Gerold Stanek

The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis were prepared by an expert panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 31[Suppl 1]:1-14). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. For each of these Ixodes tickborne infections, information is provided about prevention, epidemiology, clinical manifestations, diagnosis, and treatment. Tables list the doses and durations of antimicrobial therapy recommended for treatment and prevention of Lyme disease and provide a partial list of therapies to be avoided. A definition of post-Lyme disease syndrome is proposed.

Lyme borreliosis: Clinical case definitions for diagnosis and management in Europe

Lyme borreliosis, caused by spirochaetes of the Borrelia burgdorferi genospecies complex, is the most commonly reported tick-borne infection in Europe and North America. The non-specific nature of many of its clinical manifestations presents a diagnostic challenge and concise case definitions are essential for its satisfactory management. Lyme borreliosis is very similar in Europe and North America but the greater variety of genospecies in Europe leads to some important differences in clinical presentation. These new case definitions for European Lyme borreliosis emphasise recognition of clinical manifestations supported by relevant laboratory criteria and may be used in a clinical setting and also for epidemiological investigations.

The expanding Lyme Borrelia complex—clinical significance of genomic species?

Ten years after the discovery of spirochaetes as agents of Lyme disease in 1982 in the USA, three genomic species had diverged from the phenotypically heterogeneous strains of Borrelia burgdorferi isolated in North America and Europe: Borrelia afzelii, B. burgdorferi sensu stricto (further B. burgdorferi), and Borrelia garinii. Whereas B. burgdorferi remained the only human pathogen in North America, all three species are aetiological agents of Lyme borreliosis in Europe. Another seven genospecies were described in the 1990s, including species from Asia (Borrelia japonica, Borrelia turdi, and B. tanukii), North America (Borrelia andersonii), Europe (Borrelia lusitaniae and Borrelia valaisiana), and from Europe and Asia (Borrelia bissettii). Another eight species were delineated in the years up to 2010: Borrelia sinica (Asia), Borrelia spielmanii (Europe), Borrelia yangtze (Asia), Borrelia californiensis, Borrelia americana, Borrelia carolinensis (North America), Borrelia bavariensis (Europe), and Borrelia kurtenbachii (North America). Of these 18 genomic species B. afzelii, B. burgdorferi and B. garinii are the confirmed agents of localized, disseminated and chronic manifestations of Lyme borreliosis, whereas B. spielmanii has been detected in early skin disease, and B. bissettii and B. valaisiana have been detected in specimens from single cases of Lyme borreliosis. The clinical role of B. lusitaniae remains to be substantiated.

Multicenter comparison trial of DNA extraction methods and PCR assays for detection of Chlamydia pneumoniae in endarterectomy specimens

ABSTRACT The reported rate of detection of Chlamydia pneumoniaeDNA within atherosclerotic lesions by PCR varies between 0 and 100%. In this study, identical sets of coded experimental atheroma samples (n = 15) and spiked controls (n = 5) were analyzed by 16 test methods in nine centers by means of PCR. The positive controls were correctly identified to levels of 1, 0.1, and 0.01 inclusion bodies of C. pneumoniae/ml of tissue homogenate by 16 (100%), 11 (69%), and 3 (19%) of the test methods, respectively. Three out of 16 negative controls (19%) were rated positive. Positivity rates for atheroma samples varied between 0 and 60% for the different test methods, with the maximum concordant result for positivity being only 25% for one carotid artery sample. There was no consistent pattern of positive results among the various laboratories, and there was no correlation between the detection rates and the sensitivity of the assay used.

Epidemiology of European Lyme borreliosis.

Lyme borreliosis occurs throughout Europe and is particularly prevalent in the east. In a small proportion of untreated cases serious sequelae may occur, but Lyme borreliosis alone does not cause death. Clinical and serological diagnosis can still be problematic and the various genomospecies may cause different disease manifestations as well as differing immunological responses. However, considerable progress has been made in standardising case definitions and serological testing and interpretation. Few countries have official reporting systems for Lyme borreliosis and most figures on incidence are extrapolated from serodiagnosis data and seroprevalence studies. Geographical variations in incidence seem to correlate with the prevalence of infected ticks, which are mainly associated with varied deciduous forest. The complex ecology of Lyme borreliosis makes it difficult to implement preventive measures, so improving public knowledge of risk factors and methods for personal protection remain the best option at present.

Clinical Manifestations and Diagnosis of Lyme Borreliosis

Lyme borrelosis is a multi-systemic disease caused byBorrelia burgdorferisensu lato. A complete presentation of the disease is an extremely unusual oberservation, in which a skin lesion follows a tick bite, the lesion itself is followed by heart and nervous system involvement, and later on by arthritis; late involvement of the eye, nervous system, joints and skin may also occur. Information on the relative frequency of individual clinical manifestations of Lyme borreliosis is limited; however, the skin is most frequently involved and skin manifestations frequently represent clues for the diagnosis. The only sign that enables a reliable clinical diagnoisis of Lyme borreliosis is a typical erythema migrans. Laboratory confirmation of a borrelial infection is needed for all manifestations of Lyme borreliosis, with the exception of typical skin lesions.

European Lyme borreliosis.

Lyme borreliosis is a term introduced to designate a new nosologic entity describing the various disease states of the infection with tickor insect-borne borrelia. At least part of the Lyme borreliosis spectrum, e.g., erythema chronicum migrans’,* and acrodermatitis chronica atrophicans, has been known in Europe for many years although demonstration of the causative infectious agent was made only recently.

Identification of Borrelia burgdorferi sensu lato species in Europe

Characterisation at the species level of 142 Borrelia isolates obtained from ticks, humans and rodents in Western Europe was carried out and their geographical distribution was described. Borrelia garinii was the predominant species representing 44% of the isolates and B. afzelii and B. burgdorferi sensu stricto constituted 27% and 19% of isolates respectively. B. valaisiana, (formerly group VS116) constituted 10.5% of isolates. Some differences in the Borrelia species distribution were observed from one country to another, possibly linked to different sources of samples. In the human samples, which were mostly collected in Austria, B. afzelii was preferentially isolated from skin and B. garinii from CSF. B. afzelii was consistently isolated from rodents captured in Switzerland, but one isolate of B. garinii was obtained from a rodent in Austria. B. garinii was by far the most abundant species isolated from Ixodes ricinus ticks in all studied countries. B. valaisiana was isolated from I. ricinus ticks collected from vegetation and from I. ricinus engorged on birds.

Borrelia burgdorferi and Different Types of Morphea

Thirty patients with different clinical manifestations of morphea (circumscribed scleroderma) were investigated for serum antibodies against Borrelia burgdorferi determined by ELISA and Western blot analysis. Forty-six percent of the patients were seropositive. Western blots confirmed the ELISA results in 10 of 25 patients (40%), showing a reactivity pattern which can be seen in the course of Lyme borreliosis. In some cases the outcome after antibiotic treatment suggests a direct correlation between the further development of skin lesions and Borrelia infection. Because of these findings we suggest some morphea types to be possibly due to a B. burgdorferi infection.

Solitary Borrelial Lymphocytoma: Report of 36 Cases

SummaryThirty-six cases of borrelial lymphocytoma were detected during the period 1986 to 1990 in Slovenia. Borrelial lymphocytoma was located on the ear lobe in 17 persons, ten female and seven male, with a median age of 12 years (range 2–56). Fourteen of these 17 were children under 14 years of age. A tick bite was remembered by 15 patients a median of 30 days before borrelial lymphocytoma developed. The most frequent month of onset was September. Erythema migrans preceded or accompanied borrelial lymphocytoma in eight cases. In 15 cases, eight female and seven male, borrelial lymphocytoma was localized on the mamilla. Median age of these patients was 42 years (range 15–72). Twelve had a tick bite about 45 days (median value) before the onset of borrelial lymphocytoma, which occurred most frequently in August. Erythema migrans was reported in 13 patients and preceded borrelial lymphocytoma in ten cases. In another four patients borrelial lymphocytoma was localized on the nose, scrotum, upper arm and shoulder. Antibiotic treatment with phenoxymethyl-penicillin (n=16), ceftriaxone (n=8), doxycycline (n=9), azithromycin (n=2) and penicillin G (1) led to complete recovery within an average of three weeks in all cases.ZusammenfassungZwischen 1986 und 1990 wurden in Slowenien 36 Patienten mit einem Borrelien-Lymphozytom erfaßt. Bei 17 Patienten, 10 weiblichen und sieben männlichen, mit einem medianen Alter von 12 Jahren war das Borrelien-Lymphozytom am Ohrläppchen lokalisiert. 14 dieser Patienten waren Kinder unter 14 Jahren. 15 der Patienten hatten einen Zeckenstich 45 Tage (Median) vor Manifestation des Borrelien-Lymphozytoms, das am häufigsten im September auftrat. Ein Erythema migrans bestand gleichzeitig oder ging dem Borrelien- Lymphozytom in 8 Fällen voraus. Bei 15 Patienten, acht weiblichen und sieben männlichen, war das Borrelien-Lymphozytom an der Mammille lokalisiert. Das mediane Alter dieser Patienten war 42 Jahre (15–72). Zwölf hatten einen Zeckenstich circa 45 Tage bevor sich ein Borrelien-Lymphozytom entwickelte, das am häufigsten im August auftrat. Bei weiteren vier Patienten war das Borrelien-Lymphozytom auf der Nase, dem Scrotum, Oberarm und Schulter lokalisiert. Eine antibiotische Behandlung mit Phenoxymethylpenicillin (n=16), Ceftriaxon (n=8), Doxycyclin (n=9), Azithromycin (n=2) oder Penicillin (n=1) führte durchschnittlich innerhalb von drei Wochen zur vollständigen Heilung.