1
|
Delaney SL, Murray LA, Fallon BA. Neuropsychiatric Symptoms and Tick-Borne Diseases. Curr Top Behav Neurosci 2023; 61:279-302. [PMID: 36512289 DOI: 10.1007/7854_2022_406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
In North America, Lyme disease (LD) is primarily caused by the spirochetal bacterium Borrelia burgdorferi, transmitted to humans by Ixodes species tick bites, at an estimated rate of 476,000 patients diagnosed per year. Acute LD often manifests with flu-like symptoms and an expanding rash known as erythema migrans (EM) and less often with neurologic, neuropsychiatric, arthritic, or cardiac features. Most acute cases of Lyme disease are effectively treated with antibiotics, but 10-20% of individuals may experience recurrent or persistent symptoms. This chapter focuses on the neuropsychiatric aspects of Lyme disease, as these are less widely recognized by physicians and often overlooked. Broader education about the potential complexity, severity, and diverse manifestations of tick-borne diseases is needed.
Collapse
Affiliation(s)
- Shannon L Delaney
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA.
| | - Lilly A Murray
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
| | - Brian A Fallon
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
2
|
Fallon BA, Madsen T, Erlangsen A, Benros ME. Lyme Borreliosis and Associations With Mental Disorders and Suicidal Behavior: A Nationwide Danish Cohort Study. Am J Psychiatry 2021; 178:921-931. [PMID: 34315282 DOI: 10.1176/appi.ajp.2021.20091347] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Lyme borreliosis is a tick-borne infectious disease that may confer an increased risk of mental disorders, but previous studies have been hampered by methodological limitations, including small sample sizes. The authors used a nationwide retrospective cohort study design to examine rates of mental disorders following Lyme borreliosis. METHODS Using Denmark's National Patient Register and the Psychiatric Central Research Register, and including all persons living in Denmark from 1994 through 2016 (N=6,945,837), the authors assessed the risk of mental disorders and suicidal behaviors among all individuals diagnosed with Lyme borreliosis in inpatient and outpatient hospital contacts (N=12,156). Incidence rate ratios (IRRs) were calculated by Poisson regression analyses. RESULTS Individuals with Lyme borreliosis had higher rates of any mental disorder (IRR=1.28, 95% CI=1.20, 1.37), of affective disorders (IRR=1.42, 95% CI=1.27, 1.59), of suicide attempts (IRR=2.01, 95% CI=1.58, 2.55), and of death by suicide (IRR=1.75, 95% CI=1.18, 2.58) compared with those without Lyme borreliosis. The 6-month interval after diagnosis was associated with the highest rate of any mental disorder (IRR=1.96, 95% CI=1.53, 2.52), and the first 3 years after diagnosis was associated with the highest rate of suicide (IRR=2.41, 95% CI=1.25, 4.62). Having more than one episode of Lyme borreliosis was associated with increased incidence rate ratios for mental disorders, affective disorders, and suicide attempts, but not for death by suicide. CONCLUSIONS Individuals diagnosed with Lyme borreliosis in the hospital setting had an increased risk of mental disorders, affective disorders, suicide attempts, and suicide. Although the absolute population risk is low, clinicians should be aware of potential psychiatric sequelae of this global disease.
Collapse
Affiliation(s)
- Brian A Fallon
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York (Fallon); Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen (Madsen, Erlangsen, Benros); Danish Research Institute of Suicide Prevention, Mental Health Center Copenhagen, Capital Region of Denmark (Erlangsen); Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Erlangsen); Center of Mental Health Research, Australian National University, Canberra, Australia (Erlangsen); Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen (Benros)
| | - Trine Madsen
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York (Fallon); Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen (Madsen, Erlangsen, Benros); Danish Research Institute of Suicide Prevention, Mental Health Center Copenhagen, Capital Region of Denmark (Erlangsen); Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Erlangsen); Center of Mental Health Research, Australian National University, Canberra, Australia (Erlangsen); Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen (Benros)
| | - Annette Erlangsen
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York (Fallon); Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen (Madsen, Erlangsen, Benros); Danish Research Institute of Suicide Prevention, Mental Health Center Copenhagen, Capital Region of Denmark (Erlangsen); Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Erlangsen); Center of Mental Health Research, Australian National University, Canberra, Australia (Erlangsen); Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen (Benros)
| | - Michael E Benros
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York (Fallon); Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen (Madsen, Erlangsen, Benros); Danish Research Institute of Suicide Prevention, Mental Health Center Copenhagen, Capital Region of Denmark (Erlangsen); Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Erlangsen); Center of Mental Health Research, Australian National University, Canberra, Australia (Erlangsen); Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen (Benros)
| |
Collapse
|
3
|
Stupica D, Bajrović FF, Blagus R, Cerar Kišek T, Collinet-Adler S, Lah A, Levstek E, Ružić-Sabljić E. Clinical manifestations and long-term outcome of early Lyme neuroborreliosis according to the European Federation of Neurological Societies diagnostic criteria (definite versus possible) in central Europe. A retrospective cohort study. Eur J Neurol 2021; 28:3155-3166. [PMID: 34114701 DOI: 10.1111/ene.14962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/07/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE The characteristics and long-term outcome of Lyme neuroborreliosis (LNB) according to diagnostic certainty (definite vs. possible) are incompletely understood. METHODS In this retrospective cohort study of adults with definite or possible LNB, clinical and microbiological characteristics and long-term outcome over 12 months were evaluated at a single medical center. Severity of acute disease and long-term outcome were assessed using a composite clinical score encompassing clinical findings and symptoms and by the probability of incomplete recovery. RESULTS Amongst 311 adult patients enrolled from 2008 to 2017, 139 (44.7%) had definite LNB and 172 (55.3%) had possible LNB. The most frequent LNB manifestation was cranial neuropathy with or without meningitis (53.4%). Patients with definite LNB more often had Bannwarth syndrome (53.2% vs. 18.6%), more severe disease (6 points vs. 4 points), longer pre-treatment duration (median 21 days vs. 13.5 days), higher cerebrospinal fluid pleocytosis (median 139 × 106 /L vs. 11 × 106 /L) and higher rate of Borrelia seropositivity (84.2% vs. 68.6%) than those with possible LNB. Ceftriaxone was prescribed more often than oral doxycycline in definite LNB than in possible LNB (96.4% vs. 65.7%). Unfavorable outcomes decreased during follow-up, being higher in patients with more severe disease at enrollment and in those with possible LNB, but were not associated with antibiotic therapy. CONCLUSIONS Early LNB, most often presenting as cranial neuropathy, was definitively diagnosed in less than half of cases. A better diagnostic approach is needed to confirm borrelial etiology. Ceftriaxone was not superior to doxycycline in the treatment of early LNB, regardless of diagnostic certainty. In this retrospective cohort study of 311 adults with Lyme neuroborreliosis (LNB), allocated according to diagnostic certainty, early LNB was definitively diagnosed in less than half of cases and the most frequent LNB manifestation was cranial neuropathy with or without meningitis. Patients with definite LNB more often had Bannwarth syndrome, more severe disease, longer pre-treatment duration, higher cerebrospinal fluid pleocytosis and higher rate of Borrelia seropositivity than those with possible LNB. A better diagnostic approach is needed to confirm borrelial etiology. Ceftriaxone was not superior to doxycycline in the treatment of early LNB, regardless of diagnostic certainty.
Collapse
Affiliation(s)
- Daša Stupica
- Department of Infectious Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Fajko F Bajrović
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Rok Blagus
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Faculty of Sports, University of Ljubljana, Ljubljana, Slovenia
| | - Tjaša Cerar Kišek
- Institute for Microbiology and Immunology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Stefan Collinet-Adler
- Department of Infectious Diseases, Park Nicollet, Methodist Hospital, Saint Louis Park, MN, USA
| | - Anja Lah
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Eva Levstek
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Eva Ružić-Sabljić
- Institute for Microbiology and Immunology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
4
|
Rauer S, Kastenbauer S, Hofmann H, Fingerle V, Huppertz HI, Hunfeld KP, Krause A, Ruf B, Dersch R. Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc03. [PMID: 32341686 PMCID: PMC7174852 DOI: 10.3205/000279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 12/12/2022]
Abstract
Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis. This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults. Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany). The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.
Collapse
Affiliation(s)
| | | | | | - Volker Fingerle
- German Society for Hygiene and Microbiology (DGHM), Münster, Germany
| | - Hans-Iko Huppertz
- German Society of Paediatrics and Adolescent Medicine (DGKJ), Berlin, Germany.,German Society of Paediatric Infectology (DGPI), Berlin, Germany
| | - Klaus-Peter Hunfeld
- The German United Society of Clinical Chemistry and Laboratory Medicine (DGKL), Bonn, Germany.,INSTAND e.V., Düsseldorf, Germany
| | | | - Bernhard Ruf
- German Society of Infectious Diseases (DGI), Berlin, Germany
| | - Rick Dersch
- German Society of Neurology (DGN), Berlin, Germany.,Cochrane Germany, Faculty of Medicine, University of Freiburg, Germany
| | | |
Collapse
|
5
|
Neurologic manifestations of Lyme Borreliosis. Rev Neurol (Paris) 2019; 175:417-419. [DOI: 10.1016/j.neurol.2019.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 07/18/2019] [Accepted: 07/22/2019] [Indexed: 11/20/2022]
|
6
|
Knudtzen FC, Andersen NS, Jensen TG, Skarphédinsson S. Characteristics and Clinical Outcome of Lyme Neuroborreliosis in a High Endemic Area, 1995-2014: A Retrospective Cohort Study in Denmark. Clin Infect Dis 2018; 65:1489-1495. [PMID: 29048514 DOI: 10.1093/cid/cix568] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/26/2017] [Indexed: 11/12/2022] Open
Abstract
Background Despite a well-described symptomatology, treatment delay and sequelae are common in patients with Lyme neuroborreliosis (LNB). The aim of this study was to contribute to the knowledge about the symptomatology and epidemiology of LNB. Methods We conducted a retrospective study of all LNB cases verified by a positive Borrelia intrathecal antibody index test performed at the Department of Microbiology, Odense University Hospital, Denmark, from 1995 through 2014. Results The study included 431 patients; 126 were children. The mean incidence was 4.7 per 100 000 inhabitants per year. The median delay from neurological symptom debut to first hospital contact was 20 days and significantly longer for patients with symptom debut in the winter/early spring. The most common clinical symptoms were painful radiculitis (65.9%), cranial nerve palsy (43.4%), and headache (28.3%). A total of 30.6% were seen in >1 hospital department, and 85.6% were admitted during their course of treatment. Serum Borrelia immunoglobulin M and immunoglobulin G at the time of positive Borrelia intrathecal antibody index test were negative in 67 patients (15.5%). We found a median treatment delay of 24 days, with no improvement in our 20-year study period. Residual symptoms following treatment were found in 28.1% of patients, and risk of residual symptoms was significantly associated with delay from symptom debut to initiation of treatment. Conclusions The association between treatment delay and residual symptoms and the lack of improvement in treatment delay during the study period highlight the need for standardized diagnostic routines and a better follow-up for LNB patients. Our findings disprove that all patients with LNB develop positive serum Borrelia antibodies within 6 weeks after infection.
Collapse
Affiliation(s)
- Fredrikke Christie Knudtzen
- Department of Infectious Diseases, Clinical Center of Emerging and Vectorborne Infections (CCEVI), Odense University Hospital
| | | | - Thøger Gorm Jensen
- Department of Clinical Microbiology, CCEVI, Odense University Hospital, Denmark
| | - Sigurdur Skarphédinsson
- Department of Infectious Diseases, Clinical Center of Emerging and Vectorborne Infections (CCEVI), Odense University Hospital
| |
Collapse
|
7
|
An Enzyme-Linked Immunosorbent Spot Assay Measuring Borrelia burgdorferi B31-Specific Interferon Gamma-Secreting T Cells Cannot Discriminate Active Lyme Neuroborreliosis from Past Lyme Borreliosis: a Prospective Study in the Netherlands. J Clin Microbiol 2018; 56:JCM.01695-17. [PMID: 29367297 PMCID: PMC5869815 DOI: 10.1128/jcm.01695-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/17/2018] [Indexed: 01/31/2023] Open
Abstract
Two-tier serology testing is most frequently used for the diagnosis of Lyme borreliosis (LB); however, a positive result is no proof of active disease. To establish a diagnosis of active LB, better diagnostics are needed. Tests investigating the cellular immune system are available, but studies evaluating the utility of these tests on well-defined patient populations are lacking. Therefore, we investigated the utility of an enzyme-linked immunosorbent spot (ELISpot) assay to diagnose active Lyme neuroborreliosis. Peripheral blood mononuclear cells (PBMCs) of various study groups were stimulated by using Borrelia burgdorferi strain B31 and various recombinant antigens, and subsequently, the number of Borrelia-specific interferon gamma (IFN-γ)-secreting T cells was measured. We included 33 active and 37 treated Lyme neuroborreliosis patients, 28 healthy individuals treated for an early manifestation of LB in the past, and 145 untreated healthy individuals. The median numbers of B. burgdorferi B31-specific IFN-γ-secreting T cells/2.5 × 105 PBMCs did not differ between active Lyme neuroborreliosis patients (6.0; interquartile range [IQR], 0.5 to 14.0), treated Lyme neuroborreliosis patients (4.5; IQR, 2.0 to 18.6), and treated healthy individuals (7.4; IQR, 2.3 to 14.9) (P = 1.000); however, the median number of B. burgdorferi B31-specific IFN-γ-secreting T cells/2.5 × 105 PBMCs among untreated healthy individuals was lower (2.0; IQR, 0.5 to 3.9) (P ≤ 0.016). We conclude that the Borrelia ELISpot assay, measuring the number of B. burgdorferi B31-specific IFN-γ-secreting T cells/2.5 × 105 PBMCs, correlates with exposure to the Borrelia bacterium but cannot be used for the diagnosis of active Lyme neuroborreliosis.
Collapse
|
8
|
Middelveen MJ, Fesler MC, Stricker RB. History of Morgellons disease: from delusion to definition. Clin Cosmet Investig Dermatol 2018; 11:71-90. [PMID: 29467580 PMCID: PMC5811176 DOI: 10.2147/ccid.s152343] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Morgellons disease (MD) is a skin condition characterized by the presence of multicolored filaments that lie under, are embedded in, or project from skin. Although the condition may have a longer history, disease matching the above description was first reported in the US in 2002. Since that time, the condition that we know as MD has become a polemic topic. Because individuals afflicted with the disease may have crawling or stinging sensations and sometimes believe they have an insect or parasite infestation, most medical practitioners consider MD a purely delusional disorder. Clinical studies supporting the hypothesis that MD is exclusively delusional in origin have considerable methodological flaws and often neglect the fact that mental disorders can result from underlying somatic illness. In contrast, rigorous experimental investigations show that this skin affliction results from a physiological response to the presence of an infectious agent. Recent studies from that point of view show an association between MD and spirochetal infection in humans, cattle, and dogs. These investigations have determined that the cutaneous filaments are not implanted textile fibers, but are composed of the cellular proteins keratin and collagen and result from overproduction of these filaments in response to spirochetal infection. Further studies of the genetics, pathogenesis, and treatment of MD are warranted.
Collapse
|
9
|
Zomer TP, Vermeeren YM, Landman GW, Zwerink M, van Hees BC, van Bemmel T, van Kooten B. Depressive Symptoms in Patients Referred to a Tertiary Lyme Center: High Prevalence in Those Without Evidence of Lyme Borreliosis. Clin Infect Dis 2017; 65:1689-1694. [DOI: 10.1093/cid/cix605] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/07/2017] [Indexed: 01/31/2023] Open
|
10
|
Abstract
Lyme borreliosis is a tick-borne disease that predominantly occurs in temperate regions of the northern hemisphere and is primarily caused by the bacterium Borrelia burgdorferi in North America and Borrelia afzelii or Borrelia garinii in Europe and Asia. Infection usually begins with an expanding skin lesion, known as erythema migrans (referred to as stage 1), which, if untreated, can be followed by early disseminated infection, particularly neurological abnormalities (stage 2), and by late infection, especially arthritis in North America or acrodermatitis chronica atrophicans in Europe (stage 3). However, the disease can present with any of these manifestations. During infection, the bacteria migrate through the host tissues, adhere to certain cells and can evade immune clearance. Yet, these organisms are eventually killed by both innate and adaptive immune responses and most inflammatory manifestations of the infection resolve. Except for patients with erythema migrans, Lyme borreliosis is diagnosed based on a characteristic clinical constellation of signs and symptoms with serological confirmation of infection. All manifestations of the infection can usually be treated with appropriate antibiotic regimens, but the disease can be followed by post-infectious sequelae in some patients. Prevention of Lyme borreliosis primarily involves the avoidance of tick bites by personal protective measures.
Collapse
Affiliation(s)
- Allen C Steere
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Franc Strle
- Department of Infectious Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gary P Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla, New York, USA
| | - Linden T Hu
- Department of Molecular Biology and Microbiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joppe W R Hovius
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Xin Li
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paul S Mead
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| |
Collapse
|
11
|
Abstract
Lyme disease, caused by the Borrelia burgdorferi bacterium, is the most common vector-borne disease in the northern hemisphere. The clinical presentation varies with disease stage, and neurological manifestations (often referred to as Lyme neuroborreliosis) are reported in up to 12% of patients with Lyme disease. Most aspects of the epidemiology, clinical manifestation and treatment of Lyme neuroborreliosis are well known and accepted; only the management of so-called chronic Lyme disease is surrounded by considerable controversy. This term is used for disparate patient groups, including those who have untreated late-stage infection (for example, late neuroborreliosis), those with subjective symptoms that persist after treatment (termed 'post-treatment Lyme disease syndrome' [PTLDS]), and those with unexplained subjective complaints that may or may not be accompanied by positive test results for B. burgdorferi infection in serum (here called 'chronic Lyme disease'). The incidence of PTLDS is still a matter of debate, and its pathogenesis is unclear, but there is evidence that these patients do not have ongoing B. burgdorferi infection and, thus, do not benefit from additional antibiotic therapy. Chronic Lyme disease lacks an accepted clinical definition, and most patients who receive this diagnosis have other illnesses. Thus, a careful diagnostic work-up is needed to ensure proper treatment.
Collapse
Affiliation(s)
- Uwe Koedel
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
| | - Volker Fingerle
- Bavarian Health and Food Safety Authority &German National Reference Centre for Borrelia, Veterinärstrasse 2, 85764 Oberschleissheim, Germany
| | - Hans-Walter Pfister
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
| |
Collapse
|
12
|
Lyme disease: A rigorous review of diagnostic criteria and treatment. J Autoimmun 2015; 57:82-115. [DOI: 10.1016/j.jaut.2014.09.004] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 01/07/2023]
|
13
|
|
14
|
Zimering JH, Williams MR, Eiras ME, Fallon BA, Logigian EL, Dworkin RH. Acute and chronic pain associated with Lyme borreliosis: clinical characteristics and pathophysiologic mechanisms. Pain 2014; 155:1435-1438. [PMID: 24769365 DOI: 10.1016/j.pain.2014.04.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 04/08/2014] [Accepted: 04/17/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Jeffrey H Zimering
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Jersey Shore University Medical Center, Neptune, NJ, USA Department of Psychiatry, Columbia University, New York, NY, USA Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | | | | | | | | |
Collapse
|
15
|
Bremell D, Dotevall L. Oral doxycycline for Lyme neuroborreliosis with symptoms of encephalitis, myelitis, vasculitis or intracranial hypertension. Eur J Neurol 2014; 21:1162-7. [PMID: 24684211 DOI: 10.1111/ene.12420] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 02/24/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE The treatment recommendation for Lyme neuroborreliosis with central nervous system (CNS) symptoms is intravenous ceftriaxone, according to current American and European guidelines. For Lyme neuroborreliosis with peripheral nervous system (PNS) symptoms, treatment with intravenous ceftriaxone and oral doxycycline is considered equally effective. The purpose of this study was to evaluate the efficacy of oral doxycycline in the treatment of Lyme neuroborreliosis with CNS symptoms. METHODS Patients with Lyme neuroborreliosis who had undergone cerebrospinal fluid (CSF) sampling before and after treatment at the Department of Infectious Diseases, Sahlgrenska University Hospital, during the period 1990-2012, were included in this retrospective study. The CSF mononuclear cell count was used as a surrogate marker of treatment outcome. Comparisons of CSF mononuclear cell counts were made between patients with CNS symptoms and patients with PNS symptoms before and after treatment with oral doxycycline. RESULTS Twenty-six patients classified as having CNS symptoms and 115 patients classified as having PNS symptoms were included. The decline in CSF mononuclear cell counts did not differ significantly between the two groups of patients. All patients with CNS disease showed a marked clinical improvement after treatment, even though 62% had remaining symptoms at the end of follow-up. CONCLUSION Treatment with oral doxycycline resulted in a similar decrease in CSF mononuclear cell counts in patients with Lyme neuroborreliosis with CNS symptoms compared with patients with Lyme neuroborreliosis with PNS symptoms. The results indicate that oral doxycycline is an effective treatment for Lyme neuroborreliosis irrespective of the severity of symptoms.
Collapse
Affiliation(s)
- D Bremell
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
| | | |
Collapse
|
16
|
Eikeland R, Mygland Å, Herlofson K, Ljøstad U. Risk factors for a non-favorable outcome after treated European neuroborreliosis. Acta Neurol Scand 2013; 127:154-60. [PMID: 22690926 DOI: 10.1111/j.1600-0404.2012.01690.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2012] [Indexed: 11/27/2022]
Abstract
AIM To identify possible risk factors for reduced health-related quality of life (HRQoL) and fatigue after treated Lyme neuroborreliosis (LNB). METHODS We included 50 patients with LNB and analyzed associations between their demographic, clinical, and laboratory characteristics at baseline and outcome at 30 months assessed by the self-report questionnaires Short Form-36 (SF-36) and Fatigue Severity Scale (FSS). RESULTS Lower scores in the SF-36 domain Physical Component Summary were associated with pretreatment symptom duration >6 weeks (B = -11.0, P = 0.001) and non-complete recovery at 4 months (B = -5.5, P = 0.037) (R(2) = 0.35). Lower scores in the SF-36 domain Mental Component Summary were associated with non-complete recovery at 4 months (B = -8.9, P = 0.01 (R(2) = 0.14). Higher FSS scores were associated with pretreatment symptom duration >6 weeks (B = 1.4, P = 0.006), high scores on the composite clinical score pretreatment (B = 0.1, P = 0.003), and non-complete recovery at 4 months (B = 1.6, P = 0.005) (R(2) = 0.46). No laboratory test results were associated with these predefined outcomes. CONCLUSIONS Delayed treatment start, more symptoms and findings before treatment, and non-complete recovery at 4 months after treatment are possible predictors of a poorer HRQoL and more fatigue 30 months after treated LNB. We did not find age, gender, educational level, involvement of the central nervous system, coexisting diseases, or cerebrospinal fluid findings to be associated with reduced HRQoL or fatigue. Our findings should be replicated in future studies before any conclusions can be drawn.
Collapse
Affiliation(s)
- R. Eikeland
- Department of Neurology; Sørlandet Hospital; Arendal; Norway
| | | | - K. Herlofson
- Department of Neurology; Sørlandet Hospital; Arendal; Norway
| | - U. Ljøstad
- Department of Neurology; Sørlandet Hospital; Kristiansand; Norway
| |
Collapse
|
17
|
Sjöwall J, Ledel A, Ernerudh J, Ekerfelt C, Forsberg P. Doxycycline-mediated effects on persistent symptoms and systemic cytokine responses post-neuroborreliosis: a randomized, prospective, cross-over study. BMC Infect Dis 2012; 12:186. [PMID: 22876748 PMCID: PMC3507907 DOI: 10.1186/1471-2334-12-186] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 07/23/2012] [Indexed: 11/11/2022] Open
Abstract
Background Persistent symptoms after treatment of neuroborreliosis (NB) are well-documented, although the causative mechanisms are mainly unknown. The effect of repeated antibiotic treatment has not been studied in detail. The aim of this study was to determine whether: (1) persistent symptoms improve with doxycycline treatment; (2) doxycycline has an influence on systemic cytokine responses, and; (3) improvement of symptoms could be due to doxycycline-mediated immunomodulation. Methods/Design 15 NB patients with persistent symptoms ≥6 months post-treatment were double-blindly randomized to receive 200 mg of doxycycline or a placebo for three weeks. After a six-week wash-out period, a cross-over with a three-week course of a placebo or doxycycline was conducted. The primary outcome measures were improvement of persistent symptoms assessed by neurological examinations, a symptom severity score and estimation of the quality of life. The secondary outcome measure was changes in systemic cytokine responses. Results All 15 patients finished the study. No doxycycline-mediated improvement of post-treatment symptoms or quality of life was observed. Nor could any doxycycline-mediated changes in systemic cytokine responses be detected. The study was completed without any serious adverse events. Discussion No doxycycline-mediated improvement of post-treatment symptoms or quality of life was observed. Nor could any doxycycline-mediated changes in systemic cytokine responses be detected. The study was completed without any serious adverse events. To conclude, in this pilot study, doxycycline-treatment did not lead to any improvement of either the persistent symptoms or quality of life in post-NB patients. Accordingly, doxycycline does not seem to be the optimal treatment of diverse persistent symptoms post-NB. However, the results need to be confirmed in larger studies. Trial registration NCT01205464 (clinicaltrials.gov)
Collapse
Affiliation(s)
- Johanna Sjöwall
- Clinic of Infectious Diseases, University Hospital, SE-58185, Linköping, Sweden.
| | | | | | | | | |
Collapse
|
18
|
Skogman BH, Glimåker K, Nordwall M, Vrethem M, Ödkvist L, Forsberg P. Long-term clinical outcome after Lyme neuroborreliosis in childhood. Pediatrics 2012; 130:262-9. [PMID: 22802606 DOI: 10.1542/peds.2011-3719] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine long-term clinical outcome in children with confirmed Lyme neuroborreliosis (LNB) and to evaluate persistent subjective symptoms compared with a control group. METHODS After a median of 5 years, 84 children with confirmed LNB underwent a neurologic re-examination, including a questionnaire. Medical records were analyzed, and a control group (n = 84) was included. RESULTS The total recovery rate was 73% (n = 61). Objective neurologic findings, defined as "definite sequelae," were found in 16 patients (19%). The majority of these children had persistent facial nerve palsy (n = 11), but other motor or sensory deficits occurred (n = 5). Neurologic signs and/or symptoms defined as "possible sequelae" were found in another 7 patients (8%), mainly of sensory character. Nonspecific subjective symptoms were reported by 35 patients (42%) and 32 controls (38%) (nonsignificant). Affected daily activities or school performance were reported to the same extent in both groups (23% vs 20%, nonsignificant). CONCLUSIONS The long-term clinical recovery rate was 73% in children with confirmed LNB. Persistent facial nerve palsy occurred in 13%, whereas other motor or sensory deficits were found in another 14%. Neurologic deficits did not affect daily activities or school performance more often among patients than controls and should be considered as mild. Furthermore, nonspecific subjective symptoms such as headache, fatigue, or memory or concentration problems were reported as often among patients as controls and should not be considered as sequelae after LNB.
Collapse
Affiliation(s)
- Barbro H Skogman
- Center for Clinical Research in Dalarna (CKF), Nissersv. 3, SE-791 82 Falun, Sweden.
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
Lyme borreliosis (Lyme disease) is caused by spirochaetes of the Borrelia burgdorferi sensu lato species complex, which are transmitted by ticks. The most common clinical manifestation is erythema migrans, which eventually resolves, even without antibiotic treatment. However, the infecting pathogen can spread to other tissues and organs, causing more severe manifestations that can involve a patient's skin, nervous system, joints, or heart. The incidence of this disease is increasing in many countries. Laboratory evidence of infection, mainly serology, is essential for diagnosis, except in the case of typical erythema migrans. Diagnosed cases are usually treated with antibiotics for 2-4 weeks and most patients make an uneventful recovery. No convincing evidence exists to support the use of antibiotics for longer than 4 weeks, or for the persistence of spirochaetes in adequately treated patients. Prevention is mainly accomplished by protecting against tick bites. There is no vaccine available for human beings.
Collapse
Affiliation(s)
- Gerold Stanek
- Medical University of Vienna, Institute for Hygiene and Applied Immunology, Vienna, Austria.
| | | | | | | |
Collapse
|
20
|
Eikeland R, Mygland A, Herlofson K, Ljøstad U. European neuroborreliosis: quality of life 30 months after treatment. Acta Neurol Scand 2011; 124:349-54. [PMID: 21303350 DOI: 10.1111/j.1600-0404.2010.01482.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The prognosis after Lyme neuroborreliosis (LNB) is debated. The aim of this study was to assess health-related Quality of Life (QoL) and neurological symptoms 30 months after treatment in European patients with LNB. MATERIALS AND METHODS In a prospective case-control designed study, we investigated 50 well-characterized patients with LNB who had participated in a treatment trial for LNB 30 months earlier and 50 matched control persons with the health QoL questionnaire Short-Form 36 (SF-36), the Fatigue Severity Scale (FSS), the Montgomery and Åsberg Depression Rating Scale (MADRS), the Starkstein Apathy Scale (SAS), and the Mini Mental State (MMS). Clinical and demographic data were collected by semi-structured interviews and clinical neurological examination. RESULTS Lyme neuroborreliosis-treated patients scored lower than control persons in the SF-36 domains physical component summary (PCS) (44 vs 51 P < 0.001) and mental component summary (MCS) (49 vs 54 P = 0.010). They also scored lower than control persons in all the SF-36 subscales, except for bodily pain, and on FSS (3.5 vs 2.1 P < 0.001), but not on MMS (28 vs 29 P = 0.106). There was a difference in MADRS (3.1 vs 0. 8 P = 0.003) and SAS (13 vs 11 P = 0.016), but the scores were low in both groups. Fatigue was the most frequently reported symptom among LNB-treated patients (50%). Patients who reported complete recovery (56%) after LNB had similar QoL scores as the controls. CONCLUSION European persons treated for LNB have poorer health-related QoL and have more fatigue than persons without LNB.
Collapse
Affiliation(s)
- R Eikeland
- Department of Neurology, Sørlandet Hospital, Arendal, Norway.
| | | | | | | |
Collapse
|
21
|
Vrethem M, Widhe M, Ernerudh J, Garpmo U, Forsberg P. Clinical, diagnostic and immunological characteristics of patients with possible neuroborreliosis without intrathecal Ig-synthesis against Borrelia antigen in the cerebrospinal fluid. Neurol Int 2011; 3:e2. [PMID: 21785674 PMCID: PMC3141113 DOI: 10.4081/ni.2011.e2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 03/24/2011] [Accepted: 03/28/2011] [Indexed: 11/23/2022] Open
Abstract
The diagnosis of neuroborreliosis is not always straightforward. Intrathecal immunoglobulin (Ig) synthesis against Borrelia antigen may not be detected, at least early in the disease course. Also other neurological and infectious diagnoses have to be considered. We have studied patients with clinical possible neuroborreliosis without intrathecal Ig synthesis against Borrelia antigen in the cerebrospinal fluid (CSF) (n=17). Diagnosis was based on typical clinical history and at least one of the following findings; mononuclear leucocytosis in the CSF (n=4); typical erythema migrans >5 cm in diameter in relation to debut of symptoms (n=8); prompt clinical response to antibiotic teratment (n=14). Also other possible diagnoses had to be excluded. Seventeen patients first investigated because of suspected neuroborreliosis but later confirmed with other diagnoses were used as controls. All patients had a lumbar puncture. Borrelia specific IFN-γ and IL-4 secretion was investigated in peripheral blood (PBL) and CSF with an ELISPOT assay. Polymerase chain reaction (PCR) was used to reveal any Borrelia antigen in the CSF. Six of 17 patients with possible neuroborreliosis showed high IFN-γ secretion in peripheral blood, otherwise we found no statistically significant differences between the groups. PCR did not reveal any Borrelia antigen in CSF. The diagnosis and treatment of possible but not confirmed neuroborreliosis is a clinical challenge. The clinical response to treatment may be the best option in these cases.
Collapse
Affiliation(s)
- Magnus Vrethem
- Division of Neurology and Neurophysiology, Department of Clinical and Experimental Medicine, University Hospital, Linköping
| | - Mona Widhe
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, University Hospital, Linköping
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University Hospital, Linköping
- Unit for Autoimmunity and Immune regulation, Faculty of Health Sciences, University of Linköping
| | - Jan Ernerudh
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, University Hospital, Linköping
- Unit for Autoimmunity and Immune regulation, Faculty of Health Sciences, University of Linköping
| | - Ulf Garpmo
- Department of Microbiology, Kalmar Hospital, Sweden
| | - Pia Forsberg
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University Hospital, Linköping
| |
Collapse
|
22
|
Henningsson AJ, Tjernberg I, Malmvall BE, Forsberg P, Ernerudh J. Indications of Th1 and Th17 responses in cerebrospinal fluid from patients with Lyme neuroborreliosis: a large retrospective study. J Neuroinflammation 2011; 8:36. [PMID: 21507218 PMCID: PMC3108302 DOI: 10.1186/1742-2094-8-36] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 04/20/2011] [Indexed: 11/26/2022] Open
Abstract
Background Previous studies indicate that successful resolution of Lyme neuroborreliosis (NB) is associated with a strong T helper (Th) 1-type cytokine response in the cerebrospinal fluid (CSF) followed by a down-regulating Th2 response, whereas the role of the recently discovered Th17 cytokine response is unknown. Methods To investigate the relative contribution of different Th associated cytokine/chemokine responses, we used a multiple bead array to measure the levels of CXCL10 (Th1 marker), CCL22 (Th2 marker), IL-17 (Th17 marker) and CXCL8 (general inflammation marker), in serum and in CSF from untreated patients with confirmed NB (n = 133), and non-NB patients (n = 96), and related the findings to clinical data. Samples from patients with possible early NB (n = 15) and possible late NB (n = 19) were also analysed, as well as samples from an additional control group with orthopaedic patients (n = 17), where CSF was obtained at spinal anaesthesia. Results The most prominent differences across groups were found in the CSF. IL-17 was elevated in CSF in 49% of the patients with confirmed NB, but was not detectable in the other groups. Patients with confirmed NB and possible early NB had significantly higher CSF levels of CXCL10, CCL22 and CXCL8 compared to both the non-NB group and the control group (p < 0.0001 for all comparisons). Patients in the early NB group, showing a short duration of symptoms, had lower CCL22 levels in CSF than did the confirmed NB group (p < 0.0001). Furthermore, patients within the confirmed NB group showing a duration of symptoms <2 weeks, tended to have lower CCL22 levels in CSF than did those with longer symptom duration (p = 0.023). Cytokine/chemokine levels were not correlated with clinical parameters or to levels of anti-Borrelia-antibodies. Conclusion Our results support the notion that early NB is dominated by a Th1-type response, eventually accompanied by a Th2 response. Interestingly, IL-17 was increased exclusively in CSF from patients with confirmed NB, suggesting a hitherto unknown role for Th17 in NB. However, for conclusive evidence, future prospective studies are needed.
Collapse
Affiliation(s)
- Anna J Henningsson
- Department of Infectious Diseases, Ryhov County Hospital, Jönköping, Sweden.
| | | | | | | | | |
Collapse
|
23
|
Sjöwall J, Fryland L, Nordberg M, Sjögren F, Garpmo U, Jansson C, Carlsson SA, Bergström S, Ernerudh J, Nyman D, Forsberg P, Ekerfelt C. Decreased Th1-type inflammatory cytokine expression in the skin is associated with persisting symptoms after treatment of erythema migrans. PLoS One 2011; 6:e18220. [PMID: 21483819 PMCID: PMC3069060 DOI: 10.1371/journal.pone.0018220] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 02/25/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the good prognosis of erythema migrans (EM), some patients have persisting symptoms of various character and duration post-treatment. Several factors may affect the clinical outcome of EM, e.g. the early interaction between Borrelia (B.) burgdorferi and the host immune response, the B. burgdorferi genotype, antibiotic treatment as well as other clinical circumstances. Our study was designed to determine whether early cytokine expression in the skin and in peripheral blood in patients with EM is associated with the clinical outcome. METHODS A prospective follow-up study of 109 patients with EM was conducted at the Åland Islands, Finland. Symptoms were evaluated at 3, 6, 12 and 24 months post-treatment. Skin biopsies from the EM and healthy skin were immunohistochemically analysed for expression of interleukin (IL)-4, IL-10, IL-12p70 and interferon (IFN)-γ, as well as for B. burgdorferi DNA. Blood samples were analysed for B. burgdorferi antibodies, allergic predisposition and levels of systemic cytokines. FINDINGS None of the patients developed late manifestations of Lyme borreliosis. However, at the 6-month follow-up, 7 of 88 patients reported persisting symptoms of diverse character. Compared to asymptomatic patients, these 7 patients showed decreased expression of the Th1-associated cytokine IFN-γ in the EM biopsies (p=0.003). B. afzelii DNA was found in 48%, B. garinii in 15% and B. burgdorferi sensu stricto in 1% of the EM biopsies, and species distribution was the same in patients with and without post-treatment symptoms. The two groups did not differ regarding baseline patient characteristics, B. burgdorferi antibodies, allergic predisposition or systemic cytokine levels. CONCLUSION Patients with persisting symptoms following an EM show a decreased Th1-type inflammatory response in infected skin early during the infection, which might reflect a dysregulation of the early immune response. This finding supports the importance of an early, local Th1-type response for optimal resolution of LB.
Collapse
Affiliation(s)
- Johanna Sjöwall
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| | - Linda Fryland
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
- * E-mail:
| | - Marika Nordberg
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
- The Åland Borrelia group, the Åland Islands, Finland
| | - Florence Sjögren
- Division of Dermatology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| | - Ulf Garpmo
- Department of Clinical Microbiology, Kalmar Hospital, Kalmar, Sweden
| | | | | | - Sven Bergström
- Department of Microbiology, University of Umeå, Umeå, Sweden
| | - Jan Ernerudh
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| | - Dag Nyman
- The Åland Borrelia group, the Åland Islands, Finland
| | - Pia Forsberg
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| | - Christina Ekerfelt
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| |
Collapse
|
24
|
Henningsson A, Malmvall BE, Ernerudh J, Matussek A, Forsberg P. Neuroborreliosis—an epidemiological, clinical and healthcare cost study from an endemic area in the south-east of Sweden. Clin Microbiol Infect 2010; 16:1245-51. [DOI: 10.1111/j.1469-0691.2009.03059.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
25
|
Proof that chronic lyme disease exists. Interdiscip Perspect Infect Dis 2010; 2010:876450. [PMID: 20508824 PMCID: PMC2876246 DOI: 10.1155/2010/876450] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 03/26/2010] [Indexed: 11/17/2022] Open
Abstract
The evidence continues to mount that Chronic Lyme Disease (CLD) exists and must be addressed by the medical community if solutions are to be found. Four National Institutes of Health (NIH) trials validated the existence and severity of CLD. Despite the evidence, there are physicians who continue to deny the existence and severity of CLD, which can hinder efforts to find a solution. Recognizing CLD could facilitate efforts to avoid diagnostic delays of two years and durations of illness of 4.7 to 9 years described in the NIH trials. The risk to society of emerging antibiotic-resistant organisms should be weighed against the societal risks associated with failing to treat an emerging population saddled with CLD. The mixed long-term outcome in children could also be examined. Once we accept the evidence that CLD exists, the medical community should be able to find solutions. Medical professionals should be encouraged to examine whether: (1) innovative treatments for early LD might prevent CLD, (2) early diagnosis of CLD might result in better treatment outcomes, and (3) more effective treatment regimens can be developed for CLD patients who have had prolonged illness and an associated poor quality of life.
Collapse
|
26
|
Tjernberg I, Carlsson M, Ernerudh J, Eliasson I, Forsberg P. Mapping of hormones and cortisol responses in patients after Lyme neuroborreliosis. BMC Infect Dis 2010; 10:20. [PMID: 20137075 PMCID: PMC2827415 DOI: 10.1186/1471-2334-10-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 02/05/2010] [Indexed: 11/17/2022] Open
Abstract
Background Persistent symptoms after treatment for neuroborreliosis are common for reasons mainly unknown. These symptoms are often unspecific and could be caused by dysfunctions in endocrine systems, an issue that has not been previously addressed systematically. We therefore mapped hormone levels in patients with previous confirmed Lyme neuroborreliosis of different outcomes and compared them with a healthy control group. Methods Twenty patients of a retrospective cohort of patients treated for definite Lyme neuroborreliosis were recruited 2.3 to 3.7 years (median 2.7) after diagnosis, together with 23 healthy controls. Lyme neuroborreliosis patients were stratified into two groups according to a symptom/sign score. All participants underwent anthropometric and physiological investigation as well as an extensive biochemical endocrine investigation including a short high-dose adrenocorticotropic hormone stimulation (Synacthen®) test. In addition to hormonal status, we also examined electrolytes, 25-hydroxy-vitamin D and interleukin-6. Results Eight patients (40%) had pronounced symptoms 2-3 years after treatment. This group had a higher cortisol response to synacthen as compared with both controls and the Lyme neuroborreliosis patients without remaining symptoms (p < 0.001 for both comparisons). No other significant differences in the various baseline biochemical parameters, anthropometric or physiological data could be detected across groups. Conclusions Apart from a positive association between the occurrence of long-lasting complaints after Lyme neuroborreliosis and cortisol response to synacthen, no corticotropic insufficiency or other serious hormonal dysfunction was found to be associated with remaining symptoms after treatment for Lyme neuroborreliosis.
Collapse
Affiliation(s)
- Ivar Tjernberg
- Department of Clinical Chemistry, Kalmar County Hospital, SE-391 85 Kalmar, Sweden.
| | | | | | | | | |
Collapse
|
27
|
Mygland A, Ljøstad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I. EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Eur J Neurol 2009; 17:8-16, e1-4. [PMID: 19930447 DOI: 10.1111/j.1468-1331.2009.02862.x] [Citation(s) in RCA: 418] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- A Mygland
- Department of Neurology, Sorlandet Sykehus, Kristiansand, Norway.
| | | | | | | | | | | |
Collapse
|
28
|
Ljøstad U, Mygland A. Remaining complaints 1 year after treatment for acute Lyme neuroborreliosis; frequency, pattern and risk factors. Eur J Neurol 2009; 17:118-23. [PMID: 19645771 DOI: 10.1111/j.1468-1331.2009.02756.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE To chart remaining complaints 1 year after treatment for neuroborreliosis, and to identify risk factors for a non-favorable outcome. METHODS We followed patients treated for neuroborreliosis prospectively, and assessed outcome by a composite clinical score. The impact on outcome of clinical, demographic and laboratory factors were analyzed by univariate analyses and logistic regression. RESULTS Out of 85 patients 41 (48%) had remaining complaints; 14 had objective findings and 27 subjective symptoms. Remaining complaints were associated with pre-treatment symptom duration >or=6 weeks (OR = 4.062, P = 0.044), high pre-treatment cerebrospinal fluid (CSF) cell count (OR = 1.005, P = 0.001), and female gender (OR = 3.218, P = 0.025). Presence of CSF oligoclonal bands (OCBs) was not analyzed in the logistic regression model due to many missing observations, but was found to be more frequent both pre-treatment (P = 0.004) and after 12 months (P = 0.015) among patients with remaining complaints as compared to patients with complete recovery. Further evaluation showed that objective remaining findings, and not subjective symptoms, were associated with pre-treatment symptom duration >or=6 weeks. No difference in outcome was observed between patients treated with IV ceftriaxone and patients treated with oral doxycycline. CONCLUSION Remaining complaints are common after neuroborreliosis. The majority of the complaints are subjective. Pre-treatment symptom duration >or=6 weeks, high pre-treatment CSF cell count, and female gender seem to be risk factors for remaining complaints. Presence of CSF OCBs may also predict a non-favorable outcome, but this should be further studied. Whether subjective and objective complaints are associated with different risk factors is also an issue for future studies.
Collapse
Affiliation(s)
- U Ljøstad
- Department of Neurology, Sørlandet Hospital HF, Kristiansand, Norway.
| | | |
Collapse
|
29
|
Hildenbrand P, Craven DE, Jones R, Nemeskal P. Lyme neuroborreliosis: manifestations of a rapidly emerging zoonosis. AJNR Am J Neuroradiol 2009; 30:1079-87. [PMID: 19346313 DOI: 10.3174/ajnr.a1579] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Lyme disease has a worldwide distribution and is the most common vector-borne disease in the United States. Incidence, clinical manifestations, and presentations vary by geography, season, and recreational habits. Lyme neuroborreliosis (LNB) is neurologic involvement secondary to systemic infection by the spirochete Borrelia burgdorferi in the United States and by Borrelia garinii or Borrelia afzelii species in Europe. Enhanced awareness of the clinical presentation of Lyme disease allows inclusion of LNB in the imaging differential diagnosis of facial neuritis, multiple enhancing cranial nerves, enhancing noncompressive radiculitis, and pediatric leptomeningitis with white matter hyperintensities on MR imaging. The MR imaging white matter appearance of successfully treated LNB and multiple sclerosis display sufficient similarity to suggest a common autoimmune pathogenesis for both. This review highlights differences in the epidemiology, clinical manifestations, diagnosis, and management of Lyme disease in the United States, Europe, and Asia, with an emphasis on neurologic manifestations and neuroimaging.
Collapse
Affiliation(s)
- P Hildenbrand
- Department of Radiology, Lahey Clinic Medical Center, Burlington, MA 01805, USA.
| | | | | | | |
Collapse
|
30
|
Abstract
OBJECTIVES To survey present knowledge and controversies in European neuroborreliosis. MATERIAL AND METHODS The article is based on available literature, own experience, and a speech held by the authors. together on the Norwegian annual neurological meeting. RESULTS Diagnosis of neuroborreliosis is based on clinical neurological findings, laboratory support of borrelia infection, and indications of causality between neurological findings and borreliosis. In the absence of means to identify B. burgdorferi, antibody tests are used for laboratory diagnosis. Two to three weeks courses of IV penicillin or ceftriaxone are highly effective in neuroborreliosis. Oral doxycyclin is probably equally effective. Remaining symptoms five years after treatment for neuroborreliosis are reported in 25-50% of patients. CONCLUSIONS We suggest two levels of diagnostic accuracy; definite and possible neuroborreliosis. These case definitions are proposed to make the basis for treatment decisions. The prognosis of neuroborreliosis and pathophysiology of post-treatment conditions need further studies. Extensive treatments with antibiotics are not recommended.
Collapse
Affiliation(s)
- U Ljøstad
- Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway.
| | | |
Collapse
|
31
|
Ljøstad U, Skogvoll E, Eikeland R, Midgard R, Skarpaas T, Berg Å, Mygland Å. Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial. Lancet Neurol 2008; 7:690-5. [DOI: 10.1016/s1474-4422(08)70119-4] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
32
|
Improved laboratory diagnostics of Lyme neuroborreliosis in children by detection of antibodies to new antigens in cerebrospinal fluid. Pediatr Infect Dis J 2008; 27:605-12. [PMID: 18536620 DOI: 10.1097/inf.0b013e31816a1e29] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laboratory diagnostics in Lyme neuroborreliosis need improvement. We hereby investigate 4 new recombinant or peptide Borrelia antigens in cerebrospinal fluid in children with neuroborreliosis to evaluate their performance as diagnostic antigens. METHODS An enzyme-linked immunosorbent assay was used to detect IgG antibodies to recombinant decorin binding protein A (DbpA), BBK32, outer surface protein C (OspC), and the invariable region 6 peptide (IR6). The recombinant antigens originated from 3 pathogenic subspecies; Borrelia afzelii, Borrelia garinii, and Borrelia burgdorferi sensu stricto. Cerebrospinal fluid and serum from children with clinical features indicative for neuroborreliosis (n = 57) were analyzed. Classification of patients was based on clinical symptoms and laboratory findings. Controls were children with other neurologic diseases (n = 20) and adult patients with no proven infection (n = 16). RESULTS Sensitivity for DbpA was 82%, for BBK32 70%, for OspC 58% and for IR6 70%. Specificities were 94%, 100%, 97%, and 97%, respectively. No single antigen was superior. When new antigens were combined in a panel, sensitivity was 80% and specificity 100%. The reference flagella antigen showed a sensitivity of 60% and a specificity of 100%. Over all, the B. garinii related antigens dominated. CONCLUSIONS Recombinant DbpA and BBK32 as well as the peptide antigen IR6 perform well in laboratory diagnostics of neuroborreliosis in children. New antigens seem to improve diagnostic performance when compared with the routine flagella antigen. If different antigens are combined in a panel to cover the antigenic diversity, sensitivity improves further and a specificity of 100% can be achieve.
Collapse
|
33
|
Bednárova J. Cerebrospinal-fluid profile in neuroborreliosis and its diagnostic significance. Folia Microbiol (Praha) 2007; 51:599-603. [PMID: 17455797 DOI: 10.1007/bf02931625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Selected cerebrospinal-fluid (CSF) parameters (intrathecal synthesis of Borrelia-specific antibodies, oligoclonal IgG bands, CSF-to-serum quotient of albumin as a marker of blood-CSF barrier function and cytology) and typical CSF profile in neuroborreliosis were evaluated with the aim of elucidating possible clinical and laboratory similarities of neuroborreliosis (NB) and other neurological diseases (OND). From the cohort of 58 patients (38 diagnosed for NB, 20 with OND) NB patients had positive Borrelia-specific IgG antibodies in 97 % and positive Borrelia-specific IgM antibodies in 55 %; oligoclonal IgG bands were detected in 55%. The blood-CSF barrier was impaired in 89%, positive cytology was detected in 97% of the NB patients. Evaluation of specific intrathecal synthesis improves CSF diagnosis of NB, therefore, a combined CSF analysis has to be considered along with the clinical picture and medical history when formulating the diagnosis of NB.
Collapse
Affiliation(s)
- J Bednárova
- Department of Clinical Microbiology, Faculty Hospital Brno, Czechia.
| |
Collapse
|
34
|
Ekerfelt C, Andersson M, Olausson A, Bergström S, Hultman P. Mercury exposure as a model for deviation of cytokine responses in experimental Lyme arthritis: HgCl2 treatment decreases T helper cell type 1-like responses and arthritis severity but delays eradication of Borrelia burgdorferi in C3H/HeN mice. Clin Exp Immunol 2007; 150:189-97. [PMID: 17672870 PMCID: PMC2219278 DOI: 10.1111/j.1365-2249.2007.03474.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Lyme borreliosis is a complex infection, where some individuals develop so-called 'chronic borreliosis'. The pathogenetic mechanisms are unknown, but the type of immune response is probably important for healing. A strong T helper cell type 1 (Th1)-like response has been suggested as crucial for eradication of Borrelia and for avoiding development of chronic disease. Many studies aimed at altering the Th1/Th2 balance in Lyme arthritis employed mice deficient in cytokine genes, but the outcome has not been clear-cut, due possibly to the high redundancy of cytokines. This study aimed at studying the importance of the Th1/Th2 balance in murine Borrelia arthritis by using the Th2-deviating effect of subtoxic doses of inorganic mercury. Ninety-eight C3H/HeN mice were divided into four groups: Borrelia-infected (Bb), Borrelia-infected exposed to HgCl(2) (BbHg), controls exposed to HgCl(2) alone and normal controls. Mice were killed on days 3, 16, 44 and 65 post-Borrelia inoculation. Arthritis severity was evaluated by histology, spirochaetal load determined by Borrelia culture, IgG2a- and IgE-levels analysed by enzyme-linked immunosorbemt assay (ELISA) and cytokine-secreting cells detected by enzyme-linked immunospot (ELISPOT). BbHg mice showed less severe histological arthritis, but delayed eradication of spirochaetes compared to Bb mice, associated with increased levels of IgE (Th2-induced) and decreased levels of IgG2a (Th1-induced), consistent with a Th2-deviation. Both the numbers of Th1 and Th2 cytokine-secreting cells were reduced in BbHg mice, possibly explained by the fact that numbers of cytokine-secreting cells do not correlate with cytokine concentration. In conclusion, this study supports the hypothesis that a Th1-like response is required for optimal eradication of Borrelia.
Collapse
Affiliation(s)
- C Ekerfelt
- Division of Clinical Immunology, and Unit of Autoimmunity and Immune Regulation, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, University Hospital, Linköping, Sweden.
| | | | | | | | | |
Collapse
|
35
|
Pewter SM, Williams WH, Haslam C, Kay JM. Neuropsychological and psychiatric profiles in acute encephalitis in adults. Neuropsychol Rehabil 2007; 17:478-505. [PMID: 17676531 DOI: 10.1080/09602010701202238] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute encephalitis is an inflammation of brain tissue that can result from activity in the central nervous system (CNS) of a number of viruses. Although the neurological and psychiatric effects of encephalitis in the acute phase of the illness are well-known (Caroff, Mann, Gliatto, Sullivan, & Campbell, 2001), larger scale studies of the pattern of neuropsychological and psychiatric impairment following recovery from the acute inflammatory phase are less apparent. This paper reports the results of neuropsychological testing with a range of standardised cognitive measures in a case series of long-term post-acute participants. Psychiatric abnormality is examined using the SCL-90-R self-report scale of distress (Derogatis, 1983). We also examined the role of emerging insight in the aetiology of depression in this population. Two clusters of cognitive dysfunction were observed, one group of primarily herpes simplex cases showing a severe generalised deficit across a number of cognitive domains and a second cluster showing a variety of more isolated disorders of executive function. Abnormally high levels of distress were reported by participants, with depression, obsessive-compulsive symptoms, interpersonal sensitivity and phobic anxiety most significantly increased. Depression was found to be least severe in those with most accurate insight into their problems. Examining the correlations between cognitive and psychiatric test results demonstrates a relationship between depression and interpersonal anxiety and specific cognitive measures. Obsessive-compulsive behaviour and phobic anxiety, however, appear to exist independently of the assessed cognitive deficits.
Collapse
Affiliation(s)
- Stephen M Pewter
- Centre for Clinical Neuropsychology Research, University of Exeter School of Psychology, Exeter, UK.
| | | | | | | |
Collapse
|
36
|
Mohseni Zadeh M. Traitement et suivi des phases secondaire et tertiaire de la borréliose de Lyme. Med Mal Infect 2007; 37:368-80. [PMID: 17707605 DOI: 10.1016/j.medmal.2006.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 10/22/2022]
Abstract
The aim of this review was to analyze the current strategies of treatment and follow-up of disseminated and late Lyme borreliosis. A comprehensive search was performed using the Medline database. Only relevant reviews, expert guidelines and randomized controlled clinical trials were selected and, if necessary, open trials. Major drugs used in these studies were amoxicillin, doxycycline, penicillin G, and ceftriaxone. Oral administration of antibiotics was preferred in Lyme arthritis whereas parenteral drugs were mostly used in neuroborreliosis. The treatment duration usually ranged from 14 to 30 days. Prolonged antibiotic courses recommended by some authors in post-Lyme syndromes were not validated by several randomized placebo controlled studies. Follow up patterns were analyzed in order to determine possible prognosis parameters allowing to distinguih active Borrelia burgdorferi infection from a sequel of infection.
Collapse
Affiliation(s)
- M Mohseni Zadeh
- Service de médecine interne et de maladies infectieuses et tropicales, hôpital civil, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
| |
Collapse
|
37
|
Abstract
Lyme neuroborreliosis (LNB), the neurological manifestation of systemic infection with the complex spirochaete Borrelia burgdorferi, can pose a challenge for practising neurologists. This Review is a summary of clinical presentation, diagnosis, and therapy, as well as of recent advances in our understanding of LNB. Many new insights have been gained through work in experimental models of the disease. An appreciation of the genetic heterogeneity of the causative pathogen has helped clinicians in their understanding of the diverse presentations of LNB.
Collapse
Affiliation(s)
- Andrew R Pachner
- Department of Neurosciences, UMDNJ-New Jersey Medical School, Newark, NJ 07103, USA.
| | | |
Collapse
|
38
|
Christmann D. [Lyme borreliosis: follow up criteria after antibiotherapy?]. Med Mal Infect 2007; 37:357-9. [PMID: 17434697 DOI: 10.1016/j.medmal.2006.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 10/23/2022]
Abstract
The post therapeutic follow-up of Lyme borreliosis is managed according to clinical and serological data. The evolution of antibody rates is such that it doesn't constitute the best element to rely on for follow-up. Indeed, after a sometimes transitory increase of this rate during or after antibiotherapy, the decrease is very slow, sometimes several months, and often incomplete. The follow-up should thus be made according to clinical symptoms and their resolution. Resolution of some but not all symptoms must lead to discussing two options. The first is that of administrating a complementary antibiotherapy with a different mode of action than the first antibiotic used. The second is that this may be due to recontamination, especially in highly endemic zones, given that antibodies present have no protecting effect. In this case, a new antibiotherapy must of course be initiated.
Collapse
Affiliation(s)
- D Christmann
- Service de maladies infectieuses et tropicales, clinique médicale A, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
| |
Collapse
|
39
|
Jarefors S, Janefjord CK, Forsberg P, Jenmalm MC, Ekerfelt C. Decreased up-regulation of the interleukin-12Rbeta2-chain and interferon-gamma secretion and increased number of forkhead box P3-expressing cells in patients with a history of chronic Lyme borreliosis compared with asymptomatic Borrelia-exposed individuals. Clin Exp Immunol 2007; 147:18-27. [PMID: 17177959 PMCID: PMC1810439 DOI: 10.1111/j.1365-2249.2006.03245.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Lyme borreliosis (LB) can, despite adequate antibiotic treatment, develop into a chronic condition with persisting symptoms such as musculoskeletal pain, subjective alteration of cognition and fatigue. The mechanism behind this is unclear, but it has been postulated that an aberrant immunological response might be the cause. In this study we investigated the expression of the T helper 1 (Th1) marker interleukin (IL)-12Rbeta2, the marker for T regulatory cells, forkhead box P3 (FoxP3) and the cytokine profile in patients with a history of chronic LB, subacute LB, previously Borrelia-exposed asymptomatic individuals and healthy controls. Fifty-four individuals (12 chronic LB, 14 subacute LB, 14 asymptomatic individuals and 14 healthy controls) were included in the study and provided a blood sample. Mononuclear cells were separated from the blood and stimulated with antigens. The IL-12Rbeta2 and FoxP3 mRNA expression was analysed with real-time reverse transcription-polymerase chain reaction (RT-PCR). The protein expression of IL-12Rbeta2 on CD3(+), CD4(+), CD8(+) and CD56(+) cells was assessed by flow cytometry. Furthermore, the secretion of interferon (IFN)-gamma, IL-4, IL-5, IL-10, IL-12p70 and IL-13 was analysed by enzyme-linked immunospot (ELISPOT) and/or enzyme-linked immunosorbent assay (ELISA). Chronic LB patients displayed a lower expression of Borrelia-specific IL-12Rbeta2 on CD8(+) cells and also a lower number of Borrelia-specific IFN-gamma-secreting cells compared to asymptomatic individuals. Furthermore, chronic LB patients had higher amounts of Borrelia-specific FoxP3 mRNA than healthy controls. We speculate that this may indicate that a strong Th1 response is of importance for a positive outcome of a Borrelia infection. In addition, regulatory T cells might also play a role, by immunosuppression, in the development of chronic LB.
Collapse
Affiliation(s)
- S Jarefors
- Division of Clinical Immunology, Faculty of Health Sciences, University of Linköping, Sweden.
| | | | | | | | | |
Collapse
|
40
|
Henningsson AJ, Ernerudh J, Sandholm K, Carlsson SA, Granlund H, Jansson C, Nyman D, Forsberg P, Nilsson Ekdahl K. Complement activation in Lyme neuroborreliosis — Increased levels of C1q and C3a in cerebrospinal fluid indicate complement activation in the CNS. J Neuroimmunol 2007; 183:200-7. [PMID: 17157926 DOI: 10.1016/j.jneuroim.2006.10.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Revised: 10/30/2006] [Accepted: 10/31/2006] [Indexed: 11/25/2022]
Abstract
A strong initial inflammatory response is important in neuroborreliosis. Since complement is a main player in early inflammation, we monitored the concentration and activation of complement in plasma and cerebrospinal fluid from 298 patients, of whom 23 were diagnosed with neuroborreliosis. Using sandwich ELISAs, we found significantly elevated levels of C1q, C4, C3, and C3a in cerebrospinal fluid, but not in plasma, in patients with neuroborreliosis. This finding indicates that complement plays a role in the human immune response in neuroborreliosis, that the immunologic process is compartmentalized to the CNS, and that complement activation may occur via the classical pathway.
Collapse
Affiliation(s)
- Anna J Henningsson
- Department of Infectious Diseases, Ryhov County Hospital, 551 85, Jönköping, and Division of Clinical Immunology, Department of Molecular and Clinical Medicine, Linköping University, Sweden.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Jarefors S, Karlsson M, Forsberg P, Eliasson I, Ernerudh J, Ekerfelt C. Reduced number of interleukin-12 secreting cells in patients with Lyme borreliosis previously exposed to Anaplasma phagocytophilum. Clin Exp Immunol 2006; 143:322-8. [PMID: 16412057 PMCID: PMC1809588 DOI: 10.1111/j.1365-2249.2005.02993.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Lyme borreliosis and human granulocytic ehrlichiosis are tick-borne diseases caused by Borrelia burgdorferi and Anaplasma phagocytophilum, respectively. Infection with A. phagocytophilum has been observed to induce immunosuppression and animal studies suggest that the bacteria might also have prolonged inhibitory effects on immune cells. The aim of this study was to investigate the cytokine secretion in patients exposed previously to A. phagocytophilum and currently infected with B. burgdorferi compared with patients infected with B. burgdorferi and seronegative for A. phagocytophilum. Eight patients with erythema migrans and antibodies against A. phagocytophilum, 15 patients with erythema migrans and negative A. phagocytophilum serology and 15 non-exposed healthy individuals were included in the study. Blood mononuclear cells were stimulated with Borrelia-antigen and the number of cytokine [interleukin (IL)-4, IL-5, IL-12, IL-13 and interferon (IFN)-gamma]-secreting cells was detected by enzyme-linked immunospot (ELISPOT). This study shows that patients with a previous exposure to A. phagocytophilum and a current infection with B. burgdorferi have a lower number of Borrelia-specific cells secreting IL-12 compared to Ap seronegative patients infected with B. burgdorferi (P < 0.001), indicating impairment in the ability to mount strong Th1-responses. We suggest that this mirrors a reduced Th1 response caused by A. phagocytophilum which could influence the outcome of the Borrelia infection and, speculatively, may also have implications in other conditions.
Collapse
Affiliation(s)
- S Jarefors
- Division of Clinical Immunology, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, University of Linköping, Sweden.
| | | | | | | | | | | |
Collapse
|
42
|
Cairns V. Author's response to comments by Sigal and Hassett, Phillips et al., and Shapiro et al. Int J Epidemiol 2005. [DOI: 10.1093/ije/dyi244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
43
|
Widhe M, Skogman BH, Jarefors S, Eknefelt M, Eneström G, Nordwall M, Ekerfelt C, Croner S, Bergström S, Forsberg P, Ernerudh J. Up-regulation of Borrelia-specific IL-4- and IFN-γ-secreting cells in cerebrospinal fluid from children with Lyme neuroborreliosis. Int Immunol 2005; 17:1283-91. [PMID: 16176932 DOI: 10.1093/intimm/dxh304] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The clinical course and outcome of several infectious diseases are dependent on the type of immune response elicited against the pathogen. In adults with neuroborreliosis (NB), a type 1 response with high production of Borrelia-specific IFN-gamma, but no IL-4, has been reported. Since children have a more benign course of NB than adults, we wanted to investigate type 1 and type 2 responses in children with NB. Cerebrospinal fluid (CSF) and blood were collected from children during the acute stage of 'confirmed NB' (n = 34), 'possible NB' (n = 30) and 'non-NB' (n = 10). The number of Borrelia-specific IL-4- and IFN-gamma-secreting cells was measured by enzyme-linked immunospot assay. Borrelia-specific secretion of both IL-4 and IFN-gamma was increased in CSF in confirmed (P < 0.05) and possible (P < 0.01) NB, when compared with non-NB controls. Furthermore, children with NB had significantly higher Borrelia-specific IL-4 secretion in CSF than an adult reference material with NB (P < 0.05). There were no differences in cytokine secretion in relation to onset or recovery of neurological symptoms. Since IL-4 is known to down-regulate the pro-inflammatory and possibly harmful effects of prolonged IFN-gamma responses, the prominent IL-4 response observed in the central nervous system compartment might contribute to the more benign disease course seen in children with Lyme NB.
Collapse
Affiliation(s)
- Mona Widhe
- Division of Clinical Immunology, University of Linköping, Sweden.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Bednárová J, Stourac P, Adam P. Relevance of immunological variables in neuroborreliosis and multiple sclerosis. Acta Neurol Scand 2005; 112:97-102. [PMID: 16008535 DOI: 10.1111/j.1600-0404.2005.00418.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aims were to investigate the frequency of intrathecal synthesis of specific antibodies against measles (M), rubella (R) and varicella zoster (Z) viruses (MRZ reaction) as a diagnostic marker between multiple sclerosis (MS) and neuroborreliosis (NB) groups and to postulate the most typical cerebrospinal fluid (CSF) variables profile of these entities. METHODS Three cohorts of patients were investigated: MS (n = 42), NB (n = 27) and other neurological diseases (OND) (n = 15). Measles, rubella, varicella zoster and borrelia-specific IgG antibodies were measured by ELISA, Q(alb) (CSF/serum albumin ratio) as a marker of blood-CSF barrier function and specific antibody indices (AI) were calculated according to relevant formulae. IgG oligoclonal bands (OB) were detected by isoelectric focusing and immunoenzymatic staining. RESULTS Eighty-eight percent of MS patients had positive MRZ reaction and 26.2% had positive anti-borrelia AI. Eighty-nine percent of NB patients had positive anti-borrelia AI and two patients had individually anti-measles and rubella positive AI. MS-CSF variables profile included the presence of IgG OB in 81%, elevated Q(alb) in 31% and normal cell count in 66.7%. Of NB patients IgG OB were positive in 74%, elevated Q(alb) in 81.5% and normal cell count in 7.4%. CONCLUSION MRZ reaction was proved as statistically significant marker in differential diagnosis between MS and NB. Typical CSF variables profile of these two entities is highly supportive, especially when MRZ is included.
Collapse
Affiliation(s)
- J Bednárová
- Department of Clinical Microbiology, Faculty Hospital, Masaryk University, Brno, Czech Republic
| | | | | |
Collapse
|
45
|
Sjöwall J, Carlsson A, Vaarala O, Bergström S, Ernerudh J, Forsberg P, Ekerfelt C. Innate immune responses in Lyme borreliosis: enhanced tumour necrosis factor-alpha and interleukin-12 in asymptomatic individuals in response to live spirochetes. Clin Exp Immunol 2005; 141:89-98. [PMID: 15958074 PMCID: PMC1809414 DOI: 10.1111/j.1365-2249.2005.02820.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Innate immunity is important for early defence against borrelia spirochetes and should play a role in the clinical outcome of the infection. In order to study early cytokine responses, in vitro differentiated dendritic cells (DCs) and whole blood cells from 21 patients with different clinical outcomes of Lyme neuroborreliosis were stimulated with live borrelia spirochetes. The borrelia-induced secretion of interleukin (IL)-4, IL-10, IL-12p70, interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha in DCs and IL-1beta, IL-6, IL-8, IL-10, IL-12p70, TNF-alpha, regulated upon activation normal T cell expressed and secreted (RANTES), monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta and eotaxin in whole blood cells was measured by enzyme-linked immunospot (ELISPOT) and multiplex arrays, respectively. We found increased numbers of TNF-alpha-secreting DCs (P = 0.018) in asymptomatic seropositive individuals compared to patients with subacute neuroborreliosis and seronegative controls. Asymptomatic individuals were also found to have elevated levels of IL-12p70 (P = 0.031) in whole blood cell supernatants compared to seronegative controls. These results are in line with previous experiments using cells of the adaptive immune response, indicating that strong T helper type 1 (Th1) proinflammatory responses might be associated with a successful resolution of Lyme disease.
Collapse
Affiliation(s)
- J Sjöwall
- Divisions of Infectious Diseases, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, University Hospital, Linköping, Sweden.
| | | | | | | | | | | | | |
Collapse
|
46
|
Ekerfelt C, Jarefors S, Tynngård N, Hedlund M, Sander B, Bergström S, Forsberg P, Ernerudh J. Phenotypes indicating cytolytic properties of Borrelia-specific interferon-gamma secreting cells in chronic Lyme neuroborreliosis. J Neuroimmunol 2004; 145:115-26. [PMID: 14644037 DOI: 10.1016/j.jneuroim.2003.08.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The immuno-pathogenetic mechanisms underlying chronic Lyme neuroborreliosis are mainly unknown. Human Borrelia burgdorferi (Bb) infection is associated with Bb-specific secretion of interferon-gamma (IFN-gamma), which may be important for the elimination of Bb, but this may also cause tissue injury. In order to increase the understanding of the pathogenic mechanisms in chronic neuroborreliosis, we investigated which cell types that secrete IFN-gamma. Blood mononuclear cells from 13 patients with neuroborreliosis and/or acrodermatitis chronicum atrophicans were stimulated with Bb antigen and the phenotypes of the induced IFN-gamma-secreting cells were analyzed with three different approaches. Cells expressing CD8 or TCRgammadelta, which both have cytolytic properties, were the main phenotypes of IFN-gamma-secreting cells, indicating that tissue injury in chronic neuroborreliosis may be mediated by cytotoxic cells.
Collapse
MESH Headings
- Adult
- Aged
- Antibodies, Blocking/pharmacology
- Antigens, CD1/immunology
- Antigens, CD1d
- Borrelia burgdorferi/immunology
- CD4-Positive T-Lymphocytes/chemistry
- CD4-Positive T-Lymphocytes/immunology
- CD56 Antigen/analysis
- CD8-Positive T-Lymphocytes/chemistry
- CD8-Positive T-Lymphocytes/immunology
- Chronic Disease
- Cytotoxicity, Immunologic
- Enzyme-Linked Immunosorbent Assay
- Female
- Glycoproteins/immunology
- HLA Antigens/immunology
- Humans
- Immunomagnetic Separation
- Immunophenotyping
- Interferon-gamma/analysis
- Interferon-gamma/metabolism
- Intracellular Fluid/chemistry
- Intracellular Fluid/immunology
- Intracellular Fluid/microbiology
- Leukocytes, Mononuclear/chemistry
- Leukocytes, Mononuclear/immunology
- Leukocytes, Mononuclear/metabolism
- Lyme Neuroborreliosis/immunology
- Lyme Neuroborreliosis/metabolism
- Lyme Neuroborreliosis/microbiology
- Male
- Middle Aged
- Receptors, Antigen, T-Cell, gamma-delta/analysis
- Receptors, Antigen, T-Cell, gamma-delta/biosynthesis
- Staining and Labeling
Collapse
Affiliation(s)
- C Ekerfelt
- Division of Clinical Immunology, Department of Molecular and Clinical Medicine, University of Linköping, Linköping, Sweden.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Widhe M, Grusell M, Ekerfelt C, Vrethem M, Forsberg P, Ernerudh J. Cytokines in Lyme borreliosis: lack of early tumour necrosis factor-alpha and transforming growth factor-beta1 responses are associated with chronic neuroborreliosis. Immunology 2002; 107:46-55. [PMID: 12225362 PMCID: PMC1782772 DOI: 10.1046/j.1365-2567.2002.01500.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The clinical outcome of the tick born infection Lyme borreliosis seems to be influenced by the type of immune response mounted during the disease, as suggested by various animal models. Here we report the serum and cerebrospinal fluid levels of tumour necrosis factor-alpha (TNF-alpha), transforming growth factor beta1 (TGF-beta1) and interleukin-6 (IL-6) in samples drawn at different disease intervals during the course of non-chronic neuroborreliosis (n=10), chronic neuroborreliosis (n=15), erythema migrans (n=8, serum only) and controls (n=7). When comparing early neuroborreliosis cerebrospinal fluid samples, significantly higher levels of TNF-alpha were found in non-chronic patients than in chronic patients (P<0.05). Moreover, TGF-beta1 was increased in the early serum samples of non-chronic patients, as compared to chronic patients (P<0.01). Elevated serum levels of TGF-beta1 were also found in erythema migrans as compared to neuroborreliosis and controls (P<0.05). The high TNF-alpha levels noted in early cerebrospinal fluid samples of non-chronic patients only, possibly reflects an ongoing pro-inflammatory immune response in the central nervous system, which could be beneficial in eliminating disease. High serum levels of TGF-beta1 probably mirror an anti-inflammatory response, which might play a role in controlling the systemic immune response.
Collapse
Affiliation(s)
- Mona Widhe
- Division of Clinical Immunology, Faculty of Health Sciences, University of Linköping, Sweden.
| | | | | | | | | | | |
Collapse
|