Gary P. Wormser

An outbreak of community-acquired Pneumocystis carinii pneumonia. Initial manifestation of cellular immune dysfunction.

Eleven cases of community-acquired Pneumocystis carinii pneumonia occurred between 1979 and 1981 and prompted clinical and immunologic evaluation of the patients. Young men who were drug abusers (seven patients), homosexuals (six), or both (two) presented with pneumonia. Immunologic testing revealed that absolute lymphocyte counts, T-cell counts, and lymphocyte proliferation were depressed, and that humoral immunity was intact. Of the 11 patients, one was found to have Kaposis sarcoma, and another had angioimmunoblastic lymphadenopathy. Eight patients died. In the remaining three, no diagnosis of an immunosuppressive disease was established, despite persistence of immune defects. These cases of pneumocystosis suggest the importance of cell-mediated immune function in the defense against P. carinii. The occurrence of this infection among drug abusers and homosexuals indicates that these groups may be at high risk for this infection.

Diagnosis of lyme borreliosis.

SUMMARY A large amount of knowledge has been acquired since the original descriptions of Lyme borreliosis (LB) and of its causative agent, Borrelia burgdorferi sensu stricto. The complexity of the organism and the variations in the clinical manifestations of LB caused by the different B. burgdorferi sensu lato species were not then anticipated. Considerable improvement has been achieved in detection of B. burgdorferi sensu lato by culture, particularly of blood specimens during early stages of disease. Culturing plasma and increasing the volume of material cultured have accomplished this. Further improvements might be obtained if molecular methods are used for detection of growth in culture and if culture methods are automated. Unfortunately, culture is insensitive in extracutaneous manifestations of LB. PCR and culture have high sensitivity on skin samples of patients with EM whose diagnosis is based mostly on clinical recognition of the lesion. PCR on material obtained from extracutaneous sites is in general of low sensitivity, with the exception of synovial fluid. PCR on synovial fluid has shown a sensitivity of up to >90% (when using four different primer sets) in patients with untreated or partially treated Lyme arthritis, making it a helpful confirmatory test in these patients. Currently, the best use of PCR is for confirmation of the clinical diagnosis of suspected Lyme arthritis in patients who are IgG immunoblot positive. PCR should not be used as the sole laboratory modality to support a clinical diagnosis of extracutaneous LB. PCR positivity in seronegative patients suspected of having late manifestations of LB most likely represents a false-positive result. Because of difficulties in direct methods of detection, laboratory tests currently in use are mainly those detecting antibodies to B. burgdorferi sensu lato. Tests used to detect antibodies to B. burgdorferi sensu lato have evolved from the initial formats as more knowledge on the immunodominant antigens has been collected. The recommendation for two-tier testing was an attempt to standardize testing and improve specificity in the United States. First-tier assays using whole-cell sonicates of B. burgdorferi sensu lato need to be standardized in terms of antigen composition and detection threshold of specific immunoglobulin classes. The search for improved serologic tests has stimulated the development of recombinant protein antigens and the synthesis of specific peptides from immunodominant antigens. The use of these materials alone or in combination as the source of antigen in a single-tier immunoassay may someday replace the currently recommended two-tier testing strategy. Evaluation of these assays is currently being done, and there is evidence that certain of these antigens may be broadly cross-reactive with the B. burgdorferi sensu lato species causing LB in Europe.

PROPHYLAXIS WITH SINGLE-DOSE DOXYCYCLINE FOR THE PREVENTION OF LYME DISEASE AFTER AN IXODES SCAPULARIS TICK BITE

BACKGROUND It is unclear whether antimicrobial treatment after an Ixodes scapularis tick bite will prevent Lyme disease. METHODS In an area of New York where Lyme disease is hyperendemic we conducted a randomized, double-blind, placebo-controlled trial of treatment with a single 200-mg dose of doxycycline in 482 subjects who had removed attached I. scapularis ticks from their bodies within the previous 72 hours. At base line, three weeks, and six weeks, subjects were interviewed and examined, and serum antibody tests were performed, along with blood cultures for Borrelia burgdorferi. Entomologists confirmed the species of the ticks and classified them according to sex, stage, and degree of engorgement. RESULTS Erythema migrans developed at the site of the tick bite in a significantly smaller proportion of the subjects in the doxycycline group than of those in the placebo group (1 of 235 subjects [0.4 percent] vs. 8 of 247 subjects [3.2 percent], P<0.04). The efficacy of treatment was 87 percent (95 percent confidence interval, 25 to 98 percent). Objective extracutaneous signs of Lyme disease did not develop in any subject, and there were no asymptomatic seroconversions. Treatment with doxycycline was associated with more frequent adverse effects (in 30.1 percent of subjects, as compared with 11.1 percent of those assigned to placebo; P<0.001), primarily nausea (15.4 percent vs. 2.6 percent) and vomiting (5.8 percent vs. 1.3 percent). Erythema migrans developed more frequently after untreated bites from nymphal ticks than after bites from adult female ticks (8 of 142 bites [5.6 percent] vs. 0 of 97 bites [0 percent], P=0.02) and particularly after bites from nymphal ticks that were at least partially engorged with blood (8 of 81 bites [9.9 percent], as compared with 0 of 59 bites from unfed, or flat, nymphal ticks [0 percent]; P=0.02). CONCLUSIONS A single 200-mg dose of doxycycline given within 72 hours after an I. scapularis tick bite can prevent the development of Lyme disease.

Serodiagnosis of Lyme Disease by Kinetic Enzyme-Linked Immunosorbent Assay Using Recombinant VlsE1 or Peptide Antigens of Borrelia burgdorferi Compared with 2-Tiered Testing Using Whole-Cell Lysates

Abstract In a study of US patients with Lyme disease, immunoglobulin (Ig) G and IgM antibody responses to recombinant Borrelia burgdorferi antigen VlsE1 (rVlsE1), IgG responses to a synthetic peptide homologous to a conserved internal sequence of VlsE (C6), and IgM responses to a synthetic peptide comprising the C-terminal 10 amino acid residues of a B. burgdorferi outer-surface protein C (pepC10) were evaluated by kinetic enzyme-linked immunoassay. At 99% specificity, the overall sensitivities for detecting IgG antibody to rVlsE1 or C6 in samples from patients with diverse manifestations of Lyme disease were equivalent to that of 2-tiered testing. When data were considered in parallel, 2 combinations (IgG responses to either rVlsE1 or C6 in parallel with IgM responses to pepC10) maintained high specificity (98%) and were significantly more sensitive than 2-tiered analysis in detecting antibodies to B. burgdorferi in patients with acute erythema migrans. In later stages of Lyme disease, the sensitivities of the in parallel tests and 2-tiered testing were high and statistically equivalent

Borrelia lonestari Infection after a Bite by an Amblyomma americanum Tick

Erythematous rashes that are suggestive of early Lyme disease have been associated with the bite of Amblyomma americanum ticks, particularly in the southern United States. However, Borrelia burgdorferi, the causative agent of Lyme disease, has not been cultured from skin biopsy specimens from these patients, and diagnostic serum antibodies usually have not been found. Borrelia lonestari sp nov, an uncultured spirochete, has been detected in A. americanum ticks by DNA amplification techniques, but its role in human illness is unknown. We observed erythema migrans in a patient with an attached A. americanum tick. DNA amplification of the flagellin gene flaB produced B. lonestari sequences from the skin of the patient that were identical to those found in the attached tick. B. lonestari is a probable cause of erythema migrans in humans.

MLST of housekeeping genes captures geographic population structure and suggests a European origin of Borrelia burgdorferi

Lyme borreliosis, caused by the tick-borne bacterium Borrelia burgdorferi, has become the most common vector-borne disease in North America over the last three decades. To understand the dynamics of the epizootic spread and to predict the evolutionary trajectories of B. burgdorferi, accurate information on the population structure and the evolutionary relationships of the pathogen is crucial. We, therefore, developed a multilocus sequence typing (MLST) scheme for B. burgdorferi based on eight chromosomal housekeeping genes. We validated the MLST scheme on B. burgdorferi specimens from North America and Europe, comprising both cultured isolates and infected ticks. These data were compared with sequences for the commonly used genetic markers rrs-rrlA intergenic spacer (IGS) and the gene encoding the outer surface protein C (ospC). The study demonstrates that the concatenated sequences of the housekeeping genes of B. burgdorferi provide highly resolved phylogenetic signals and that the housekeeping genes evolve differently compared with the IGS locus and ospC. Using sequence data, the study reveals that North American and European populations of B. burgdorferi correspond to genetically distinct populations. Importantly, the MLST data suggest that B. burgdorferi originated in Europe rather than in North America as proposed previously.

Duration of antibiotic therapy for early Lyme disease. A randomized, double-blind, placebo-controlled trial.

Context Optimal antibiotic treatment for patients with early Lyme disease is unclear. Contribution This single-center randomized, double-blind, placebo-controlled trial found that patients with erythema migrans given any of the follwoing regimens had high response rates, defined as resolution of erythema migrans and symptoms at 30 months: 20 days of doxycycline, 83.9%; 10 days of doxycycline, 90.3%; and 10 days of doxycycline plus a single intravenous dose of ceftriaxone, 86.5%. Patients given doxycycline plus ceftriaxone more often had diarrhea than patients given doxycycline alone. Implications Oral doxycycline alone for 10 days is sufficient treatment for patients with early Lyme disease that manifests as erythema migrans. The Editors Although Lyme disease is the most common vector-borne disease in the United States (1), the appropriate duration of treatment for its most common manifestation, erythema migrans, remains unclear. A small open-label prospective study reported in 1983 found that outcome did not improve when tetracycline therapy was extended from 10 days to 20 days (2). However, most recent treatment trials have used antibiotic regimens of approximately 3 weeks (3-5), and some authorities recommend 20 to 30 days of therapy (6). This change in practice has occurred in the absence of additional prospective studies on the duration of treatment and is a source of ongoing controversy. Another uncertain issue in the management of patients with erythema migrans is whether Borrelia burgdorferi, the etiologic agent, has disseminated to the central nervous system at the time of presentation (7). If so, the outcome of therapy might be enhanced by treatment with a parenteral agent such as ceftriaxone, which readily crosses the bloodbrain barrier. To address these concerns, we conducted a placebo-controlled study comparing 10 days of doxycycline with both 10 days of doxycycline plus one dose of ceftriaxone and 20 days of doxycycline. Methods Patients at least 16 years of age who had erythema migrans and satisfied the U.S. Centers for Disease Control and Preventions surveillance definition of Lyme disease (an annular erythematous skin lesion 5 cm in diameter) (8) entered the study between 1992 and 1994. Volunteers were recruited primarily through the walk-in Lyme Disease Diagnostic Center at the Westchester Medical Center, Valhalla, New York. Exclusion criteria included pregnancy or lactation, allergy to a tetracycline or a -lactam antibiotic, receipt of antibiotic treatment for Lyme disease for more than 48 hours before enrollment, meningitis or advanced heart block, or any underlying conditions that might interfere with evaluability or follow-up. All patients gave written informed consent, and the institutional review board at New York Medical College approved the study protocol. Patients were randomly assigned to one of three treatment groups: 1) a single 2-g dose of intravenous ceftriaxone followed by 10 days of oral doxycycline capsules twice daily, then by 10 days of oral placebo capsules [cornstarch], identical in appearance to the doxycycline capsules, twice daily; 2) a placebo injection [5% dextrose] followed by 10 days of oral doxycycline, 100 mg twice daily, and then by 10 days of oral placebo twice daily; or 3) a placebo injection followed by 20 days of oral doxycycline twice daily. Since ceftriaxone is yellow, infusion bags were kept covered to maintain masking. The pharmacy dispensed study medications in accordance with a randomization schedule that was based on a computer-generated random-number code with a permuted block size of 9. Clinical staff involved in recruitment of participants or in assessing clinical outcomes were isolated from the allocation process and blinded to treatment assignment. Randomization was stratified by whether patients were symptomatic (defined as having any systemic symptoms or having multiple erythema migrans lesions) or asymptomatic (defined as having a single erythema migrans lesion and no systemic symptoms). This was done to ensure that patients who may have had dissemination of B. burgdorferi were equally represented in the three treatment groups. Evaluation Trained study personnel interviewed participants and performed physical examination at baseline and 10 days, 20 days, 3 months, 6 months, 12 months, 24 months, and 30 months after initiation of therapy. If appointments were missed, patients were interviewed by telephone; however, this occurred in fewer than 5% of patient interactions. A neurologist performed complete neurologic examination at baseline, 20 days, 3 months, 12 months, 24 months, and 30 months. At 18 months, an evaluation was conducted by telephone. Structured questionnaires using both closed- and open-ended questions were used. Symptom scores were recorded on a visual analogue scale (9). A blood sample was obtained for serologic testing (enzyme-linked immunosorbent assay) at all visits. Complete blood count was determined and serum chemistries were performed at baseline, day 10, and day 20. Electrocardiography was done at baseline and was repeated if results were abnormal. Patients were considered unevaluable if they did not adhere to study medication. Nonadherence was defined as taking fewer than 90% of prescribed capsules or not returning pill containers at the 10- or 20-day visit, receiving an intercurrent antibiotic within the first 20 days, not meeting study inclusion criteria, or not attending follow-up visits after the baseline visit. Patients who had an intercurrent episode of erythema migrans due to reinfection were considered unevaluable from that point onward. Outcome was characterized as complete response, partial response, or failure. Early treatment response was assessed at 20 days. At this time, complete response was defined as resolution of erythema migrans and associated symptoms and return to preLyme disease health status. Partial response was defined as resolution of erythema migrans but incomplete resolution or development of subjective symptoms. Failure was defined as the occurrence of any one of the following during the first 20 days: no clinical improvement by day 10; recurrence of erythema migrans; recurrence of fever attributed by the study physician to Lyme disease; development of new objective rheumatologic, cardiac, or neurologic manifestations of Lyme disease that were not present within the first 10 days; or the occurrence of meningitis, advanced heart block, or other objective manifestation of Lyme disease requiring intravenous therapy. Late response was evaluated at 3 months, 12 months, and 30 months. Complete response was defined as no recurrence of erythema migrans or associated symptoms and the continued absence of objective rheumatologic, cardiac, or neurologic manifestations of Lyme disease, with return to preLyme disease health status. Partial response was defined as no recurrence of erythema migrans and the continued absence of objective manifestations of Lyme disease, but incomplete resolution or development of subjective symptoms of uncertain cause. Failure was defined as the occurrence of objective manifestations of Lyme disease. Safety Assessment Drug safety was monitored by recording adverse events (solicited by open-ended semi-structured interview) and results of laboratory tests during treatment. Neurocognitive Evaluation At baseline, 12 months, and 30 months, a psychologist performed neurocognitive testing consisting of the Booklet Categories Test, the California Verbal Learning Test, the Wechsler Memory ScaleRevised, the Block Design Test, the Trail Making Test (Parts A and B), the Boston Naming Test, the Symbol Digit Modalities Test (written and oral), the Beck Depression Inventory, and the Symptom Checklist-90Revised. Healthy volunteers without a history of Lyme disease were recruited to serve as controls for the psychiatric interview and the neuropsychological testing. Spouses were preferred as controls since they were usually similar to the patients in age, socioeconomic level, and place of residence. Controls were 27 persons with a mean age (SD) of 42.6 15.2 years; 22% were men. Statistical Analysis Groups were compared by using one-way analysis of variance for continuous variables and the chi-square test for categorical variables (two-tailed). Data were analyzed both for participants who adhered to the study protocol and on an intention-to-treat basis. Patient blinding was evaluated at the 30-month visit by using the chi-square test and the statistic (10). For the neuropsychological tests, analysis of variance techniques were used to examine differences among treatment and control groups. For analysis of raw test scores, analysis of covariance was used, controlling for the effects of age, sex, and education. Test scores that were normalized to population standards (11-19) were analyzed by using one-way analysis of variance. For all analysis of variance models, residual plots were generated to verify adequate model fit. In the few situations in which test scores were not normally distributed or model fit was questionable, nonparametric procedures (the KruskalWallis test) or conventional transformations were applied. For categorical results, the chi-square test or the Fisher exact test was used. If the treatment variable in the global tests achieved the liberal cut-point of a P value less than 0.10, pairwise comparisons were conducted. In these instances, the Bonferroni adjustment was applied to the P value to control for multiple comparisons. Sample size was based on the estimated frequency of postLyme disease syndrome, defined as an array of subjective symptoms, such as fatigue, arthralgias, or myalgias, that may occur after infection. It was assumed that 30% of patients receiving the least effective treatment would develop postLyme disease syndrome. A more effective treatment was assumed to reduce the rate to 5%. Using an level of 0.05, two-tailed testing, and a Bonferroni multiple compari

The clinical spectrum of early lyme borreliosis in patients with culture-confirmed erythema migrans

BACKGROUND The diagnosis of erythema migrans (EM), the characteristic rash of early Lyme borreliosis, is based primarily on its clinical appearance since it often occurs prior to the development of a specific antibody response. Other skin disorders, however, may be confused with EM. METHODS Between June 1991 and September 1993, a prospective study was conducted at the Lyme Disease Diagnostic Center of the Westchester County Medical Center to isolate Borrelia burgdorferi systematically from patients with Em, and to characterize the clinical manifestations of patients with culture-documented infection. Skin biopsies and/or needle aspirates of the advancing margin of primary lesions, and blood specimens from adult patients were cultured for B burgdorferi in modified Barbour-Stoenner-Kelly medium at 33 degrees C. RESULTS B burgdorferi was recovered from 79 patients (49 [62%] males) ranging in age from 16 to 76 years old (mean, 43 +/- 14 years old). Maximum EM diameter (mean, 16 +/- 10 cm; range, 6-73 cm) was a function of EM duration (mean 6.7 +/- 6.4 days; range, 1-39 days) (correlation coefficient = 0.7; P < 0.001). Twenty (25%) patients had noted a tick bite at the site of the primary lesion a mean of 10 days (range, 1-27 days) before onset. Multiple EM lesions (range, 2-70) were present in 14 (18%) patients. Systemic symptoms were present at the time of culture in 54 patients (68%) including fatigue (54%), arthralgia (44%), myalgia (44%), headache, (42%), fever and/or chills (39%), stiff neck (35%), and anorexia (26%). Thirty-three patients (42%) had at least one objective finding on physical examination in addition to EM, including 18 (23%) with localized lymphadenopathy, 13 (16%) with fever (t > or = 37.8 degrees C), seven (9%) with tender neck flexion, six (8%) with joint tenderness, and 1 each with joint swelling, nuchal rigidity, and facial nerve palsy. No patient had new electrocardiogram evidence of atrioventricular block. Liver function assays were abnormally elevated in 37% of patients. Thirty-four percent of patients were seropositive by enzyme-linked immunosorbent assay at presentation. Most others rapidly seroconverted so that 69 of 78 evaluable patients (88%) were seropositive at some point during the first month after diagnosis. CONCLUSIONS We describe the largest group of culture-positive patients with EM from the United States to date. Although systemic symptoms were present in most patients, objective evidence of advanced disease was uncommon. Our patients with culture-confirmed EM were less sick than those described in the days before culture confirmation was possible. The ability to isolate B burgdorferi from lesional skin of large numbers of patients with EM should make culture-positive patients the standard by which to define manifestations of early Lyme borreliosis associated with this rash. Microbiologic documentation of Lyme borreliosis will help delineate the manifestations of this illness, and should form the framework for research directed at pathophysiology, diagnosis, treatment, and prevention.

Natural History of Colonization with Vancomycin-Resistant Enterococcus Faecium

OBJECTIVE To determine the incidence, duration, and genetic diversity of colonization with vancomycin-resistant Enterococcus faecium (VREF). SETTING Oncology unit of a 650-bed university hospital. METHODS Surveillance perianal swab cultures were performed on admission and weekly. The molecular relatedness of VREF isolates was determined by pulsed-field gel electrophoresis and by the hybridization pattern of the vanA resistance determinant. RESULTS During 8 months of surveillance, the VREF colonization rate was 16.6 patients per 1,000 patient-hospital days, which was 10.6 times greater than the VREF infection rate. Eighty-six patients with VREF colonization were identified. Colonization persisted for at least 7 weeks in the majority of patients. Of 36 colonized patients discharged from the hospital and then readmitted, an average of 2 1/2 weeks later, 22 (61%) patients still were colonized with VREF. Of the 14 patients who were VREF-negative at readmission, only three patients remained culture-negative throughout hospitalizations. PFGE demonstrated that colonization with the same VREF isolate may persist for at least 1 year, and patients may be colonized with more than one strain of VREF. CONCLUSION VREF colonization is at least 10-fold more prevalent than infection among oncology patients. Colonization often persists throughout lengthy hospitalizations and may continue for long periods following hospitalization.

Opportunistic Infection in Previously Healthy Women: Initial Manifestations of a Community-Acquired Cellular Immunodeficiency

Opportunistic infections and unusual tumors have been reported in an unprecedented outbreak of community-acquired cellular immune deficiency among homosexual and drug-abusing men. We report five women with the same syndrome. The women were residents of metropolitan New York City closely associated with drug abuse either by personal use (our patients) or close sexual contact with an abuser (one patient). One patient was bisexual. All five patients developed Pneumocystis carinii pneumonia as well as combinations of other opportunistic infections including oral candida, disseminated mycobacteria, and ulcerative herpes simplex infections. All patients had marked depression of cellular immune function. Three patients died. The appearance of this syndrome in women has important implications with regard to the epidemiology and etiology of this emerging syndrome.