Pulsed high-dose cefotaxime therapy in refractory Lyme borreliosis

Lyme borreliosis

Lyme borreliosis is a tick-borne infectious disease caused by the spirochaetes Borrelia burgdorferi, B. garinii and B. afzelii. It comprises a wide spectrum of symptoms affecting skin, musculoskeletal system, heart, eyes, central and peripheral nervous system. The diagnosis is based on clinical findings in combination with detection of specific IgM and/or IgG antibodies. Diagnostic problems arise from patients with non-specific symptoms and positive IgG antibody detection. Adequate antibiotic therapy cures more than 90% of the patients. However, in some patients repeated therapy is necessary and a small number of patients develop chronic arthritis or other features. While there is currently no vaccine available, prevention of tick bite is the most effective prophylaxis.

Standardised in vitro susceptibility testing of Borrelia burgdorferi against well-known and newly developed antimicrobial agents--possible implications for new therapeutic approaches to Lyme disease

Lyme disease represents a disorder of potentially chronic proportions, and relatively little is known about the in vivo pharmacodynamic interactions of antimicrobial agents with borreliae. So far, evidence-based drug regimens for the effective treatment of Lyme disease have not been definitively established. Moreover, therapeutic failures have been reported for almost every suitable antimicrobial agent currently available. Resistance to treatment and a protracted course of the disease, therefore, continue to pose problems for clinicians in the management of patients suffering from chronic Lyme disease. Further characterisation of the antibiotic susceptibility pattern and a better understanding of the interactions of B. burgdorferi with antimicrobial agents are urgently needed and continue to be crucial owing to considerable differences in the experimental conditions and test methods applied. The development of easily performed, new techniques for the sensitivity testing of B. burgdorferi provides the opportunity to study factors affecting the bacteriostatic and bactericidal action of recently introduced chemotherapeutic agents under more standardised conditions. For the first time, these studies provide direct evidence that, in addition to beta-lactams, macrolides, and tetracyclines which are recommended for stage-dependent treatment of Lyme borreliosis, other recently introduced substances, such as fluoroquinolones, everninomycins, and the ketolide family of antimicrobial agents, also show enhanced in vitro activity against borreliae. Some of these compounds, if effective in vivo as well, may prove to be useful agents in the treatment of certain manifestations of Lyme disease. As such, their potential role should be evaluated further by in vivo experiments and clinical trials. Finally, these antimicrobial agents may turn out to be very effective therapeutic alternatives on account of their oral availability, favourable pharmacodynamic profiles, and high tissue levels in cases where beta-lactames or tetracyclines cannot be administered without detrimental side-effects.

Borrelia burgdorferi detected by culture and PCR in clinical relapse of disseminated Lyme borreliosis

A total of 165 patients with disseminated Lyme borreliosis (diagnosed in 1990-94, all seropositive except one culture-positive patient) were followed after antibiotic treatment, and 32 of them were regarded as having a clinically defined treatment failure. Of the 165 patients, 136 were tested by polymerase chain reaction (PCR) during the follow-up. PCR was positive from the plasma of 14 patients 0-30 months after discontinuation of the treatment, and 12 of these patients had a clinical relapse. In addition, Borrelia burgdorferi was cultured from the blood of three patients during the follow-up. All three patients belonged to the group with relapse, and two of them were also PCR positive. This report focuses on the 13 patients with clinical relapse and culture or PCR positivity. Eight of the patients had culture or PCR-proven initial diagnosis, the diagnosis of the remaining five patients was based on positive serology only. All 13 patients were primarily treated for more than 3 months with intravenous and/or oral antibiotics (11 of them received intravenous ceftriaxone, nine for 2 weeks, one for 3 weeks and one for 7 weeks, followed by oral antibiotics). The treatment caused only temporary relief in the symptoms of the patients. All but one of them had negative PCR results immediately after the first treatment. The patients were retreated usually with intravenous ceftriaxone for 4-6 weeks. None of them was PCR positive after the retreatment. The response to retreatment was considered good in nine patients. We conclude that the treatment of Lyme borreliosis with appropriate antibiotics for even more than 3 months may not always eradicate the spirochete. By using PCR, it is possible to avoid unnecessary retreatment of patients with 'post-Lyme syndrome' and those with 'serological scars' remaining detectable for months or years after infection.

Management of Lyme arthritis

Musculoskeletal complaints and findings can be features of Lyme disease and can occur following treatment. Only with a good understanding of the pathogenesis of these problems can further evaluation and a proper therapeutic scheme be developed.

A proposal for the reliable culture of Borrelia burgdorferi from patients with chronic Lyme disease, even from those previously aggressively treated

Since culture of Borrelia burgdorferi from patients with chronic Lyme disease has been an extraordinarily rare event, clarification of the nature of the illness and proving its etiology as infectious have been difficult. A method for reliably and reproducibly culturing B. burgdorferi from the blood of patients with chronic Lyme disease was therefore sought by making a controlled blood culture trial studying 47 patients with chronic Lyme disease. All had relapsed after long-term oral and intravenous antibiotics. 23 patients with other chronic illness formed the control group. Positive cultures were confirmed by fluorescent antibody immuno-electron microscopy using monoclonal antibody directed against Osp A, and Osp A PCR. 43/47 patients (91%) cultured positive. 23/23 controls (100%) cultured negative. Although persistent infection has been, to date, strongly suggested in chronic Lyme disease by positive PCR and antigen capture, there are major problems with these tests. This new method for culturing B. burgdorferi from patients with chronic Lyme disease certainly defines the nature of the illness and establishes that it is of chronic infectious etiology. This discovery should help to reestablish the gold standard in laboratory diagnosis of Lyme disease.

Prevalence of antibodies to tick-borne encephalitis virus and Borrelia burgdorferi sensu lato in samples from patients with abnormalities in the cerebrospinal fluid

Within the last few years, an increase in cases of tick-borne encephalitis (TBE) as well as an expansion of TBE-endemic regions have been noted in southern Germany. In 1994, a patient was diagnosed for the first time with TBE that had been acquired in Saarland. Up to this point, the Saarland had been considered TBE-free. In a retrospective study, we tested serum samples from 904 patients with abnormalities in the cerebrospinal fluid (CSF) for TBE antibodies. The IgG ELISA used (Immunozym-FSME-IgG, Immuno GmbH, Heidelberg, Germany) yielded 47 positive and 134 borderline sera. The percentage of positive sera showed a significant increase during the time period studied (1989-1994): One IgG-positive serum sample was also IgM-positive. Of the CSF samples, 2 were IgG-positive and 7 were borderline for IgG. In three patients, a positive intrathecal antibody index (IAI) was found, indicating an incrathecal antibody production. An analysis of the vaccination history of the patients showed that only 19% of the patients with a positive TBE IgG titre and only 5.9% of the borderline patients had been vaccinated against TBE. We compared 98 patients that tested positive or borderline for TBE IgG with 98 sex-and-age-matched patients that tested negative. The parameters studied included the patient's complaints upon discharge, the average duration of stationary treatment and 16 different neurological symptoms. We did not observe any significant differences between the two groups. We also tested the sera of 704 of the 904 patients for antibodies to Borrelia burgdorferi (Borrelia burgdorferi ELISA, Genzyme Virotech GmbH, Rüsselsheim, Germany). 155 (22.0%) of the sera were IgG-positive, 136 (19.3%) were borderline, 32 patients (4.6%) had a positive intrathecal antibody index (IAI). The fact that no patient with a clinically manifest case of TBE had acquired the disease in the Saarland indicates that the actual risk of acquiring an acute TBE in the Saarland is very low, despite the high percentage of samples that tested positive for IgG in the ELISA. The increase in the number of serum samples that tested positive for TBE IgG during the last years could be explained by an expansion of TBE regions into the Saarland, increasing vaccination of the population or more travel to endemic regions. The proportion of patients with IgG antibodies to Borrelia was 22%. Because only part of the patients suffered from an acute, clinically manifest borreliosis, and since the serum IgG titre had remained positive for many years after contact with the microorganisms, we suspected that a large percentage of the population would show signs of a clinically silent infection in their sera. 4.6% of the patients had a positive IAI quotient, a clear indication of neuroborreliosis.

Borrelia burgdorferi-associated primary cutaneous B cell lymphoma: complete clearing of skin lesions after antibiotic pulse therapy or intralesional injection of interferon alfa-2a

We report two patients with low-grade malignant primary cutaneous B cell lymphoma in association with Borrelia burgdorferi infection. Extracutaneous manifestations were ruled out by standard staging procedures. Infection with Borrelia burgdorferi was confirmed by cultivation from lesional skin in both patients. In the first patient skin lesions cleared completely after pulse therapy with cefotaxime, whereas in the second patient antibiotic treatment failed. In this patient, however, skin lesions completely cleared after intralesional injection of interferon alfa-2a. Antibiotic treatment or intralesional injection of interferon alfa-2a should be considered as a first-line treatment of Borrelia burgdorferi-associated primary cutaneous B cell lymphoma before more aggressive conventional therapeutic modalities (e.g., radiation therapy) are applied.

Persistence of Borrelia burgdorferi in experimentally infected dogs after antibiotic treatment

In specific-pathogen-free dogs experimentally infected with Borrelia burgdorferi by tick exposure, treatment with high doses of amoxicillin or doxycycline for 30 days diminished but failed to eliminate persistent infection. Although joint disease was prevented or cured in five of five amoxicillin- and five of six doxycycline-treated dogs, skin punch biopsies and multiple tissues from necropsy samples remained PCR positive and B. burgdorferi was isolated from one amoxicillin- and two doxycycline-treated dogs following antibiotic treatment. In contrast, B. burgdorferi was isolated from six of six untreated infected control dogs and joint lesions were found in four of these six dogs. Serum antibody levels to B. burgdorferi in all dogs declined after antibiotic treatment. Negative antibody levels were reached in four of six doxycycline- and four of six amoxicillin-treated dogs. However, in dogs that were kept in isolation for 6 months after antibiotic treatment was discontinued, antibody levels began to rise again, presumably in response to proliferation of the surviving pool of spirochetes. Antibody levels in untreated infected control dogs remained high.

Treatment of Lyme arthritis

The efficacy of different therapeutic regimens for Lyme arthritis is reviewed. The first treatment for Lyme arthritis, intramuscular benzathine penicillin 2.4 million units weekly for 3 weeks, had a success rate of 35%. Another study employed intravenous penicillin G at a dosage of 20 million units daily for 10 days, which cured 55% of patients. Intravenous ceftriaxone has been shown to be superior to penicillin with a response rate of 94%. However, these results have been challenged in recent reports. Oral doxycycline or amoxicillin in association with probenecid seems to work equally well although neuroborreliosis was more frequent following treatment with amoxicillin. An anecdotal report indicates the usefullness of long-term benzathine penicillin for chronic Lyme arthritis. Long-term antibiotic therapy, which is recommended also for Reiter's syndrome, may be useful for eradicating the sanctuaries of Borrelia burgdorferi. Disease-modifying drugs such as hydroxychloroquine or sulphasalazine, a drug which is commonly used in reactive arthritis following enteric infections, may be of value in Lyme arthritis resistant to antibiotics but have not been tested to date. The role of intraarticular injections of steroids or synovectomy is still controversial. Antibiotic treatment is the cornerstone of Lyme arthritis treatment. Additional interventions should be studied for patients with Lyme arthritis resistant to antibiotics.

Long-term results in patients with Lyme arthritis following treatment with ceftriaxone

A total of 35 patients with late stage Lyme borreliosis with involvement of the joints was followed up until 3 years after a 14 day course of 2 g ceftriaxone once daily i.v. Diagnosis was confirmed by indirect and direct microbiological methods as well as clinical signs and symptoms. Long term clinical results in 26 patients at 36 months were complete response or marked improvement in 19, relapse in six and new manifestations in four of the cases, respectively. Possible mechanisms for non-responding to therapy are discussed. Therapy was well tolerated; in no case discontinuation of treatment was necessary due to adverse drug reactions. The treatment results in this group of 35 patients with Lyme arthritis are considered successful. The data obtained are consistent with expectations based on the published experiences with ceftriaxone in this indication.

Persisting complaints attributed to chronic Lyme disease: possible mechanisms and implications for management

A better understanding of the natural history of Lyme disease and of possible causes for persisting symptoms other than active infection is needed to optimize management of patients with persistent symptoms. Review of patients seen at a Lyme disease referral center and of the immunologic and clinical literature on Lyme disease suggests most symptoms that persist after therapy can be explained by one or more of seven proposed pathogenetic mechanisms, only one of which includes active ongoing infection. Individualization of care and reanalysis of patients problems are crucial if misdiagnosis and overtreatment of Lyme disease are to be avoided.