Seronegative Lyme disease. Dissociation of specific T- and B-lymphocyte responses to Borrelia burgdorferi

Lyme disease: clinical manifestations, diagnosis, and treatment

Lyme disease, caused by the spirochete Borrelia burgdorferi, is the most common vector-borne disease in the United States. The causative organism is transmitted through cutaneous inoculation by infected ixodid ticks. Illness typically begins in the summer with the characteristic skin rash, erythema migrans, and associated flulike symptoms. Weeks to months later, the majority of untreated individuals experience one or more manifestations of disseminated Lyme disease, primarily involving the nervous system, heart, and joints. Diagnosis is based on recognition of the appropriate signs and symptoms in the setting of travel to or residence in an endemic area, and supported by serological testing. All stages of the illness are responsive to antibiotics, although treatment is more efficacious when begun early in the course of Lyme disease.

Acute peripheral facial palsy: CSF findings and etiology

CSF and serum were examined in acute and convalescence phase from 56 patients with acute idiopathic peripheral facial palsy. CSF protein analysis, viral and borrelia serology were performed. Borrelia infection was found in 9/56 cases and was often associated with inflammatory CSF findings. One patient each had serological evidence for a recent or ongoing infection with herpes simplex, varicella zoster, adeno, influenza B, echo and Epstein-Barr virus, but none had specific intrathecal antibody synthesis; 11 patients had a serological pattern compatible with a reactivated Epstein-Barr virus infection. Eleven patients displayed mononuclear CSF pleocytosis. Four of them had a borrelia infection. A disturbed blood-brain barrier was observed in 19 patients. Intrathecal immunoglobulin synthesis as indicated by elevated IgM-indices was found in 16 patients and by IgG indices in three. Nine patients had oligoclonal IgG bands in serum and CSF, three exclusively in CSF. It is concluded that patients with facial palsy often have inflammatory CSF findings, indicating a generalised central nervous system affection, and not only a mononeuritis. The importance of viral infections in the pathogenesis is still obscure. Borrelia is the most common infectious cause of facial palsy.

Molecular detection of persistent Borrelia burgdorferi in the urine of patients with active Lyme disease

Current diagnostic tests for Lyme disease (LD) are dependent upon the host serologic response and are insensitive early in infection and, possibly, following antibiotic therapy. We cloned a library of Borrelia burgdorferi 297 DNA and studied one clone, Ly-1, for its potential in diagnostic and pathogenic studies. Using pulsed-field electrophoresis, we demonstrated that Ly-1 is of chromosomal origin and estimated that the B. burgdorferi chromosome is approximately 1,100 kb in size. The 3.7-kb Ly-1 clone hybridizes with geographically diverse strains of B. burgdorferi. No cross hybridization occurs with DNA from human cells, Escherichia coli, Staphylococcus aureus, Clostridium difficile, or the closely related B. hermsii. We used a dot blot assay to detect 100 pg of B. burgdorferi DNA. We partially determined the nucleotide sequence of Ly-1 and used it to select and synthesize oligonucleotides for use in the polymerase chain reaction (PCR). Two different primer pairs were found to amplify DNA from nine geographically diverse isolates. We could detect 10 fg (less than 10 molecules) of B. burgdorferi or less than five spirochetes added to human urine. Finally, we were able to use the PCR to detect B. burgdorferi DNA in the urine of four of eight patients with suspected active LD (three with arthritis and one with neurologic manifestations), all of whom responded to antibiotic treatment. In contrast, those patients who were PCR negative either had inactive disease or had been appropriately treated and did not respond to additional antibiotics, and all four control urine specimens were PCR negative. We conclude that B. burgdorferi DNA can be sensitively detected by the PCR with the primers and methods we describe and that the urinary tract is a site of persistent infection in some cases of human LD, an observation of potential diagnostic and pathogenic importance.

Canine Lyme borreliosis

Lyme borreliosis is now the most commonly reported tick-transmitted disease in humans and is an important disease in dogs. Case reports of canine Lyme borreliosis have appeared in the literature during the last 6 years, but a complete description of the disease still is not available. Until an accurate diagnostic scheme is developed, the disease will remain incompletely understood. A nonlocalizing polyarthropathy is the most commonly described clinical manifestation of canine Lyme borreliosis, but other syndromes probably also exist. The difficulty in making a diagnosis is a result of the fact that dogs do not develop a characteristic skin lesion to mark the beginning of their disease, and many dogs become seropositive but never develop clinical manifestations. Also, Borrelia burgdorferi has been isolated from the blood of healthy dogs, which suggests that detecting a spirochetemia may not have diagnostic significance. Newer diagnostic tests are being evaluated, but at present the diagnosis of canine Lyme borreliosis should be one of exclusion. After other common illnesses are ruled out, serology and response to antibiotic therapy help suggest a diagnosis. Once the disease is accurately diagnosed, efficient therapeutic schemes will be developed based on randomized therapeutic trials. In addition, vaccines are being developed. Currently, without the ability to diagnose the disease accurately, their efficiency can not be demonstrated adequately. Future findings surely will change our understanding of this disease.

Lyme disease in the highlands

Serological results for Borrelia burgdorferi were examined for one year. The results suggest a 'pocket' of infection in one Highland general practice. In this practice, most of the patients had exposure to tick bites and rashes were frequent. There were difficulties in relating serological results to clinical features and management of some patients.

Chronic neurologic manifestations of Lyme disease

BACKGROUND AND METHODS

Lyme disease, caused by the tick-borne spirochete Borrelia burgdorferi, is associated with a wide variety of neurologic manifestations. To define further the chronic neurologic abnormalities of Lyme disease, we studied 27 patients (age range, 25 to 72 years) with previous signs of Lyme disease, current evidence of immunity to B. burgdorferi, and chronic neurologic symptoms with no other identifiable cause. Eight of the patients had been followed prospectively for 8 to 12 years after the onset of infection.

RESULTS

Of the 27 patients, 24 (89 percent) had a mild encephalopathy that began 1 month to 14 years after the onset of the disease and was characterized by memory loss, mood changes, or sleep disturbance. Of the 24 patients, 14 had memory impairment on neuropsychological tests, and 18 had increased cerebrospinal fluid protein levels, evidence of intrathecal production of antibody to B. burgdorferi, or both. Nineteen of the 27 patients (70 percent) had polyneuropathy with radicular pain or distal paresthesias; all but two of these patients also had encephalopathy. In 16 patients electrophysiologic testing showed an axonal polyneuropathy. One patient had leukoencephalitis with asymmetric spastic diplegia, periventricular white-matter lesions, and intrathecal production of antibody to B. burgdorferi. Among the 27 patients, associated symptoms included fatigue (74 percent), headache (48 percent), arthritis (37 percent), and hearing loss (15 percent). At the time of examination, chronic neurologic abnormalities had been present from 3 months to 14 years, usually with little progression. Six months after a two-week course of intravenous ceftriaxone (2 g daily), 17 patients (63 percent) had improvement, 6 (22 percent) had improvement but then relapsed, and 4 (15 percent) had no change in their condition.

CONCLUSIONS

Months to years after the initial infection with B. burgdorferi, patients with Lyme disease may have chronic encephalopathy, polyneuropathy, or less commonly, leukoencephalitis. These chronic neurologic abnormalities usually improve with antibiotic therapy.

Comparative in vitro and in vivo susceptibilities of the Lyme disease spirochete Borrelia burgdorferi to cefuroxime and other antimicrobial agents

The in vitro and in vivo susceptibilities of the Lyme disease pathogen Borrelia burgdorferi to cefuroxime were compared with those of several other antibiotics commonly used to treat this disease. Cefuroxime demonstrated a higher MBC in vitro (1.0 microgram/ml) than ceftriaxone (0.08 microgram/ml) or erythromycin (0.32 microgram/ml), but the MBC was similar to that of amoxicillin (0.8 microgram/ml) and doxycycline (1.6 micrograms/ml). B. burgdorferi was considerably less susceptible to tetracycline (3.2 micrograms/ml) and penicillin G (6.4 micrograms/ml). Of the three other Borrelia species tested, two (Borrelia turicatae and Borrelia anserina) also demonstrated susceptibility to cefuroxime, while the third (Borrelia hermsii) was less susceptible. Results obtained with four antimicrobial agents in the in vivo hamster model parallel the antibiotic susceptibilities in the in vitro study. The three antibiotics with similar MBCs in vitro, i.e., cefuroxime, doxycycline, and amoxicillin, demonstrated comparable activities in preventing borreliosis in B. burgdorferi-challenged hamsters (50% curative doses = 28.6, 36.5 and 45.0 mg/kg, respectively). Penicillin G, which demonstrated the highest MBC in vitro, had very weak protective activity in the hamster model system. These results indicate that the in vitro and in vivo activities of cefuroxime against B. burgdorferi are comparable to those of several oral antibiotics currently being used in the treatment of early Lyme disease and suggest that the oral form of this cephalosporin may be an effective alternative therapy for this disease.

Long-term persistence of specific T- and B-lymphocyte responses to Borrelia burgdorferi following untreated neuroborreliosis

Follow-up studies on 56 patients who suffered from antibiotically untreated, acute, monophasic neuroborreliosis five to 23 years ago revealed significant positive levels of IgG antibodies to Borrelia burgdorferi (Bb) in the serum and cerebrospinal fluid (CSF) of 20 patients (IFT, ELISA, Bb-specific IgG Western blot, Bb-specific IEF-IgG immunoblot). Nine of 10 tested patients had a definitely positive T-cell proliferative response to whole B. burgdorferi, with a mean (+/- -SEM) stimulation index of 7.2 +/- 1.8. Because the patients studied exhibited no, or only mild to medium sequelae without any evidence of a chronic-progressive disease, we interpret the long-term persistence of specific T- and B-lymphocyte responses to B. burgdorferi as an "immunological scar syndrome". Finally, diagnostic criteria of active neuroborreliosis are proposed.

Childhood Lyme borreliosis in Europe

Lyme borreliosis is a multisystem disorder common in childhood. It is an acute and persistent anthropozoonotic infection caused by the spirochete Borrelia burgdorferi (Bb) which is transmitted by Ixodes ticks. After the tick bite in summer, erythema migrans, meningoradiculoneuritis, or carditis may develop within the same season. Later manifestations may be oligo-arthritis, progressive encephalomyelitis, or acrodermatitis chronica atrophicans. The most common course is probably asymptomatic. Connatal infection is possible. Diagnosis is established mainly by history and clinical manifestations. The antibody response to Bb can be measured in serum and cerebrospinal fluid. Tests may be false-negative early in the course of the disease or after early treatment. False-positive results may be caused by cross-reactions. Interpretation of test results must also consider unrelated anamnestic titres or asymptomatic infection. Treatment with appropriate antibiotics cures the disease in most patients, however some patients may not respond. The optimal drug has not yet been found. Best prophylaxis is by early removal of the tick from the skin.

The many faces and phases of borreliosis. I. Lyme disease

Lyme disease is increasingly being reported throughout the United States and many parts of the world. Borrelia burgdorferi, the etiologic agent of Lyme disease, is a spirochete that, not unlike the treponema of syphilis, can cause a spectrum of disease from the initial skin lesion, through widely varied symptoms and signs, to chronic neurologic and arthritic disability. The borrelial spirochete and Lyme disease are the subject of this review. A subsequent article will review other definite and possible cutaneous manifestations of borreliosis.

Neuro-ophthalmologic manifestations of Lyme disease

Lyme disease is a tick-borne spirochetal infection characterized by skin rash, neurologic, cardiac, and arthritic findings. The authors report six patients with Lyme disease who had neuro-ophthalmologic manifestations. One patient had meningitis with papilledema, two had optic neuritis, and one had neuroretinitis. Three patients had sixth nerve paresis, two of whom cleared quickly, whereas multiple cranial nerve palsies and subsequent optic neuropathy developed in another. Early recognition of neuro-ophthalmologic findings can help in the diagnosis and treatment of Lyme disease.

Reactivity of human Lyme borreliosis sera with a 39-kilodalton antigen specific to Borrelia burgdorferi

Borrelia burgdorferi is the causative agent of Lyme borreliosis, a spirochetal illness with a variety of acute clinical manifestations that may lead to debilitating neurological and arthritic complications. Diagnosis is difficult because symptoms mimic a variety of unrelated clinical conditions, spirochetes cannot always be isolated from infected patients, and current serological tests are frequently inconclusive because of the presence of cross-reacting non-B. burgdorferi antibodies. To identify antigens specific to B. burgdorferi that could be used in the serodiagnosis of Lyme borreliosis, we screened a Borrelia DNA expression library in Escherichia coli for antigens reactive with human Lyme borreliosis sera. One clone carried a 6.3-kilobase EcoRI chromosomal fragment (pSPR33), which encoded two species-specific antigens with molecular masses of 28 (P28) and 39 (P39) kilodaltons (kDa). These two antigens were immunologically distinct from OspA, OspB, and the 41-kDa flagellin. Ninety-four serum specimens from patients having Lyme borreliosis were tested for reactivity with P39. All of 33 the serum specimens with immunofluorescence assay titers of greater than or equal to 1:256, 13 of 17 serum specimens with titers of 1:128, and 14 of 44 serum specimens with titers of less than or equal to 1:64 reacted with P39. Notably, many sera reactive to P39 did not appear to react with the 41-kDa flagellin. Therefore, antibody to P39 could be mistaken for antibody to the 41-kDa flagellin in tests of human sera by Western blot (immunoblot). Twenty-five control serum specimens, which included sera from syphilitic, relapsing fever, and amyotrophic lateral sclerosis patients as well as from 10 normal individuals, did not react to P39. Our data suggest that P39 may be a useful antigen for the serological confirmation of Lyme borreliosis.

Lyme carditis in immunodeficient mice during experimental infection of Borrelia burgdorferi

Recently, we described the severe combined immunodeficiency (scid) mouse as a laboratory model for B. burgdorferi infection. Scid mice inoculated with the virulent low-passage tick isolate Borrelia burgdorferi ZS7 developed a severe pancarditis involving endocardium, myocardium and epicardium in the absence of functional B- or T-cells. Soon after inoculation perivascular infiltration was observed, later diffuse infiltration of the interstitium of the subendocardial and subepicardial areas was seen. The infiltrate was mainly mononuclear and predominantly composed of Mac-1+ cells. Concomitantly, fibroblast proliferation and augmented collagen deposition occurred in the interstitium. This was associated with the presence of B. burgdorferi organisms. The histopathological and ultrastructural findings observed in scid mice resemble those observed in human Lyme carditis. The data emphasize the suitability of the scid mouse as a model in which to study the role of the immune system in the pathogenesis of Lyme carditis.

Summary of the first 100 patients seen at a Lyme disease referral center

PURPOSE AND PATIENTS AND METHODS

Lyme disease is a major clinical problem in a number of endemic areas in the United States. In areas where anxiety about the disease is high, patients and physicians often ascribe clinical concerns to Lyme disease. Incorrect diagnosis often leads to unnecessary antibiotic treatment (often prolonged or repeated intravenous therapy). This report summarizes the cases of the first 100 patients referred to the Lyme Disease Center at Robert Wood Johnson Medical School.

RESULTS

In only 37 of the patients referred was Lyme disease, either current or preceding, the explanation for the complaints. Many of the patients had another definable arthropathy. Twenty-five of the patients had fibromyalgia, which has not previously been reported in Lyme disease. Three of these patients had active Lyme disease at the time of evaluation, and 17 had a history suggesting preceding Lyme disease. Approximately half of the 91 courses of antibiotic therapy given to these 100 patients before referral were probably unwarranted.

CONCLUSIONS

Anxiety about possible late manifestations of Lyme disease has made Lyme disease a "diagnosis of exclusion" in many endemic areas. Persistence of mild to moderate symptoms after adequate therapy and misdiagnosis of fibromyalgia and fatigue may incorrectly suggest persistence of infection, leading to further antibiotic therapy. Attention to patient anxiety and increased awareness of these musculoskeletal problems after therapy should decrease unnecessary therapy of previously treated Lyme disease.

The enlarging clinical spectrum of Lyme disease: Lyme cerebral vasculitis, a new disease entity

The case of a patient with cerebral vasculitis with a right thalamic infarct associated with cerebral spinal fluid Lyme disease is presented. This entity has not been described in the United States, and only one similar case in the world literature could be found. The patient presented with a progressive headache and subsequent development of grand mal seizure activity. Lyme disease has been associated with cranial nerve palsies, peripheral and cranial radiculopathies, aseptic meningitis, encephalitic symptoms, chorea, and demyelinating polyneuropathy presenting like Guillain-Barré syndrome. These syndromes can occur separately or in combination. Stroke and strokelike syndromes have been attributed to Lyme disease. The literature concerning the neurologic manifestations of Lyme disease is reviewed.

Odontogenic cervical necrotizing fasciitis

Necrotizing fasciitis is a severe soft-tissue infection characterized by diffuse necrosis of fascia and subcutaneous tissue; initially, skin and muscle are usually spared. The trunk, abdomen, perineum, and extremities are the most commonly involved areas. The case of a 55-year-old man with a cervical necrotizing fasciitis from an infected tooth is presented. The medical history, etiology, anatomy, precipitating factors, clinical presentation, and therapy of this infection are discussed. Early recognition allows effective therapy with aggressive surgical intervention, broad-spectrum antibiotics, and supportive care. Misdiagnosis (eg, as cellulitis) and delayed surgical treatment can result in severe systemic toxicity and a mortality rate that approaches 40%.

Histopathological findings in the central and peripheral nervous systems in neuroborreliosis. A report of three cases

Very little is known about tissue changes and pathophysiological mechanisms in Garin-Boujadoux-Bannwarth syndrome. We report histopathological findings in the central and peripheral nervous systems of three typical cases. In the acute stage of the disease mononuclear perivascular infiltrations with mainly T-helper cells were the prominent finding, whereas after treatment there was no vessel involvement. The fibre changes in the peripheral nervous system consisted of axonal degeneration. No Borrelia burgdorferi-specific antigen could be detected by immunohistochemical methods. Thus vasculitis might be one of the primary pathophysiological mechanisms for the involvement of the nervous system.

Sequestration of antibody to Borrelia burgdorferi in immune complexes in seronegative Lyme disease

To find out whether apparent seronegativity in patients strongly suspected of having Lyme disease can be due to sequestration of antibodies in immune complexes, such complexes were isolated and tested for antibody to Borrelia burgdorferi. In a blinded analysis the antibody was detected in all 10 seronegative Lyme disease patients with erythema chronicum migrans (ECM), in none of 19 patients with other diseases, and in 4 of 12 seronegative patients who probably had Lyme disease but had no ECM. These findings were confirmed by western blot, which also showed that immune complex dissociation liberated mainly antibody reactive to the 41 kD antigen and sometimes antibody to an approximate 30 kD antigen. Complexed B burgdorferi antibody was also found in 21 of 22 (95%) of seropositive patients with active disease, 3 additional seronegative but cell mediated immune reactive patients, and 3 other seronegative patients who eventually became seropositive. Apparent B burgdorferi seronegativity in serum immune complexes may thus be due to sequestration of antibody in immune complexes.

Incidence of tick-bite in man in Aland Islands: reference to the spread of Lyme borreliosis

The common tick Ixodes ricinus is a vector both for the virus of tick-borne viral encephalitis (Kumlinge disease, KD) and of Borrelia burgdorferi (Lyme borreliosis, LB). Bites of the tick are believed to be common in Aland, an island province of Finland in the Baltic Sea. KD has been seen there for many years, and cases of LB have been diagnosed lately. The purpose of this study was to find the incidence of tick-bite among the population with possible implications for the spread of LB. A questionnaire was sent to 561 persons greater than 8 years of age out of a total of 21,281 in order to record tick-bites and erythema chronicum migrans (ECM). The number of answers was 519 (92.5%). 441 persons (85%) had been bitten by ticks, 146 greater than 10 times. 14 probands had had ECM, 73 other rashes around the tick-bite. It is concluded that tick-bites are very common among the population, and thus conditions are favourable for the spread of any tick-borne infection such as LB. The number of patients with secondary or tertiary LB diagnosed in the area is presently 17. It is likely that there are many undetected cases in the area.

Ocular Lyme borreliosis

In six patients with ocular Lyme borreliosis, bilateral granulomatous iridocyclitis and vitritis were present in five. One of these five also had bilateral optic neuritis. Another patient developed combined trochlear and facial nerve palsies. A syndrome resembling pars planitis with atypical features such as granulomatous keratic precipitates and posterior synechiae should prompt a search for Lyme borreliosis. Topical corticosteroid therapy is necessary to prevent complications of anterior segment inflammation caused by Lyme uveitis, but the benefit of systemic and periocular corticosteroids is uncertain. Oral antibiotics may be effective in treating early stages of ocular Lyme borreliosis. In later stages, intravenous antibiotic therapy is indicated.

Clinical features and treatment of Lyme disease

Lyme disease is caused by the spirochete Borrelia burgdorferi, which is carried by infected ticks. This disorder has a variable clinical course with multisystem manifestations, including dermatologic, neurologic, cardiac, and rheumatologic abnormalities. Although Lyme disease has been commonly associated with stages, the utility of staging may be limited due to the inconsistency of clinical manifestations among patients. Furthermore, stages may overlap as a result of the acute and chronic phases of the disease. The laboratory characteristics of Lyme disease are highly variable. The use of microbiologic cultures in establishing the diagnosis requires several weeks and has a low yield of positivity. Serologic assays using indirect immunofluorescence and enzyme-linked immunosorbence are preferred. Because of the highly variable features of Lyme disease, clinical and laboratory features must be correlated and interpreted in the context of the disease. Treatment should be initiated as early as possible after the onset of illness. Prompt therapeutic intervention may result in early resolution of the dermatologic hallmark, erythema chronicum migrans, as well as prevention and attenuation of subsequent complications.

Lyme disease

Within the last decade, Lyme borreliosis has emerged as a complex new infection whose distribution is worldwide. The disorder is caused by a recently recognized spirochete, B. burgdorferi, transmitted by ticks of the I. ricinus complex. Certain species of mice are critical in the life cycle of the spirochete, and deer appear to be crucial to the tick. Although the disorder's basic outlines are similar everywhere, there are regional variations in the causative spirochete, animal hosts, and clinical manifestations of the illness. In the United States, Lyme disease commonly begins in summer with a characteristic skin lesion, erythema migrans, accompanied by flu-like or meningitis-like symptoms. Weeks or months later, the patients may have neurologic or cardiac abnormalities, migratory musculoskeletal pain, or arthritis, and more than a year after onset, some patients have chronic joint, skin, or neurologic abnormalities. After the first several weeks of infection, almost all patients have a positive antibody response to the spirochete, and serologic determinations are currently the most practical laboratory aid in diagnosis. Treatment with appropriate antibiotics is usually curative, but longer courses of therapy are often needed later in the illness, and some patients may not respond.

Aspects of the diagnosis of Lyme borreliosis

Attempts were made to culture spirochetes from the cerebrospinal fluid of 105 patients with suspected Lyme borreliosis with neurological complications. At the final evaluation, only 38 patients fulfilled the criteria of neuroborreliosis. Spirochetes were cultured from the cerebrospinal fluid of four of these patients. All four had pleocytosis in their cerebrospinal fluid and a history of neurological symptoms of only four to ten days. Two had no detectable antibodies in their cerebrospinal fluid against any of the isolated spirochetes, neither when tested with an ELISA nor by Western blot. A distinctly stronger antibody reaction to the homologous isolate than to the heterologous isolates was found in serum and cerebrospinal fluid from one patient. The cells of the isolates were morphologically similar and showed a very similar protein pattern when analyzed by SDS-PAGE. Cells of all isolates reacted with the monoclonal antibodies H5332 and H9724, which also react with Borrelia burgdorferi isolate B31, the type species. One isolate lost a major protein of 23 kD after subcultivation for four months. We conclude that isolation of spirochetes from cerebrospinal fluid is not suitable as a routine method but might prove successful in clinically selected cases of Lyme borreliosis. The patient antibody response to spirochetal components was analyzed with Western blot. Antibodies to low-molecular components including a major protein with a molecular weight of 21-23 kD, and to a 41-kD major flagellar protein, were the first to appear in serum and in CSF samples. No single band in the immunoblots was found to be specific. By requiring a 41 kD band together with at least one low-molecular band for a positive immunoblot, 53 of 68 (78%) patients with neuroborreliosis had positive IgM and/or IgG serum immunoblots by visual reading of coded material. Western blot was more sensitive than ELISA based on a sonicate antigen which identified 40 of the 68 (59%) patient samples as positive, but not significantly more sensitive than ELISA based on a purified flagellum antigen which identified 50 of 68 (74%). Western blot tended to be more sensitive than the flagellum ELISA regarding sera from patients with neurological symptoms of 2 weeks or shorter duration. However, there was a tendency towards a lower specificity regarding the serological diagnosis of current Lyme borreliosis by Western blot than by sonicate and flagellum ELISAs.(ABSTRACT TRUNCATED AT 400 WORDS)

Bilateral keratitis in Lyme disease

Lyme disease, caused by the spirochete Borrelia burgdorferi, has ophthalmic manifestations. The authors describe two cases of Lyme keratitis characterized by multiple focal, nebular opacities at varying levels of the stroma which may progress to edema, neovascularization, and scarring. Close observation, in addition to systemic antibiotic therapy, may be sufficient if the visual axis is not involved, and the patient is asymptomatic.

Lyme disease. The hidden pandemic

Physicians will recognize Lyme disease faster if they maintain a high index of suspicion in a young patient with arthritis accompanied by negative rheumatoid factor and antinuclear antibody in combination with cardiac conduction problems or lymphocytic meningitis. The Lyme spirochete (Borrelia burgdorferi) has notable sensitivity to tetracycline, penicillin, and erythromycin; therefore, proper and complete treatment of the disease, once it is identified, can be easily achieved. Finkel observed that Lyme disease manifests itself as a "great imitator," as do many disorders caused by a spirochete. The total impact of Lyme disease on public health will be known only when the disease is fully recognized, consistently reported, and adequately managed.

Lyme borreliosis in Finland in 1986-1988

In 1986-1988 there were 123 patients with positive serology for Lyme borreliosis out of 4000 sera referred to the Department of Bacteriology and Immunology, University of Helsinki. Of the 63 patients with positive serology in 1986-1987 20 showed a predominant involvement of the nervous system, 18 complained of joint symptoms and 11 patients merely showed a skin involvement including 8 patients with erythema chronicum migrans (ECM) and 3 patients with acrodermatitis chronica atrophicans (ACA). Two of the patients had unspecific general symptoms and in 5 patients the type of involvement remained unknown. The serology was considered to be falsely positive in 2 patients with tuberculous meningitis, in one with syphilis and in another with recurrent fever.

Lyme disease

Neurological problems form an important part of the clinical spectrum of Lyme disease. A triad of aseptic meningoencephalitis, cranial neuritis and peripheral neuritis is unique to the disease. However, the list of neurological manifestations described includes pseudotumour cerebri, hemiparesis, demyelinating disorders, optic atrophy, recurrent laryngeal nerve palsy and purulent meningitis so that Lyme disease must now be considered in the differential diagnosis of a wide range of neurological disorders.

Lyme borreliosis and multiple sclerosis

There is now general consensus that tertiary Lyme borreliosis affecting the central nervous system does exist. Clinical, neuropathologic, laboratory and epidemiologic features indicate clearly that tertiary Lyme borreliosis of the CNS is a distinct entity and there is no etiologic association with multiple sclerosis.

New chemotherapeutic approaches in the treatment of Lyme borreliosis

1. It was demonstrated that while B. burgdorferi may be sensitive to relatively small concentrations of penicillin and ceftriaxone, the organism is killed slowly. This implies that, as in syphilis, prolonged blood levels of these drugs may be necessary in order to ensure cure. In contrast, the activity of tetracycline is more rapid in its action but is more dependent on drug concentration achieved. Unfortunately, the MIC and MBC for some strains are at or above the peak level achieved under optimal conditions. 2. Increasing the concentrations of penicillin or ceftriaxone above the MIC for the organism has little effect on the rate of killing. In contrast, the killing by tetracycline can be augmented by increasing concentrations of the drug. 3. Ceftriaxone is more active than penicillin, as measured by MIC, against the five strains of B. burgdorferi tested. 4. Ceftriaxone was efficacious in the treatment of Lyme borreliosis, which was recalcitrant to penicillin therapy. In a randomized trial comparing ceftriaxone to high-dose penicillin therapy, ceftriaxone was significantly more efficacious than penicillin in the treatment of the late complications of Lyme borreliosis.