Serologic evaluation of patients from Missouri with erythema migrans-like skin lesions with the C6 Lyme test

Southern tick-associated rash illness (STARI), also known as Masters disease, affects people predominantly in the Southeast and South Central United States. These patients exhibit skin lesions that resemble erythema migrans (EM), the characteristic skin lesion in early Lyme disease. The etiology of STARI remains unknown, and no serologic test is available to aid in its diagnosis. The C6 Lyme enzyme-linked immunosorbent assay was used to evaluate coded serum specimens from patients with STARI at two laboratory sites. The specimens tested at one site consisted of acute- and convalescent-phase samples that were obtained from nine STARI patients from Missouri and from one patient with documented Borrelia lonestari infection who acquired this infection in either North Carolina or Maryland. All of these samples were C6 negative. Seventy acute- or convalescent-phase specimens from 63 STARI patients from Missouri were C6 tested at the second site. All but one of these STARI specimens were also negative. In contrast, of nine acute- and nine convalescent-phase serum specimens obtained from culture-confirmed Lyme disease patients with EM from New York state, seven were C6 positive at the acute stage, and eight were positive at convalescence. The C6 test is negative in patients with STARI, providing further evidence that B. burgdorferi is not the etiologic agent of this disease.

Molecular and serological diagnosis of Borrelia burgdorferi infection among patients with diagnosed Erythema migrans

The aim of the study was to assess the frequency of Borrelia burgdorferi DNA detection in the blood and urine of patients diagnosed with erythema migrans, and compare the results of PCR-based methods with ELISA methodology. The latter was used to detect serum antibodies against Borrelia burgdorferi of the IgM and IgG classes, before and after antibiotic therapy. The study included 86 patients hospitalized in the Department of Infectious Diseases and Neuroinfections in the Medical Academy in Białystok, diagnosed with the erythema migrans phase of Lyme borreliosis. Examinations were carried out twice: the first at the moment of diagnosis (Trial 1), the second after 4 weeks of antibiotic therapy. The study showed that antibiotic therapy in the early phase of borreliosis does not decrease the sensitivity of PCR and that after 4 weeks of therapy (Trial 2), spirochete DNA is still detectable in most patients (45/86). There was no correlation between detectability of spirochete DNA and the presence of antibodies against B. burgdorferi s.l. (assessed by ELISA) during the course of erythema migrans. The largest percentage of positive results in the detection of B. burgdorferi s.l. DNA was observed in patients who simultaneously possessed IgM and IgG antibodies against B. burgdorferi, while the lowest percentage of PCR positive results was among patients with only IgM antibodies.

Erythema Migrans Mimicking Cervical Cellulitis with Deep Neck Infection in a Child with Lyme Disease

In the early stage of Lyme disease, atypical lesions of erythema migrans rash can develop and extend over the neck region, mimicking cervical cellulitis with deep neck infection. Here, we report a 9-year-old Taiwanese boy with a recent history of exposure to deer during his visit to Nanto County in central Taiwan. Cervical cellulitis with lymphadenitis was initially diagnosed. Erythema migrans developed in the following days and Lyme disease was finally diagnosed by a Western immunoblot test. Alertness to this unique clinical feature is required for prompt differential diagnosis of Lyme disease with a presentation of erythema migrans mimicking cervical cellulitis.

Antibodies to Borrelia burgdorferi in erythema migrans patients

Determination of antibodies against Borrelia burgdorferi has supporting value in the diagnose of Lyme disease. The purpose of this study was to determine the production of antibodies in a defined group of patients.

MATERIAL AND METHODS

The study analysed antibodies in the group of 25 patients with erythema migrans. For the detection of antibodies Immunofluorescence methods, ELISA and Western blot were used.

RESULTS

The detection of antibodies by Imunoflorescence methods proved positivity of the titre 1:256 in 14 patients and 9 patients were borderline, with the titre 1:128. Majority of the antibodies detected were of IgM class. The ELISA IgM test found positive reaction in 12 patients and 2 borderline results. IgG antibodies were found significantly more often by ELISA test than by Immunofluorescence. The Western blotting results were IgM positive in 9 patients, 6 were borderline. Only 5 patients have positive IgM results in all tests (Immunofluorescence, ELISA and at least one positive result out of three IgM Western blots).

DISCUSSION AND CONCLUSION

The tests which detect Borrelia burgdorferi antibodies are not standardized. They have variable sensitivity and specificity and their standardization is complicated with respect to great heterogenicity of Borrelia burgdorferi strains circulating in individual regions of Europe. The high specificity of antibodies to individual borrelia antigens are presently pointing towards the need to use, when in diagnostic confusion, more tests, which could detect antibodies also to other borrelia antigens (Tab. 3, Ref. 14). Full Text (Free, PDF) www.bmj.sk.

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 immunofluorescence assay (IFA) and LIAISON® in patients with different clinical manifestations of Lyme borreliosis

Serological tests for detection of borrelial antibodies are frequently used in laboratory diagnostics of Lyme borreliosis. Unfortunately these tests are not standardized and the results obtained with different assays may not be concordant. The aim of the present study was to compare two different serological tests, IFA and LIAISON, for detection of Borrelia burgdorferi sensu lato IgM and IgG antibody. We analyzed the serological immune response in 383 patients with different clinical manifestations of Lyme borreliosis and in 49 healthy blood donors. LIAISON detected IgM and IgG antibodies more often than IFA in all groups of patients except those with chronic Lyme borreliosis. The differences were significant for IgM and IgG antibodies in patients with solitary erythema migrans and in those with early disseminated Lyme borreliosis. There was no significant difference in the specificity of the two tests.

The impact of immunosuppression on erythema migrans. A retrospective study of clinical presentation, response to treatment and production of Borrelia antibodies in 33 patients

BACKGROUND

Little is known about the potential influence of immunosuppression on erythema migrans, the hallmark of early Lyme borreliosis.

METHODS

We performed a retrospective study to assess the impact of immunosuppression on erythema migrans in 33 patients with a malignant or autoimmune disease, chronic infection, or immunosuppressive therapy for organ transplantation. Only patients with active disease status and/or current immunosuppressive therapy were included. Pre-treatment clinical parameters, such as presentation of the skin lesion and presence of extracutaneous signs and symptoms, the disease course during a median follow-up of 9 months after therapy and serum anti-Borrelia burgdorferi antibodies before therapy and by the end of follow-up in the 33 immunosuppressed patients were statistically compared with 75 otherwise healthy patients with erythema migrans. The 75 control patients were matched for sex, age and antibiotic therapy.

RESULTS

With the exception of the site of erythema migrans lesions, which were found more often on the trunk than on the legs in the immunosuppressed patients (vice versa in immunocompetent patients), we found no significant differences for all investigated parameters between the two groups.

CONCLUSIONS

It appears that immunosuppression does not influence clinical presentation, response to therapy, or production of anti-B. burgdorferi antibodies of patients with erythema migrans. It is thus not necessary to treat immunosuppressed patients with erythema migrans differently from immunocompetent patients.

Clinical appearance of erythema migrans caused by Borrelia afzelii and Borrelia garinii – effect of the patient's sex

AIM

The aim in this survey was to study the clinical characteristics of infections caused by Borrelia genospecies in patients with erythema migrans where borrelial origin was confirmed by polymerase chain reaction. The aim was also to study factors influencing the clinical appearance of erythema migrans.

METHODS

The study was conducted in southern Sweden from May 2001 to December 2003 on patients 18 years and older attending with erythema migrans at outpatient clinics. All erythema migrans were verified by polymerase chain reaction, photographed and categorized as "annular" or "non-annular" lesions. A logistic regression model was used to analyze relations between the appearance of the erythema migrans (i.e. annular or non-annular) and factors that influenced its clinical appearance.

RESULTS

A total of 118 patients, 54 women (45.8%) and 64 men (54.2%), fulfilled the inclusion criteria. Of these patients, 74% were infected by B. afzelii and 26% by B. garinii (p < 0.001). A total of 45% (38/85) of the erythema migrans were annular, 46% (39/85) were nonannular and 9.4% (8/85) were atypical. For men infected by B. afzelii, the odds ratio of developing non-annular erythema migrans was 0.09 (95% CI: 0.03-0.33) in comparison with women with the same infection.

CONCLUSIONS

In this prospective study of a large series of erythema migrans, where infecting genospecies were confirmed by polymerase chain reaction, the sex of patients infected with B. afzelii had a strong influence on the appearance of the rash. Patients infected by B. garinii more often had non-annular erythema migrans and a more virulent infection with more individuals presenting with fever, raised levels of C-reactive protein and seroreactivity in the convalescence sera.

[Early diagnosis of Lyme borreliosis]

The local inflammatory reaction following a tick bite varies considerably, so that in particular the frequently atypical variations result in a wrong diagnosis and thus to inappropriate treatment. If a tick bite is followed within three weeks by flue-like or neurological symptoms, or joint swelling in the vicinity of the bite, a serological investigation work-up should be carried out. In the early stage, however, Borrelia-specific antibodies can be detected in only 30-80% of the patients. However, during the further course of the illness, the specific IgM and IgG antibody titers almost always increase.

[Stage-oriented treatment of Lyme borreliosis]

Every manifestation of Lyme borreliosis needs to be treated with antibiotics. The type of antibiotic applied and duration of treatment will depend on the stage and severity of the disease. Erythema migrans, Borrelia lymphocytoma, Lyme arthritis and acrodermatitis chronica atrophicans are primarily treated orally. If neurological symptoms, severe Lyme carditis or eye manifestations are present, intravenous treatment is initially recommended. For oral therapy, doxycycline, amoxicillin, cefuroxime and, if intolerance is shown, azithromycin, are available. For intravenous treatment ceftriaxone, cefotaxime or penicillin G is employed. The overall prognosis for treated Lyme borreliosis is good. However, in particular when manifestations with substantial organic injury have persisted, incomplete healing must be expected. With the exception of erythema migrans, every manifestation should be subjected to a careful diagnostic work-up prior to the start of treatment, because premature antibiotic administration is not only associated with an elevated risk for the patient, but can also mask important diagnostic signs.

Lyme disease: questions and discussion

Diagnosis of Lyme disease is problematic and results in both overtreatment and mistreatment. Attention to epidemiology and physical findings will prevent inappropriate investigations and therapies. The disease has tropisms for specific tissues, and medical care should be tailored to the site and severity of infection.

[Western-blot with VLSE protein and "in vivo" antigens in Lyme borreliosis diagnosis]

The aim of the study was the evaluation of the efficiency of Western blot (EcoLine) test detecting simoultanous presence of IgM and IgG antibodies against B. burgdorferi in diagnosis of early and late stage of Lyme borreliosis. The comparison of results achieved by performing test Western-blot, ELISA (based on recombinant antigens of three genospecies of Borrelia) and EIA (based on antigens of one B. burgdorferi genospecies). The tests Western blot: EcoLine (Virotech) with antygens "in vivo", ELISA Borrelia IgM, IgG recombinant (Biomedica), EIA: B. b. ss. IgG, EIA B. garinii IgG, EIA B. afzelii IgG (TestLine) were used. Results showed efficacy of detecting IgM, IgG antibodies against VlsE simultanously and IgG antibodies against "in vivo" antigens in diagnosis of early stages of Lyme disease when atypical picture skin lessions arise diagnostic doubts and in discerning early and late stage of disease. The EIA tests based on one B. burgdoreferi genospecies seem less effective in comparison to ELISA tests based on 3 genospecies antigens.

[Multilocular large erythemas and fever]

A 44-year old man consulted our emergency room three months after returning from holidays in Sri Lanka: Following a short episode of fever, he observed rise of four large reddish skin lesions that central paling. We considered infection with Borrelia burgdorferi (erythema migrans), streptoccoci (erysipelas), or fungi (tinea corporis). Erysipelas was improbable because of slow progression with little systemic inflammatory response, fungi were not detected in direct microscopic examination. Aspect of the skin lesions was typical for erythema migrans, however, we were not familiar with multilocular appearance of this disease. Nevertheless--on the basis of clinical observations and detection of serum IgM against Borrelia burdorferi--we diagnosed multilocular erythema migrans and treated with doxycycline 200 mg daily for 10 days. The skin lesions completely disappeared within a few days. Erythema migrans may present unilocular or multilocular, depending on Borrelia species involved. In Europe (mainly B. afzelii and B. garinii), multilocular manifestation is rare and, therefore, often misinterpreted. It is important, however, to diagnose and treat multilocular erythema migrans because early hematogenic dissemination is underlying. In America B. burgdorferi sensu stricto infection more often presents with multilocular erythema migrans and systemic clinical manifestations.

Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions

BACKGROUND

The most common and most recognizable feature of Borrelia burgdorferi infection (Lyme disease) is the skin lesion erythema migrans (EM). An illness associated with an EM-like skin lesion, but which is not caused by B. burgdorferi, occurs in many southern states in the United States (southern tick-associated rash illness [STARI], also known as Masters disease).

METHODS

Clinical features of 21 cases of EM-like skin lesions in 21 patients from Missouri were compared in a prospective study with those of 101 cases in 97 patients with EM-like skin lesions from New York.

RESULTS

Among Missouri cases, the peak incidence of EM-like skin lesions occurred earlier in the year than it did among New York cases (P<.001). Case patients from Missouri were more likely to recall a tick bite than were case patients from New York (85.7% and 19.8%, respectively; P<.001), and the time period from tick bite to onset of the skin lesion was shorter among Missouri case patients (6.1+/-4.2 days and 10.4+/-6.1 days, respectively; P=.011). Missouri case patients were less likely to be symptomatic than were New York case patients (19.0% and 76.2%, respectively; P<.001), and Missouri case patients were less likely to have multiple skin lesions (4.8% and 26.7%, respectively; P=.042). EM-like lesions in Missouri cases were smaller in size than those in New York cases (8.3+/-2.2 cm and 16.4+/-11.5 cm, respectively; P<.001), more circular in shape (P=.004), and more likely to have central clearing (76.2% and 21.6%, respectively; P<.001). After antibiotic treatment, Missouri case patients recovered more rapidly than did New York case patients (P=.037).

CONCLUSION

Cases of EM-like skin lesion in patients from Missouri and New York have distinct clinical presentations.

Lyme-Borreliose

Lyme borreliosis is a tick transmitted infectious disease caused by different genospecies of Borrelia burgdorferi sensu lato. In USA only one species B. burgdorferi sensu stricto is prevalent, whereas in Europe at least 5 different pathogenic species could be identified. The most prevalent species are B. afzelii and B. garinii. Infection is not always causing disease. In early infection, a localized skin inflammation, called erythema migrans, occurs around the tick bite, hematogenous dissemination of Borrelia causes flu like symptoms up to meningitis and multiple erythemata migrantia on the skin. In late stage multiple organ systems can be affected, in Europe especially the skin with various forms of acrodermatitis chronica atrophicans, the central and peripheral nervous system, joints and heartmuscle. Lyme borreliosis can be diagnosed by the typical history, the clinical symptoms and the elevated Borrelia specific IgM- and IgG-antibodies in serum and CSF according to the MIQ guidelines, in special cases B. burgdorferi can be cultivated or DNA detected by PCR. Therapy of choice for early infection is oral antibiotics like doxycycline, amoxicillin and cefuroxime for at least 10 days up to 21 days. Late stage infections should be treated for 3-4 weeks. Patients with neurological symptoms should be treated intravenously with ceftriaxone or penicillin G.

Lyme borreliosis in Portugal caused by Borrelia lusitaniae? Clinical report on the first patient with a positive skin isolate

BACKGROUND

Borrelia lusitaniae was isolated from an Ixodes ricinus tick in Portugal in 1993 for the first time. Further, this borrelia genospecies has been found in ixodid ticks collected around the coasts of southern Portugal and North Africa. Its reservoir has not been defined yet. B. lusitaniae was isolated once until now from a patient with a long standing and expanding skin disorder.

PATIENT AND METHODS

A 46-year-old Portuguese woman presented with a skin lesion on the left thigh which had evolved slowly over ten years. The patient reported limb paraesthesias, cramps, chronic headaches, and cardiac rhythm disturbances. History of tick bites was negative nor had the patient ever noticed a skin lesion comparable with erythema chronicum migrans. Skin biopsies were taken for histological evaluation, culture and DNA detection. Antibodies to borrelia were searched by indirect immunofluorescence assay and Western-blot.

RESULTS

A bilateral carpal tunnel syndrome and local synovitis was diagnosed. Dermato-histology was normal, serology was negative. Spirochaetal organisms were cultured from a skin biopsy and identified as B. lusitaniae. The patient improved after a 2-week course of intravenous ceftriaxone; the skin lesions did not expand further.

CONCLUSIONS

This culture confirmed skin infection by B. lusitaniae in a patient from Portugal suggests an additional human pathogen out of the B. burgdorferi sensu lato complex in Europe, particularly in Portugal.

Current Diagnosis and Treatment of Lyme Disease

In more than 80% of cases, Lyme disease presents with an erythema migrans rash, but its characteristics can vary. Carditis, cranial palsies, lymphocytic meningitis, oligoarticular arthritis are manifestations of disseminated infection. Serological tests are helpful, but must be interpreted with caution. Standard antibiotic treatment regimens are highly effective.