Surgical (over) treatment of pediatric Lyme arthritis: a need for faster Borrelia testing

Pediatric Lyme arthritis is described but not well-characterized in urban populations. Similarities in clinical features between Lyme and septic arthritis also results in some patients with Lyme arthritis undergoing surgical treatment. The aims of this study are to (1) characterize Lyme arthritis in an urban population and (2) determine what factors predispose patients with Lyme arthritis to undergoing surgery. We performed a retrospective review of children with Lyme arthritis at a single academic institution in New York City from 2016 to 2021. Inclusion criteria were age ≤18 years, involvement of a major joint, and positive Lyme serology. Patients treated with irrigation and debridement were compared to those treated non-surgically using Chi-squared tests with a significance of P  < 0.05. A total of 106 children with Lyme arthritis were included. Mean age was 9.5 years; 61.3% were male, and 71.7% were Caucasian. 46.2% lived in regions with an average household income >$100 000; 70.8% had private insurance. Ten patients (9.4%) underwent surgery for suspected septic arthritis. The operative group was more likely to have an elevated heart rate, white blood cell count, C-reactive protein level, erythrocyte sedimentation rate level and synovial cell count ( P  < 0.05). Patients were more likely to undergo surgery if they presented to the emergency department than to the clinic ( P  = 0.03). The average time for a Lyme test to result was 43.5 h, averaging 8.7 h after the surgical start time. Lyme arthritis occurs commonly in an urban pediatric population. Surgery is performed in ~10% of Lyme arthritis patients. More efficient diagnostic tests may reduce this rate.

Lyme Arthritis of the Pediatric Elbow: A Case Series

Most patients with untreated Lyme disease will experience joint symptoms. Owing to their resemblance in clinical presentation, Lyme arthritis and septic arthritis are often difficult to differentiate. However, their treatment is different. The elbow is rarely the first joint to present with symptoms. Therefore, Lyme disease is not commonly included in the differential diagnosis for children presenting with isolated elbow pain. The authors report 4 cases of monoarticular Lyme arthritis presenting in the elbow. There was an average delay of diagnosis of 4.75 days. Three cases were treated with oral antibiotics alone; 1 case was treated with unnecessary surgery due to uncertainty of the diagnosis and the delay in the laboratory performing the Lyme serology tests. The authors strongly recommend that Lyme serology be performed on an emergent basis to prevent unneeded surgery. [Orthopedics. 2018; 41(4):e511-e515.].

Lyme disease--unusual medical encounter for an urologist

Lyme disease also called ,,the illness with a thousand faces" ("The Great Imitator") because it may mimic very well the symptoms and signs of other diseases, is an unusual medical encounter for the urologist. Every patient with Lyme disease has his own clinical feature, while the superposition over an unknown but easy to discover urological disease may lead to a misdiagnosis.

CASE PRESENTATION

Male patient A. P. was an emergency transfer in our clinic with multiple system organ failure. The mirage of first imaging finding, bilateral obstructive ureteral calculi was obviated after the serological confirmation of Lyme disease suspected after the thorough history obtained from his family. The intensive care treatment, broad-spectrum antibiotics and hemodialysis sessions, together with external urinary drainage, lead to the improvement of the patient status, and subsequent proper urological treatment to urolithiasis cure.

CONCLUSIONS

This case identifies several challenges faced by practitioners, challenges which involve the diagnosis and the treatment of Lyme disease associated with urolithiasis. Although Lyme disease remains a controversial clinical entity, its diagnosis is based on a history of possible exposure to ticks, the appearance of specific clinical symptoms, whether or not combined with serological tests.

Lack of Borrelia burgdorferi DNA in synovial samples from patients with antibiotic treatment-resistant Lyme arthritis

OBJECTIVE

To determine whether Borrelia burgdorferi DNA may be detected in synovial tissue from patients with Lyme arthritis who have persistent synovial inflammation after antibiotic treatment.

METHODS

Synovial specimens obtained at synovectomy from 26 patients with antibiotic treatment-resistant Lyme arthritis and from 10 control subjects were tested for B burgdorferi DNA using 3 primer-probe sets that target genes encoding outer surface proteins A or B or a flagellar protein (P41) of the spirochete.

RESULTS

The 26 patients with Lyme arthritis, who had received antibiotic therapy for a mean total duration of 8 weeks prior to synovectomy, and the 10 control subjects each had negative polymerase chain reaction (PCR) results in synovial samples. When the samples were spiked with approximately 1-10 B burgdorferi, all but 1 had positive PCR results, suggesting that spirochetal DNA could have been detected in most of the unspiked samples if it had been present.

CONCLUSION

These results indicate that synovial inflammation may persist in some patients with Lyme arthritis after the apparent eradication of the spirochete from the joint with antibiotic therapy.

[Pars plana vitrectomy in Borrelia burgdorferi endophthalmitis]

BACKGROUND

Ocular manifestations of Lyme borreliose present with unusual forms of conjunctivitis, keratitis, optic nerve disease, uveitis, vitritis and rarely endophthalmitis.

CASE REPORT

A 57-year-old man working as logger in Sax-ony-Anhalt suffering from an endophthalmitis on his left eye was referred to us. The vision of his left eye was intact light perception and hand motions. The slit-lamp examination revealed severe inflammation of the anterior chamber with hypopyon, posterior synechiae, and opacity of the posterior lens capsule. Funduscopy showed no red reflex, no retinal details. In the local hospital serum analysis was performed and showed in Western-Blot IgM- and IgG-antibodies against Borrelia burgdorferi. Despite of intravenous application of ceftriaxon for 14 days panuveitis persisted, and endophthalmitis developed when antibiotic therapy was finished.

RESULTS

During pars plana vitrectomy a sharply delineated cystic lesion containing yellowish fluid was revealed, and creamy yellow fluid was aspirated. Microscopically in hematoxylineosin stained slides of the aspirate structures consistent with Borrelia burgdorferi were found. Postoperatively vision increased to 1/15. Despite of a second intravenous ceftriaxon treatment for 14 days we observed a retinal vasculitis in the follow up of 6 months.

CONCLUSIONS

Despite intravenous ceftriaxon-therapy borrelia burgdorferi must have survived in the vitreous body. Further investigations are required with respect to the use of other antibiotics or immunosuppressives.

Diagnosis and treatment of Lyme arthritis

Lyme arthritis typically causes intermittent attacks of oligoarticular arthritis in a few large joints, especially the knee. A small percentage of patients may develop chronic arthritis, again affecting primarily the knee. The diagnosis is usually based on the presence of this characteristic clinical picture, exposure in an endemic area, and a positive IgG antibody response to B. burgdorferi determined by ELISA and Western blotting. In addition, spirochetal DNA can often be detected in joint fluid by PCR. Joint involvement in this infection can usually be treated successfully with a 1- or 2-month course of oral doxycycline or amoxicillin, but patients with certain genetic and immune markers may have persistent arthritis despite treatment with oral or intravenous antibiotics. If patients have persistent arthritis despite a second course of antibiotics and if the results of PCR testing are negative, the author treats such patients with anti-inflammatory agents or arthroscopic synovectomy.

Chronic Lyme disease arthritis: review of the literature and report of a case of wrist arthritis

A case of Lyme arthritis with advanced degenerative changes localized to the midcarpal joint was treated with a limited wrist arthrodesis with relief of pain and improved function. Chronic Lyme arthritis occurs as the third stage of Lyme disease. Serologic testing and a history of a characteristic rash may be helpful in the diagnosis. Radiographic and histopathologic findings are nonspecific, with both degenerative and inflammatory characteristics. Intravenous antibiotics provide an effective treatment of chronic Lyme arthritis.

Treatment of refractory chronic Lyme arthritis with arthroscopic synovectomy

Of 20 patients who underwent arthroscopic synovectomy for refractory chronic Lyme arthritis of the knee, 16 (80%) had resolution of joint inflammation during the first month after surgery or soon thereafter, and they have remained well during the 3-8-year followup period. Three of these 16 patients who were more disabled preoperatively, still had mild functional limitation at long-term followup. The remaining 4 patients (20%) had persistent or recurrent synovitis. We conclude that arthroscopic synovectomy is effective in treating chronic Lyme arthritis in patients in whom the disease does not respond to antibiotic therapy.

Human necrotizing splenitis caused by Borrelia burgdorferi

A 25-year-old Hispanic male presented to the emergency room with complaints of severe left upper quadrant pain. Physicians determined that the patient had an acute inflammatory process with a possible diagnosis of splenic abscess. A splenectomy was performed. Histologic examination of the tissue sections revealed extensive necrosis and inflammation, but no etiologic agent was discernible. Microbiologic cultures of the tissue had negative results. A Dieterle silver stain revealed an overwhelming number of spirochetal bacteria most closely resembling Borrelia spp. The patient's serum was tested for serologic evidence of antibody to Borrelia burgdorferi with the following results; by indirect fluorescent antibody 1:32; by enzyme-linked immunosorbent assay for IgM, 1:320; and Western blotting had positive results for the presence of B. burgdorferi outer-surface protein antibodies. This is the first human case report of an acute necrotizing splenitis resulting from B. burgdorferi.