Lyme borreliosis

Lower Frequency of Multiple Erythema Migrans Skin Lesions in Lyme Reinfections, Europe

The erythema migrans (EM) skin lesion is the most common clinical manifestation of Lyme borreliosis. Information about EM in Lyme borreliosis reinfection is limited. Of the 12,384 cases with diagnosed EM at an outpatient clinic during 1990-2014 in Slovenia, 1,962 (15.8%) cases occurred in patients who were treated previously for Lyme borreliosis, including 1,849 (94.2%) who had previously had EM. The percentage of reinfected patients who sought care with disseminated Lyme borreliosis at the time of reinfection, as manifested by multiple EM skin lesions, was significantly lower than for EM patients with no history of Lyme borreliosis (5.5% [108/1,962] vs. 7.4% [769/10,427]; p = 0.002). None of the clinical manifestations of Lyme borreliosis in Europe will completely protect against EM developing in patients in the future. The reoccurrence of Lyme borreliosis manifested by multiple EM lesions is significantly less likely than for patients with no history of Lyme borreliosis.

Sex- and Age-Specific Lyme Disease Testing Patterns in the United States, 2019 and 2022

OBJECTIVES

Serologic testing is a useful adjunct for the diagnosis of Lyme disease, a major public health problem in certain US regions. We aimed to determine whether Lyme disease serologic testing and results differed by sex and age group.

METHODS

We identified 2 cohorts of individuals across all ages who underwent serologic testing for Lyme disease at a national reference laboratory in 2019 (cohort 1) and 2022 (cohort 2). If an individual had multiple tests in the same year, we included only the first test. We excluded individuals who had been tested in the previous 5 years.

RESULTS

Cohorts 1 and 2 consisted of 578 052 and 550 674 people, respectively. Fewer males than females were tested in cohort 1 (42.7% vs 57.3%) and cohort 2 (42.3% vs 57.7%), although similar numbers were tested for both sexes among nonadults. More males than females had a positive test result in cohort 1 (53.9% more males) and cohort 2 (52.9% more males). The odds ratio of receiving a positive test result among males versus females was 2.09 (95% CI, 2.01-2.17) in cohort 1 and 2.12 (95% CI, 2.05-2.19) in cohort 2. Among people with positive test results, females (except children) were more likely than males to have positive immunoglobulin M and negative immunoglobulin G results, which can serve as a marker of early infection (odds ratio = 1.43 [95% CI, 1.31-1.55] in cohort 1 and 1.38 [95% CI, 1.29-1.47] in cohort 2).

CONCLUSIONS

Further studies are needed to understand whether the observed differences in Lyme disease testing and positivity result from sex- and age-associated disparities in social behavior, health care seeking, clinical practice, or other factors.

Review of atypical optic neuritis

Optic neuritis (ON), an inflammatory optic neuropathy, is among the most common causes of visual loss. In its initial clinical appearance, ON may have unilateral or bilateral presentation, and anterior (papillitis) or retrobulbar localization. Traditionally, cases are divided into typical and atypical ON. In the Western hemisphere, most typical cases of optic nerve inflammation are associated with multiple sclerosis (MS). However, ON may also be associated with a series of disorders of known or initially undetected origin. Atypical ON has a somewhat different clinical picture from typical ON, and encompasses neuromyelitis optica spectrum disease (NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), idiopathic recurrent neuroretinitis (NR), chronic relapsing inflammatory ON (CRION), ON within systemic autoimmune diseases, paraneoplastic and neuritis during or after infectious diseases or vaccination. The causes should be meticulously worked up, to address the therapeutic and prognostic challenges posed by these conditions. Here, we provide a brief overview of atypical ON, as encountered in our clinical practice, and additionally discuss the possible occurrence of optic neuropathies other than inflammatory and other ocular diseases within these disorders.

Plasma levels of the neuron damage markers brain-derived tau and glial fibrillary acidic protein in Lyme neuroborreliosis: A longitudinal study

BACKGROUND

A reliable blood biomarker for neuroborreliosis (NB) has yet to be identified. This study investigated levels of neuron damage markers glial fibrillary acidic protein (GFAP) and brain-derived tau (BD-tau) over six months of follow-up in patients with NB. The aim was to evaluate the potential of these biomarkers for monitoring treatment response and prognostic purposes.

METHODS

A retrospective longitudinal cohort study including plasma collected at diagnosis and approximately three- and six-months post diagnosis from adult NB patients enrolled at the Department of Infectious Diseases, Rigshospitalet between 2018 and 2020. BD-tau concentrations were measured in-house using the Single Molecule Array (Simoa) HD-X platform, while GFAP concentrations were assessed on the same platform utilizing the GFAP Discovery Kit. Changes in biomarker concentrations were analyzed using linear mixed models with an unstructured covariance pattern, with follow-up included as a categorical fixed effect.

RESULTS

A total of 23 patients (median age: 63 years; male/female ratio: 16/7) with 56 plasma samples were analyzed; 12 patients had complete samples. GFAP and BD-tau levels showed minimal variation throughout the study period. Patients with persistent symptoms had GFAP concentrations that were 55 % higher at diagnosis compared to those who fully recovered, though this difference was not statistically significant (p = 0.09). No significant associations were observed between biomarker levels and treatment response or long-term outcomes.

CONCLUSIONS

This longitudinal study did not find BD-tau or GFAP to be effective blood biomarkers for monitoring treatment response or predicting outcomes in NB.

UHPLC-MS/MS-based untargeted metabolite profiling of Lyme neuroborreliosis

The diagnosis of Lyme neuroborreliosis (LNB) requires the demonstration of intrathecal synthesis of Borrelia antibodies in a patient's cerebrospinal fluid (CSF), which involves the invasive procedure of a lumbar puncture. This study serves as a feasibility study aimed at exploring the potential of using serum samples, which are easily obtainable routine clinical samples, for LNB diagnostics via advanced metabolomics techniques. Serum samples were collected from confirmed LNB patients before and after treatment, with post-treatment samples serving as controls. The objective of the study was to find stable biomarkers for acute LNB through untargeted metabolomics analysis using ultrahigh-performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/MS). The study focused on biomarkers that could be reliably detected in serum samples stored under typical clinical conditions, without the need for special handling, ensuring consistent detection over time. The analysis revealed 26,978 molecular features (MFs), of which 1,746 were statistically significant (p < 0.001). Further manual investigation into 91 of the most prominent MFs revealed 53 potential biomarkers for LNB, individually or in combination. The workflow developed provides a comprehensive platform for biomarker detection, with potential applications in both research and clinical settings for LNB and other infections. This minimally invasive diagnostic approach is promising, and additional validation and future studies are needed for it to be considered as a practical alternative or a complement to CSF-based diagnostics of LNB in everyday clinical practice.

Lyme Carditis With Complete Heart Block

Lyme disease, the most common tick-borne infection in North America, can lead to multi-organ involvement, including Lyme carditis. This report describes the case of a 42-year-old male who presented with a third-degree atrioventricular (AV) block due to Lyme carditis. The patient reported a history of a recent tick bite and erythema migrans rash, followed by progressive fatigue, palpitations, and dyspnea. Initial electrocardiogram (EKG) revealed third-degree AV block with ventricular escape rhythm, necessitating temporary transvenous pacing and intravenous ceftriaxone therapy. Within 48 hours, the patient significantly improved, transitioning to first-degree AV block with a decreasing PR interval. After clinical stabilization, intravenous ceftriaxone was switched to oral doxycycline, and the patient was discharged with outpatient follow-up. This case emphasizes the significance of early recognition and treatment of Lyme carditis to prevent life-threatening complications and avoid unnecessary permanent pacemaker implantation.

Prevalence of Borrelia burgdorferi sensu lato infection in the Czech Republic

INTRODUCTION

Lyme borreliosis (LB), an infection caused by Borrelia burgdorferi sensu lato (Bbsl), is the most common tick-borne disease in Europe. To further characterize the LB burden in the Czech Republic, we conducted a seroprevalence study and estimated the incidence of symptomatic Bbsl infections.

METHODS

Anti-Bbsl IgM and IgG antibodies were detected in sera collected from the adult population in 2011 -2012 by enzyme-linked immunosorbent assay and immunoblot tests at the National Reference Laboratory. The incidence of symptomatic Bbsl infections was estimated from the seroprevalence results and the symptomatic proportion and duration of persistence of anti-Bbsl IgG antibodies in Bbsl-infected individuals. Surveillance under-detection of symptomatic Bbsl infections was estimated by comparing surveillance-reported and seroprevalence-based incidence.

RESULTS

Samples from 1996 adults were tested; the median age (range) was 45 (18 -87) years; 1037 (52.0 %) were female. The prevalence (with 95 % confidence interval) of anti-Bbsl IgG, and IgM and/or IgG (IgM/IgG) antibodies was 6.3 % (5.3 -7.5 %), and 9.5 % (8.3 -10.9 %), respectively. The IgM/IgG prevalence was 7.8 % (6.5 -9.2 %) in Bohemia and 15.3 % (12.2 -19.0 %) in Moravia. There were an estimated 30,563 (26,550 -34,962) symptomatic incident Bbsl infections in adults in the Czech Republic in 2012, for an incidence of 352.2 (306.0 -402.9) symptomatic Bbsl infections per 100,000 adults per year. There were an estimated 11 (10 -13) symptomatic Bbsl infections for each surveillance-reported LB case in the Czech Republic in 2012.

CONCLUSIONS

There is high incidence of symptomatic Bbsl infections in the Czech Republic, particularly in Moravia. Interventions are needed to address the substantial burden of LB in the Czech Republic.

Neuroborreliosis at the region of Asturias, Spain (2009-2022): Analysis of 38 cases

INTRODUCTION

Diagnosis of neurological involvement in Lyme disease is based on two-step serological testing and cerebrospinal fluid pleocytosis. In Spain its incidence is much lower than in other European countries, being Asturias the region with the highest incidence. We tried to analyse the clinical and epidemiological aspects in the main hospital in Asturias.

MATERIAL Y METHODS

Retrospective observational study of patients admitted for Lyme disease in our center over 14years (2009-2022). Clinical, analytical and evolutionary variables were analyzed after one year. Active neuroborreliosis was diagnosed after registering pleocytosis and positive serologies at the cerebrospinal fluid.

RESULTS

108 episodes were analyzed, corresponding to 100 patients coded at discharge as Lyme disease. 58 episodes are discarded due to diagnostic or coding error. 51 episodes were considered active disease, being 38 diagnosed of neuroborreliosis. Tick bite recall and erythema were reported in 55.3% and 31.6% of patients. The most frequent neurological syndromes were radiculoneuritis (36.84%), bilateral facial palsy (13.56%), radiculoneuritis and bilateral facial palsy (10.52%) and multiple cranial mononeuropathy (10.52%), among others. 78.9% achieved a complete recovery, and 15.79% developed post-treatment Lyme disease syndrome.

DISCUSSION

Despite the high incidence of Lyme disease in Asturias, the cases based on hospital admission that can be classified as active disease are lower than those published based on hospital coding. The main source of diagnostic error is positive serological results, without other clinical context, especially in patients studied for cognitive impairment or encephalopathy.

Residual Symptoms and Quality of Life After Treated Lyme Neuroborreliosis: Case-Control Study (QoLYME)

Background

Earlier studies revealed that 10%-50% of patients reported remaining complaints after treatment for Lyme neuroborreliosis (LNB). The aim of our study was to assess symptoms and quality of life in patients with diagnosed and treated LNB and to compare them with findings in the general population.

Methods

Adults with LNB receiving adequate antibiotics were included between 2015 and 2021 in 2 tertiary hospitals. Two controls without Lyme borreliosis history were included for each case patient, matched by age and geographic area. All participants were interviewed to answer a standardized questionnaire. Fatigue was assessed by the Fatigue Severity Scale (FSS) and quality of life by the 12-Item Short Form Survey, including physical component summary (PCS) and mental component summary (MCS) scores.

Results

Fifty-three patients and 104 controls were included. The mean age (SD) was 62 (13) years in both groups; 66% were male in the LNB group and 44% in the control group (P = .01). Fatigue (68% vs 48%, respectively; P = .02), memory disorders (60% vs 38%; P < .01), and attention disorders (32% vs 17%; P = .05) were significantly more frequent in the LNB group than in controls. In multivariable analysis, no association was found between LNB and FSS scores (odds ratio, 1.6 [95% confidence interval, .9-3.0]; P = .15) or between LNB and MCS scores (0.8 [.4-1.5]; P = .45); however, patients with LNB had lower PCS scores (0.5 [.3-.9]; P = .03).

Conclusions

Several symptoms were similar in patients with LNB and controls. Quality of life was slightly impaired in patients with LNB and PCS scores were lower, but there were no differences in MCS or FSS scores. Reassurance and specific rehabilitation measures could be provided to these patients.

Single-cell transcriptome analysis of the early immune response in the lymph nodes of Borrelia burgdorferi-infected mice

Lyme borreliosis is a disease caused by Borrelia burgdorferi sensu lato bacteria. Borrelia burgdorferi is known to induce prolonged extrafollicular immune responses and abnormal germinal centre formation. The infection fails to generate a neutralizing type of immunity, eventually establishing a persistent infection. Here, we performed single-cell RNA sequencing to characterize the immune landscape of lymph node lymphocytes during the early Borrelia burgdorferi infection in a murine model. Our results indicate key features of an extrafollicular immune response four days after Borrelia burgdorferi infection, including notable B cell proliferation, immunoglobulin class switching to IgG3 and IgG2b isotypes, plasmablast differentiation, and the presence of extrafollicular B cells identified through immunohistochemistry. Additionally, we found infection-derived upregulation of suppressor of cytokine signalling genes Socs1 and Socs3, along with downregulation of genes associated with MHC II antigen presentation in B cells. Our results support the central role of B cells in the immune response of a Borrelia burgdorferi infection, and provide cues of mechanisms behind the determination between extrafollicular and germinal centre responses during Borrelia burgdorferi infection.

Climate-induced expansion of Lyme disease in east central Ohio

The geographical distribution of Lyme disease has been attributed to changes in Earth's climate and associated distribution of its vector, ticks of the genus Ixodes. This study focuses on the impact of climatic and meteorological conditions on Lyme disease transmission in East Central Ohio, an emerging hotspot of cases. Using county-level data from 2001 to 2023, we analyzed the relationship between Lyme disease cases and temperature, precipitation, and the Southern Oscillation Index (SOI) using a distributed lag nonlinear model (DLNM). Results show that warmer winter temperatures, higher precipitation, and negative SOI values (El Niño conditions) were significantly associated with increased Lyme disease incidence and displayed delayed effects of 6 to18 months. These findings suggest that climate change, with its potential to bring milder winters and increased spring and summer rainfall, may further exacerbate Lyme disease cases in Ohio.

A core genome MLST scheme for Borrelia burgdorferi sensu lato improves insights into the evolutionary history of the species complex

Multi-locus sequence typing (MLST) based on eight genes has become the method of choice for Borrelia typing and is extensively used for population studies. Whole-genome sequencing enables studies to scale up to genomic levels but necessitates extended schemes. We have developed a 639-loci core genome MLST (cgMLST) scheme for Borrelia burgdorferi sensu lato (s.l.) that enables unambiguous genotyping and improves the robustness of phylogenies and lineage resolution within species. Notably, all inner nodes of the cgMLST phylogenies had consistently high statistical support. Analyses of the genetically homogeneous European B. bavariensis population support the notion that cgMLST provides high discriminatory power even for closely related isolates. While isolates differed maximally in one MLST locus, there were up to 179 cgMLST loci differences. Thus, the developed cgMLST scheme for B. burgdorferi s.l. resolves lineages at a finer resolution than MLST and improves insights into the evolutionary history of the species complex.

Evaluating neurofilament light chain serum levels as a diagnostic marker for Lyme neuroborreliosis

Background

Serum neurofilament light chain (sNfL) is a biomarker for neuro-axonal injury.

Objectives

To assess sNfL's utility as a diagnostic marker for Lyme neuroborreliosis (LNB).

Methods

We compared serum and CSF NfL levels in LNB patients and age-matched controls. Age-adjusted NfL values were used in receiver operating characteristic (ROC) analysis.

Design

Retrospective cohort study.

Results

Eighty-six patients (30 LNB, 29 with-, and 27 without neurological disorders) were included. Compared to individuals without neurological disease, LNB patients showed increased serum (median (interquartile range, IQR): 36.3 pg/ml (19.3-112.0) vs 20 pg/ml (12.9-37.3), p < 0.001) and CSF NfL levels (median (IQR): 1000.0 pg/ml (286.0-6471.0) vs 182 pg/ml (99.3-474.0), p < 0.001). NfL concentrations were similar in LNB and other neurological disorders. ROC analysis of age-adjusted sNfL and CSF NfL levels showed areas under the curve of 0.78 (95% confidence interval (CI): 0.66-0.89) and 0.83 (95% CI: 0.71-0.94), respectively.

Conclusion

sNfL concentrations lack sufficient diagnostic capability for LNB diagnosis.

Investigation of genes expression of the JAK/STAT signalling pathway and AMPs in the presence of Borrelia spirochetes in Ixodes ricinus

Multicellular animals need to control the spread of invading pathogens. This is a particular challenge for blood-feeding vectors such as ticks, which ingest large amounts of blood potentially laden with harmful microorganisms. Ticks have a basic innate immune system and protect themselves from infection through innate immune responses involving pathways such as Janus kinase (JAK) or the signalling transducer activator of transcription (STAT). Direct antimicrobial defence occurs through the rapid synthesis of numerous antimicrobial agents including antimicrobial peptides (AMPs). The tick Ixodes ricinus is one of the main vectors of the Lyme disease pathogen, the spirochete Borrelia burgdorferi sensu lato. Data suggest that the JAK/STAT signalling pathway controls the expression of AMPs and regulates the infection of the pathogen in the tick body. The innate immune system during the off-host period keeps the level of spirochete infection in check. Spirochetes may influence the innate immune response in ticks. Therefore, the aim of this study was to analyse the expression of the genes related to the JAK/STAT pathway and selected AMPs in questing ticks in which B. burgorferi s.l. was detected. In the ticks infected with spirochetes, overexpression of genes related to the JAK/STAT signalling pathway was observed in the case of STAM and SOCS genes. AMPs genes such as def1, ric, lzs were overexpressed with different expression patterns. The results obtained suggest that AMPs may be involved in infection management in ticks.

Borrelia burgdorferi tolerates alteration to P66 porin function in a murine infectivity model

Borrelia burgdorferi exists in a complex enzootic life cycle requiring differential gene regulation. P66, a porin and adhesin, is upregulated and essential during mammalian infection, but is not produced or required within the tick vector. We sought to determine whether the porin function of P66 is essential for infection. Vancomycin treatment of B. burgdorferi cultures was used to screen for P66 porin function and found to generate spontaneous mutations in p66 (bb0603). Three novel, spontaneous, missense P66 mutants (G175V, T176M, and G584R) were re-created by site-directed mutagenesis in an infectious strain background and tested for infectivity in mice by ID50 experiments. Two of the three mutants retained infectivity comparable to the isogenic control, suggesting that B. burgdorferi can tolerate alteration to P66 porin function during infection. The third mutant exhibited highly attenuated infectivity and produced low levels of P66 protein. Interestingly, four isolates that were recovered for p66 sequencing from mouse tissues revealed novel secondary point mutations in genomic p66. However, these secondary mutations did not rescue P66 porin function. New structural modeling of P66 is presented and consistent with these experimental results. This is the first work to assess the contribution of P66 porin function to B. burgdorferi pathogenesis.

Barriers and Predictors of Lyme Disease Vaccine Acceptance: A Cross-Sectional Study in Poland

BACKGROUND/OBJECTIVES

Lyme disease (LD) is a major public health problem in Europe and the United States, with increasing incidence and not many prevention options. Vaccine hesitancy might be a significant barrier to successful vaccination campaigns having in mind previous vaccine development failures. This study aimed to evaluate the public's perception of LD vaccination in Poland, assess willingness to vaccinate, and identify factors influencing vaccination attitudes.

METHODS

A cross-sectional survey was conducted among parents of children hospitalized at the University Children's Hospital in Bialystok, Poland. The survey consisted of 29 questions regarding demographics, LD knowledge, vaccine attitudes, and perceived risks. Data were collected between January and December 2023 and analyzed using descriptive and inferential statistics to identify predictors of respondents' positive vaccination attitudes.

RESULTS

A total of 503 valid responses were analyzed. Most respondents (72.4%) showed positive attitudes towards vaccination, while 18.5% were neutral and 9.1% were negative. Trust in health experts emerged as an important predictor of vaccination acceptance (OR 22.84; p < 0.001). More than 80% of participants recognized an LD vaccine as necessary, and 64.21% believed it would reduce their concerns about LD. Willingness to vaccinate was influenced by general positive vaccine attitudes, recognized danger of LD, and belief in the vaccine's ability to ease fears. Notably, 40.8% of respondents were uncertain about vaccine risks, with this group tending to be younger, less educated, and expressing lower trust in medical professionals.

CONCLUSIONS

Public perception of LD in Poland indicates a high acceptance of a potential LD vaccine. Still, addressing vaccine hesitancy remains critical, particularly among undecided or neutral respondents. Building trust in healthcare professionals and addressing safety worries are important to increasing future LD vaccine use.

Proportion of confirmed Lyme neuroborreliosis cases among adult patients with suspected early European Lyme neuroborreliosis

PURPOSE

To determine the frequency of confirmed Lyme neuroborreliosis (LNB) cases in adult patients with three different clinical presentations consistent with early LNB.

METHODS

Data were obtained through routine health care at the UMC Ljubljana, Slovenia from 2005 to 2022, using clinical pathways. The patients were classified into three groups: (i) radicular pain of new onset (N = 332); or (ii) involvement of cranial nerve(s) but without radicular pain (N = 997); or (iii) erythema migrans (EM) skin lesion(s) in conjunction with symptoms suggestive of nervous system involvement but without either cranial nerve palsy or radicular pain (N = 240). The diagnosis of LNB considered the following variables: the presence of: (1) neurologic symptoms consistent with LNB (with no other obvious explanation); (2) cerebrospinal fluid (CSF) pleocytosis (> 5 × 106 leukocytes/L); and (3) demonstration of intrathecal synthesis of borrelial antibodies, and/or cultivation of borrelia from CSF, and/or the presence of EM. Patients fulfilling only the first two criteria were interpreted as having possible LNB, while those who satisfied all three criteria were regarded as having confirmed LNB.

RESULTS

Of 1569 adult patients, 348 (22.2%) had confirmed LNB and 70 (4.5%) others had possible LNB. The proportion of confirmed LNB cases was the highest for patients with radicular pain (217/332, 65.4%), followed by the group with EM and neurologic symptoms (47/240, 19.6%), and those with cranial neuritis (84/997, 8.4%).

CONCLUSION

Only 22% of patients evaluated had confirmed LNB. The proportion of confirmed LNB cases correlated with clinical presentation and was highest among patients with recent onset of radicular pain.

Disseminated Marginal Zone Lymphoma in a Patient with Lyme Neuroborreliosis: A Case Report

Introduction

Lyme borreliosis has been associated with lymphoma, particularly cutaneous lymphomas. The literature is conflicted regarding the effect of antibiotic therapy in cutaneous marginal zone lymphomas (MZLs) in individuals with Lyme borreliosis. We present a patient diagnosed with Lyme neuroborreliosis (LNB) and disseminated MZL.

Case Presentation

A 67-year-old man was seen due to 6 weeks of neuropathic pain with nightly worsening, headache, and 5 kg weight loss. Two weeks prior to symptom debut, he had a tick bite in the left groin, no subsequent rash. A lumbar puncture revealed mononuclear pleocytosis and elevated CSF protein. The patient was admitted and started on ceftriaxone. The Borrelia burgdorferi intrathecal test showed intrathecally produced Borrelia antibodies, and treatment was changed to doxycycline with a total treatment duration of 21 days. A PET/CT revealed enlarged lymph nodes with increased FDG uptake. On pathological examination, the CSF showed 62% clonal B cells - compatible with low-grade B-cell lymphoma. Examination of bone marrow and an inguinal lymph node confirmed disseminated MZL. A control lumbar puncture 8 weeks later showed declining pleocytosis and clonal B cells. At last follow-up 20 months later, he was still asymptomatic and had not required antineoplastic treatment.

Conclusion

To our knowledge, this is the first published case of LNB with non-cutaneous B-cell lymphoma treated and remitting on antibiotics alone. Antibiotic treatment for Borrelia-positive lymphomas has yet to be investigated with high-evidence study designs, so clinicians are encouraged to publish both positive and negative findings relevant to this. We believe this case brings new perspectives to future diagnosis and treatment of lymphomas in patients with verified Lyme borreliosis.

Lyme neuroborreliosis in Japan: Borrelia burgdorferi sensu lato as a cause of meningitis of previously undetermined etiology in hospitalized patients outside of the island of Hokkaido, 2010-2021

BACKGROUND AND PURPOSE

Clinical manifestations of Lyme borreliosis (LB), caused by Borrelia burgdorferi sensu lato (Bbsl), include erythema migrans, Lyme neuroborreliosis (LNB), carditis, and arthritis. LB is a notifiable disease in Japan with <30 surveillance-reported LB cases annually, predominately from Hokkaido Prefecture. However, LB, including LNB, may be under-diagnosed in Japan since diagnostic tests are not readily available. We sought to determine if LNB could be a cause of previously undiagnosed encephalitis or meningitis in Japan.

METHODS

Investigators at 15 hospitals in 10 prefectures throughout Japan retrieved serum and/or cerebrospinal fluid (CSF) samples collected in 2010-2021 from 517 patients hospitalized with encephalitis or meningitis which had an etiology that had not been determined. Samples were tested for Bbsl-specific antibodies using ELISA and Western blot tests. In alignment with the European Union LNB case definition, a confirmed LNB case had CSF pleocytosis and intrathecal production of Bbsl-specific antibodies and a probable LNB case had a CSF sample with pleocytosis and Bbsl-specific antibodies.

RESULTS

LNB was identified in three hospitalized patients with meningitis of previously undetermined etiology: a male resident of Aomori Prefecture was a confirmed LNB case, and two female residents of Oita Prefecture were probable LNB cases. None of the patients with confirmed or probable LNB had traveled in the month prior to symptom onset and none had samples previously tested for LB.

CONCLUSION

The identification of previously undiagnosed LNB cases indicates a need for enhanced disease awareness in Japan, particularly beyond Hokkaido Island, and more readily available LB diagnostic testing.

Detection of Borrelia burgdorferi sensu lato by proteomics: a complementary diagnosis tool on erythema migrans biopsies

OBJECTIVES

We have developed targeted proteomics in the context of Lyme borreliosis (LM) as a new direct diagnostic tool for detecting Borrelia proteins in the skin of patients with erythema migrans. If satisfactory, this proteomic technique could be used in addition to culture and/or PCR for disseminated infections where Borrelia detection is essential to demonstrate active infection. In these infections, the diagnosis is indirect and relies mainly on serology.

METHODS

We recruited 46 patients with LM and 11 controls and collected two skin biopsies from each patient. One biopsy was used for Borrelia burgdorferi sensu lato PCR and culture and the other one was for targeted mass-spectrometry-based proteomics. Six markers of infection were selected for proteomics: Outer surface protein C (OspC), flagellin, enolase, lipoprotein gi|365823350, decorin binding protein A, and glyceraldehyde-3-phosphate dehydrogenase.

RESULTS

Culturing Borrelia from the biopsies increased the sensitivity of the methods. Among the patients included for analysis, 61% (28 patients), 61% (28), and 46% (21) were detected as positive by proteomics, PCR, and culture, respectively. PCR and proteomics were complementary. OspC and flagellin were the most frequently detected protein markers of infection by proteomics, which in some patients, detected up to nine peptides for the flagellin.

DISCUSSION

It is possible to identify bacterial makers from the skin by proteomics. Our approach can be used to diagnose tick-borne diseases such as LM.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02414789.

Clinical characteristics and serological profiles of Lyme disease in children: a 15-year retrospective cohort study in Switzerland

Background

Lyme disease (LD) is caused by Borrelia burgdorferi and is the most common tickborne disease in the northern hemisphere. Although classical characteristics of LD are well-known, the diagnosis and treatment are often delayed. Laboratory diagnosis by serological testing is recommended for most LD manifestations. The objective of this study was to describe clinical characteristics and associated serological profiles in children with LD.

Methods

This retrospective cohort study included children aged 0-18 years, diagnosed with LD according to current guidelines at University Children's Hospital Zurich between January 1, 2006 and December 31, 2020. Two-tier serological testing with the recomWell enzyme-linked immunosorbent assay and recomLine Western blot (MIKROGEN Diagnostik, MIKROGEN GmbH, Neuried, Germany) was performed at the Institute of Medical Microbiology, University of Zurich.

Findings

In total, 469 children diagnosed with LD were included (median age, 7.9 years); 190 patients (40.5%) with Lyme neuroborreliosis (LNB), 171 (36.5%) patients with skin manifestations (erythema migrans, n = 121; multiple erythema migrans, n = 11; borrelial lymphocytoma, n = 37; and acrodermatitis chronica atrophicans, n = 2), and 108 (23.0%) patients with Lyme arthritis. We observed seasonal variations for patients with skin manifestations and LNB, with high prevalence in May-October, but not for patients with Lyme arthritis. Significant differences between LD manifestation groups were found for age, inflammatory parameters, and specificity and concentration of B. burgdorferi-specific serum antibody responses. We observed distinct patterns of pronounced serum antibody responses against B. burgdorferi antigens in LNB (IgM against VlsE, p41, and OspC) and Lyme arthritis (IgG against p100, VlsE, p58, p41, p39, and p18).

Interpretation

Our study is one of the largest and most detailed for children with LD. We present unique findings regarding the differences in clinical characteristics and immune responses between various manifestations of LD in children.

Funding

No specific funding to disclose for this study.

Ticks and tick-borne pathogens on Belle-Île-en-Mer: An exploratory study in a western French island environment

The islands of Brittany provide unique ecosystems for ticks and tick-borne diseases owing to their oceanic climate, influencing interactions among ticks, hosts, and pathogens. We conducted a preliminary investigation on Belle-Île-en-Mer, an island off the Atlantic coast of Brittany in western France, to assess the prevalence of questing adult ticks and associated human pathogenic bacteria. Dermacentor spp. were found to dominate the tick population (61 %): 23 % Dermacentor reticulatus and 77 % D. marginatus. Haemaphysalis punctata (27 %) was also prevalent on the island, and Ixodes ricinus (12 %) was detected for the first time on Belle-Île-en-Mer. Both Dermacentor species harbored either Rickettsia slovaca (24 %) or Rickettsia raoultii (20 %), whereas I. ricinus carried Borrelia burgdorferi sensu lato and Anaplasma phagocytophilum but not Borrelia miyamotoi or Neoehrlichia mikurensis. Detection of two potentially pathogenic species in the B. burgdorferi sensu lato complex, B. afzelii and B. lusitaniae, along with A. phagocytophilum underscores the current risk of Lyme borreliosis and anaplasmosis. The high prevalence of Rickettsia infection in Dermacentor indicates an additional risk of human rickettsioses.

Cardiac Magnetic Resonance Imaging in Lyme Carditis-A Case Series and Review of Literature

Lyme carditis is an uncommon but potentially fatal manifestation of early disseminated Lyme disease. Timely diagnosis poses a clinical challenge due to the highly variable and non-specific symptomatology that can be easily overlooked, as well as the limited availability of specific and non-invasive diagnostic tests for assessing cardiac involvement. While cardiac magnetic resonance (CMR) imaging is the standard imaging modality for diagnosing various etiologies of cardiomyopathy, its application in Lyme carditis remains understudied. In this study, we present two cases of CMR-proven Lyme carditis and provide a comprehensive review of the existing literature on the use of CMR in this condition.

Proportion of confirmed Lyme neuroborreliosis cases among patients with suspected early European Lyme neuroborreliosis

Purpose

To determine the frequency of confirmed Lyme neuroborreliosis (LNB) cases in adult patients with three different clinical presentations consistent with early LNB.

Methods

Data were obtained through routine health care at the UMC Ljubljana, Slovenia from 2005-2022, using clinical pathways. The patients were classified into three groups: i) radicular pain of new onset (N = 332); or ii) involvement of cranial nerve(s) but without radicular pain (N = 997); or iii) erythema migrans (EM) skin lesion(s) in conjunction with symptoms suggestive of nervous system involvement but without either cranial nerve palsy or radicular pain (N = 240). The diagnosis of LNB considered the following variables: the presence of: 1) neurologic symptoms consistent with LNB (with no other obvious explanation); 2) cerebrospinal fluid (CSF) pleocytosis (> 5×106 leukocytes/L); and 3) demonstration of intrathecal synthesis of borrelial antibodies, and/or cultivation of borrelia from CSF, and/or the presence of EM. Patients fulfilling only the first two criteria were interpreted as having possible LNB, while those who satisfied all three criteria were regarded as having confirmed LNB.

Results

Of 1569 adult patients, 348 (22.2%) had confirmed LNB and 70 (4.5%) others had possible LNB. The proportion of confirmed LNB cases was the highest for patients with radicular pain (217/332, 65.4%), followed by the group with EM and neurologic symptoms (47/240, 19.6%), and those with cranial neuritis (84/997, 8.4%).

Conclusion

Only 22% of patients evaluated had confirmed LNB. The proportion of confirmed LNB cases correlated with clinical presentation and was highest among patients with recent onset of radicular pain.

Assessment of occupational exposure of soldiers to Lyme disease and Borrelia miyamotoi disease in selected military training areas from northern Poland

Ixodes ricinus tick is a vector of bacteria of Borreliella genus and Borrelia miyamotoi. Exposure to ticks constitutes occupational risk to soldiers, but the current knowledge on this subject is still limited. Therefore, the aim of this study was to evaluate tick abundance and prevalence of infection with Borreliella spp. and/or B. miyamotoi. Ticks were collected from vegetation on Drawsko, Ustka and Orzysz military training areas. Additionally, ticks infesting soldiers were also obtained. Ticks were examined by nested PCR and sequencing of flaB gene fragment. General Linear Models of One Variable was used for analysis of mean tick abundance and Maximum Likelihood technique based on log-linear analysis of contingency tables was used for analysis of prevalence of pathogens in ticks. Molecular phylogenetic analyses were also performed. 852 I. ricinus were collected from vegetation from three military areas. The overall mean abundance of ticks was almost 4 ticks/100 m2. Season of study had a significant effect on density of total ticks, infected nymphs and females and infected nymphs, which were higher in spring-early summer. Total prevalence of pathogens was 25.7% in 711 questing ticks, and 16.0% in 282 I. ricinus collected from soldiers. Six species of Borreliella and Borrelia were identified with predominance of B. afzelii. It should be assumed that there is a risk for soldiers of acquiring infection after tick bite. The awareness of presence of pathogens in ticks should be raised in military.

Two decades of research on Borrelia burgdorferi sensu lato in questing Ixodes ricinus ticks in Slovakia

Introduction

In Europe, Borrelia burgdorferi sensu lato (s.l.), the causative agent of Lyme borreliosis is transmitted by the castor bean tick, Ixodes ricinus. In the last decades, global changes affect the spread of ticks and also their bionomics. The aim of this study was summarization of a large dataset obtained during 20 years of research.

Methods

The research was carried out in 1999-2019 at 16 localities in Slovakia that were continuously monitored. In total, 17,249 questing I. ricinus ticks were tested for the presence of B. burgdorferi s.l.

Results

The total prevalence of infected ticks was 18.8% (3,248/17,249), with 15.1% (1,557/10,302) infected nymphs and 24.3% (1,691/6,947) infected adults. Nine species of B. burgdorferi s.l. were identified. Borrelia afzelii (37.1%), B. garinii/bavariensis (24.7%), and B. valaisiana (15.4%) were the most frequent and were present at all study sites, followed by B. lusitaniae (12.6%), B. burgdorferi sensu stricto (4.1%) and B. spielmanii (1.6%). Borrelia bavariensis was confirmed only in four samples (0.1%), however, detection of this species has been performed only since 2017. Borrelia bissettii and B. kurtenbachii were both recorded in one case. The total prevalence differed significantly among four habitat types (urban, suburban, natural, agricultural). The highest infection prevalence was confirmed in natural habitat (22.0%), the lowest in urban habitat (13.2%). In addition, molecular analysis was carried out on part of the collected ticks previously morphologically identified as I. ricinus. The analysis did not confirm the occurrence of Ixodes inopinatus in Slovakia.

Conclusion

Long-term monitoring of the abundance and spread of ticks as well as the prevalence and genetic variability of tick-borne pathogens can reveal the impact of global climatic and socio-economic changes on different habitats, including natural foci of tick-borne pathogens.

Lyme disease in companion animals: an updated state-of-art and current situation in Portugal

Lyme disease (LD) is a globally distributed zoonotic multisystemic condition caused by gram-negative spirochete bacteria of the Borrelia burgdorferi complex, transmitted through tick bites. Research on LD in domestic animals in Portugal is limited, potentially leading to underestimating its prevalence. This disease affects many species, including humans, making it a critical public health issue. In domestic animals, LD often presents subclinically or with non-specific clinical signs, complicating its diagnosis. Nevertheless, veterinarians should always consider LD in cases with a history of tick exposure and compatible clinical signs. Diagnostic confirmation can be achieved through serological and other complementary tests. Treatment involves eradicating the bacterial infection and managing clinical signs using a combination of antibiotics, analgesics, anti-inflammatories, and other medications. Effective prevention primarily relies on tick control measures. This review aims to provide an up-to-date state-of-the-art LD, particularly in Portugal.

Incidence of symptomatic Lyme borreliosis in nine European countries

OBJECTIVES

To better understand the Lyme borreliosis (LB) burden in Europe, we aimed to estimate the incidence of symptomatic Borrelia burgdorferi sensu lato (Bbsl) infections after adjusting public health LB surveillance data for under-detection of symptomatic Bbsl infections.

METHODS

Data from seroprevalence studies and estimates of the symptomatic proportion and duration of antibody detection in Bbsl-infected individuals, derived from reviews of the published literature, were used to adjust public health LB surveillance data to estimate the incidence of symptomatic Bbsl infection in nine European countries from 2018 to 2022.

RESULTS

The prevalence of anti-Bbsl antibodies ranged from 2.3% in Romania to 9.4% in Germany. Under-detection multipliers varied across surveillance systems; using 10-year duration of antibody detection, multipliers were 2.4-10.5 in countries reporting all LB cases and 54.6-722.2 in countries reporting only Lyme neuroborreliosis cases. The incidence of symptomatic Bbsl infection adjusted for under-detection was highest in Finland, Germany, Norway, Poland, and Switzerland, intermediate in the Czech Republic and Denmark, and lowest in Ireland and Romania.

CONCLUSION

Adjustment of LB surveillance for under-detection found a high incidence of symptomatic Bbsl infection in several European countries. Differences in LB surveillance systems should be considered when comparing surveillance data between countries and when estimating LB disease burden.

Sensorineural hearing loss in Lyme neuroborreliosis

BACKGROUND

Sensorineural hearing loss (SNHL) has been suggested to occur in patients with Lyme neuroborreliosis (LNB); however, a clear association has never been documented. The present study prospectively investigated the development of SNHL in patients admitted for treatment of LNB using distortion-product-oto-acoustic emissions (DPOAE) as a measure of cochlear function.

METHODS

DOAE were measured in patients with LNB on the day of diagnosis, during treatment, and 30-60 days after discharge. Frequencies were categorized as Low (1, 1.5, 2 kHz), Mid (3, 4, 5 kHz), Mid-high (6, 7, 8 kHz), and High (9, 10 kHz). Pure Tone Audiometry (PTA3) was performed at discharge and 60 days after. Patients were treated with i.v. ceftriaxone or oral doxycycline for 14 days according to guidelines.

RESULTS

DPOAE measurements were obtained in 25 patients with LNB at admission and in 18 patients at follow-up. Median age was 56 years (IQR, 48-64 years), and 16 (67%) were men. Fourteen (78%) of 18 patients showed improvement in Emission Threshold Levels (ETL) from admission to follow-up in low, mid-, and mid-high frequency categories, where ETLs increased by median levels of 3.2 (-4.1 to 8.3), 7.5 (-2.8 to 9.8), and 4.7 dB (-4.3 to 10.1). A decline was observed in the high frequency category, median -3.3 dB (-9.1 to 6.7). SNHL defined by pure tone average (PTA3) >20 dB was present in 11 out of 23 (48%) at discharge and in 9 out of 16 patients (56%) 60 days after discharge, which differed significantly from matched controls (Mann-Whitney test, p = 0.036).

CONCLUSION

LNB can lead to cochlear outer-hair cell dysfunction, resulting in temporary and long-term SNHL.

Development, Optimization, and Validation of a Quantitative PCR Assay for Borrelia burgdorferi Detection in Tick, Wildlife, and Human Samples

Tick-borne pathogens are growing in importance for human and veterinary research worldwide. We developed, optimized, and validated a reliable quantitative PCR (qPCR; real-time PCR) assay to assess Borrelia burgdorferi infection by targeting two B. burgdorferi genes, ospA and flaB. When assessing previously tested tick samples, its performance surpassed the nested PCR in efficiency, sensitivity, and specificity. Since the detection of Borrelia is more difficult in mammalian samples, the qPCR assay was also assessed using wildlife tissues. For wildlife samples, the sensitivity and specificity of ospA primers, with the incorporation of a pre-amplification step, was equivalent or superior to the nested PCR. For human samples, no primer set was successful with human tissue without culture, but we detected Borrelia with ospA and flaB primers in 50% of the Lyme culture samples, corresponding to 60% of the participants with a Lyme disease diagnosis or suspicion. The specificity of amplification was confirmed by Sanger sequencing. The healthy participant culture samples were negative. This PCR-based direct detection assay performs well for the detection of Borrelia in different biological samples. Advancements in detection methods lead to a better surveillance of Borrelia in vectors and hosts, and, ultimately, enhance human and animal health.

Lyme serology in non-endemic countries: Why do we request it and what do we find?

BACKGROUND

The primary objectives of our research were to analyze Lyme serology results from pediatric patients, identify the clinical reasons for ordering these tests, and assess the clinical relevance of the serology results in the context of Lyme disease.

METHODS

Our study, conducted at a reference pediatric hospital in a non-endemic region for Lyme disease, included all pediatric patients for whom Lyme serology was requested. ELISA and Western blot results were documented. Presenting complaints and findings at the time of admission were recorded. Diagnostic tests were categorized as first-step tests if conducted during the initial visit. Subsequent tests, sent due to the inability to establish a diagnosis based on the results of the first-line tests, were defined as second and third-step tests, respectively.

RESULTS

219 patients, for whom Lyme serology had been requested for varying reasons, were included in our study. The most prevalent complaints and indications observed in the presentations of patients with serology requests were as follows: headache(24.7%), paresis/paresthesia(14.6%), and painful or blurred vision(13.2%). Serology was primarily requested in the presence of neurological(59.4%) and ocular symptoms(13.2%). 68% of the tests were requisitioned during the initial consultation. Nevertheless, it was discerned that no patient received a diagnosis of Lyme disease.

CONCLUSION

According to the guidelines, Lyme serology should only be performed when there is a realistic possibility of exposure to infected ticks, particularly in patients who have had untreated erythema migrans or those with a history of a tick bite presenting with unexplained joint or neurological symptoms. Our data, in line with these guidelines, suggests that unnecessary Lyme serology testing in non-endemic areas, where exposure is highly unlikely, may lead to false-positive results and unnecessary follow-up testing, as illustrated by the high rate of false-positive ELISAs in our cohort.

Evolution of Lyme Borreliosis Epidemiology in Primary Care and Hospital Settings in France During the COVID-19 Pandemic

Background: Lyme borreliosis (LB) remains a public health concern in France despite improved patient management and medical care. Stay-at-home restrictions during the COVID-19 pandemic, which affected participation in outdoor recreational activities and disrupted access to health care services, may have impacted the risk of developing LB. Methods: We analyzed data from two general practitioner networks in France (Sentinel Network and an electronic medical records database [EMR]) and the national hospital discharge database to describe LB epidemiology in 2020-2021 and compare it to previous years. Google Trends' search volume was used to evaluate the association between the population's interest in LB and the evolving epidemiology. Results: Annual LB incidence rates in primary care decreased from 104 cases/100,000 population in 2018 to 71/100,000 in 2021 and from 82/100,000 to 60/100,000 according to Sentinel Network and EMR, respectively. Google Trends' search volume for "Lyme" followed a similar trend, one year earlier. Annual hospitalizations were stable from 2012-2019 (1.6/100,000 on average) and declined to 1.3/100,000 in 2020 and 1.1/100,000 in 2021. This decline was observed primarily in adults (e.g., 3.4/100,000 in 2017-2019 to 1.8/100,000 in 2020-2021 for 70-79 years of age). Changes in regional incidence rates in primary care from 2017-2019 to 2020-2021 ranged from -75% to 208%. Hospitalizations decreased in all regions except in Bretagne. Conclusions: The estimated LB incidence decreased in 2020 and 2021 compared with previous years but this change may not be related to COVID-19. The incidence decrease observed in primary care could result from reduced population interest in LB, leading to lower care-seeking behavior. The decrease in LB hospitalizations may be explained by changes in clinical practice. Surveillance systems are critical to understand the evolution of LB epidemiology. However, external factors impacting incidence estimates should be considered.

Repeated doxycycline treatment among patients with neuroborreliosis: a nationwide, population-based, registry-based, matched cohort study

OBJECTIVES

To investigate receipt of antibiotics among patients with neuroborreliosis after initial antibiotic treatment, likely attributable to posttreatment symptoms.

METHODS

We performed a nationwide, matched, population-based cohort study in Denmark (2009-2021). We included all Danish patients with neuroborreliosis, i.e. a positive Borrelia burgdorferi intrathecal antibody index test and a cerebrospinal fluid leukocyte count ≥10 × 106/l, and initially treated with doxycycline. To form a comparison cohort, we randomly extracted individuals from the general population matched 1:10 to patients with neuroborreliosis on date of birth and sex. The main outcome was receipt of doxycycline, and the secondary outcome was receipt of phenoxymethylpenicillin. We calculated short-term (<1 year) and long-term (≥1 year) hazard ratios (HR) with 95% confidence intervals (95%CI).

RESULTS

We included 463 patients with neuroborreliosis and 2,315 comparison cohort members. Compared with the comparison cohort members, patients with neuroborreliosis initially treated with doxycycline had increased receipt of additional doxycycline within 1 year (HR: 38.6, 95%CI: 17.5-85.0) and ≥1 years (HR: 3.5, 95%CI: 1.9-6.3). Compared with comparison cohort members, patients with neuroborreliosis had no increased receipt of phenoxymethylpenicillin (<1 year HR 1.0, 95%CI: 0.7-1.3; ≥1 years HR 1.2, 95%CI: 0.9-1.5).

CONCLUSIONS

After initial antibiotic treatment, patients with neuroborreliosis have increased receipt of doxycycline particularly within one year after initial antibiotic therapy but also subsequently. The lack of increased receipt of phenoxymethylpenicillin suggests that the receipt of doxycycline was not merely due to differences in healthcare-seeking behaviour, increased risk of early Lyme borreliosis due to exposure, or differences in antibacterial usage in general.

Incidence of hospitalizations related to Lyme disease and other tick-borne diseases using Discharge Abstract Database, Canada, 2009-2021

To estimate rates of hospitalizations for tick-borne diseases (TBDs) in Canada, retrospective analysis was conducted to determine the incidence of patients diagnosed with TBDs during their hospital stay in Canada, and describe demographic characteristics, temporal trends and geographic distributions, from 2009 through 2021. Codes from the International Classification of Diseases, Tenth Revision (ICD-10-CA) were used to capture diagnoses of TBDs in the Discharge Abstract Database (DAD) in Canadian hospitals. From 2009 through 2021, 1,626 patients were diagnosed with TBDs during their hospital stay. Of these, 1,457 were diagnosed with Lyme disease (LD), 162 with other TBDs, and seven were diagnosed with more than one TBD. Annual hospitalization counts for LD showed a significant increase from 50 in 2009 to 259 in 2021 (incidence rate per 100,000 population of 0.1 and 0.7, respectively). Epidemiologic patterns for hospitalized LD cases, including increases and variation in annual incidences, seasonality, demographics and geographic distribution, are consistent with those elucidated in national LD surveillance data. Amongst 162 patients diagnosed with other tick-borne diseases, discharge diagnoses were: rickettsiosis (32.7%), spotted fever due to rickettsia rickettsii (23.5%), tularemia (21.0%), babesiosis (8.6%), other tick-borne viral encephalitis (6.2%), tick-borne relapsing fever (4.9%), and Colorado tick fever (0.6%). Annual incidence increased only for rickettsiosis from 3 to 12 patients over the study period. Monitoring the data of hospitalizations using the DAD provided insights into the burden of emerging TBDs, the severity of illnesses and the population most at risk.

Cardiac Manifestations of Lyme Disease

Lyme disease (LD) is an inflammatory disorder caused by an infectious bacterial agent and is the most common tick-borne illness in the United States and Europe. About 1.5-10% of adults infected with LD develop cardiac complications. This review summarizes the current knowledge of the epidemiology, pathophysiology, and diagnosis of Lyme carditis (LC), as well as the different manifestations of LD in the cardiovascular system. This review will primarily highlight the effect of LD on the cardiac conduction system and also discuss its effect on the myocardium, pericardium, valves, and coronary arteries. The management and prognosis of LC will be reviewed here as well. While this is a comprehensive review of the current literature on LC, there remain many questions regarding the complex relationship between LD and the heart.

Evaluation of the Epitogen Lyme Detect IgG ELISA: a novel peptide multiplexing approach

Lyme Borreliosis (LB), or Lyme disease, is a growing health concern caused by Borrelia burgdorferi sensu lato (Bbsl) bacteria transmitted through tick bites, and untreated cases can lead to severe health complications. Existing serology tests, while valuable, have low sensitivity in early infection stages where diagnosis is vital, interpretation variability, and false positives from cross-reactivity, while direct detection methods also suffer from low sensitivity, due to the inconsistent presence of Bbsl components in clinical samples. This study validated the diagnostic performance of the novel Epitogen Lyme Detect IgG enzyme-linked immunosorbent assay (ELISA) based on scaffold-displayed peptide antigens, using 120 specific immunodominant epitopes selected from 37 antigenic bacterial proteins corresponding to the main pathogenic Bbsl genospecies. Using 220 serum samples from Scottish patients with early, late, and disseminated LB, the assay's sensitivity was compared with that of the LIAISON Borrelia IgG CLIA, while specificity was assessed with 198 control samples, including healthy individuals and patients with diseases that are humorally similar. The Epitogen Lyme Detect IgG assay demonstrated comparable performance to the LIAISON Borrelia IgG in disseminated and late LB (Lyme neuroborreliosis, acrodermatitis chronica atrophicans, and Lyme arthritis). Notably, the Epitogen Lyme Detect IgG showed significantly higher sensitivity in patients with suspected erythema migrans, while maintaining high specificity. The Epitogen Lyme Detect IgG ELISA offers a promising advancement in LB diagnostics, demonstrating its potential for more accurate and timely diagnosis, particularly in the early stages of LB infection.IMPORTANCELyme Borreliosis (LB), caused by Borrelia burgdorferi sensu lato bacteria, poses significant health risks if undiagnosed or diagnosed late. Current diagnostic tests have limitations, especially in early-stage detection. This study validates the Epitogen Lyme Detect IgG enzyme-linked immunosorbent assay, demonstrating superior sensitivity in early LB detection while maintaining high specificity. The Epitogen Lyme Detect IgG comprises a suite of 120 immunodominant IgG epitopes/peptides from 37 bacterial antigens, covering the main LB-causing species: Borrelia burgdorferi sensu stricto, Borrelia afzelii, Borrelia garinii, and Borrelia mayonii. The novel design of multiplexing peptide antigens onto a scaffold to facilitate expression, correct folding, and orientation of the relevant peptides offers a promising advancement, potentially leading to more accurate and timely LB diagnoses and improving patient outcomes.

Optimising Transformation Efficiency in Borrelia: Unravelling the Role of the Restriction-Modification System of Borrelia afzelii and Borrelia garinii

Borrelia spp. are transmitted to humans by the bite of an infected tick. In Europe, Borrelia afzelii and Borrelia garinii are the main causative agents of Lyme borreliosis, one of the most prevalent tick-borne diseases in the northern hemisphere. In bacteria such as Borrelia spp., a restriction-modification system (RMS) protects against the harmful introduction of foreign DNA. The RMS comprises two activities: methyltransferase and endonuclease. This study is aimed to characterize the RMS of B. afzelii and B. garinii. First, we identified potential RMS genes. The predicted genes were cloned into a methylase-deficient Escherichia coli strain and digested with methylation-sensitive restriction enzymes to verify methyltransferase activity. Additionally, the RMS proteins were purified to evaluate endonuclease activity. Subsequently, methylated and unmethylated plasmids were used to investigate the effect of methylation on endonuclease activity and transformation efficiency. We identified four possible RMS genes in B. afzelii and four RMS genes in B. garinii. We analyzed the presence of these genes in patient isolates and observed a high degree of heterogeneity. The restriction pattern of DNA methylated by each of the four recombinantly expressed genes provided strong evidence that all encode adenine-specific methyltransferases. After 24 h of incubation with purified RMS proteins, we observed complete digestion of unmethylated plasmid DNA, demonstrating endonuclease activity. Finally, we proved that methylation protects against endonuclease activity and increases transformation efficiency.

Borrelia burgdorferi infections in children and adolescents in Switzerland - a seroprevalence study 2023/2024 (BOBUINCA)

BACKGROUND

Lyme borreliosis is one of the most prevalent tick-borne diseases in Europe. Studies on seroprevalence of Borrelia burgdorferi IgG antibodies in children are rare. The aim of this study was to determine the seroprevalence of B. burgdorferi IgG antibodies in children and adolescents residing in North-Western Switzerland and neighbouring countries.

METHODS

Prospective cross-sectional observational single-centre study using left-over plasma of asymptomatic paediatric patients. Included were children aged 1-17 years living in North-Western Switzerland and bordering areas of France and Germany. Excluded were children with symptoms of Lyme borreliosis or a chronic disease possibly affecting plasma antibodies (immunodeficiency syndrome, systemic lupus erythematosus) or with such medication (e.g., intravenous immunoglobuline treatment, allogenic stem cell transplantation, immunosuppressive treatment) as well as refugees seeking asylum. IgG antibodies against B. burgdorferi were measured by ELISA and positive or borderline results by line blot. Positivity was defined as scenario 1: ELISA positive/line blot positive or borderline OR ELISA borderline/line blot positive. Scenario 2: ELISA positive or borderline/line blot positive. A multivariable logistic regression model for seropositivity was applied.

RESULTS

962 children were included (mean age 9.63 years, standard deviation 5.01, 54.5% males). Seroprevalence for scenario 1 was 13.3% (95% CI: 11.2-15.6) and for scenario 2 11.2% (95% CI: 9.3-13.4). Seroprevalence (scenario 1) was comparable for age groups, sex and rural versus urban residence.

CONCLUSION

This study shows an increased seroprevalence for B. burgdorferi in the paediatric age compared to previous childhood studies. We also found an increased risk for B. burgdorferi infection at young age.

Current and emerging approaches for eliminating Borrelia burgdorferi and alleviating persistent Lyme disease symptoms

Lyme disease is the most prevalent tick-borne infection caused by Borrelia burgdorferi bacteria in North America. Other Borrelia species are predominately the cause of this disease in Eurasia with some distinct and various overlapping manifestations. Consequently, caution must be exercised when comparing the disease and its manifestations and treatment regimens in North America and Europe. Diagnosis of the early Lyme disease remains difficult using the currently FDA approved serological tests in the absence of a reported tick bite or of erythema migrans in many individuals, non-specific initial symptoms, and the absence of detectable anti-Borrelia antibodies in the prepatent period of infection. Furthermore, it is difficult to distinguish persistence of infection and disease versus reinfection in the endemic regions of Lyme disease by serological assays. If early infection remains untreated, spirochetes can disseminate and could affect various organs in the body with a variety of disease manifestations including arthralgias and musculoskeletal pain, neurologic symptoms and anomalies, and acrodermatitis chronicum atrophicans (ACA) in Europe. Although most patients recover after antibiotic treatment, an estimated ∼10-20% patients in the United States show persistence of symptoms known as post-treatment Lyme disease syndrome (PTLDS). The causes and biomarkers of PTLDS are not well-defined; however, several contributing factors with inconsistent degree of supporting evidence have been suggested. These include antigenic debris, dysregulation of immunological response, bacterial persisters, or combination of these features. This review highlights currently employed treatment approaches describing different antimicrobials used, and vaccine candidates tried to prevent B. burgdorferi infection.

Natural selection and recombination at host-interacting lipoprotein loci drive genome diversification of Lyme disease and related bacteria

Lyme disease, caused by spirochetes in the Borrelia burgdorferi sensu lato clade within the Borrelia genus, is transmitted by Ixodes ticks and is currently the most prevalent and rapidly expanding tick-borne disease in Europe and North America. We report complete genome sequences of 47 isolates that encompass all established species in this clade while highlighting the diversity of the widespread human pathogenic species B. burgdorferi. A similar set of plasmids has been maintained throughout Borrelia divergence, indicating that they are a key adaptive feature of this genus. Phylogenetic reconstruction of all sequenced Borrelia genomes revealed the original divergence of Eurasian and North American lineages and subsequent dispersals that introduced B. garinii, B. bavariensis, B. lusitaniae, B. valaisiana, and B. afzelii from East Asia to Europe and B. burgdorferi and B. finlandensis from North America to Europe. Molecular phylogenies of the universally present core replicons (chromosome and cp26 and lp54 plasmids) are highly consistent, revealing a strong clonal structure. Nonetheless, numerous inconsistencies between the genome and gene phylogenies indicate species dispersal, genetic exchanges, and rapid sequence evolution at plasmid-borne loci, including key host-interacting lipoprotein genes. While localized recombination occurs uniformly on the main chromosome at a rate comparable to mutation, lipoprotein-encoding loci are recombination hotspots on the plasmids, suggesting adaptive maintenance of recombinant alleles at loci directly interacting with the host. We conclude that within- and between-species recombination facilitates adaptive sequence evolution of host-interacting lipoprotein loci and contributes to human virulence despite a genome-wide clonal structure of its natural populations.

IMPORTANCE

Lyme disease (also called Lyme borreliosis in Europe), a condition caused by spirochete bacteria of the genus Borrelia, transmitted by hard-bodied Ixodes ticks, is currently the most prevalent and rapidly expanding tick-borne disease in the United States and Europe. Borrelia interspecies and intraspecies genome comparisons of Lyme disease-related bacteria are essential to reconstruct their evolutionary origins, track epidemiological spread, identify molecular mechanisms of human pathogenicity, and design molecular and ecological approaches to disease prevention, diagnosis, and treatment. These Lyme disease-associated bacteria harbor complex genomes that encode many genes that do not have homologs in other organisms and are distributed across multiple linear and circular plasmids. The functional significance of most of the plasmid-borne genes and the multipartite genome organization itself remains unknown. Here we sequenced, assembled, and analyzed whole genomes of 47 Borrelia isolates from around the world, including multiple isolates of the human pathogenic species. Our analysis elucidates the evolutionary origins, historical migration, and sources of genomic variability of these clinically important pathogens. We have developed web-based software tools (BorreliaBase.org) to facilitate dissemination and continued comparative analysis of Borrelia genomes to identify determinants of human pathogenicity.

Incidence of symptomatic Borrelia burgdorferi sensu lato infection in Romania, 2018-2023

BACKGROUND

Lyme borreliosis (LB), caused by Borrelia burgdorferi sensu lato (Bbsl), is the most common tick-borne disease in Europe. Although public health surveillance for LB has been conducted in Romania since 2007, the extent of under-detection of Bbsl infections by LB surveillance has not been estimated. We therefore estimated the under-detection of symptomatic Bbsl infections by LB surveillance to better understand the LB burden in Romania.

METHODS

The number of incident symptomatic Bbsl infections were estimated from a seroprevalence study conducted in six counties (population 2.3 M) and estimates of the symptomatic proportion and duration of persistence of anti-Bbsl immunoglobulin G (IgG) antibodies. The number of incident symptomatic Bbsl infections were compared with the number of surveillance-reported LB cases to derive an under-detection multiplier, and then the under-detection multiplier was applied to LB surveillance data to estimate the incidence of symptomatic Bbsl infection from 2018 to 2023.

RESULTS

We estimate that there were 1968 individuals with incident symptomatic Bbsl infection in the six counties where the seroprevalence study was conducted in 2020, compared with the 187 surveillance-reported LB cases, resulting in an under-detection multiplier of 10.5 (i.e., for every surveillance-reported LB case, there were 10.5 symptomatic incident Bbsl infections). The incidence of symptomatic Bbsl infection in the six counties was 86.9/100,000 population in 2023, similar to the incidence in 2018-2020 (86.0) and higher than in 2021-2022 (40.3).

CONCLUSIONS

There is a higher incidence of symptomatic Bbsl infection than is reported through public health surveillance for LB in Romania. Additional efforts are needed to strengthen disease prevention and address the important public health problem of LB.

Rapid single-tier serodiagnosis of Lyme disease

Point-of-care serological and direct antigen testing offers actionable insights for diagnosing challenging illnesses, empowering distributed health systems. Here, we report a POC-compatible serologic test for Lyme disease (LD), leveraging synthetic peptides specific to LD antibodies and a paper-based platform for rapid, and cost-effective diagnosis. Antigenic epitopes conserved across Borrelia burgdorferi genospecies, targeted by IgG and IgM antibodies, are selected to develop a multiplexed panel for detection of LD antibodies from patient sera. Multiple peptide epitopes, when combined synergistically with a machine learning-based diagnostic model achieve high sensitivity without sacrificing specificity. Blinded validation with 15 LD-positive and 15 negative samples shows 95.5% sensitivity and 100% specificity. Blind testing with the CDC's LD repository samples confirms the test accuracy, matching lab-based two-tier results, correctly differentiating between LD and look-alike diseases. This LD diagnostic test could potentially replace the cumbersome two-tier testing, improving diagnosis and enabling earlier treatment while facilitating immune monitoring and surveillance.

Common Non-Rheumatic Medical Conditions Mimicking Fibromyalgia: A Simple Framework for Differential Diagnosis

Fibromyalgia (FM) is a chronic non-inflammatory disorder mainly characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and a constellation of other symptoms. For this reason, delineating a clear distinction between pure FM and FM-like picture attributable to other common diseases can be extremely challenging. Physicians must identify the most significant confounders in individual patients and implement an appropriate diagnostic workflow, carefully choosing a minimal (but sufficient) set of tests to be used for identifying the most plausible diseases in the specific case. This article discusses prevalent non-rheumatological conditions commonly observed in the general population that can manifest with clinical features similar to primary FM. Given their frequent inclusion in the differential diagnosis of FM patients, the focus will be on elucidating the distinctive clinical characteristics of each condition. Additionally, the most cost-effective and efficient diagnostic methodologies for accurately discerning these conditions will be examined.

Sample-to-answer direct real-time PCR detection of Anaplasma phagocytophilum, Ehrlichia spp., and Babesia spp. infections in whole-blood specimens

Emerging tick-borne illnesses, such as anaplasmosis, babesiosis, or ehrlichiosis, are caused by obligate intracellular pathogens that have clinically comparable presentations. Diagnostics used in laboratories today are serologic assays and blood smear analyses, which have known diagnostic limits. This study evaluated the performance of a sample-to-answer direct real-time PCR laboratory-developed test for the multiplex qualitative detection of Anaplasma, Babesia, and Ehrlichia DNA in whole-blood specimens. Compared to two standard-of-care (SOC) methods, the DiaSorin tick-borne laboratory-developed test for Anaplasma detection demonstrated a positive percent agreement (PPA) and negative percent agreement (NPA) of 100% (95% CI, 0.80 to 1.0) and 89% (95% CI, 0.74 to 0.97), respectively with a discordant rate of 9.3% against microscopy. After discordant resolution, the NPA increased to 100%. For Babesia, the test demonstrated a PPA of 100% (95% CI, 0.90 to 1.0) and NPA of 100% (95% CI, 0.90 to 1.0). Compared to a SOC PCR method Anaplasma samples showed a PPA of 100% (95% CI, 0.66 to 1.0) and NPA of 100% (95% CI, 0.90 to 1.0). Ehrlichia results showed a PPA of 100% (95% CI, 0.69 to 1.0) and NPA of 100% (95% CI, 0.90 to 1.0). The total percent agreement was 98% (95% CI, 0.95 to 0.99) with a κ statistic of 0.95 (95% CI, 0.90 to 0.99) or almost perfect agreement compared to SOC methods. This laboratory-developed test for detecting Anaplasma, Babesia, and Ehrlichia DNA provides rapid and reliable detection of tick-borne infections without nucleic acid extraction.

IMPORTANCE

This work demonstrates that detection of tick-borne illnesses, such as anaplasmosis, babesiosis, or ehrlichiosis, can be performed directly from whole blood with no extraction. The assay described here has a high positive and negative percent agreement with existing methods and is used as the standard of care. An increasing incidence of tick-borne illness combined with shortage of well-trained technologists to perform traditional manual testing, testing options that can be adapted to various lab settings, are of the utmost importance.

Tick-Borne Illnesses in Emergency and Wilderness Medicine

This review highlights the causative organisms, clinical features, diagnosis, and treatment of the most common tick-borne illnesses in the United States, including Lyme disease, Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis, tularemia, Powassan virus, and alpha-gal syndrome. Tick bite prevention strategies and some basic tick removal recommendations are also provided.

Lyme Neuroborreliosis in the Context of Dementia Syndromes

Lyme disease (LD) can affect the skin, joints, heart, and nervous system as a multisystemic condition. The cause of the illness is the spirochete of the genus Borrelia. These pathogens can affect the skin, joints, heart, and nervous system. Lyme neuroborreliosis (LNB) is the term for the disease, which occurs when the nervous system gets involved. Regarding geographical distribution, LNB is more prevalent in Europe than in North America. The most significant change in pathogenesis is inflammation of the central nervous system (CNS) and peripheral nervous system (PNS). Furthermore, clinically, it can represent a variety of neurological manifestations, such as meningitis, encephalitis, radiculopathies, and cranial neuritis. However, dementia-like syndrome is an infrequent manifestation of Lyme disease. Our review article aims to summarize the similarities and differences between dementia-like syndrome in LNB and that in primary neurodegenerative diseases, as well as to look for a correlation between the pathogenesis of the disease and the possibility of developing dementia-like syndrome. The world literature lacks sufficiently convincing data on the relationship between spirochete infection and primary dementia syndromes. However, cases of secondary dementia syndrome due to nervous system involvement as well as post-treatment have been described. A thorough examination, medical history, laboratory and imaging studies, cerebrospinal fluid (CSF) examination, MRI, and fludeoxyglucose-18-positron emission tomography (FGD-PET) are required to differentiate between these syndromes.

Erythema Migrans in Patients with Post-Traumatic Splenectomy

Information on asplenic Lyme borreliosis (LB) patients with erythema migrans (EM) is lacking. We compared the course and outcome of 26 EM episodes in 24 post-trauma splenectomized patients (median age 51 years) diagnosed at a single clinical center in Slovenia during 1994-2023 with those of 52 age- and sex-matched patients with EM but with no history of splenectomy. All patients were followed for one year. A comparison of pre-treatment characteristics revealed that EM in splenectomized patients was of shorter duration before diagnosis (4 vs. 8 days, p = 0.034) with a smaller EM diameter (10.5 vs. 14 cm, p = 0.046), and more frequently fulfilled criteria for disseminated LB (3/26, 11.5% vs. 0%, p = 0.034). Treatment failure occurred in 5/26 (19.2%) EM episodes in splenectomized patients versus 0/52 in non-splenectomized patients (p = 0.003). The five treatment failure cases were retreated with antibiotic regimens used to treat EM and had complete resolution of all symptoms/signs. In conclusion, our study showed that splenectomized adult patients with EM differ somewhat in presentation and more often have treatment failure compared with non-splenectomized patients with EM.

Diagnostic patterns of serum inflammatory protein markers in children with Lyme neuroborreliosis

Definite diagnosis of Lyme neuroborreliosis (LNB) requires investigation of serum and cerebrospinal fluid (CSF). Thus, lumbar puncture is necessary, and requires administration of sedating drugs in children. This study aimed to investigate if a pattern of different inflammatory biomarkers in serum could contribute to the selection of children for lumbar puncture in suspected LNB. Patients were included from a cohort of children who was previously investigated for LNB including serum and CSF sampling during the years 2010-2014. The multiplex proximity extension assay (PEA) inflammation panel Target 96 (Olink Bioscience, Uppsala, Sweden) was used to examine 92 biomarkers in serum. Based on the presence of CSF pleocytosis and Borrelia-specific antibodies, patients were divided into a definite LNB group (n=61) and a non-LNB control group (n=58). Following PEA and statistical analysis with multivariate logistic regression, five biomarkers remained significant (p < 0.001), which were included in a calculation of protein index. The index biomarkers were CST5, IL-15RA, CXCL10, DNER and CX3CL1. A receiver operating characteristic curve was constructed from the index, which showed an 80 % sensitivity and 81 % specificity. Area under the curve was 0.889. We offer evidence that, with further refinements, patterns of serum biomarkers might help identify those children more or less likely to have LNB, perhaps ultimately decreasing the need for lumbar punctures.

Clinical characteristics of children with Borrelia-related peripheral facial palsy and utility of cerebrospinal fluid testing

AIM

To describe the aetiology and clinical characteristics of acute peripheral facial palsy (PFP) in children and investigate the utility of the European Federation of Neurological Societies (EFNS) criteria for diagnosing Borrelia-related PFP (BPFP) based on cerebrospinal fluid (CSF) testing and the Centers for Disease Control and Prevention (CDC) criteria based on serology.

METHODS

We retrospectively identified children aged <18 years diagnosed with acute PFP between 2014 and 2020. We used the EFNS criteria as the gold standard and the CDC criteria for diagnosing BPFP.

RESULTS

Out of 257 children with PFP, 93 (36%) fulfilled the EFNS or CDC criteria for BPFP. We found a discrepancy between the EFNS criteria with CSF testing and the CDC without CSF testing in 27 (14%) of the 190 children with available data. Of the 37 children with PFP and ≥2 symptoms of fever, fatigue, nausea/vomiting or meningeal symptoms, 31 (84%) fulfilled the EFNS criteria for BPFP.

CONCLUSION

Borrelia is a common cause of PFF in children, and its prevalence is higher in children with systemic symptoms. Also, CSF testing did not have decisive management implications in most cases. Therefore, clinical evaluation and Borrelia serology could be the initial steps in the diagnosis of PFP in children.

Frequency of Lyme disease in patients with tick contact and identification of ticks from Bolu province of Turkey

BACKGROUND OBJECTIVES

Lyme disease is a multisystemic disease caused by the bacteria in the Borrelia burgdorferi sensu lato complex, which is transmitted by ticks of the Ixodes genus. Although there are seroprevalence studies and case reports of Lyme disease from various regions in Turkey, there is no widespread epidemiological research. This study aimed to determine the frequency of Lyme disease in the cases followed-up after tick contact and to examine the isolated ticks to reveal tick population from Bolu province.

METHODS

In this study, cases who applied to the emergency department due to tick contact between April and September 2020 were firstly evaluated in our infectious diseases and clinical microbiology outpatient clinic on the third day of exposure and antibodies against Lyme disease were investigated with the IFA method to exclude the patients who were previously exposed to B. burgdorferi. Thereafter, patients were requested to continue outpatient visits at the 1 st and 3 rd month control. At these controls, serum samples were taken to study B.burgdorferi antibodies with the ELISA method which were stored at - 20°C until the study day.

RESULTS

Out of 123 patients who came to first control, 69 patients continued later to at least one of the two controls (either at first or third month). Of these 69 patients, only one (1.4%) was diagnosed with Lyme borreliosis according to clinical and laboratory features. Erythema migrans did not occur in any of the cases. Serum samples were assessed by ELISA method. Asymptomatic infection was detected in 22 cases (30.5%). In addition, we could obtain 46 ticks from our cases and two genera were identified. Forty-two (91.3%) were Ixodes spp. , and two (4.3%) were Hyalomma spp.

INTERPRETATION CONCLUSION

In this study, which was carried out for the first time in the province of Bolu, it was concluded that the cases presenting with a history of tick contact were most frequently exposed to Ixodes spp ticks, and the probability of developing Lyme borreliosis was low (1,4%) during the three-month follow-up period. Further studies with more number of cases and more extended follow-up period are needed.