Occurrence of Lyme disease infection in a non-endemic area in Northern Italy

BACKGROUND

In Italy, the incidence of human tick-borne disease has increased over the last decades. Since 2015 a multidisciplinary group has been established in Sacco Hospital for the management of the patients affected by Lyme disease (LD). A retrospective evaluation (2015-2017) was performed for LD in non-endemic areas.

METHODS

Retrospective analysis of all 1000 samples for 800 patients screened for LD antibodies at the Sacco Hospital in 3 years (2015-2017). Clinical and epidemiological data were collected and compared with the serological results.

RESULTS

Among the 800 patients screened, 134 of them were diagnosed with borreliosis during 2015 (37 cases), 2016 (31 cases) and 2017 (66 cases). Localized LD was diagnosed 100 out of 134 cases (69%): in most of them (N.=63) erythema migrans has been documented; in 37 out of 100 it was not possible to detect it. In only three cases, patients complained of different clinical symptoms such as headache, arm and facial pain respectively. 23 out of 134 cases (16%) showed a persistence of serological positivity and symptoms with osteomuscular involvement and fatigue, despite the therapy (late LD). In that same study 11 out of 134 patients (7%) received a diagnosis of neuroborreliosis.

CONCLUSIONS

Our data reported a high percentage of LD infection (19%) in a non-endemic area. The definition of a Multidisciplinary Working Group and a clinical care pathway allowed a better clinical management of LD cases treated in Sacco Hospital, Milan.

Treatment of erythema migrans with doxycycline for 10 days versus 15 days

BACKGROUND

The efficacy of 10-day doxycycline treatment in patients with erythema migrans has been assessed in the United States but not in Europe. Experts disagree on the significance of post-Lyme borreliosis symptoms.

METHODS

In a noninferiority trial, the efficacies of 10 days and 15 days of oral doxycycline therapy were evaluated in adult European patients with erythema migrans. The prevalence of nonspecific symptoms was compared between patients with erythema migrans and 81 control subjects without a history of Lyme borreliosis. The efficacy of treatment, determined on the basis of clinical observations and microbiologic tests, was assessed at 14 days and at 2, 6, and 12 months. Nonspecific symptoms in patients and controls were compared at 6 months after enrollment.

RESULTS

A total of 117 patients (52%) were treated with doxycycline for 15 days, and 108 (48%) received doxycycline for 10 days. Twelve months after enrollment, 85 of 91 patients (93.4%) in the 15-day group and 79 of 86 (91.9%) in the 10-day group had complete response (difference, 1.6 percentage points; upper limit of the 95% confidence interval, 9.1 percentage points). At 6 months, the frequency of nonspecific symptoms in the patients was similar to that among controls.

CONCLUSIONS

The 10-day regimen of oral doxycycline was not inferior to the 15-day regimen among adult European patients with solitary erythema migrans. Six months after treatment, the frequency of nonspecific symptoms among erythema migrans patients was similar to that among control subjects.

CLINICAL TRIALS REGISTRATION

NCT00910715.

Evaluation of real-time PCR targeting hbb gene for Borrelia species identification

Several molecular methods have been employed for Borrelia species identification. Newly developed technology, real-time polymerase chain reaction (RT-PCR), combines simultaneous amplification, detection and differentiation of strains in one PCR run. The aim of the study was to perform and evaluate RT-PCR for Borreliaburgdorferi sensu lato species identification. Borrelia species identification was accomplished on 374 Borrelia strains using two approaches: 1.) MluI restriction of entire borrelial chromosome (MluI-large restriction fragment patterns, LRFP), and 2.) RT-PCR targeting hbb gene and specific melting temperature (Tm) detection. The results of the two molecular methods were compared. With MluI-RFLP we were able to differentiate all Borrelia species and their subtypes within particular species. RT-PCR based on Tm determination identified unique strains within the species Borreliaafzelii (Tm 66.11 degrees C), B. burgdorferi sensu stricto (Tm 68.18 degrees C), Borreliaspielmanii (Tm 59.45 degrees C) and Borreliavalaisiana (Tm 59.62 degrees C). We were not able to distinguish the last two species that shared almost identical Tm. The large majority of Borreliagarinii strains shared Tm 51.42 degrees C, while subtype Mlg4 was characterized by Tm 56.87 degrees C. Strains of Borrelialusitaniae species also were heterogeneous; human isolate had Tm 63.47 degrees C while two tick isolates shared Tm 61.77 degrees C. Differences inside hbb gene enabled differentiation of the majority of Borrelia species, and revealed two clusters within B. garinii and B. lusitaniae species, respectively, but it was not possible to distinguish B. spielmanii form B. valaisiana. The major advantage of RT-PCR was that it was easy to perform and that the results were obtained within a few hours.

Comparison of PCR methods and culture for the detection of Borrelia spp. in patients with erythema migrans

The sensitivities of two PCR assays and culture were compared for the detection of Borrelia spp. in skin specimens of 150 patients with typical erythema migrans. In addition, the accuracy of the methods for the identification of Borrelia spp. was compared by analysing culture isolates and material obtained directly from skin biopsy specimens. Borrelia burgdorferi sensu lato was isolated from 73 (49%) of 150 skin biopsy specimens. Using a nested PCR targeting the rrf-rrl region and a PCR targeting the flagellin gene, 107 (71%) and 36 (24%) specimens, respectively, were positive. With both PCRs, positive results were more frequent with culture-positive samples (67/73 (92%) and 24/73 (33%) for the nested and flagellin PCRs, respectively) than with culture-negative samples (40/77 (52%) and 12/77 (16%) for nested and flagellin PCR, respectively). Pulsed-field gel electrophoresis after MluI restriction identified 69/73 (95%) isolates, of which 58/69 (84%) were Borrelia afzelii and 11/69 (16%) were Borrelia garinii. After MseI restriction of PCR products amplified from the intergenic rrf-rrl region, B. afzelii was identified in 73/107 (68%) samples, B. garinii in 22/107 (21%) samples, and both species in 11/107 (10%) samples. The corresponding results for culture-positive specimens were 41/69 (59%), 14/69 (20%), and 7/69 (10%). Comparison of the results for specimens positive according to both approaches revealed complete uniformity in 80% of the cases. Overall, nested PCR was the most sensitive method for the demonstration of Borrelia spp. in erythema migrans skin lesions, followed by culture and PCR targeting the flagellin gene. The congruence of identification results obtained by analyzing culture isolates and material obtained directly from skin biopsies was relatively high but incomplete.

Comparison of different Borrelia burgdorferi sensu lato strains for detection of immune response in patients with erythema migrans

The aim of the present study was to establish which combination of serological method and Borrelia strain used as an antigen would provide the most appropriate demonstration of borrelial infection in patients with eythema migrans residing in Slovenia. Four different strains were chosen as antigens: two strains of B. afzelii and two strains of B. garinii which differed in their expression of the outer proteins OspA, OspB and OspC. Each individual strain was used as antigen in immunofluorescence test (IFT), enzyme-linked immunosorbent assay (EIA) with whole borrelial cells, and EIA with ultrasonicated borrelial cells. With these 12 different tests, 100 samples were examined for the presence of specific IgM and IgG antibodies: 50 sera of blood donors and 50 sera of patients with erythema migrans. The latter were further subdivided into skin culture-positive and -negative subgroups. A commercial Western blot (WB) test was performed for 26 sera of the control group and 25 sera of patients with erythema migrans. The four different methods had distinct specificity and sensitivity. The most specific approaches were IFT (100% for IgM and 90-92% for IgG) and the WB test (100% for IgM and 73% for IgG), followed by EIA with whole borrelial cells (80-98% for IgM and 76-84% for IgG) and EIA with ultrasonicated borrelial cells (76-94% for IgM and 72-80% for IgG). The sensitivity levels of all these tests were low. The most sensitive were EIA tests with whole borrelial cells (28-36% for IgM and 32-42% for IgG) followed by EIA with ultrasonicated borrelial cells (22-32% for IgM and 24-36% for IgG), the WB test (16% for IgM and 32% for IgG) and IFT (0-2% for IgM and 14-20% for IgG). The following methods gave significant differences between patients and negative controls in detecting IgM antibodies: EIA with whole borrelial cells with both B. afzelii antigens and with antigen B. garinii that expressed OspA and OspC, EIA with ultrasonicated borrelial cells with antigen B. afzelii that expressed OspA, OspB and OspC. In detecting IgG antibodies, significant differences were observed between EIA with whole borrelial cells and with antigen B. afzelii that expressed OspA and OspB. Borreliae were isolated from the skin of 34/50 (68%) patients with erythema migrans: two strains failed to grow, while 26/32 (81%) strains were identified as B. afzelii, 5/32 (16%) as B. garinii and 1/32 (3%) as B. burgdorferi sensu stricto. No statistically significant differences in serologic test results between culture-positive and -negative patients with erythema migrans were found.

Doxycycline versus ceftriaxone for the treatment of patients with chronic Lyme borreliosis

BACKGROUND

Therapeutic guidelines for treatment of late manifestations of Lyme borreliosis have not yet become well established. Patients with symptoms suggesting central nervous system involvement are often treated with courses of intravenous ceftriaxone. This is an expensive treatment approach with potentially severe side effects. We compared the efficacy, side effects and costs of doxycycline and ceftriaxone in the treatment of such patients.

PATIENTS AND METHODS

Adult patients qualified for the study if they had nonspecific symptoms suggesting central nervous system involvement for more than six months (but without overt clinical signs of the involvement), had positive serum borrelial antibody titers and/or erythema migrans prior to the onset of symptoms, had not been previously treated with antibiotics and did not have pleocytosis in the cerebrospinal fluid. Patients were given either 100 mg of oral doxycycline twice daily for 4 weeks (23 patients) or 2 g of intravenous ceftriaxone daily for 2 weeks followed by 100 mg of doxycycline twice daily for another 2 weeks (23 patients). Clinical outcome was assessed during a 12-month follow-up period.

RESULTS

Improvement in the frequency and/or the intensity of symptoms was reported by more than two-thirds of the 46 patients enrolled in the study. The two treatment regimens were found to be correspondingly effective. Photosensitivity reactions and gastrointestinal symptoms were noted more often among patients receiving doxycycline than in those receiving ceftriaxone. Treatment with doxycycline proved to be much cheaper than with ceftriaxone.

CONCLUSIONS

In patients with previously untreated chronic Lyme borreliosis with symptoms suggesting central nervous system involvement but without overt clinical signs of it, and without pleocytosis in the cerebrospinal fluid, treatment with doxycycline is as effective as with ceftriaxone. Treatment with doxycycline is cheap and relatively safe, but gastrointestinal symptoms and photosensitivity reactions can be expected more often than with ceftriaxone.

Electrocardiographic findings in children with erythema migrans

OBJECTIVE

To assess electrocardiographic findings in children with erythema migrans and to compare them with findings obtained in a healthy control group of comparable age and with a similar proportion of boys and girls.

METHODS

Electrocardiograms were carried out in 147 children under the age of 15 years before treatment with antibiotics for erythema migrans (solitary 68 patients, multiple 79 patients) and in the control group of 148 healthy children.

RESULTS

Abnormal electrocardiographic findings were detected more often in healthy children than in patients (14% versus 5%; P = 0.0303) and among patients more often in boys than in girls (10% versus 0%; P = 0.0107). Electrocardiographic abnormalities characteristic for Lyme borreliosis, such as atrioventricular blocks, were rare: in patients with erythema migrans only one child had first-degree atrioventricular block; in the control group one child had first-degree and another had second-degree atrioventricular block. Patients with erythema migrans had shorter PR and RR intervals and lower R and S wave voltages in V1 than the healthy children. Comparison among patients with solitary and multiple erythema migrans did not reveal significant electrocardiographic differences. The frequency of electrocardiographic abnormalities in patients with erythema migrans was not associated with the presence of systemic symptoms, or with the presence of meningitis or the isolation of Borrelia burgdorferi sensu lato from the blood.

CONCLUSIONS

Electrocardiographic abnormalities in children with erythema migrans are mild, nonspecific and rare. The presence of clinical signs and symptoms indicative or suggestive of disseminated Lyme borreliosis is not associated with higher frequency of such abnormalities. Comparison of findings in patients with erythema migrans and healthy children revealed several distinctions, some of which might have been interpreted as a result of altered activity of the autonomic nervous system.

Comparison of findings for patients with Borrelia garinii and Borrelia afzelii isolated from cerebrospinal fluid

BACKGROUND

The most common cause of Lyme neuroborreliosis in Europe is Borrelia garinii, followed by Borrelia afzelii. However, no series describing patients with culture-confirmed cases of Lyme neuroborreliosis have been published, and no comparison of findings for patients with B. garinii and B. afzelii isolated from cerebrospinal fluid (CSF) has been reported.

METHODS

All adult patients identified at a single medical center during a 10-year period who had borreliae isolated from CSF and typed as B. garinii or B. afzelii (using large DNA fragment patterns obtained with the MluI restriction endonuclease and separated with pulsed-field gel electrophoresis) were included.

RESULTS

A comparison of 23 patients who had B. garinii isolated from CSF with 10 patients who had B. afzelii isolated from CSF revealed that a reliable clinical diagnosis of Lyme neuroborreliosis (before obtaining a CSF culture and intrathecal borrelial antibody production result) was established more frequently in the B. garinii group than in the B. afzelii group (19 of 23 patients vs. 1 of 10 patients). Patients in the B. garinii group reported radicular pains and expressed meningeal signs more often, but reported dizziness less often (occurrences of several other symptoms and/or signs were comparable). Lymphocytic pleocytosis, as well as several other CSF abnormalities, were frequent among patients with B. garinii isolated from CSF but were rare among patients in the B. afzelii group.

CONCLUSIONS

Patients with B. garinii isolated from their CSF have a distinct clinical presentation, compared with patients with B. afzelii. B. garinii causes what, in Europe, is appreciated as typical early Lyme neuroborreliosis (Bannwarth syndrome), whereas the clinical features associated with B. afzelii are much less specific and more difficult to diagnose.

Erythema migrans in solid-organ transplant recipients

Six adult solid-organ transplant recipients who had chronic drug-induced immunosuppression and who presented with solitary erythema migrans were treated with antibiotics administered at the same dosage and for the same duration used for the treatment of early, localized Lyme borreliosis in immunocompetent patients. The patients had a smooth course of illness and a favorable outcome but did not develop a measurable borrelial serum antibody response.

Differentiation ofBorrelia burgdorferi sensu lato species by temperature gradient gel electrophoresis

Borrelia burgdorferi sensu lato is a multispecies complex of pathogenic spirochetes, causing Lyme borreliosis. Due to clinical, epidemiological, and taxonomical implications, there is a need for identification of isolated Borrelia strains. In the present study, we have optimized TGGE for B. burgdorferi sensu lato species differentiation and the results were compared with two reference methods, namely PFGE and restriction of 5S-23S intergenic space region PCR product. A differentiation of B. garinii, B. afzelii, and B. burgdorferi senso stricto species with TGGE was possible and intraspecies variation was detected. Results compared between TGGE, PFGE, and restriction of 5S-23S intergenic space region PCR product showed no difference in specificity of species identification.

Risk of culture-confirmed borrelial persistence in patients treated for erythema migrans and possible mechanisms of resistance

Erythema migrans (EM) develops at the site of the tick bite in 77-90% of Lyme borreliosis (LB) patients and is therefore a common manifestation of early disease. Clinical treatment failures have been reported in early LB cases for almost every suitable antimicrobial agent. The exact risk of resistance to antibiotic treatment in patients with EM, however, is not known and there are few published cases of culture-proven treatment failure. Moreover, currently available diagnostic techniques cannot reliably discriminate between possible reinfection, true endogenous relapse and co-infection with other tick-borne pathogens. These drawbacks together with the phenomenon of resistance to therapy in individual patients undoubtedly contribute to the inconsistencies surrounding the optimal treatment regimens for LB and are often misinterpreted and misused to support prolonged antibiotic treatment regimens. The question for the underlying mechanisms of possible antimicrobial resistance in Borrelia burgdorferi sensu lato remains unresolved but a better understanding of such genetic or phenotypic mechanisms would be helpful for the treatment of LB and other spirochetal diseases. Investigations on this issue, at best, should start with borrelial isolates cultured from patients before the start of antibiotic therapy and again after the conclusion of treatment. This task, however, remains challenging insofar, as culture is rarely successful under routine laboratory conditions after antimicrobial therapy. Here, we review recent clinical and experimental data on treatment resistance in EM patients suggesting that, although rare, borrelial persistence does occur at the site of the infectious lesion after antibiotic treatment. Borrelial persistence, however, is unlikely to result from acquired resistance against antimicrobial agents that were used for initial specific chemotherapy.

Comparison of isolation rate of Borrelia burgdorferi sensu lato in MKP and BSK-II medium

Different media have been utilized for borrelial cultivation. The aim of the present study was to evaluate the isolation rate of Borrelia burgdorferi sensu lato from two commonly used media, i.e. modified Kelly-Pettenkofer (MKP) and Barbour-Stoenner-Kelly II (BSK-II) medium, and to compare the isolated strains with regard to their phenotypic and genotypic characteristics. Skin biopsy specimens of 2 x 2 x 4 mm were taken from the peripheral site of human solitary erythema lesions and were divided in two pieces, one of which was inoculated into MKP and the other one into BSK-II medium. Species analysis of the obtained strains was performed and their plasmid and protein profiles were determined. Borrelia strains were isolated from 48/96 patients (50%) with erythema migrans. We obtained in 26/48 patients (54%) from MKP as well as from BSK-II, in 11 patients (23%) only from MKP, and in another 11 (23%) only from BSK-II medium a positive result. B. afzelii was isolated from 43 patients (23 were positive in both media, nine in MKP only and 11 in BSK-II medium only), while B. garinii was isolated from five patients (in three from both media, in two from MKP only). All strains of the obtained strain pairs were identical according to species and the type within the species. Plasmid profiles were identical in 17/21 B. afzelii strain pairs (81%) and in 1/3 B. garinii strain pairs; in 6/24 strain pairs, distinctions in the number of plasmids or in their molecular mass were present. Differences in the protein profile were found in 7/24 strain pairs (29%). The distinctions were uniform and were limited to the expression of OspC. In conclusion, our study showed comparable Borrelia isolation rates from MKP and BSK-II medium. The results of the present study indicate that human patients with Lyme borreliosis may simultaneously harbor heterogeneous B. burgdorferi s.l. strains.

Susceptibility of Borrelia afzelii strains to antimicrobial agents

The aim of the present study was to determine the susceptibility of Borrelia afzelii strains to antibiotics, and to test the hypothesis that persistence of borrelia in skin, after therapy, is a consequence of resistance to the antibiotic used for treatment. Ten B. afzelii strains isolated from skin of seven adult patients (two with acrodermatitis chronica atrophicans, five with erythema migrans) were studied. In three patients B. afzelii was isolated from erythema migrans lesion before antibiotic therapy and 2-3 months after treatment with cefuroxime axetil (two patients) or with ceftriaxone (one patient). MICs and MBCs for amoxicillin, azithromycin, ceftriaxone, cefuroxime, doxycycline and amikacin were measured. There was total resistance to amikacin but isolates were susceptible to all other antibiotics except one isolate that was resistant to cefuroxime, MIC > 4 mg/L. Comparison of MBC values after 3 and 6 weeks' incubation revealed comparable results for azithromycin and ceftriaxone while for amoxicillin, cefuroxime and doxycycline, some differences were found. In one of the patients from whom there were borrelia isolated before and after treatment with cefuroxime axetil, both isolates were resistant to cefuroxime. In the other two patients, the paired isolates were susceptible to the antibiotic used for therapy.

Prevalence and incidence of Lyme borreliosis among Slovene forestry workers during the period of tick activity

OBJECTIVES

To establish the prevalence and incidence of symptomatic and asymptomatic infection with Borrelia burgdorferi sensu lato during the period of tick activity, to compare the risk of infection with B. burgdorferi s.l. for forestry workers and indoor workers in Slovenia, and to compare the outcome of an in-house immunofluorescent assay (IFA) and a commercially available enzyme-linked immunosorbent assay (ELISA).

METHODS

The study included 122 forestry workers; the control group consisted of 93 indoor workers. All participants were examined twice in 2002: before the beginning of tick activity (March) and at the end of tick activity (November). At each examination, principal demographic and epidemiological data were collected and a blood sample taken for serological analysis. Specific IgM and IgG antibodies against B. burgdorferi s.l. in the paired sera were determined with an in-house IFA and a commercially available ELISA flagellin test (DAKO).

RESULTS

9.8% of the forestry workers and 4.3% of the indoor workers tested positive for IgG with the IFA (p = 0.26); 23.8% of the forestry workers and 9.7% of the indoor workers tested positive for IgG with the ELISA (p = 0.02). During the study period the incidence of symptomatic Lyme borreliosis was 2.3% and the rate of IgG and/or IgM seroconversion of 10.2% was the same with both tests.

CONCLUSIONS

The seroprevalence of antibodies against B. burgdorferi s.l. among the Slovene forestry workers was greater than among the indoor workers, but the difference between the two groups was not significant when the IFA was used. The incidence of Lyme borreliosis during the period of tick activity was lower than we expected, with a large proportion of seroconversions being asymptomatic.

Comparison of growth of Borrelia afzelii, B. garinii, and B. burgdorferi sensu stricto in MKP and BSK-II medium

Lyme borreliosis is a tick-borne disease caused by genetically diverse Borrelia strains including B. afzelii, B. garinii, and B. burgdorferi sensu stricto (s.s.). The aim of the present study was to assess and compare the growth of one strain per species of B. afzelii, B. garinii, and B. burgdorferi s.s. in modified Kelly-Pettenkofer (MKP) and Barbour-Stonner-Kelly-II (BSK-II) medium, and to check for the presence of the overgrowth after inoculating the media with a mixture of two different Borrelia species. All three Borrelia strains grew well in both media. In the majority of the experiments the number of B. afzelii cells was higher in MKP than in BSK-II medium while for B. garinii and B. burgdorferi s.s. a tendency for better growth in BSK-II than MKP was established. In a mixture of equivalent amounts of two species, B. burgdorferi s.s. as a rule overgrew the other two species while in the mixture of B. afzelii and B. garinii the latter was a "dominant" strain. Comparing the performance of the two media, B. burgdorferi s.s. usually overgrew either B. afzelii or B. garinii in MKP as well as in BSK-II medium, however, the results were found to be statistically significant only for MKP medium. In the mixture of B. afzelii and B. garinii the latter was the predominant species but significant differences were established only for BSK-II medium. It seems that the overgrowth is predominantly the result of the characteristics of the individual Borrelia species and most probably not a consequence of growth differences in the two culture media. Further work with a larger number of strains is needed to confirm these findings.

Comparison of Erythema Migrans Caused by Borrelia afzelii and Borrelia garinii

BACKGROUND

We compared epidemiological and clinical characteristics of patients with erythema migrans (EM) caused by Borrelia afzelii and Borrelia garinii.

PATIENTS AND METHODS

200 consecutive adult patients with B. afzelii isolated from the skin lesion and 53 consecutive adult patients with EM caused by B. garinii qualified for the present study.

RESULTS

Comparison of the two groups revealed several distinctions. Patients with EM caused by B. garinii were older, had their skin lesions more often located on the trunk but less often on extremities, had shorter incubation and faster evolution of EM, more often reported associated local and certain systemic symptoms, had abnormal liver function test results more often and were more frequently seropositive.

CONCLUSION

Early localized Lyme borreliosis caused by B. afzelii and B. garinii has distinct epidemiological and clinical characteristics. Clinical features of EM depend upon the genospecies of Borrelia burgdorferi sensu lato causing the illness.

Comparison of self-assessment and scutal index for the duration of Ixodes ricinus tick attachment

Experimental studies have shown that the efficacy of transmission of B. burgdorferi sensu lato from an infected tick to an experimental animal is significantly associated with the duration of tick attachment. Scutal index is the ratio between body length and scutum width and was found to be an objective indicator of the duration of Ixodes scapularis tick attachment, but no data for I. ricinus have been published. In this preliminary report on 30 volunteers with an attached I. ricinus tick (21 had an adult female tick and 9 a nymph), none developed any sign of Lyme borreliosis but we were able to demonstrate two asymptomatic seroconversions in a six-week follow-up period. Twenty-six (87%) volunteers claimed that they were able to determine the approximate duration of tick attachment; participants with attached adult female ticks estimated the duration of attachment to be 30 (2-90) hours, while those with attached nymphs reported 48 (18-90) hours (p = 0.681). Scutal indices were 3.2 (2-5) for nymphs and 3.2 (1-5) for adult ticks, indicating 60- and 48-hour attachment, respectively. According to the volunteers' assessment and scutal index findings, approximately 80% and 45% of adult female ticks were removed within 48 hours after the tick bite (p = 0.032), respectively, while the corresponding values for nymphs were 85% and 17% (p = 0.053). Our findings were limited by low numbers of volunteers and by the lack of experimental data on the value of the scutal index for estimation of the duration of I. ricinus tick attachment.

Double infection with tick borne encephalitis virus and Borrelia burgdorferi sensu lato

The limited information on co-infection with Borrelia burgdorferi sensu lato and tick-borne encephalitis (TBE) virus was a stimulus for presentation of two patients with well-defined double infection of the central nervous system. TBE virus and B. burgdorferi sensu lato infections are searched for in all patients with lymphocytic meningitis and/or meningoencephalitis admitted to our department. During the last ten years we identified two patients who had ELISA IgM and IgG antibodies to TBE virus in serum and a positive PCR result for TBE virus in cerebrospinal fluid as well as B. burgdorferi sensu lato isolated from cerebrospinal fluid. Intrathecal production of borrelial antibodies was not proven in either of the two patients. These findings show that in patients with acute lymphocytic meningitis originating in regions endemic for Lyme borreliosis and TBE, the possibility of concomitant infection should be considered.

Children with multiple erythema migrans: are there any pre-treatment symptoms and/or signs suggestive for central nervous system involvement?

OBJECTIVE

To establish eventual signs and symptoms suggestive for central nervous system involvement in children with multiple erythema migrans.

METHODS

Patients younger than 15 years with multiple erythema migrans, diagnosed at our department from 1996 to 2000, were included in this prospective study. Demographic, clinical and laboratory findings were obtained and compared for a group of patients with pleocytosis (interpreted as a sign of central nervous system involvement) and a group of children with normal cerebrospinal fluid findings.

RESULTS

Cerebrospinal fluid pleocytosis (cell counts > or = 5 x 10(6)/l) was detected in 55/214 (25.7%) children; it was lymphocytic in 94.5% of patients and ranged from 5 to 320 (median, 10 x 10(6)/l). Compared with the group with normal cerebrospinal fluid findings, patients with pleocytosis more often reported having had Lyme borreliosis in the past (8/55 versus 3/159; p = 0.0011), had longer incubation periods (25.5 versus 14 days; p = 0.0269), larger diameter of the largest erythema migrans at the time of first examination (10 versus 5.5 cm; p = 0.0055), higher frequency of associated systemic symptoms (45.5% versus 21.4%; p = 0.0011), positive meningeal signs (10.9% versus 1.9%; p = 0.0100), borrelial IgG antibodies in cerebrospinal fluid (3/49 versus 0/150; p = 0.0142) and B. burgdorferi s.l. isolated from cerebrospinal fluid (7/52 versus 1/147; p = 0.0004), but less often had mild initial disease (67.3% versus 88.7%; p = 0.0006).

CONCLUSIONS

Cerebrospinal fluid pleocytosis was detected in 25.7% of children with multiple erythema migrans. Although several clinical and laboratory abnormalities were present significantly more often in patients with elevated cell counts than with normal cerebrospinal fluid findings, discriminatory significance for the majority of these abnormalities was low, particularly because of low negative predictive values. In more than 2/3 of patients with pleocytosis the initial disease was mild, fewer than 1/2 reported systemic symptoms, and meningeal signs were expressed in only 11%.

Isolation of Borrelia burgdorferi sensu lato from a fibrous nodule in a patient with acrodermatitis chronica atrophicans

A 66-year-old woman presented with a 2-year history of acrodermatitis chonica atrophicans of her left hand and associated fibrous nodules. In addition to skin changes she experienced profound fatigue, and pains and swelling of the left elbow and dorsum of the left hand. On clinical examination, typical livid-red discoloration of the skin distally from the left elbow was evident with atrophy on the dorsum of the hand. Nodules with diameters from 0.5 to 2 cm were present around the olecranon and along the ulnar region. The indirect immunofluorescent assay (IFA) without absorption in serum revealed negative borrelial IgM and positive IgG (1:512) antibody titres. Histological findings on tissue specimens were compatible with acrodermatitis chronica atrophicans and fibrous nodule tissue, respectively. Cultures in MKP medium of biopsy specimens from the involved skin and from one of the nodules were positive. Both isolates were identified as B. afzelii with concordant protein and plasmid profiles. The patient received a 3-week course of ceftriaxone (2 g daily, i.v.). Her condition progressively improved: pains and swelling vanished by the end of treatment, fibrous nodules diminished and skin lesions gradually began to fade. According to a MEDLINE literature search this is the first report of the isolation of B. burgdorferi sensu lato from a fibrous nodule in a patient with acrodermatitis chronica atrophicans.

Solitary borrelial lymphocytoma in adult patients

During the period from 1986 to 2000, 85 adult patients with solitary borrelial lymphocytoma were diagnosed at the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia. There were 36 (42.4%) females and 49 (57.6%) males with a median age of 49 (15-74) years. Borrelial lymphocytoma was located on the breast (nipple--areola mammae region) in 68 (80%) patients, on the ear lobe in eight (9.4%), and in other locations in nine (10.6%). A concomitant erythema migrans enabling clinical diagnosis of Lyme borreliosis was registered or reported in 67 (78.8%) patients. Fifteen (17.6%) patients had no accompanying symptoms, 34 (40%) reported local and constitutional symptoms, 23 (27.1%) recounted only local symptoms, and 13 (15.3%) patients had solely constitutional symptoms. Clinical findings indicating early disseminated borrelial infection were observed at the first visit in 12 (14.1%) patients: six (7.1%) had multiple erythema migrans, one had meningitis, one meningoradiculitis and arthritis, one radiculoneuritis and arthritis, one peripheral facial palsy and concomitant meningitis, and two arthritis. In addition, one of the patients with borrelial lymphocytoma on the breast had acrodermatitis chronica atrophicans. A seropositive response to borrelial antigens was found in 30 (35.3%) patients at the initial examination. In 11/46 (23.9%) patients, infection with Borrelia burgdorferi sensu lato was confirmed by isolation of the agent from lymphocytoma tissue. Eight out of nine (88.9%) typed borrelial strains were found to be B. afzelii, and one (11.1%) B. bissettii. Patients were treated with doxycycline, azithromycin, amoxycillin, cefuroxime-axetil, phenoxymethylpenicillin, or ceftriaxone. Median time to complete disappearance of lymphocytoma was 28 days (range 7-270 days) after the institution of antibiotic treatment; disappearance took longer in patients with prolonged duration of the skin lesion prior to treatment. Treatment failure was registered in 11 (12.9%) patients who were later re-treated. The outcome of borrelial infection assessed at the end of a follow-up period of one year was favourable.

Comparison of pulsed-field gel electrophoresis (PFGE) and two different polymerase chain reactions (PCRs) for species identification of Borrelia burgdorferi sensu lato strains

The purpose of the present study was to compare the findings of three different molecular-biological methods for Borrelia burgdorferi sensu lato species identification: (i) large DNA fragments pattern obtained with Mlul restriction endonuclease and separated with pulsed-field gel electrophoresis (PFGE); (ii) polymerase chain reaction (PCR), the region inside the 16S rRNA gene multiplied with species-specific primers; and (iii) PCR, the interspace region between the 5S and 23S rRNA genes amplified, the PCR product restricted with Msel restriction endonuclease and fragments separated in polyacrylamide gel. Forty-eight Borrelia strains isolated from diverse clinical materials and two tick strains were analyzed. Each of the 50 isolates analyzed by PFGE was found to be a single species: 30 B. afzelii, 14 B. garinii, and 6 B. burgdorferi sensu stricto. PCR amplification of 16S rRNA with species-specific primers revealed a single species in 41/50 samples and in nine samples two species were detected. PCR of the 5S-23S interspace region restricted with MseI restriction endonuclease detected a single species in 48/50 samples and a mixture of two species was found in 2/50 samples. In all cases where a single species was identified using PCR the species was in accordance with the PFGE result, and in all cases where a mixture of two species was identified by PCR one of the species was the same as that detected by PFGE. Using a criterion of complete concordance of the results a significant difference in species identification was found when PFGE and the 16S rRNA PCR were compared (p = 0.0026), but not between 5S-23S interspace PCR and PFGE (p = 0.4949) or between 16S rRNA and 5S-23S interspace PCRs (p = 0.0552). PCR assays were faster and easier to perform than PFGE for Borrelia species identification, however PFGE remains a standard procedure for analyzing isolates and demonstrating heterogeneity within species.

Solitary erythema migrans in children: comparison of treatment with azithromycin and phenoxymethylpenicillin

OBJECTIVE

To compare clinical effectiveness and side effects of treatment with azithromycin or phenoxymethylpenicillin in children with solitary erythema migrans.

METHODS

Consecutive patients younger than 15 years, referred to our institution in 1998 and 1999 with previously untreated typical solitary erythema migrans, were included in this prospective study. Basic demographic features and clinical data were collected by means of a questionnaire. The efficiency of treatment of acute disease, development of later major and/or minor manifestations of Lyme borreliosis and side effects of treatment were surveyed by follow-up visits during the first year.

RESULTS

Forty-two patients received azithromycin 20 mg/kg/day for the first day followed by 10 mg/kg/day for a further four days and phenoxymethylpenicillin 100,000 IU/kg/day for 14 days. No differences in demographic and clinical pre-treatment characteristics were present in the two groups, with the exception of the duration of erythema migrans before treatment (3 days in the azithromycin group versus 4 days in the phenoxymethylpenicillin group; p = 0.0320). The clinical course during the post-treatment period revealed no significant differences between the two groups in the duration of EM (3 days versus 4 days; p = 0.2471), the appearance of minor manifestations of Lyme borreliosis (17.5% in the azithromycin group versus 24.4% in the phenoxymethyl-penicillin group; p = 0.6252), or in the emergence of major manifestations of Lyme borreliosis (one patient in each treatment group). One year after antibiotic treatment all patients were asymptomatic. Side effects of treatment were observed in 5.3% of patients treated with azithromycin and in 6% treated with phenoxymethylpenicillin. The appearance of "Herxheimer's reaction" at the beginning of treatment was recorded in 7 out of 42 patients (6%) in each treatment group.

CONCLUSIONS

Azithromycin and phenoxymethylpenicillin are equally effective in treatment of children with solitary erythema migrans and have comparable side effects.

Characterization of Borrelia burgdorferi sensu lato strains isolated from human material in Slovenia

The aim of the study was to assess genotypic and phenotypic diversity among a large number of clinical isolates of Borrelia burgdorferi sensu lato obtained from patients in Slovenia. Plasmid profiles and species identification were determined by PFGE, protein profiles by SDS-PAGE. Of 706 B. burgdorferi sensu lato human isolates 599 (85%) were found to be B. afzelii, 101 (14%) B. garinii and six (1%) B. burgdorferi sensu stricto. The vast majority of strains (605; 86%) were isolated from skin, 58 (8%) from blood, and 43 (6%) from CSF. When analysed by RFLP, B. afzelii strains were unique, while heterogeneity was found within B. garinii and B. burgdorferi sensu stricto species. An unusual plasmid content was found in 52/706 (7%) isolated strains, more often in B. garinii than in B. afzelii strains. A plasmid dimer was found in B. afzelii and B. garinii strains, whereas multiple copies of the large plasmid were associated nearly exclusively with B. garinii strains. Analysis of protein profiles revealed that OspA and OspB are expressed more often by B. afzelii strains, and OspC by B. garinii strains. Heterogeneity of Borrelia strains may play a significant role in the virulence and pathogenesis of the infection. Differences in antigenic components have an important impact on serological testing and vaccine development.

Sensitivity of culture and polymerase chain reaction for the etiologic diagnosis of erythema migrans

Skin biopsy samples from 150 patients with typical cutaneous manifestation of Lyme borreliosis, erythema migrans, were cultivated for the presence of Borrelia burgdorferi sensu lato in modified Kelly Pettenkofer (MKP) medium and analysed with two different polymerase chain reactions using either flagellin or nested OspA primers. Cultivation was successful in 75 of 150 (50%) skin samples. Out of 70 strains that were typed using PFGE, B. afzelii was identified in 60 (86%), B. garinii in 10 (14%) specimens, while no B. burgdorferi sensu stricto strains were found. B. burgdorferi sensu lato DNA was detected with polymerase chain reaction in 28% and 61% of skin samples, using flagellin and nested OspA primers, respectively. Concordant results in all three procedures employed in the present study were found in 62 (41%) specimens: 25/150 (17%) were positive with all three methods and 37/150 (25%) samples were completely negative.

Cerebrospinal fluid findings in adult patients with multiple erythema migrans

This prospective study was performed at the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia, in the period from 1991 to 2000. We included all adult patients with multiple erythema migrans who gave consent to lumbar puncture, had routine blood and CSF tests performed, and borrelial antibody titres in CSF and blood determined. In the majority of these patients skin, blood, and CSF specimens were cultured in MKP medium for the presence of Borrelia. Of 332 patients with multiple erythema migrans, 200 (115 females, 85 males, aged 15-80 years) fulfilled inclusion criteria. The median number of skin lesion was three (2-60). Sixty-three (31.5%) patients had no associated symptoms, whereas 137 (68.5%) patients (including two with arthritis, six with radicular pain, a patient with facial palsy, another patient with foot palsy and a patient with transitory diplopia) reported local and/or constitutional symptoms. Routine CSF examination revealed abnormal results in 62/200 (31%) patients: lymphocytic pleocytosis (6-1119 x 10(6)/L leukocytes) was found in 15 (7.5%) patients (six were clinically without systemic symptoms, six had mild systemic symptoms, three reported radicular pains) and elevated CSF protein concentration was present in 52 (26%) patients (nine also had elevated CSF cell counts). Intrathecal borrelial antibody production was demonstrated in eight (4%) patients (only three of them had elevated CSF cell counts) and B. burgdorferi sensu lato was isolated from skin lesions, blood, and CSF in 77/191 (40.3%), 3/154' (1.95%), and 2/200 (1%) patients, respectively. B. afzelii predominated among the isolates. In patients with multiple erythema migrans abnormal CSF findings are not rare and may be present without any clinical sign of central nervous system involvement.

Cerebrospinal fluid findings in patients with symptoms suggesting chronic Lyme borreliosis

BACKGROUND

Patients with non-specific long-lasting symptoms such as headache, concentration disturbances, and vertigo and who have positive serum borrelial antibody titres are often assumed to have chronic Lyme borreliosis. Because of the possibility that they may have central nervous system involvement they are frequently treated with courses of i.v. ceftriaxone. We assessed central nervous system involvement by examining cerebrospinal fluid samples in a group of such patients.

PATIENTS AND METHODS

Adult patients who qualified for the study had non-specific symptoms suggesting central nervous system involvement for longer than six months (but without overt clinical signs of such involvement) and positive serum borrelial antibody titres and/or erythema migrans prior to the onset of symptoms. Cerebrospinal fluid was examined in all patients.

RESULTS

None of the 77 patients included in the study (median duration of symptoms 18 months) had pleocytosis and there was no isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid. Mildly elevated protein concentration and intrathecal borrelial IgG antibody synthesis were demonstrated in 16 (21%) and 7 (9.1%) patients, respectively.

CONCLUSIONS

In patients with non-specific long-lasting symptoms attributed to Lyme borreliosis but with the absence of overt clinical signs suggesting central nervous system involvement, the findings of cerebrospinal fluid examination are usually in the normal range. Routine treatment of such patients with i.v. ceftriaxone is not to be encouraged.

Evaluation of immunofluorescence test (IFT) and immuno (western) blot (WB) test in patients with erythema migrans

The diagnosis of Lyme borreliosis is based on the recognition of typical clinical signs and is assisted by laboratory confirmation of borrelial infection. The aim of the present study was to assess the value of an immunofluorescence test (IFT) and an immuno (western) blot (WB) test for the detection of Borrelia burgdorferi sensu lato antibodies in patients with erythema migrans residing in Slovenia. We determined specific IgM and IgG antibodies in 117 patients with erythema migrans and 96 healthy persons using an IFT (in-house test) and a commercial WB test. Skin biopsies of erythema migrans lesions were cultured, and isolated strains were identified with PFGE. There were 66/117 (56.4%) culture-positive and 51/117 (43.6%) culture-negative patients. B. afzelii was found in 52/62 (84%) and B. garinii in 10/62 (16%) biopsies. IFT-IgM antibodies were established in 2/117 (1.7%) erythema migrans patients and in none of the control group, while WB-IgM antibodies were present in 56/117 (48%) patients with erythema migrans and 21/96 (22%) members of the control group (p = 0.002). IFT-IgG antibodies were demonstrated in 3/117 (2.2%) erythema migrans patients and 2/96 (4%) persons of the control group, while corresponding values for WB-IgG were 36/117 (31%) and 26/96 (27%), respectively (non-significant differences). IgM antibodies directed against p41 and OspC, and IgG antibodies directed against p41, p18 and OspC were frequently found in both erythema migrans patients and the control group. The only significant difference between erythema migrans patients and the control group in the WB test was in the reaction of IgM antibodies with OspC antigen, which was found in 54/117 (46%) erythema migrans patients and 18/96 (18.8%) healthy persons (p < 0.0001). The immune response in patients with erythema migrans was very similar to that of the control group determined with either the IFT or WB test.

Analysis of Borrelia burgdorferi sensu lato isolated from cerebrospinal fluid

Involvement of the nervous system in Lyme borreliosis may occur with or without erythema migrans and it may present with a variety of neurological symptoms. In this study we analysed phenotypic and genotypic characteristics of 40 Borrelia strains isolated from cerebrospinal fluid (CSF) of 38 Slovenian patients with different clinical manifestations of Lyme borreliosis. In seven of the patients, Borreliae were also isolated from skin lesions. Species identification and plasmid profiles were determined by pulsed-field gel electrophoresis and protein profiles by SDS-PAGE. MluI digestion profiles of Borrelia burgdorferi sensu lato DNA showed that 25 (62.5%) isolates were B. garinii, 14 (35%) B. afzelii, and one (2.5%) B. burgdorferi sensu stricto. All strains, except one, possessed a large plasmid and a varying number of smaller plasmids. Three (7.5%) isolates exhibited an unusual plasmid profile, with a large plasmid dimer or three copies of the large plasmid. In protein analyses, all strains expressed OspA protein. OspB was present significantly more often in B. afzelii than B. garinii strains (p=0.0000), while OspC was more often present in B. garinii than B. afzelii strains (p=0.0052). In the seven patients with Borreliae isolated also from the skin, the CSF and skin isolates were identical, either B. garinii (six patients) or B. afzelii (one patient). Species and plasmid heterogeneity as well as antigen diversity could play a role in the pathogenesis of the infection. When combined with our own earlier data, the results suggest species-related organotropism.

Isolation of Borrelia burgdorferi sensu lato from blood of children with solitary erythema migrans

OBJECTIVES

To establish the frequency of isolation of Borrelia burgdorferi sensu lato from blood of children with solitary erythema migrans (EM) in Europe, to determine the strains of the isolated borreliae and to compare the clinical course and the outcome of the disease according to positive and negative blood culture result.

METHODS

In the prospective study we included 134 consecutive patients younger than 15 years with solitary EM, referred to our institution in 1996 and 1997. One milliliter of blood was withdrawn before treatment and cultured in modified Kelly-Pettenkofer medium. Isolated borreliae were typed according to LRFP analysis. Patients were treated with either penicillin V or cefuroxime axetil for 14 days. The posttreatment course was surveyed by follow-up visits during 1 year.

RESULTS

B. burgdorferi sensu lato was isolated in 12 of 134 (9%) patients. Eleven blood isolates were typed: 10 were found to be B. afzelii and 1 was Borrelia garinii. Comparison of blood culture-positive and -negative patients revealed no differences in pretreatment characteristics or in posttreatment clinical course. However, worsening of local and/or systemic signs and symptoms at the beginning of antibiotic therapy (Jarish-Herxheimer's reaction) was identified more often in the blood culture-positive than in the blood culture-negative group (5 of 12 vs. 17 of 122, respectively; P = 0.0274).

CONCLUSIONS

The isolation rate of B. burgdorferi sensu lato from the blood of children with solitary EM was 9%. The majority of the isolates were B. afzelii. Blood culture-positive patients treated with oral antibiotics were not at greater risk for unfavorable course of the disease than patients with negative blood culture result.

Isolation of Borrelia burgdorferi sensu lato from blood of patients with erythema migrans

BACKGROUND

We assessed the isolation rate of Borrelia burgdorferi sensu lato from blood in European patients with typical erythema migrans and evaluated the course and outcome of their illness.

PATIENTS AND METHODS

Adult patients diagnosed with erythema migrans and from whom borreliae cultured from blood were included in this study.

RESULTS

Borreliae were isolated from the blood of 35/2,828 (1.2%) patients, on average 7 days (range 1-47 days) after the appearance of erythema migrans. Only seven (20%) patients reported constitutional symptoms. 24/35 isolates were typed of which 20 were Borrelia afzelii and four were Borrelia garinii. 31 (88.6%) patients were treated with oral antibiotics while four (11.4%) received ceftriaxone iv. The course and outcome of the illness were favorable in all patients.

CONCLUSION

In European patients with erythema migrans the yield of blood culturing was low, spirochetemia was often clinically silent and the course and outcome of the illness were favorable; the predominantly isolated strain was B. afzelii.

Demographic features, clinical characteristics and laboratory findings in children with multiple erythema migrans in Slovenia

OBJECTIVE

To identify demographic, clinical and laboratory characteristics of children with multiple erythema migrans (EM) in Slovenia.

METHODS

We prospectively studied patients aged 15 years and less, examined at our department for multiple EM in 1996 and 1997. Demographic and clinical data were collected by means of a questionnaire. In addition, basic haematological and biochemical investigations, serologic testing, and Borrelia cerebrospinal fluid and blood cultures were performed.

RESULTS

Ninety-five children (44 girls, 55 boys) aged 1 to 13.5 (median, 4.5) years fulfilled the inclusion criteria. A tick bite was recalled by 23%. The incubation period was 10.5 (range, 1 to 150) days, the duration of skin lesions before the initial examination 4 (range, 1 to 54) days, and the median number of skin lesions, 4.5 (range, 2 to 35). The initial disease was mild in 81% of patients. Local and systemic symptoms were reported by 11% and 30% of children, respectively. Clinical signs accompanying EM lesions were found in 42%. Cerebrospinal pleocytosis (predominantly lymphocytic) was seen in 18% of patients; none of them had frank clinical evidence of central nervous system involvement. Serum IgM and IgG antibodies were detected in 28% and 22% of children, respectively. In 3/79 (4%) patients, Borreliae were isolated from the blood and in 2/83 (2%) from the cerebrospinal fluid. In 2/81 (2%) children, borrelial IgG intrathecal antibody production was demonstrated.

CONCLUSIONS

Multiple EM in Slovene children is a mild disease. However, some patients had an associated, usually asymptomatic, infection of the central nervous system.

Low sero-prevalence of Lyme borreliosis in the forested mountainous area of Gorski Kotar, Croatia

AIM

Clinical forms of Lyme disease in Gorski Kotar have occurred only sporadically, in contrast to the northwestern Croatia and the neighboring areas of Slovenia, which are well-known Lyme borreliosis endemic regions. Our aim was to assess the level of sero-prevalence of Borrelia burgdorferi sensu lato in a high-risk population of forestry workers in the mountainous region of Gorski Kotar, Croatia, and compare it with the sero-prevalence in the residents of that area and the neighboring littoral region.

METHODS

A sero-epidemiological study was conducted on 520 healthy subjects, divided in 3 groups: the first group included 234 forestry workers, residents of Gorski Kotar, the second 100 residents of various professions in the same region, and the third 186 subjects of various professions from the neighboring littoral region. The sera were collected during the winters of two successive years, 1997 and 1998. Lyme borreliosis serology was performed by indirect immunofluorescence assay. Sera from 10 hunting dogs from Gorski Kotar were also analyzed.

RESULTS

The IgG antibodies to B. burgdorferi sensu lato were found in 11 examinees (4.7%) from the group of forestry workers, in 3 (3%) from the second group, and in 5 (2.7%) from the third group. Four out of 10 dogs (40%) had IgG antibodies against B. burgdorferi.

CONCLUSION

Our results show that the forest and mountainous area of Gorski Kotar, Croatia, has the characteristics of a low sero-prevalence area, in contrast to the endemic neighboring areas.

Diffuse reversible alopecia in patients with Lyme meningitis and tick-borne encephalitis

Alopecia occurring after febrile bacterial and viral infection is a phenomenon well known since the beginning of the century. To evaluate the occurrence of alopecia in tick transmitted disease, 23 adult patients with Lyme meningitis and 71 patients with tick-borne encephalitis were included in a prospective study and were followed up for one year. Diffuse alopecia occurred within three months after the outbreak of disease in 3 out of 23 (13%) patients with Lyme meningitis and in 40 out of 71 (56.3%) patients with tick-borne encephalitis. The mean duration of alopecia was 2 to 3 months and alopecia was reversible in all patients.

Infection of small mammals with Borrelia burgdorferi sensu lato in Slovenia as determined by polymerase chain reaction (PCR)

Thirty-four small mammals collected in the vicinity of Ljubljana were tested for the presence of Borrelia burgdorferi sensu lato by polymerase chain reaction (PCR) of urinary bladder tissues, using universal flagellin primers and species specific rRNA primers. Seventeen small mammals (50%) were found to be positive, and 7 small mammals were infected with two species of B. burgdorferi sensu lato simultaneously. The most commonly found species was B. afzelii (n = 14), followed by B. burgdorferi sensu stricto (n = 7) and B. garinii (n = 3), as determined by species-specific primers. We conclude that PCR is a rapid and reliable method to detect infection with B. burgdorferi sensu lato in small mammals.

Comparison of cefuroxime axetil and phenoxymethyl penicillin for the treatment of children with solitary erythema migrans

OBJECTIVE

To compare the clinical efficacy and drug-related adverse effects of 14 days of treatment with cefuroxime axetil 30 mg/kg/day or phenoxymethyl penicillin 100,000 IU/kg/day in the treatment of children with erythema migrans.

METHODS

Consecutive patients younger than 15 years, referred to our institution in 1996 with solitary erythema migrans and without prior antibiotic therapy, were included in this prospective study. Basic demographic features and clinical data were collected by questionnaire. The efficacy of the treatment of acute disease, development of major and/or minor manifestations of Lyme borreliosis and drug-related adverse effects were surveyed at follow-up visits during the first year after the initiation of antibiotic treatment.

RESULTS

Forty-six patients received cefuroxime axetil (group C) and 44, phenoxymethyl penicillin (group P). The two groups differed in terms of age (patients in group C were younger), but no other differences in demographic and clinical pre-treatment characteristics were present. The clinical course during the post-treatment period revealed no significant differences between the two groups: the duration of erythema migrans (7.1 +/- 7.5 days in group C, 10.6 +/- 19.3 days in group P) and the appearance of minor manifestations of Lyme borreliosis (8.8% in group C, 9.1% in group P) were comparable; no major manifestations were recorded. Twelve months after antibiotic treatment all patients were free of symptoms. The patients treated with cefuroxime axetil had more drug-related adverse effects than did those treated with phenoxymethyl penicillin (26.1% versus 6.8%, p = 0.0301). "Herxheimer's reaction" at the beginning of treatment was identified more often in group C than in group P, but the difference was not statistically significant.

CONCLUSIONS

Cefuroxime axetil and phenoxymethyl penicillin are equally effective in the treatment of children with solitary erythema migrans; however drug-related adverse effects were more frequently observed with cefuroxime axetil.

Has the presence or absence of Borrelia burgdorferi sensu lato as detected by skin culture any influence on the course of erythema migrans?

The aim of this prospective study was to compare epidemiological and clinical data in patients with a positive Borrelia burgdorferi sensu lato culture and culture-negative erythema migrans skin lesions. Of the 546 adult patients with erythema migrans seen at our institution in 1997 in whom a skin biopsy was performed and the specimen cultured for the presence of B. burgdorferi sensu lato, 235 (43%) had a positive and 311 (57%) a negative skin culture. More women than men were present in both groups and women were also significantly older than men. Tick bites resulting in culture-positive erythema migrans predominated in May (p = 0.012), while in August and September tick bites with subsequent culture-negative skin lesions were more common (p = 0.018 and 0.011, respectively). Similarly, erythema migrans lesions noticed by our patients in May were significantly more often Borrelia culture positive than negative (p = 0.004), while lesions appearing in October were significantly more often culture negative (p = 0.004). In addition to these seasonal differences, the comparison of the large number of Borrelia skin culture-positive and -negative patients with erythema migrans also revealed differences in several clinical parameters including a larger diameter of skin lesions in the culture-positive group (p = 0.007 at presentation, and p = 0.039 at registration, respectively), a lesser number of multiple skin lesions (7/235 versus 27/311, p = 0.006), and a lower frequency of signs/symptoms (p = 0.039) associated with erythema migrans lesions in culture-positive than in culture-negative patients. We have no plausible explanation for the majority of these rather unexpected findings. Of the 59 patients who, prior to biopsy, had received brief courses of antibiotics known to be effective in the treatment of erythema migrans, 12 (20.3%) were culture positive. As anticipated, the ratio of culture positivity in pretreated patients was significantly lower (p < 0.001) than in those without antecedent antibiotic therapy.

Lyme borreliosis and peripheral facial palsy

From 1994 to 1996, 114 consecutive patients older than 15 years who presented at the Department of Infectious Diseases, University Medical Centre, Ljubljana, fulfilled the criteria for inclusion into this study on the borrelial aetiology of peripheral facial palsy (PFP). The study was restricted to patients without a conceivable explanation for their PFP, erythema migrans or history of erythema migrans, clinical signs/symptoms of frank meningitis or any other neurological manifestation in addition to PFP. In 22 (19.3%) of these 114 patients borrelial infection was confirmed by one of the following: in 3 (13.6%) by the isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid (CSF), in 11 (50%) by the presence of intrathecal antibody production, and in 8 (36.4%) by seroconversion to borrelial antigens. Additional 20 (17.5%) patients interpreted as having had a probable borrelial infection, had positive (> or = 1:256) IFA IgM and/or IgG borrelial serum antibody titres, and in 9 (7.9%) patients borderline borrelial antibody titres (1:128) were found (interpreted as a possible infection). In 63 (55.3%) patients the serological tests remained negative. Lymphocytic pleocytosis was found at the first visit in 12/22 (54.5%) patients with confirmed borrelial infection, in 3/20 (15%) with probable infection, in 1/9 (11.1%) with possible infection, and in 10/63 (15.9%) patients with symptoms of unknown aetiology. Patients with confirmed borrelial infection had abnormal CSF findings significantly more often than did patients with symptoms of unknown aetiology (p = 0.0139 for lymphocytic pleocytosis and/or elevated CSF protein levels, and p = 0.0010 for lymphocytic pleocytosis). Local and systemic signs/-symptoms were also more common in patients with confirmed borrelial infection than in those with an symptoms of unknown aetiology (p = 0.0258). In Slovenia which is a highly endemic region for Lyme borreliosis, borrelial infection is a frequent cause of PFP in adult patients. PFP may occur early in the course of LB, prior to measurable antibody response, indicating the need for serologic follow-up. Abnormal CSF results and the presence of additional local and/or systemic symptoms are factors indicating a higher possibility of borrelial aetiology of PFP and should alert physicians to suspect LB.

Erythema migrans in the immunocompromised host

From 1990 to 1996 a total of 67 adult patients with typical erythema migrans (EM) and a previously identified immunocompromised condition were investigated at the University Medical Centre, Department of Infectious Diseases, Ljubljana, Slovenia. The course and outcome of borrelial infection were compared with 67 previously healthy age and sex-matched individuals with EM who were examined at our institution in the same year. Clinical characteristics of Lyme borreliosis before treatment and the duration of EM after the institution of therapy with antibiotics including amoxicillin, azithromycin, cefuroxime-axetil, doxycycline, and ceftriaxone were comparable in both groups. The occurrence of early disseminated borrelial infection before treatment and the frequency of treatment failure (defined as the onset of severe minor or major manifestations of Lyme borreliosis, persistence of B. burgdorferi sensu lato in the skin and/or persistence of EM after treatment) were found significantly more often in immunocompromised patients than in the control group (16/67 versus 6/67, respectively; p = 0.0358). Re-treatment was required in 13 (19.4%) patients of the immunocompromised group and only in five (7.5%) patients of the control group (p = 0.0762). However, in spite of the more severe course and the more frequent need for re-treatment among patients whose immune system was impaired, the outcome of borrelial infection after one year was favourable in both groups.

Lyme meningitis: a one-year follow up controlled study

Thirty-six patients with Lyme meningitis diagnosed at the Department of Infectious Diseases, University Medical Centre, Ljubljana in 1993 and 1994 were enrolled in a prospective study. All patients had lymphocytic meningitis, negative serum IgM antibody titres to tick-borne encephalitis virus and met at least one of the following four criteria: i) isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid (2 patients), ii) intrathecal borrelial antibody production (22 patients) iii) seroconversion to borrelial antigens (3 patients) and/or iv) erythema migrans in the period of four months prior to the onset of neurological involvement (21 patients). All patients underwent antibiotic treatment and were followed up for one year. The results of our study revealed that Lyme meningitis frequently occurs without meningeal signs and is often accompanied by additional neurological and/or other manifestations of Lyme borreliosis. During the first year after antibiotic treatment, minor and major manifestations of Lyme borreliosis persisted or occurred for the first time in several patients. They were not infrequent even at the examination performed one year after therapy.

Comparison of peripheral and central biopsy sites for the isolation of Borrelia burgdorferi sensu lato from erythema migrans skin lesions

To compare peripheral and central biopsy sites for the isolation of Borrelia burgdorferi sensu lato from typical erythema migrans lesions, two biopsy specimens (one from the margin and the other from the center of the lesion) were taken from each of 53 adult patients. Thirty-four (32.1%) of the 106 biopsy specimens and 23 (43.4%) of the 53 patients were culture-positive. Spirochetes were isolated in 19 (35.9%) of the 53 central and 15 (28.3%) of the 53 peripheral biopsies (nonsignificant difference). In 8 cases only the central specimen, in 4 cases only the peripheral specimen, and in 11 cases both specimens were positive. In a comparison of 36 annular and 17 homogeneous lesions, borreliae were isolated from 15 (41.7%) of the former and 8 (47.1%) of the latter. In the annular-lesion biopsies, 11 central and 12 peripheral specimens were culture-positive. In the homogeneous-lesion biopsies, eight central and three peripheral specimens were culture-positive (nonsignificant difference); there were no culture-positive results solely for the margin of homogeneous lesions. This study demonstrates that B. burgdorferi sensu lato may be isolated from the central aspect of erythema migrans lesions as efficiently as from the peripheral aspect.

Concomitant infection with tick-borne encephalitis virus and Borrelia burgdorferi sensu lato in patients with acute meningitis or meningoencephalitis

From September 1992 to August 1993, 338 patients over the age of 15 years presented to the Department of Infectious Diseases, University Medical Centre Ljubljana, with acute lymphocytic meningitis. In 89 of these patients (26.3%) serum IgM and IgG antibodies against tick-borne encephalitis (TBE) virus were detected, and in 59 patients (17.5%) a borrelial etiology of disease was demonstrated by one or more of the following presence of intrathecal antibody production, seroconversion to borrelial antigens, presence of erythema migrans, and/or isolation of Borrelia burgdorferi sensu lato from skin or cerebrospinal fluid. Of the 148 patients who fulfilled criteria for TBE or borrelial infection, concomitant infection with TBE virus and B. burgdorferi sensu lato was demonstrated in 12 patients (3.6% of all patients presenting with acute lymphocytic meningitis). In the majority of patients with concomitant infection the clinical features at presentation were characteristic of, or consistent with, TBE. In addition, during follow-up studies, eight of the 12 patients subsequently developed signs and symptoms compatible with minor and/or major manifestations of Lyme borreliosis. Six patients were diagnoses with neuroborreliosis based on signs or symptoms and/or laboratory tests. These findings show that in patients with acute lymphocytic meningitis or meningoencephalitis, originating in TBE and Lyme borreliosis endemic regions, the possibility of concomitant infection should be considered.

Azithromycin and doxycycline for treatment of Borrelia culture-positive erythema migrans

Adult patients with typical solitary erythema migrans, participating in prospective therapeutic studies on early Lyme borreliosis at the Lyme borreliosis Outpatient's Clinic, University Department of Infectious Diseases in Ljubljana, in 1991 to 1993, and followed up for 1 year, were included in the study. Only patients who were treated with azithromycin or doxycycline and in whom Borrelia burgdorferi was isolated from the border of the skin lesion prior to institution of antibiotic treatment were selected for presentation in this report. Fifty-eight patients received azithromycin (500 mg twice daily for the first day, followed by 500 mg once daily for 4 days) and 42 patients received doxycycline (100 mg twice daily for 14 days). The median duration of skin lesions after the beginning of treatment was 6.5 (2-30) days in the azithromycin group and 8 (2-35) days in the doxycycline group (non-significant difference). During the follow-up of 12 months one patient in each group developed major later manifestations of Lyme borreliosis and in 19 patients minor manifestations appeared: in nine (15.5%) treated with azithromycin and in ten (23.8%) receiving doxycycline. In one patient in the azithromycin group and in one patient in the doxycycline group B. burgdorferi was isolated from normal appearing skin at the site of previous erythema migrans 2 months after the institution of antibiotic therapy. Five (8.6%) patients receiving azithromycin and nine (21.4%) patients receiving doxycycline reported mild to moderate gastrointestinal discomfort. In addition, five patients treated with doxycycline developed photosensitivity.

Treatment of borrelial lymphocytoma

Treatment results in 65 patients with borrelial lymphocytoma (22 on the ear lobe and 43 on the breast), registered at the Department of Infectious Diseases, University Medical Centre Ljubljana, from January 1986 to March 1995, are presented. When lymphocytoma was the sole manifestation of Lyme borreliosis or associated with erythema migrans only patients were treated orally with doxycycline, phenoxymethylpenicillin or amoxicillin for 14 days, or azithromycin for 5 days (15, 19, six and 12 patients, respectively). When signs and symptoms of disseminated borrelial infection were present (seven patients) or clinically suspected (six patients) patients received ceftriaxone or penicillin G i.v. for 14 days. Lymphocytoma disappeared within a few weeks after the institution of treatment. The speed of regression depended on the duration of lymphocytoma before the institution of therapy. The number of patients was too low and pretreatment characteristics were too heterogeneous to enable a reliable comparison of the efficacy of different antibiotics. It appears that the effectiveness of doxycycline and azithromycin is comparable and that amoxicillin performs well, but some findings may indicate that phenoxymethylpenicillin is less effective than some newer antibiotics. The optimal agent, dosage and duration of therapy for borrelial lymphocytoma have not been determined.