steroid injections had been performed due to relapsing or remaining symptoms. All of these 8 patients showed immediate resolution of symptoms after intraarticular steroid injections. Four of them (50%) remained asymptomatic so far with a follow-up period between five up to 40 months. In two cases, multiple intraarticular corticosteroid injections were required; three patients received additional or consecutive treatment with systemic antirheumatic treatment. Patients with antibiotic refractory arthritis showed a higher rate of positivity of the IgG p58 and OspC immunoblot bands (p = 0.05) at presentation. Antibodies against OspA, an indicator of later stage infection, occurred more frequently in the refractory group without reaching significant level. No clinical marker as indicator for severe or prolonged course of Lyme arthritis was identifiable. A quarter of childhood Lyme arthritis patients were refractory to antibiotics and required antirheumatic treatment. Intraarticular steroid injections in childhood Lyme arthritis refractory to antibiotics can lead to marked clinical improvement.
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Affiliation(s)
- S Nimmrich
- Centre of Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany,
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Esposito S, Bosis S, Sabatini C, Tagliaferri L, Principi N. Borrelia burgdorferi infection and Lyme disease in children. Int J Infect Dis 2013; 17:e153-8. [DOI: 10.1016/j.ijid.2012.09.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 09/26/2012] [Indexed: 12/01/2022] Open
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Management of paediatric Lyme disease in non-endemic and endemic areas: data from the Registry of the Italian Society for Pediatric Infectious Diseases. Eur J Clin Microbiol Infect Dis 2012; 32:523-9. [DOI: 10.1007/s10096-012-1768-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/16/2012] [Indexed: 10/27/2022]
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Abstract
BACKGROUND Lyme arthritis most commonly affects the knee. It is not commonly considered in the differential diagnosis of monoarticular hip pain. There are only a few case reports describing Lyme disease presenting with isolated hip involvement. The purpose of this study is to review our experience with primary Lyme arthritis of the hip. METHODS Clinical records at a tertiary children's referral center in a Lyme endemic region were scanned for key words "Lyme" and "hip." Patients with isolated Lyme disease of the hip were included. Diagnosis was made based on Centers for Disease Control guidelines. Clinical presentation, laboratory evaluation, and treatment information were recorded for eligible patients. RESULTS Eight patients met eligibility criteria with an average age of 9.5 years (3 to 20y). All patients presented with hip pain (8), limp (3), or refusal to bear weight (5). One of 8 patients had a fever >38.5°C. Two of 8 patients had a peripheral white blood cell count >12,500/mm and 3 of 8 patients had an erythrocyte sedimentation rate>40 mm/h. Aspiration was performed on 5 patients, with a median synovial fluid white blood cell of 41,500/mm (21,500 to 73,500/mm). Three of 8 patients were treated surgically; all patients were treated with antibiotics and were asymptomatic at last follow-up. With the exception of 1 case, there was a delay before appropriate antibiotics were started. CONCLUSIONS Primary monoarticular Lyme arthritis of the hip is uncommon. Clinical presentation and laboratory findings are variable, and differentiating it from septic arthritis or toxic synovitis of the hip may be difficult. In areas where Lyme disease is endemic, it should be considered in the differential diagnosis of monoarticular hip pain associated with an effusion. LEVEL OF EVIDENCE Level IV, Case Series.
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Lyme Disease. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Boggs SR, Cunnion KM, Raafat RH. Ceftriaxone-induced hemolysis in a child with Lyme arthritis: a case for antimicrobial stewardship. Pediatrics 2011; 128:e1289-92. [PMID: 21969285 DOI: 10.1542/peds.2010-1570] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Guidelines for the treatment of Lyme arthritis were published by the Infectious Diseases Society of America in 2006 and recommended oral doxycycline for initial therapy. We report here the case of a young girl treated with intravenous ceftriaxone who subsequently developed drug-induced autoimmune hemolytic anemia and renal failure. Her severe sequelae highlight the importance of antimicrobial stewardship. We review here the goals of antimicrobial stewardship and several strategies for achieving them. In addition, we briefly discuss the rare adverse drug event experienced by our patient.
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Affiliation(s)
- Sarah R Boggs
- Division of Infectious Diseases, Children's Hospital of The King's Daughters and Eastern Virginia Medical School, Norfolk, VA 23508, USA.
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Strle K, Jones KL, Drouin EE, Li X, Steere AC. Borrelia burgdorferi RST1 (OspC type A) genotype is associated with greater inflammation and more severe Lyme disease. THE AMERICAN JOURNAL OF PATHOLOGY 2011; 178:2726-39. [PMID: 21641395 DOI: 10.1016/j.ajpath.2011.02.018] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 01/10/2011] [Accepted: 02/03/2011] [Indexed: 11/28/2022]
Abstract
Evidence is emerging for differential pathogenicity among Borrelia burgdorferi genotypes in the United States. By using two linked genotyping systems, ribosomal RNA intergenic spacer type (RST) and outer surface protein C (OspC), we studied the inflammatory potential of B. burgdorferi genotypes in cells and patients with erythema migrans or Lyme arthritis. When macrophages were stimulated with 10 isolates of each RST1, RST2, or RST3 strain, RST1 (OspC type A)-stimulated cells expressed significantly higher levels of IL-6, IL-8, chemokine ligand (CCL) 3, CCL4, tumor necrosis factor, and IL-1β, factors associated with innate immune responses. In peripheral blood mononuclear cells, RST1 strains again stimulated significantly higher levels of these mediators. Moreover, compared with RST2, RST1 isolates induced significantly more interferon (IFN)-α, IFN-γ, and CXCL10, which are needed for adaptive immune responses; however, OspC type I (RST3) approached RST1 (OspC type A) in stimulating these adaptive immune mediators. Similarly, serum samples from patients with erythema migrans who were infected with the RST1 genotype had significantly higher levels of almost all of these mediators, including exceptionally high levels of IFN-γ-inducible chemokines, CCL2, CXCL9, and CXCL10; and this pronounced inflammatory response was associated with more symptomatic infection. Differences among genotypes were not as great in patients with Lyme arthritis, but those infected with RST1 strains more often had antibiotic-refractory arthritis. Thus, the B. burgdorferi RST1 (OspC type A) genotype, followed by the RST3 (OspC type I) genotype, causes greater inflammation and more severe disease, establishing a link between spirochetal virulence and host inflammation.
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Affiliation(s)
- Klemen Strle
- Division of Rheumatology, Allergy and Immunology, the Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Musculoskeletal features of Lyme disease: understanding the pathogenesis of clinical findings helps make appropriate therapeutic choices. J Clin Rheumatol 2011; 17:256-65. [PMID: 21778908 DOI: 10.1097/rhu.0b013e318226a977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with Lyme disease, that is, active infection with Borrelia burgdorferi, experience many types of musculoskeletal complaints, with different explanatory mechanisms. Appropriate therapy depends on understanding the underlying cause of the complaint and addressing that specific root cause. In the case of active infection the dosage, duration, drug, and method of administration of antibiotics should be determined by the state of the infection and history of prior therapy, according to the established and validated recommendations of the Infectious Disease Society of America. Many patients have musculoskeletal complaints not attributable to active infection; some patients have residual complaints following a documented infection that has been adequately treated with antibiotics previously, and others never had true B. burgdorferi infection in the first place. For such patients, antibiotics are not warranted and in fact may be physically and emotionally harmful. Complaints following an episode of Lyme disease are not necessarily due to ongoing infection, especially adequately treated. Consideration of other diagnoses may suggest use of other effective modalities, including physical therapy and emotional support. Appropriate ordering and interpretation of the various validated seroconfirmatory tests available to study B. burgdorferi infection are critical, as these tests are often misapplied and misconstrued in pursuit of strategies aimed at eliminating patients' suffering. Although seronegative Lyme disease has been reported, seronegativity in a reputable laboratory makes the likelihood of Lyme arthritis very low. On the other hand, a positive result from certain unvalidated laboratories or novel assays proves nothing and should not be viewed as substantiating the diagnosis.
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Treating pediatric Lyme arthritis. Nat Rev Rheumatol 2010; 6:312. [DOI: 10.1038/nrrheum.2010.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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