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

The Role of the Microbiota-Gut-Brain Axis and Antibiotics in ALS and Neurodegenerative Diseases

: The human gut hosts a wide and diverse ecosystem of microorganisms termed the microbiota, which line the walls of the digestive tract and colon where they co-metabolize digestible and indigestible food to contribute a plethora of biochemical compounds with diverse biological functions. The influence gut microbes have on neurological processes is largely yet unexplored. However, recent data regarding the so-called leaky gut, leaky brain syndrome suggests a potential link between the gut microbiota, inflammation and host co-metabolism that may affect neuropathology both locally and distally from sites where microorganisms are found. The focus of this manuscript is to draw connection between the microbiota-gut-brain (MGB) axis, antibiotics and the use of "BUGS AS DRUGS" for neurodegenerative diseases, their treatment, diagnoses and management and to compare the effect of current and past pharmaceuticals and antibiotics for alternative mechanisms of action for brain and neuronal disorders, such as Alzheimer disease (AD), Amyotrophic Lateral Sclerosis (ALS), mood disorders, schizophrenia, autism spectrum disorders and others. It is a paradigm shift to suggest these diseases can be largely affected by unknown aspects of the microbiota. Therefore, a future exists for applying microbial, chemobiotic and chemotherapeutic approaches to enhance translational and personalized medical outcomes. Microbial modifying applications, such as CRISPR technology and recombinant DNA technology, among others, echo a theme in shifting paradigms, which involve the gut microbiota (GM) and mycobiota and will lead to potential gut-driven treatments for refractory neurologic diseases.

Bull's-Eye and Nontarget Skin Lesions of Lyme Disease: An Internet Survey of Identification of Erythema Migrans

Introduction. Lyme disease is an emerging worldwide infectious disease with major foci of endemicity in North America and regions of temperate Eurasia. The erythema migrans rash associated with early infection is found in approximately 80% of patients and can have a range of appearances including the classic target bull's-eye lesion and nontarget appearing lesions. Methods. A survey was designed to assess the ability of the general public to distinguish various appearances of erythema migrans from non-Lyme rashes. Participants were solicited from individuals who visited an educational website about Lyme disease. Results. Of 3,104 people who accessed a rash identification survey, 72.7% of participants correctly identified the classic target erythema migrans commonly associated with Lyme disease. A mean of 20.5% of participants was able to correctly identify the four nonclassic erythema migrans. 24.2% of participants incorrectly identified a tick bite reaction in the skin as erythema migrans. Conclusions. Participants were most familiar with the classic target erythema migrans of Lyme disease but were unlikely to correctly identify the nonclassic erythema migrans. These results identify an opportunity for educational intervention to improve early recognition of Lyme disease and to increase the patient's appropriate use of medical services for early Lyme disease diagnosis.

Antibody reactivity to Borrelia burgdorferi sensu stricto antigens in patients from the Brazilian Amazon region with skin diseases not related to Lyme disease

In the present study, we report the occurrence of borreliosis in patients from the Brazilian Amazonic region. Nineteen (7.2%) out of 270 dermatological patients with different skin diseases (no one with clinical Lyme disease), tested positive by ELISA for Borrelia burgdorferi. Serum samples from 15 out of the 19 ELISA-positive patients were further evaluated by Western blot. Presence of Borrelia burgdorferi specific IgG was confirmed in eight (53.3%) out of the 15 patients. All eight patients with ELISA and Western blot positive reactions were treated with doxycycline, according to the Centers for Disease Control and Prevention guidelines. One of them had clinical manifestations of colagenosis and was sent to the Department of Internal Medicine for further investigation. Data presented here suggested that borreliosis "lato sensu" is in the Brazilian Amazon region.

Borrelia Burgdorferi "sensu lato" in Brazil: Occurrence confirmed by immunohistochemistry and focus floating microscopy

In the present study, we report the occurrence of Lyme's borreliosis in patients from the Brazilian Amazon Region. Borreliosis was investigated by immunohistochemistry and focus floating microscopy for Borrelia burgdorferi in skin biopsy samples from 22 patients with both clinical and histopathology evidences compatible with Erythema Migrans. Spirochetes were detected by specific immunohistochemistry and focus floating microscopy for B. burgdorferi in samples from five patients. Clinical cure of the cutaneous lesions was observed in all the patients after treatment with doxycycline regimen as proposed by the Center Disease Control guidelines. A limitation of our study was the fact that we were not able to isolate and culture these organisms. These are the first known Brazilian cases of borreliosis to have Focus Floating Microscopy confirmation.

Borreliose de Lyme simile: uma doença emergente e relevante para a dermatologia no Brasil

Neste trabalho de revisão são apresentadas doenças relacionadas com espiroquetas do gênero Borrelia, agentes etiológicos de diferentes enfermidades comuns ao homem e a animais. Enfatizou-se a Borrelia burgdorferi lato sensu, que inclui diferentes espécies causadoras de doenças e com envolvimento sistêmico, com interesse em várias especialidades médicas, como dermatologia, reumatologia, cardiologia e neurologia. Considerando que existem diferenças quanto ao agente etiológico, além dos aspectos clínicos e laboratoriais, quando comparada com a borreliose de Lyme causada pelas Borrelia burgdorferi, B. garinii e B. afzelli, a infecção no Brasil deve ser referida como borreliose de Lyme simile. O eritema migratório recidivante é a principal manifestação clínica da borreliose existente tanto no Brasil como nos demais países. Essa lesão clássica está relacionada com a picada do carrapato vetor e inicia-se como uma mácula ou pápula cutânea avermelhada, de caráter expansivo, eventualmente surgem lesões semelhantes múltiplas a distância. A manifestação clínica da enfermidade, em especial o envolvimento cutâneo, é o parâmetro diagnóstico mais relevante, e os exames complementares sorológicos confirmam a suspeita clínica.

Arthropods in dermatology

Arthropods are important in medicine for a multitude of reasons. Their bites and stings may induce allergic reactions, ranging from annoying to life-threatening. Many arthropod products are also capable of inciting allergic responses in sensitized persons. In recent years, bites and stings have gained greater attention owing to increased concern about disease transmission. A common hypersensitivity response to arthropod bites, stings, and products is papular urticaria. This eruption occurs primarily in children, who eventually "outgrow" this disease, probably through desensitization after multiple arthropod exposures. Papular urticaria is most often caused by fleas or bedbugs, but virtually any arthropod is capable of inducing such a reaction. Two arthropod classes of medical importance are the Arachnida (spiders, scorpions, ticks, and mites) and the Insecta (lice, fleas, bedbugs, flies, bees, and ants). Animals in these two classes are probably responsible for more morbidity and mortality worldwide than are any other group of venomous creatures. In general, the diagnosis of arthropod bites and stings is dependent on maintenance of a high index of suspicion and familiarity with the arthropod fauna not only in one's region of practice, but also in the travel regions of one's patients. Learning objective At the completion of this learning activity, participants should be familiar with the clinical manifestations caused by a variety of arthropods as well as the treatment and possible sequelae of arthropod attacks.

Dermatoses from ticks

Ticks are ectoparasites that cause dermatologic disease directly by their bite and indirectly as vectors of bacterial, rickettsial, protozoal, and viral diseases. In North America, where ticks are the leading cause of vector-borne infection, dermatologists should recognize several tick species. Basic tick biology and identification will be reviewed. Tick bites cause a variety of acute and chronic skin lesions. The tick-borne diseases include Lyme disease, tick-borne relapsing fever, tularemia, babesiosis, Rocky Mountain spotted fever, other spotted fevers, ehrlichiosis, Colorado tick fever, and others. The epidemiology, clinical features, diagnosis, and treatment of these diseases are reviewed with an emphasis on cutaneous manifestations. Finally, the prevention of diseases caused by ticks is reviewed.

Estudo histopatológico de casos de eritema crônico migratório diagnosticados em Manaus

FUNDAMENTOS: O estudo das alterações histopatológicas em relação ao eritema crônico migratório (doença de Lyme) e a demonstração do agente etiológico em tecidos são pouco divulgados no Brasil e na Região Norte. OBJETIVOS: Descrever as principais alterações histopatológicas existentes nas biópsias cutâneas de pacientes com diagnóstico clínico de eritema crônico migratório (ECM). Demonstrar a Borrelia sp em cortes histológicos. MATERIAL E MÉTODOS: Biópsias da pele de 31 pacientes foram incluídas em parafina para obtenção de cortes histológicos que foram corados em hematoxilina eosina (HE) pelo Warthin Starry e Warthin Starry modificado pH 4.0 (pirocatecol), visando investigar as principais alterações histopatológicas e demonstrar Borrelia sp respectivamente. RESULTADOS: As principais alterações verificadas foram: na epiderme, espongiose em 15 casos (44,12%); na derme, infiltrado constituído por linfócitos, histiócitos e eosinófilos em oito casos (15,69%)s. O infiltrado na derme foi encontrado em torno de vasos com disposição em manguito em nove casos (29,04%). A Borrelia sp foi detectada em um caso (3,22%) pela técnica de coloração de Warthin Starry. CONCLUSÕES: Os infiltrados na derme, constituídos por linfócitos, histiócitos e eosinófilos apresentavam as seguintes disposições: em torno de vasos em forma de manguito e no interstício; em torno de vasos e no interstício. Essa composição e distribuição foram consideradas de maior relevância para o diagnóstico de ECM. Pela primeira vez, na região amazônica brasileira foi demonstrada a presença de Borrelia sp em biópsia de paciente com suspeita diagnóstica de ECM em corte histológico corado pela técnica de Warthin Starry.

Erythema multiforme and persistent erythema as early cutaneous manifestations of Lyme disease

We report two cases of borreliosis (Lyme disease) with unusual cutaneous manifestations, erythema multiforme, and persistent erythema. The lesions in both of our patients had distinctive histopathologic features. To our knowledge, this is the first report of erythema multiforme and persistent erythema as early cutaneous manifestations of Lyme disease.

Atypical lymphoid infiltrates arising in cutaneous lesions of connective tissue disease

Atypical lymphoid infiltrates occurring in the setting of connective-tissue disease (CTD) comprise malignant neoplasms of B-cell or T-cell phenotypes and various reactive lymphoid hyperplasias, such as myoepithelial sialadenitis, lymphocytic thyroiditis, and lymphocytic interstitial pneumonitis. We describe 17 patients with atypical lymphoid infiltrates arising in cutaneous lesions of CTD, the spectrum of which included lupus erythematosus, dermatomyositis, relapsing polychondritis, and lichen sclerosus et atrophicus. There were two principal categories, pseudolymphoma and malignant lymphoma, the former representing 15 of the 17 cases. The clinical and histologic features and possible pathogenetic mechanisms are discussed.

Cutaneous clues to systemic disease

Scleroderma, psoriasis, lichen planus, and other skin disorders may signal a more serious internal disease. Physicians who recognize such clues can initiate early treatment while disease is in its early stages. The authors of this article describe several of the more common dermatologic conditions linked to systemic disease, including connective tissue, inflammatory, immunobullous, and infectious diseases.

Successful amplification of DNA specific for Finnish Borrelia burgdorferi isolates in erythema chronicum migrans but not in circumscribed scleroderma lesions

Early diagnosis of Borrelia burgdorferi infection, hampered by the absence of detectable antibodies in most patients with erythema chronicum migrans is important to prevent late-stage neurologic, rheumatologic, and skin disorders. Furthermore, B. burgdorferi has been claimed to be the causative agent in localized scleroderma (morphea). We used PCR amplification to search for B. burgdorferi outer surface protein OspA-specific sequences in DNA obtained from lesional skin biopsies on Finnish patients with clinically suspect erythema chronicum migrans, lymphocytoma, morphea, or with diverse skin manifestations and persistent high antibodies to B. burgdorferi flagellar antigen. Seronegative patients with other skin lesions served as controls. The amplicons obtained with primers specific for B. burgdorferi type strain B31 ospA sequence did not hybridize to the corresponding probes, and thus the DNA amplified from a Finnish B. burgdorferi erythema chronicum migrans skin isolate was sequenced. This 98-nucleotide sequence of ospA (332-429) showed 11% to 14% nucleotide divergence compared with the North American type strain (B31), several European strains, and an East Siberian tick strain. The sequence was almost identical (99%) to a Swedish isolate from acrodermatitis chronica atrophicans. Using oligonucleotides specific for the Finnish strain, a positive polymerase chain reaction-based hybridization was obtained in six of seven untreated erythema chronicum migrans patients infected in Finland or in Estonia, and in the lymphocytoma patient. Only two of the erythema chronicum migrans patients had IgG or IgM antibodies to flagellin. However, all seven morphea lesions as well as the other lesions were polymerase chain reaction negative. Polymerase chain reaction-based hybridization of B. burgdorferi OspA gene from skin-derived DNA thus provides a sensitive and specific diagnostic tool. In conditions not unequivocally known to be caused by B. burgdorferi, like in morphea, this assay was negative. We also demonstrate that peri-Baltic B. burgdorferi isolates show homology in their OspA genes but differ from geographically more distant isolates.

Lyme disease in Rio de Janeiro, Brazil

Five patients living in Rio de Janeiro, Brazil, were found to have Lyme disease. These are among the first known cases in South America.

Lyme borreliosis--a review and present situation in Japan

The skin diseases Erythema (chronicum) migrans (ECM, EM), Lymphadenosis benigna cutis (LABC), and Acrodermatitis chronica atrophicans (ACA) have long been described in northern Europe, and dermatologists are very familiar with these manifestations, which have been successfully treated with penicillin for about 40 years without the causative agent being known. Certain neurologic symptoms could be linked to tickbites during the 1920's and later also to EM. In 1977, Steere et al. reported a new form of inflammatory arthritis, mainly in school children in the community of Lyme, Connecticut, U.S.A., which they could also associate with preceding erythema and tickbites. Five years later, Burgdorfer was able to isolate Borrelia spirochetes from Ixodes ticks, which are known to be vectors of Lyme disease as well as of EM and ACA. The following year, Borrelia spirochetes were also isolated from Ixodes ticks and from skin lesions of patients in Sweden and Germany. These findings resulted in a large number of reports of new discoveries related to this infection, which is now known under the names of tick-borne or Lyme borreliosis and, in the U.S., also as Lyme disease or Lyme arthritis. It has proven to be a great imitator disease, mainly through its involvement of the neurological system, and to be far more widespread than previously thought. The full course of the disease is not yet known, however it is clinically, like another spirochetosis, syphilis, divided into early and late stages. Manifestations involve mainly the skin, the joints, the nervous system (Neuroborreliosis), and the heart. Antibiotic treatment is effective, especially in the early stages. Like syphilis, the disease can be self-healing without treatment. People who are exposed to ticks should be aware of the risk of contracting this disease, also in Japan where Ixodes ticks have been shown to be carriers of Borrelia spirochetes. Cases, particularly of EM, but also with neurological symptoms, have already been diagnosed in Hokkaido, Honshu, Shikoku, and Kyushu. As Lyme borreliosis is now proven to exist in Japan, it is beneficial for dermatologists to know about the various presentations of this disease. This paper will briefly summarize the historical background, the clinical stages, the diagnosis, and the treatment of Lyme borreliosis, with a summary of the present situation in Japan.

The many faces and phases of borreliosis II

Borrelia burgdorferi, the etiologic agent of Lyme disease, has also been associated with other cutaneous conditions. Acrodermatitis chronica atrophicans and lymphadenosis benigna cutis are also caused by B. burgdorferi. Recent evidence links some cases of progressive facial hemiatrophy of Parry-Romberg, benign lymphocytic infiltrate of the skin (Jessner-Kanof), lichen sclerosus et atrophicus, morphea, and Shulman syndrome with borreliae. This article reviews the manifestations of the diseases definitely linked to borreliosis and the evidence linking borreliae to progressive facial hemiatrophy, benign lymphocytic infiltrate, lichen sclerosus et atrophicus, morphea, and Shulman syndrome.