Rational diagnosis and treatment in unclassified arthritis: how clinical data may guide requests for Lyme serology and antibiotic treatment

To improve the appropriateness and efficiency of diagnostic serological tests and subsequent antibiotic treatment, clinical data from 102 patients with unclassified arthritis were analysed to investigate whether the presence of positive IgG antibodies to Borrelia burgdorferi could be predicted. The clinical data were blindly ranked from 1 to 4 (1, Lyme arthritis unlikely; 4, Lyme arthritis very likely). Antibodies to B burgdorferi were positive in nine of 102 patients (9%). Six of 15 (40%) patients with rank numbers 3 and 4 were positive for antibodies to B burgdorferi, in contrast with only three of 87 (3%) patients with rank numbers 1 and 2. The likelihood ratio of positive Lyme serology for patients ranked 3 and 4 was 12.0, for patients ranked 2 to 4, 4.5, and for patients with arthritis of the knee, 3.0. These likelihood ratios were associated with a post-test probability of 55, 30, and 20% respectively. The clinical history in patients with unclassified arthritis can largely predict the presence of antibodies to B burgdorferi. The absolute value of a likelihood ratio can be a contributing factor in deciding to request tests for antibodies to B burgdorferi in patients with unclassified arthritis.

Diagnostic tools in Lyme borreliosis: clinical history compared with serology

The occurrence of a history of clinical Lyme borreliosis and the prevalence of positive antibodies to Borrelia burgdorferi were studied in 431 Dutch hunters. The majority of the hunters (336 or 78%) did not report any complaints and had no positive IgG antibodies to B. burgdorferi. Sixty-five hunters (15.1%) had no clinical manifestations but did not have positive antibodies to B. burgdorferi. Only 1.9% of the population studied had had past symptoms of definite or probable Lyme borreliosis. Likelihood ratios were high (21.3) for the recognition of erythema migrans, but much lower for tick bites (3.6) or positive IgG Lyme serology (3.5). Clinical history turned out to be a more powerful diagnostic tool than Lyme serology.

Is there any evidence for an association between ankylosing spondylitis and Borrelia burgdorferi infection?

The suggested relationship between Borrelia burgdorferi and seronegative spondyloarthropathies has been studied in 125 patients with ankylosing spondylitis (AS). IgG antibodies to Borrelia burgdorferi were present in 11 of 125 patients (8.8%) and in 25 of 125 controls (20%). No patient had clinical Lyme borreliosis. HLA-B27 status was known for 82 patients with AS. There was no difference between B27+ and B27 patients. This study provides no evidence that Borrelia burgdorferi is associated with AS.

Lyme arthritis in The Netherlands: a nationwide survey among rheumatologists

A nationwide survey among all 118 Dutch rheumatologists (response rate 85%) yielded 42 patients with Lyme arthritis. The arthritis was nonpersistent in all these patients. A tick bite was reported by 23 of these 42 patients (55%). Erythema migrans was recalled by 19 patients (45%). Cardiac manifestations occurred in 4 patients (9%) and neurologic symptoms in 14 patients (33%). By immunoabsorbent assay or immunofluorescence technique 37 patients (88%) had positive IgG antibodies to Borrelia burgdorferi. The distribution of HLA-DR alleles of 28 of these patients was not different from the healthy population. The response to antibiotic treatment was considered good in 34 patients (81%). The clinical features of the Dutch patients with Lyme arthritis closely resemble the description of the disease reported from the United States.

Increased numbers of suppressor-cytotoxic cells in a patient with carbamazepine hypersensitivity

A patient is presented with a clinical syndrome of erythroderma, fever, liver function abnormalities, eosinophilia and atypical lymphocytosis due to carbamazepine hypersensitivity. Immunological analysis of peripheral blood mononuclear cells was performed using mouse monoclonal antibodies against T-cell and Ia antigens. A 12-fold increase in the absolute numbers of suppressor-cytotoxic T-cells was found, resulting in a reversed helper/suppressor ratio. Also the number of Ia-positive cells was greatly increased. Carbamazepine may induce a reversible proliferation and activation of the suppressor-cytotoxic subset of T-cells. Implications and pathogenetic possibilities are briefly discussed.