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Tetens MM, Omland LH, Dessau R, Ellermann-Eriksen S, Andersen NS, Jørgensen CS, Østergaard C, Bodilsen J, Søgaard KK, Bangsborg J, Nielsen AC, Møller JK, Chen M, Niemann CU, Lebech AM, Obel N. Risk of haematologic cancers among individuals tested for Borrelia burgdorferi antibodies, and Borrelia burgdorferi seropositive individuals: a nationwide population-based matched cohort study. Clin Microbiol Infect 2024; 30:231-239. [PMID: 37871679 DOI: 10.1016/j.cmi.2023.10.017] [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] [Received: 08/08/2023] [Revised: 09/28/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVES In a nationwide, matched cohort study, we aimed to investigate risks of haematologic cancers among individuals tested for Borrelia burgdorferi (Bb) antibodies, and among serum Bb seropositive individuals. METHODS We identified all Bb seropositive individuals in Denmark (1993-2020) (n = 52 200) and constructed two age- and sex-matched comparison cohorts: (a) Bb seronegative controls (n = 104 400) and (b) background population controls (n = 261 000). We calculated short-term OR (aOR) (<1 month of study inclusion), and long-term hazard ratios (aHR) (>1 month after study inclusion) adjusted for age and sex. We stratified seropositive individuals on only Bb-IgM seropositive (n = 26 103), only Bb-IgG seropositive (n = 18 698), and Bb-IgM-and-IgG seropositive (n = 7399). RESULTS Compared with the background population, individuals tested for Bb antibodies had increased short-term (aOR: 12.6, 95% CI: 10.1-15.6) and long-term (aHR: 1.3, 95% CI: 1.2-1.4) risk of haematologic cancers. The Bb seropositive individuals had no increased risk of haematologic cancers compared with those who tested negative for Bb, except that Bb-IgM-and-IgG seropositive individuals had increased long-term risk of chronic lymphatic leukaemia (aHR: 2.0, 95% CI: 1.2-3.4). DISCUSSION Our results suggest that Bb antibody testing is included in the work-up of unspecific symptoms preceding diagnosis of haematologic cancers. Bb-IgM-and-IgG seropositivity was associated with a two-fold increased long-term risk of chronic lymphatic leukaemia, which warrants further investigation.
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Affiliation(s)
- Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Lars Haukali Omland
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ram Dessau
- Department of Clinical Microbiology, Zealand Hospital, Slagelse, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Nanna S Andersen
- Clinical Centre for Emerging and Vector-borne Infections, Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark; Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | | | - Christian Østergaard
- Department of Clinical Microbiology, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kirstine K Søgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jette Bangsborg
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev Hospital, Herlev, Denmark
| | - Alex Christian Nielsen
- Department of Clinical Microbiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens Kjølseth Møller
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Clinical Microbiology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ming Chen
- Department of Clinical Microbiology, Sønderborg Hospital, Sønderborg, Denmark
| | - Carsten Utoft Niemann
- Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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2
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Omland LH, Bodilsen J, Tetens MM, Helweg-Larsen J, Jarløv JO, Ziebell M, Ellermann-Eriksen S, Justesen US, Frimodt-Møller N, Mortensen PB, Obel N. Risk of Psychiatric Disorders, Use of Psychiatric Hospitals, and Receipt of Psychiatric Medication in Patients With Brain Abscess in Denmark. Clin Infect Dis 2023; 76:315-322. [PMID: 36124707 DOI: 10.1093/cid/ciac773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/02/2022] [Accepted: 09/13/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND It is unknown whether patients diagnosed with brain abscess have an increased risk of psychiatric disorders. METHODS In this nationwide, population-based matched cohort study from Denmark, we compared the incidence of psychiatric disorders, use of psychiatric hospitals, and receipt of psychiatric medications between patients diagnosed with brain abscess and individuals from the general population, matched on date of birth, sex, and residential area. RESULTS We included 435 patients diagnosed with brain abscess and 3909 individuals in the comparison cohort: 61% were male and median age was 54 years. Patients diagnosed with brain abscess were more likely to suffer from comorbidity. The risk of a hospital diagnosis of psychiatric disorders was increased the first 5 years of observation. In the subpopulation, who had never been in contact with psychiatric hospitals or received psychiatric medication before study inclusion, the risk of developing psychiatric disorders was close to that of the background population, especially when we excluded dementia from this outcome. There was a substantial increase in the receipt of anxiolytics and antidepressants. The difference in the proportion of individuals who received anxiolytics and antidepressants increased from 4% (95% confidence interval [CI], 0%-7%) and 2% (95% CI, -1% to 5%) 2 years before study inclusion to 17% (95% CI, 12%-21%) and 11% (95% CI, 7%-16%) in the year after study inclusion. CONCLUSIONS Patients with brain abscess without prior psychiatric disorders or receipt of psychiatric medicine are not at increased risk psychiatric disorders diagnosed in psychiatric hospitals, but they have an increased receipt of psychiatric medication.
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Affiliation(s)
- Lars Haukali Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Bodilsen
- Department of Clinical Microbiology, Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Malte Mose Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Otto Jarløv
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Morten Ziebell
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Ulrik Stenz Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Preben Bo Mortensen
- Centre for Integrated Register-Based Research at Aarhus University (CIRRAU), Aarhus, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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3
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Sigurdardottir AH, Knudtzen FC, Nymark A, Bang M. Fatigue and cognitive impairment in neuroborreliosis patients posttreatment-A neuropsychological retrospective cohort study. Brain Behav 2022; 12:e2719. [PMID: 36017773 PMCID: PMC9480899 DOI: 10.1002/brb3.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/21/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The aim of this study was to determine the prevalence of fatigue and cognitive impairment in patients with neuroborreliosis (NB) posttreatment and to determine whether delayed treatment initiation led to higher levels of fatigue and cognitive impairment. METHODS The study population consisted of 88 patients with NB included between October 10, 2014, and August 21, 2020, at the Clinical Center for Emerging and Vector-borne Infections at Odense University Hospital, Denmark. The Symbol Digit Modalities Test (SDMT) was used as a cognitive screening test, and the Modified Fatigue Impact Scale (MFIS) was used to assess the patients' level of fatigue over the course of a year. RESULTS Overall, 14.3% of patients had an SDMT score indicative of cognitive impairment, and 38.8% of patients reported experiencing fatigue 12 months posttreatment. We found no statistically significant differences in fatigue or cognitive impairment when comparing the patients who had a treatment delay of ≤14 days and those with a treatment delay of >14 days (p > .05) 12 months posttreatment. A random effects regression model showed a significant positive correlation between longer treatment delay and higher MFIS scores, indicating higher levels of fatigue. CONCLUSIONS The results of this study show that both the early and late treatment groups improved significantly over a 12-month period in terms of both cognitive symptoms and fatigue. However, it also showed that a substantial subgroup of patients with NB still suffer from fatigue and cognitive impairment 12 months posttreatment.
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Affiliation(s)
- Anna Helena Sigurdardottir
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Fredrikke Christie Knudtzen
- Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Anita Nymark
- Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Malcolm Bang
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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4
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Abstract
The central or peripheral nervous systems may be involved in up to 15% of patients with untreated infection with B burgdorferi sensu lato, characteristic involvement including meningitis, cranial neuritis, and radiculoneuritis. Diagnosis, based on a logical combination of clinical context and antibody-based testing, is usually straightforward, as is treatment. Misconceptions about what does and does not constitute neurologic disease, and about laboratory testing in this infection, have resulted in widespread anxiety that a broad range of other disorders may be attributable to nervous system Lyme disease. This article will review the reasons for these misunderstandings and the arguments against them.
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Affiliation(s)
- John J Halperin
- Overlook Medical Center, Summit, NJ 07901, USA; Sidney Kimmel Medical College of Thomas Jefferson University.
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5
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Early Disseminated Lyme Disease: Cranial Neuropathy, Meningitis, and Polyradiculopathy. Infect Dis Clin North Am 2022; 36:541-551. [PMID: 36116833 DOI: 10.1016/j.idc.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Early disseminated Lyme disease can involve the peripheral or central nervous system, but with early diagnosis and treatment, prognosis for full recovery is excellent. The typical clinical presentations of neuroborreliosis are highlighted, and an approach to diagnosis and treatment is described.
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6
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Halperin JJ, Eikeland R, Branda JA, Dersch R. Lyme neuroborreliosis: known knowns, known unknowns. Brain 2022; 145:2635-2647. [PMID: 35848861 DOI: 10.1093/brain/awac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Lyme borreliosis affects the nervous system in three principal ways-mononuclear cell meningitis, cranial neuropathies and radiculoneuropathies-the last a broad term encompassing painful radiculopathy, unifocal and multifocal peripheral nerve involvement. Diagnostic tools have been significantly refined-including improved peripheral blood and CSF serodiagnostics-and much has been learned about the interactions between the causative pathogen and the nervous system. Despite these advances in our understanding of this disease, a broad range of other disorders continue to be misattributed to nervous system Lyme borreliosis, supported by, at best, limited evidence. These misattributions often reflect limited understanding not only of Lyme neuroborreliosis but also of what constitutes nervous system disease generally. Fortunately, a large body of evidence now exists to clarify many of these issues, establishing a clear basis for diagnosing nervous system involvement in this infection and, based on well performed studies, clarifying which clinical disorders are associated with Lyme neuroborreliosis, which with non-neurologic Lyme borreliosis, and which with neither.
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Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, 99 Beauvoir Ave., Summit, NJ 07901, USA.,Department of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.,Department of Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Randi Eikeland
- National Advisory on Tick-borne Diseases, Sørlandet Hospital Trust, Egvsveien 100, 4615 Kristiansand, Norway.,Faculty of Health and Sport Sciences, University of Agder, 4879 Grimstad, Norway
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA.,Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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7
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Mens H, Fjordside L, Gynthersen RMM, Ørbæk MT, Andersen ÅB, Andreasson U, Blennow K, Sellebjerg F, Zetterberg H, Lebech AM. Neurofilament Light in Cerebrospinal Fluid is Associated With Disease Staging in European Lyme Neuroborreliosis. J Cent Nerv Syst Dis 2022; 14:11795735221098126. [PMID: 35832609 PMCID: PMC9272052 DOI: 10.1177/11795735221098126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Drivers of differences in disease presentation and symptom duration in Lyme neuroborreliosis (LNB) are currently unknown. Objectives We hypothesized that neurofilament light (NfL) in cerebrospinal fluid (CSF) would predict disease location and sequelae in a historic LNB cohort. Design Using a cross-sectional design and archived CSF samples from 185 patients diagnosed with LNB, we evaluated the content of NfL in the total cohort and in a subgroup of 84 patients with available clinical and paraclinical information. Methods Individuals were categorized according to disease location: a. Central nervous system (CNS) with stroke (N=3), b. CNS without stroke (N=11), c. Peripheral nervous system (PNS) with cranial nerve palsy (CNP) (N=40) d. PNS without CNP (N=30). Patients with hospital follow-up more than 6 months after completed antibiotic therapy were categorized as having LNB associated sequelae (N=15). Results At diagnosis concentration of NfL exceeded the upper reference level in 60% (105/185), especially among individuals above 30 years. Age-adjusted NfL was not found to be associated with symptom duration. Age-adjusted NfL was significantly higher among individuals with CNS involvement. Category a. (stroke) had significantly higher NfL concentrations in CSF compared to all other categories, category b. (CNS involvement without stroke) had significantly higher values compared to the categories of PNS involvement. We found no significant difference between the categories with PNS involvement (with or without CNP). Significantly higher NfL was found among patients with follow-up in hospital setting. Conclusion Comparison of NfL concentrations between the 4 groups of LNB disease manifestations based on clinical information revealed a hierarchy of neuron damage according to disease location and suggested evolving mechanisms with accelerated injury especially when disease is complicated by stroke. Higher values of NfL among patients with need of follow-up in hospital setting suggest NfL could be useful to identify rehabilitative needs.
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Affiliation(s)
- Helene Mens
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lasse Fjordside
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rosa M M Gynthersen
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Mathilde T Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Åse Bengaard Andersen
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, The University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, The University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, The University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong Central College, Hong Kong, China.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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8
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Andreassen S, Solheim AM, Ljøstad U, Mygland Å, Lorentzen ÅR, Reiso H, Beyer MK, Harbo HF, Løhaugen GCC, Eikeland R. Cognitive function in patients with neuroborreliosis: A prospective cohort study from the acute phase to 12 months post treatment. Brain Behav 2022; 12:e2608. [PMID: 35593485 PMCID: PMC9226812 DOI: 10.1002/brb3.2608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 04/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Long-term cognitive problems after neuroborreliosis treatment remain a subject of debate. We have previously shown that cognitive problems are not present in the acute phase of neuroborreliosis, although fatigue is common. The aim of this study was to re-assess the same patient cohort and evaluate long-term outcomes. METHODS In this follow-up, we re-assessed 58 patients with well-characterized neuroborreliosis 12 months after completing treatment. The same protocol with eight subtests measuring attention and processing speed and the Fatigue Severity Scale (FSS) were used to compare the results from the acute phase to 12 months post treatment. RESULTS We found no changes in attention or processing speed but a reduction in the level of fatigue (median score on FSS: 4.9 vs. 3.9, p < .001) from the acute phase to 12 months post treatment. CONCLUSION The patient group did not develop problems with attention or processing speed post treatment, while the level of fatigue decreased.
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Affiliation(s)
- Silje Andreassen
- Department of Pediatrics, Sørlandet Hospital, Arendal, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Marit Solheim
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Habilitation, Sørlandet Hospital, Kristiansand, Norway
| | - Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway.,The Norwegian National Advisory Unit on Tick-borne diseases, Kristiansand, Norway
| | - Harald Reiso
- The Norwegian National Advisory Unit on Tick-borne diseases, Kristiansand, Norway
| | - Mona Kristiansen Beyer
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Hanne Flinstad Harbo
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Randi Eikeland
- The Norwegian National Advisory Unit on Tick-borne diseases, Kristiansand, Norway.,Department of Health and Nursing Sciences, University of Agder, Kristiansand, Norway
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9
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Omland LH, Bodilsen J, Larsen JH, Jarløv JO, Ziebell M, Ellermann-Eriksen S, Justesen US, Frimodt-Møller N, Obel N. Socioeconomic functioning in patients with brain abscess – a nationwide, population-based cohort study in Denmark. J Infect 2022; 84:621-627. [DOI: 10.1016/j.jinf.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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Abstract
In recent decades, the incidence of tick-borne encephalitis (TBE) in Sweden has increased. To calculate the burden of disease over a 17-year period, we analyzed data from the Swedish National Health Data Register for TBE cases diagnosed during 1998–2014. We compared healthcare use and sick leave associated with 2,429 persons with TBE with a referent cohort of 7,287 persons without TBE. Patients with TBE were hospitalized for significantly more days during the first year after disease onset (11.5 vs. 1.1 days), logged more specialist outpatient visits (3.6 vs. 1.2 visits), and logged more sick leave days (66 vs. 10.7 days). These differences generally increased over time. The case-fatality rate for TBE was 1.1%. Our calculated cost of TBE to society provides a baseline for decisions on immunization programs. Analyzing register data, our study adds to clinical studies of smaller cohorts and model-based studies that calculate disease burden.
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11
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Persistent Anti- Borrelia IgM Antibodies without Lyme Borreliosis in the Clinical and Immunological Context. Microbiol Spectr 2021; 9:e0102021. [PMID: 34937165 PMCID: PMC8694107 DOI: 10.1128/spectrum.01020-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of the study was to investigate the etiology of persistent IgM antibodies against Borrelia burgdorferi sensu lato (sl) and to analyze their association with nonspecific symptoms. The study group comprised individuals with persistent IgM antibodies in the absence of IgG. The relation between ELISA values and time elapsed since past erythema migrans (EM) was analyzed. Previous antibiotic treatments were assessed. The association between persistent IgM and nonspecific symptoms was evaluated statistically. Specificity of IgM antibodies for outer surface protein C (OspC) of B. burgdorferi sl was examined by immunoblotting. Further, we investigated the cross-reactivity with Borrelia-unrelated proteins. Fifty-nine patients (46 women; 78%) were included in the study group. The mean IgM-ELISA values did not change significantly during follow-up (median 6.2 months). The mean ELISA value in the study group was dependent on time elapsed since past EM. Nonspecific symptoms improved significantly more often in patients with lower IgM ELISA results. Persistent IgM antibodies were specific for the C-terminal PKKP motif of OspC. Cross-reacting C-terminal PKKP antigens from both human and prokaryotic origins were identified. We demonstrate that the C-terminal PKKP motif plays a main role for the reactivity of persistent Borrelia IgM toward OspC. However, cross-reactivity to other eukaryotic and/or prokaryotic antigens may hamper the specificity of OspC in the serological diagnosis of Lyme borreliosis. Lack of improvement of nonspecific symptoms was associated with higher IgM ELISA values. IMPORTANCE The reactivity of human IgM with the outer surface protein C (OspC) of Borrelia burgdorferi sensu lato is frequently used to detect Borrelia specific IgM in commercial immunoassays, and such antibodies usually occur in the early phase of the infection. We identified a group of individuals with persistent Borrelia IgM without symptoms of Lyme borreliosis. We used their sera to demonstrate that the C-terminal epitope of OspC binds the IgM. Strikingly, we found that the same epitope occurs also in certain proteins of human and environmental origin; the latter include other bacteria and food plants. Our experimental data show that these Borrelia-unrelated proteins cross-react with the OpsC-specific IgM. This knowledge is important for the development of serologic assays for Lyme borreliosis and provides a cross-reactive explanation for the persistence of Borrelia-IgM.
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12
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Bodilsen J, Larsen L, Brandt CT, Wiese L, Hansen BR, Andersen CØ, Lüttichau HR, Helweg-Larsen J, Storgaard M, Nielsen H. Existing Data Sources for Clinical Epidemiology: The Danish Study Group of Infections of the Brain Database (DASGIB). Clin Epidemiol 2021; 13:921-933. [PMID: 34675681 PMCID: PMC8500496 DOI: 10.2147/clep.s326461] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022] Open
Abstract
Central nervous system (CNS) infections are rare diseases that are associated with considerable morbidity and mortality. Increased knowledge based on contemporary data is a prerequisite for improved management and prevention of these serious conditions. Yet, population-based databases of patients hospitalized with CNS infections remain scarce. The Danish Study Group of Infections of the Brain (DASGIB) has prospectively registered information on all adults ≥18 years of age admitted with CNS infections at departments of infectious diseases in Denmark since 2015. The main variables collected are baseline demographics, blood and cerebrospinal fluid tests, imaging results, and outcome using the Glasgow Outcome Scale score. To investigate important aspects for each type of CNS infections, additional variables are included specifically for bacterial meningitis, viral meningitis, encephalitis, brain abscess, neurosyphilis, and Lyme neuroborreliosis. From 2015 to 2020, a total of 3579 cases of CNS infections have been recorded in the DASGIB database. Using the unique civil registration number assigned to all Danish residents, the database can be unambiguously linked with nationwide healthcare registries at the individual level. This enables researchers to conduct detailed population-based and longitudinal observational studies of risk and prognosis of CNS infections and to compare them with matched population cohorts. The database is well-suited for epidemiological research and the DASGIB network forms a solid infrastructure for future national and international collaborations.
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Affiliation(s)
- Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, 9000, Denmark
| | - Lykke Larsen
- Department of Infectious Diseases, Odense University Hospital, Odense, 5000, Denmark
| | - Christian Thomas Brandt
- Department of Infectious Diseases, Nordsjællands Hospital, Hillerød, 3400, Denmark.,Department of Infectious Diseases, Sjælland University Hospital, Roskilde, 4000, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Sjælland University Hospital, Roskilde, 4000, Denmark
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, 2650, Denmark
| | | | - Hans Rudolf Lüttichau
- Department of Infectious Diseases, Herlev Gentofte Hospital, Copenhagen, 2730, Denmark
| | | | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, 8200, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, 9000, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, 9000, Denmark
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13
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Haahr R, Tetens MM, Dessau RB, Krogfelt KA, Bodilsen J, Andersen NS, Møller JK, Roed C, Christiansen CB, Ellermann-Eriksen S, Bangsborg JM, Hansen K, Benfield TL, Andersen CØ, Obel N, Lebech AM, Omland LH. Risk of Neurological Disorders in Patients With European Lyme Neuroborreliosis: A Nationwide, Population-Based Cohort Study. Clin Infect Dis 2021; 71:1511-1516. [PMID: 31598647 DOI: 10.1093/cid/ciz997] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Lyme neuroborreliosis (LNB), caused by the tick-borne spirochetes of the Borrelia burgdorferi sensu lato species complex, has been suggested to be associated with a range of neurological disorders. In a nationwide, population-based cohort study, we examined the associations between LNB and dementia, Alzheimer's disease, Parkinson's disease, motor neuron disease, epilepsy, and Guillain-Barré syndrome. METHODS We used national registers to identify all Danish residents diagnosed during 1986-2016 with LNB (n = 2067), created a gender- and age-matched comparison cohort from the general population (n = 20 670), and calculated risk estimates and hazard ratios. RESULTS We observed no long-term increased risks of dementia, Alzheimer's disease, Parkinson's disease, motor neuron diseases, or epilepsy. However, within the first year, 8 (0.4%) of the LNB patients developed epilepsy, compared with 20 (0.1%) of the comparison cohort (difference, 0.3%; 95% confidence interval, .02-.6%). In the LNB group, 11 (0.5%) patients were diagnosed with Guillain-Barré syndrome within the first year after LNB diagnosis, compared with 0 (0.0%) in the comparison cohort. After the first year, the risk of Guillain-Barré was not increased. CONCLUSIONS LNB patients did not have increased long-term risks of dementia, Alzheimer's disease, Parkinson's disease, motor neuron diseases, epilepsy, or Guillain-Barré. Although the absolute risk is low, LNB patients might have an increased short-term risk of epilepsy and Guillain-Barré syndrome.
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Affiliation(s)
- Rasmus Haahr
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Karen A Krogfelt
- Department of Virus and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark.,Department of Natural Sciences and Environment, Roskilde University, Roskilde, Denmark
| | - Jacob Bodilsen
- Departments of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark.,Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Clinical Centre for Emerging and Vector-Borne Infections, Odense University Hospital, Odense, Denmark
| | - Jens K Møller
- Department of Clinical Microbiology, Vejle Hospital, Vejle, Denmark
| | - Casper Roed
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jette M Bangsborg
- Department of Clinical Microbiology, Herlev University Hospital, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas L Benfield
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ø Andersen
- Department of Clinical Microbiology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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14
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Mac S, Bahia S, Simbulan F, Pullenayegum EM, Evans GA, Patel SN, Sander B. Long-Term Sequelae and Health-Related Quality of Life Associated With Lyme Disease: A Systematic Review. Clin Infect Dis 2021; 71:440-452. [PMID: 31773171 DOI: 10.1093/cid/ciz1158] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022] Open
Abstract
Lyme disease (LD) is the most commonly reported vector-borne disease, but its clinical consequences remain uncertain. We conducted a systematic review of the long-term sequelae and health-related quality of life (HRQoL) associated with LD in North America and Europe. We performed searches in 6 electronic databases up to December 2018 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including observational studies reporting long-term sequelae, HRQoL, and prognostic factors. We included 46 studies, published between 1994 and 2019. Based on 21 studies reporting attributable outcomes, higher proportions of sequelae reported from exposed patients were: neck pain, myalgia, arthralgia, paresthesia, sleep disorder, poor appetite, and concentration difficulties. Patients with PTLDS reported impaired HRQoL compared to the general US population. Included studies were highly heterogeneous in terms of study design, settings, patient characteristics, and quality. Patients with LD are more likely to report nonspecific long-term sequelae, especially those experiencing persistent symptoms posttreatment. Opportunities exist for prospective longitudinal studies to better understand LD outcomes.
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Affiliation(s)
- Stephen Mac
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,THETA Collaborative, University Health Network, Toronto, Canada
| | - Simran Bahia
- Department of Biochemistry, University of Ottawa, Ottawa, Canada
| | | | - Eleanor M Pullenayegum
- The Hospital for Sick Children (SickKids), Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Gerald A Evans
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Queen's University, Kingston, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Samir N Patel
- Public Health Ontario, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,THETA Collaborative, University Health Network, Toronto, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Canada.,Public Health Ontario, Toronto, Canada
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15
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Tetens MM, Lebech AM, Omland LH. Psychiatric Medication Use After Possible Neuroborreliosis-Reply. JAMA Psychiatry 2021; 78:340-341. [PMID: 33502432 DOI: 10.1001/jamapsychiatry.2020.4421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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16
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Omland LH, Holm-Hansen C, Lebech AM, Dessau RB, Bodilsen J, Andersen NS, Roed C, Christiansen CB, Ellermann-Eriksen S, Midgley S, Nielsen L, Benfield T, Hansen ABE, Andersen CØ, Rothman KJ, Sørensen HT, Fischer TK, Obel N. Long-Term Survival, Health, Social Functioning, and Education in Patients With an Enterovirus Central Nervous System Infection, Denmark, 1997-2016. J Infect Dis 2021; 222:619-627. [PMID: 32236420 DOI: 10.1093/infdis/jiaa151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/31/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The long-term clinical course of patients with an enterovirus central nervous system infection (ECI) is poorly understood. METHODS We performed a nationwide population-based cohort study of all Danish patients with ECI diagnosed 1997-2016 (n = 1745) and a comparison cohort from the general population individually matched on date of birth and sex (n = 17 450). Outcomes were categorized into mortality and risk of cancer and likely measures of neurological sequelae: neuropsychiatric morbidities, educational landmarks, use of hospital services, employment, receipt of disability pension, income, number of sick leave days, and nursing home residency. RESULTS Mortality in the first year was higher among patients with ECI (mortality rate ratio [MRR] = 10.0; 95% confidence interval [CI], 4.17-24.1), but thereafter mortality was not higher (MMR = 0.94; 95% CI, 0.47-1.86). Long-term outcomes for patients with ECI were not inferior to those of the comparison cohort for risk of cancer, epilepsy, mental and behavioral disorders, dementia, depression, school start, school marks, high school education, use of hospital services, employment, receipt of disability pension, income, days of sick leave, or nursing home residency. CONCLUSIONS Diagnosis of an ECI had no substantial impact on long-term survival, health, or social/educational functioning.
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Affiliation(s)
- Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Holm-Hansen
- Department of Virus and Specialist Microbiological Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Bodilsen
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Casper Roed
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Sofie Midgley
- Department of Virus and Specialist Microbiological Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Lene Nielsen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ann-Brit E Hansen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ø Andersen
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kenneth J Rothman
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Boston University, Boston, Massachusetts, USA
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Boston University, Boston, Massachusetts, USA
| | - Thea K Fischer
- Department of Virus and Specialist Microbiological Diagnostics, Statens Serum Institute, Copenhagen, Denmark.,Department of Infectious Diseases, University of Southern Denmark, Odense, Denmark.,Centre for Global Health, University of Southern Denmark, Odense, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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17
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Tetens MM, Haahr R, Dessau RB, Krogfelt KA, Bodilsen J, Andersen NS, Møller JK, Roed C, Christiansen CB, Ellermann-Eriksen S, Bangsborg JM, Hansen K, Andersen CØ, Lebech AM, Obel N, Omland LH. Assessment of the Risk of Psychiatric Disorders, Use of Psychiatric Hospitals, and Receipt of Psychiatric Medication Among Patients With Lyme Neuroborreliosis in Denmark. JAMA Psychiatry 2021; 78:177-186. [PMID: 33026438 PMCID: PMC7542530 DOI: 10.1001/jamapsychiatry.2020.2915] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The association of Lyme neuroborreliosis with the development of psychiatric disease is unknown and remains a subject of debate. OBJECTIVE To investigate the risk of psychiatric disease, the percentage of psychiatric hospital inpatient and outpatient contacts, and the receipt of prescribed psychiatric medications among patients with Lyme neuroborreliosis compared with individuals in a matched comparison cohort. DESIGN, SETTING, AND PARTICIPANTS This nationwide population-based matched cohort study included all residents of Denmark who received a positive result on an intrathecal antibody index test for Borrelia burgdorferi (patient cohort) between January 1, 1995, and December 31, 2015. Patients were matched by age and sex to a comparison cohort of individuals without Lyme neuroborreliosis from the general population of Denmark. Data were analyzed from February 2019 to March 2020. EXPOSURES Diagnosis of Lyme neuroborreliosis, defined as a positive result on an intrathecal antibody index test for B burgdorferi. MAIN OUTCOMES AND MEASURES The 0- to 15-year hazard ratios for the assignment of psychiatric diagnostic codes, the difference in the percentage of psychiatric inpatient and outpatient hospital contacts, and the difference in the percentage of prescribed psychiatric medications received among the patient cohort vs the comparison cohort. RESULTS Among 2897 patients with Lyme neuroborreliosis (1646 men [56.8%]) and 28 970 individuals in the matched comparison cohort (16 460 men [56.8%]), the median age was 45.7 years (interquartile range [IQR], 11.5-62.0 years) for both groups. The risk of a psychiatric disease diagnosis and the percentage of hospital contacts for psychiatric disease were not higher among patients with Lyme neuroborreliosis compared with individuals in the comparison cohort. A higher percentage of patients with Lyme neuroborreliosis compared with individuals in the comparison cohort received anxiolytic (7.2% vs 4.7%; difference, 2.6%; 95% CI, 1.6%-3.5%), hypnotic and sedative (11.0% vs 5.3%; difference, 5.7%; 95% CI, 4.5%-6.8%), and antidepressant (11.4% vs 6.0%; difference, 5.4%; 95% CI, 4.3%-6.6%) medications within the first year after diagnosis, after which the receipt of psychiatric medication returned to the same level as the comparison cohort. CONCLUSIONS AND RELEVANCE In this population-based matched cohort study, patients with Lyme neuroborreliosis did not have an increased risk of developing psychiatric diseases that required hospital care or treatment with prescription medication. The increased receipt of psychiatric medication among patients with Lyme neuroborreliosis within the first year after diagnosis, but not thereafter, suggests that most symptoms associated with the diagnosis subside within a short period.
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Affiliation(s)
- Malte M. Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rasmus Haahr
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ram B. Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Karen A. Krogfelt
- Department of Virus and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark,Department of Natural Sciences and Environment, Roskilde University, Roskilde, Denmark
| | - Jacob Bodilsen
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark,Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S. Andersen
- Clinical Centre for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Jens K. Møller
- Department of Clinical Microbiology, Vejle Hospital, Vejle, Denmark
| | - Casper Roed
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B. Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jette M. Bangsborg
- Department of Clinical Microbiology, Herlev University Hospital, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Ø. Andersen
- Department of Clinical Microbiology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars H. Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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18
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Omland LH, Vestergaard HT, Dessau RB, Bodilsen J, Andersen NS, Christiansen CB, Ellermann-Eriksen S, Nielsen L, Andersen CØ, Lebech AM, Obel N. Characteristics and long-term prognosis of Danish patients with varicella zoster virus detected in the cerebrospinal fluid, compared with the background population. J Infect Dis 2021; 224:850-859. [PMID: 33417703 DOI: 10.1093/infdis/jiab013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/07/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Risk factors for and long-term outcomes following detection of varicella zoster virus (VZV) DNA in the cerebrospinal fluid (CSF) are unknown. METHODS We performed a nationwide population-based cohort study of all Danish residents who had VZV DNA detected in the CSF by polymerase chain reaction (PCR) between 1 January 1997 and 1 March 2016 (VZV cohort; n = 517) and an age- and sex- matched comparison cohort from the general Danish population (n = 9823). We examined potential risk factors and mortality, neurologic morbidity, psychiatric morbidity, redemption of medicine prescribed for the nervous system and social outcomes. RESULTS Prior hospital admission, redemption of immunosuppressive medicine, comorbidity and immunosuppressive conditions were associated with detection of VZV DNA in the CSF. Mortality was increased in the VZV cohort, especially during the first year of observation and among patients with encephalitis. Patients in the VZV cohort had an increased risk of dementia and epilepsy. The redemption of antiepileptics and antidepressants was increased in the VZV cohort. CONCLUSIONS Immunosuppression and comorbidity are associated with increased risk of detection of VZV DNA in the CSF and the condition is associated with increased mortality and neurological morbidity.
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Affiliation(s)
- Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hanne T Vestergaard
- Department of Virus and Specialist Microbiological Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Bodilsen
- Department of Clinical Microbiology, Aalborg University hospital, Aalborg, Denmark.,Department of Infectious Diseases, Aalborg University hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Clinical Microbiology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Microbiology, Medical Service, Region Skåne, Lund, Sweden
| | | | - Lene Nielsen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Christian Ø Andersen
- Department of Clinical Microbiology, Hvidovre Hospital, Copenhagen, University of Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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19
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Ørbæk M, Bodilsen J, Gynthersen RMM, Shekhrajka N, Nordberg CL, Larsen L, Storgaard M, Brandt C, Wiese L, Hansen BR, Luttichau HR, Andersen AB, Mens H, Nielsen H, Lebech AM. CT and MR neuroimaging findings in patients with Lyme neuroborreliosis: A national prospective cohort study. J Neurol Sci 2020; 419:117176. [PMID: 33130434 DOI: 10.1016/j.jns.2020.117176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND We aimed to describe the use and findings of cranial computerized tomography (CT-head), spine and brain magnetic resonance imaging (MRI-spine/MRI-brain) in Lyme neuroborreliose (LNB). METHODS Patients with LNB were identified using a nationwide, population-based prospective cohort of all adults treated for neuroinfections at departments of infectious diseases in Denmark from 2015 to 2019. Multivariate logistic regression analyses assessed associations between clinical characteristics and MRI-findings consistent with LNB. RESULTS We included 368 patients (272 definite LNB and 96 probable LNB), 280 scans were performed in 198 patients. Neuroimaging was associated with older age (59 vs. 57, p = 0.03), suspicion of other diseases (77% vs. 37%, p < 0.0001), no history of tick bites (58% vs. 43%, p = 0.01), physical/cognitive deficits prior to admission (15% vs 5%, p = 0.006), peripheral palsy (10% vs. 2%, p = 0.0008), encephalitis (8% vs. 1%, p = 0.0007) and cognitive impairment (8% vs. 2%, p = 0.03) compared with those without neuroimaging. Normal or incidental findings were common (93/98 CT-head and 154/182 MRI). 1/98 CT-head, 19/131 MRI-brain and 6/51 MRI-spine had findings consistent with LNB. Symptoms ≥45 days was associated with MRI-findings consistent with LNB (adjusted odds ratio (aOR) 4.2, 95%confidence interval 1.2-14.4, p = 0.02). CONCLUSION In this Danish cohort including 368 LNB-patients, use of neuroimaging was common and often performed in older comorbid patients without previous tick-bite intended to investigate alternative diagnoses. The results were in general without pathology and neuroimaging cannot exclude LNB or replace lumbar puncture. MRI is of value when investigating alternative neurological diseases and may support suspicion of LNB in cases with meningeal/leptomeningeal/neural enhancement.
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Affiliation(s)
- Mathilde Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Denmark
| | | | - Nitesh Shekhrajka
- Department of Neuroradiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Lykke Larsen
- Department of Infectious Diseases, Odense University Hospital, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark; Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark
| | - Hans R Luttichau
- Department of Infectious Diseases, Herlev Gentofte Hospital, Copenhagen, Denmark
| | - Aase Bengaard Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Helene Mens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
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20
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Skovsbo Clausen A, Ørbæk M, Renee Pedersen R, Oestrup Jensen P, Lebech AM, Kjaer A. 64Cu-DOTATATE Positron Emission Tomography (PET) of Borrelia Burgdorferi Infection: In Vivo Imaging of Macrophages in Experimental Model of Lyme Arthritis. Diagnostics (Basel) 2020; 10:diagnostics10100790. [PMID: 33036200 PMCID: PMC7601205 DOI: 10.3390/diagnostics10100790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022] Open
Abstract
Macrophages play a key role in the inflammatory response in Lyme arthritis (LA) and could be a target for diagnosing and monitoring active Borrelia burgdorferi sensu lato (Bb) infection. Therefore, we evaluated the potential of macrophage imaging using 64Cu-DOTATATE PET/CT for detection of Bb activity in a murine model of LA. LA was established in C3H/HeNRj mice infected with Bb B31 strain ML23 pBBE22luc. Bioluminescence imaging was performed to detect migration of spirochetes and inflammatory phagocytes to the joints. Three weeks post-infection 64Cu-DOTATATE PET/CT imaging was performed at an early (3 h) and late (48 h) time point. Plasma levels of a systemic macrophage marker in plasma CD163 were measured. 64Cu-DOTATATE uptake in infected joints was increased at the early (p < 0.0001) and late time points (p = 0.0005) compared with uptake in non-infected controls. No significant difference in plasma levels of CD163 was measured. 64Cu-DOTATATE PET allows for in vivo detection and quantification of LA locally in the joints through non-invasive visualization of macrophages. In contrast, measurement of a systemic macrophage marker in plasma, CD163, did not allow to detect disease. We suggest that 64Cu-DOTATATE PET could become a valuable diagnostic tool for in situ detection of Bb infection-related inflammation.
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Affiliation(s)
- Anne Skovsbo Clausen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, DK-2100 Copenhagen, Denmark;
- Cluster for Molecular Imaging, Department of Biomedical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Mathilde Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; (M.Ø.); (A.-M.L.)
| | - Regitze Renee Pedersen
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, DK-2200 Copenhagen, Denmark; (R.R.P.); (P.O.J.)
| | - Peter Oestrup Jensen
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, DK-2200 Copenhagen, Denmark; (R.R.P.); (P.O.J.)
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Center for Rheumatology and Spine Diseases, Institute for Inflammation Research, Copenhagen University Hospital, Rigshospitalet, DK-2100, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; (M.Ø.); (A.-M.L.)
- Institute of Clinical Medicine, University of Copenhagen, DK-2100 Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, DK-2100 Copenhagen, Denmark;
- Cluster for Molecular Imaging, Department of Biomedical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
- Correspondence: ; Tel.: +45-35327504
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21
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Tetens MM, Haahr R, Dessau RB, Krogfelt KA, Bodilsen J, Andersen NS, Møller JK, Roed C, Christiansen CB, Ellermann-Eriksen S, Bangsborg JM, Hansen K, Benfield TL, Andersen CØ, Obel N, Omland LH, Lebech AM. Changes in Lyme neuroborreliosis incidence in Denmark, 1996 to 2015. Ticks Tick Borne Dis 2020; 11:101549. [PMID: 32993955 DOI: 10.1016/j.ttbdis.2020.101549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022]
Abstract
Lyme neuroborreliosis (LNB) has recently been added to the list of diseases under the European Union epidemiological surveillance in order to obtain updated information on incidence. The goal of this study was to identify temporal (yearly) variation, high risk geographical regions and risk groups, and seasonal variation for LNB in Denmark. This cohort-study investigated Danish patients (n = 2791) diagnosed with LNB (defined as a positive Borrelia burgdorferi sensu lato (s.l.) intrathecal antibody test) between 1996-2015. We calculated incidence and incidence ratios of LNB by comparing 4-yr groups of calendar-years, area of residency, sex and age, income and education groups, and the number of new LNB cases per month. The incidence of LNB was 2.2 per 100,000 individuals and year in 1996-1999, 2.7 in 2004-2007 and 1.1 per 100,000 individuals in 2012-2015. Yearly variations in LNB incidence were similar for most calendar-year groups. LNB incidence was highest in Eastern Denmark and among males and individuals who were 0-14 yrs old, who had a yearly income of >449,000 DKK, and who had a Master's degree or higher education. The number of LNB cases was highest from July to November (p < 0.001). In conclusion, based on Danish nationwide data of patients with positive B. burgdorferi s.l. intrathecal antibody index (1996-2015) the incidence of LNB was found to increase until 2004-2007 but thereafter to decline. European surveillance studies of Lyme borreliosis should be encouraged to monitor the incidence trend.
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Affiliation(s)
- Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Rasmus Haahr
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Karen A Krogfelt
- Department of Virus and Microbiological Special Diagnostics, Statens Serum Institut, Denmark; Department of Natural Sciences and Environment, Roskilde University, Denmark
| | - Jacob Bodilsen
- Departments of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Departments of and Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Clinical Centre for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Jens K Møller
- Department of Clinical Microbiology, Vejle Hospital, Vejle, Denmark
| | - Casper Roed
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jette M Bangsborg
- Department of Clinical Microbiology, Herlev University Hospital, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas L Benfield
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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22
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Dahl V, Wisell KT, Giske CG, Tegnell A, Wallensten A. Lyme neuroborreliosis epidemiology in Sweden 2010 to 2014: clinical microbiology laboratories are a better data source than the hospital discharge diagnosis register. ACTA ACUST UNITED AC 2020; 24. [PMID: 31115310 PMCID: PMC6530252 DOI: 10.2807/1560-7917.es.2019.24.20.1800453] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BackgroundIn a study from 2013 that prioritised communicable diseases for surveillance in Sweden, we identified Lyme borreliosis as one of the diseases with highest priority. In 2014, when the present study was designed, there were also plans to make neuroborreliosis notifiable within the European Union.AimWe compared possibilities of surveillance of neuroborreliosis in Sweden through two different sources: the hospital discharge register and reporting from the clinical microbiology laboratories.MethodsWe examined the validity of ICD-10 codes in the hospital discharge register by extracting personal identification numbers for all cases of neuroborreliosis, defined by a positive cerebrospinal fluid-serum anti-Borrelia antibody index, who were diagnosed at the largest clinical microbiology laboratory in Sweden during 2014. We conducted a retrospective observational study with a questionnaire sent to all clinical microbiology laboratories in Sweden requesting information on yearly number of cases, age group and sex for the period 2010 to 2014.ResultsAmong 150 neuroborreliosis cases, 67 (45%) had received the ICD-10 code A69.2 (Lyme borreliosis) in combination with G01.9 (meningitis in bacterial diseases classified elsewhere), the combination that the Swedish National Board of Health and Welfare recommends for neuroborreliosis. All 22 clinical laboratories replied to our questionnaire. Based on laboratory reporting, the annual incidence of neuroborreliosis in Sweden was 6.3 cases per 100,000 in 2014.ConclusionThe hospital discharge register was unsuitable for surveillance of neuroborreliosis, whereas laboratory-based reporting was a feasible alternative. In 2018, the European Commission included Lyme neuroborreliosis on the list of diseases under epidemiological surveillance.
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Affiliation(s)
- Viktor Dahl
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.,Public Health Agency of Sweden, Stockholm, Sweden
| | | | - Christian G Giske
- Division of microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of clinical microbiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anders Wallensten
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Public Health Agency of Sweden, Stockholm, Sweden
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23
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Hansen ABE, Vestergaard HT, Dessau RB, Bodilsen J, Andersen NS, Omland LH, Christiansen CB, Ellermann-Eriksen S, Nielsen L, Benfield T, Sørensen HT, Andersen CØ, Lebech AM, Obel N. Long-Term Survival, Morbidity, Social Functioning and Risk of Disability in Patients with a Herpes Simplex Virus Type 1 or Type 2 Central Nervous System Infection, Denmark, 2000-2016. Clin Epidemiol 2020; 12:745-755. [PMID: 32765109 PMCID: PMC7371560 DOI: 10.2147/clep.s256838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background The long-term prognosis following herpes simplex virus (HSV) central nervous system (CNS) infection is still debated. Patients and Methods We examined outcomes in all Danish residents who, during 2000–2016, tested PCR positive for HSV-1 (n=208) or HSV-2 (n=283) in the cerebrospinal fluid, compared to comparison cohorts from the general population (n=2080 and n=2830). Results One-year mortality was increased among HSV-1 patients (difference 19.3%; 95% CI: 13.6% to 25.0%) and HSV-2 patients (difference 5.3%; 95% CI: 2.5% to 8.1%), but thereafter mortality was not increased. After exclusion of persons diagnosed with cancer prior to study inclusion, one-year mortality difference for HSV-2 patients was 1.7% (−0.1% to 3.5%). After five years, HSV-1 patients had lower employment (difference −19.8%; 95% CI: −34.7% to −4.8%) and higher disability pension rates (difference 22.2%; 95% CI: 8.4% to 36.0%) than the comparison cohort, but similar number of inpatient days, outpatient visits, and sick leave. HSV-2 patients had employment and disability pension rates comparable to the comparison cohort, but more inpatient days (difference 1.5/year; 95% CI: −0.2 to 3.2), outpatient visits (difference 1.3/year; 95% CI: 0.3 to 3.2), and sick leave days (difference 9.1/year; 95% CI: 7.9 to 10.4). Conclusion HSV-1 and HSV-2 CNS infections differ substantially with respect to prognosis. HSV-1 CNS infection is followed by increased short-term mortality and long-term risk of disability. HSV-2 CNS infection has no substantial impact on mortality or working capability but is associated with increased morbidity.
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Affiliation(s)
- Ann-Brit E Hansen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Infectious Diseases, Amager Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne T Vestergaard
- Department of Virus & Microbiological Special Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Bodilsen
- Departments of Infectious Diseases and Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Lene Nielsen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Amager Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Ø Andersen
- Department of Clinical Microbiology, Amager Hvidovre University Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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24
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Abstract
PURPOSE OF REVIEW To review the recent evidence clarifying the symptomatology and diagnosis of nervous system Lyme disease. RECENT FINDINGS Two-tier testing combining pairs of ELISAs, using C6 or VlsE assays to replace second tier Western blots, may eliminate confusion about test interpretation. Cerebrospinal fluid (CSF) can be informative in diagnosing central nervous system (CNS) Lyme disease, not peripheral nervous system (PNS) disorders. CSF CXCL13 may provide useful adjunctive information in CNS infection; its specificity remains to be defined. Lyme encephalopathy is not indicative of CNS infection. Post treatment Lyme disease symptoms do not occur in patients who have had definite CNS Lyme infection. Whether post treatment Lyme disease symptom (PTLDS) is an actual entity, or reflects anchoring bias when commonly occurring symptoms arise in patients previously treated for Lyme disease, remains to be determined. Regardless, these symptoms do not reflect CNS infection and do not respond to additional antimicrobial therapy. SUMMARY Serologic testing is robust in individuals with a priori likelihood of infection of greater than 2-6 weeks duration. Western blots provide useful confirmation of screening ELISAs, but may be replaced by second ELISAs. CSF testing, including CXCL13, may be informative in CNS Lyme, not PNS, and is generally normal in Lyme encephalopathy. PTLDS does not occur following CNS infection, and may not be a distinct entity.
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25
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Munro APS, Dorey RB, Owens DR, Steed DJ, Petridou C, Herdman T, Jones CE, Patel SV, Pryde K, Faust SN. High frequency of paediatric facial nerve palsy due to Lyme disease in a geographically endemic region. Int J Pediatr Otorhinolaryngol 2020; 132:109905. [PMID: 32035348 DOI: 10.1016/j.ijporl.2020.109905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Idiopathic facial nerve palsy (FNP) is an uncommon but important presentation in children, with Lyme disease known to be a common cause. The UK county of Hampshire is a high incidence area of Lyme disease. We conducted a retrospective review of the investigation and management of paediatric FNP at a large University hospital, including serologic testing and treatment of Lyme disease. METHODS We conducted a retrospective chart review of children under 18 presenting between January 1st, 2010 and December 31st, 2017 with a diagnosis of FNP. Patients with clear non-Lyme aetiology at presentation were excluded. Data was collected on demographics, initial presentation, investigations including Lyme serology, and management. RESULTS A total of 93 children were identified, with an even proportion of male to female and median age 9.3 years (IQR 4.6-12 years). A history of rash was present in 5.4%, tick bite in 14% and recent travel to, or residence in the New Forest in 22.6%. Lyme serology was performed in 81.7% of patients, of which 29% were positive. Antibiotics were prescribed for 73.1% of patients, oral steroids for 44% and aciclovir for 17.2%. CONCLUSION Lyme disease is a significant cause of FNP in this endemic area of the UK, and there was a large degree of variability in management prior to national guideline publication. Areas with endemic Lyme disease should consider introducing local guidelines supporting routine investigation and management for FNP, including empiric treatment for Lyme disease in accordance with NICE guidelines to improve care and reduce variability.
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Affiliation(s)
- Alasdair P S Munro
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom.
| | - Robert B Dorey
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Daniel R Owens
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Duncan J Steed
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Christina Petridou
- Public Health England Rare and Imported Diseases Laboratory, Porton Down, Salisbury, United Kingdom
| | - Trent Herdman
- Public Health England Rare and Imported Diseases Laboratory, Porton Down, Salisbury, United Kingdom
| | - Christine E Jones
- Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Sanjay V Patel
- Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Kate Pryde
- Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
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26
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Eikeland R, Ljøstad U, Helgeland G, Sand G, Flemmen HØ, Bø MH, Nordaa L, Owe JF, Mygland Å, Lorentzen ÅR. Patient-reported outcome after treatment for definite Lyme neuroborreliosis. Brain Behav 2020; 10:e01595. [PMID: 32153118 PMCID: PMC7177557 DOI: 10.1002/brb3.1595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/05/2020] [Accepted: 02/13/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To chart patient-reported outcome measures (PROMs) in Norwegian patients treated for definite neuroborreliosis (NB). MATERIAL AND METHODS Adult patients treated for definite NB 1-10 years earlier supplied demographics, symptoms and treatment during NB, and answered validated questionnaires; Fatigue Severity Scale (FSS), Hospital Anxiety and Depression Scale (HADS), health-related quality of life questionnaire (RAND-36), and Patient Health Questionnaire (PHQ-15). RESULTS A higher proportion of NB-treated persons reported severe fatigue, defined as FSS score ≥ 5, than in Norwegian normative data, but when removing persons with confounding fatigue associated comorbidities (n = 69) from the analyses, there was no difference between groups. Physical health-related quality of life (RAND-36 PCS), mean FSS score, proportions of persons reporting moderate or severe somatic symptom burden (PHQ-15 score ≥ 10), anxiety (HADS-A ≥ 8), or depression (HADS-D ≥ 8) did not differ between NB-treated persons and reference scores. Mental health-related quality of life (RAND-36 MCS) was poorer than in normative data (47.1 vs. 53.3), but associated with anxiety, depression and current moderate or severe somatic symptom burden, and not with NB characteristics. CONCLUSIONS Results on validated PROM questionnaires measuring fatigue, anxiety, depression, self-reported somatic symptom burden, and physical health-related quality did not differ between persons treated for definite NB 1-10 years earlier and reference scores. NB-treated persons tended to report a slightly poorer mental health-related quality of life than found in normative data, but when adjusting for confounders the causative connection is questionable. Overall, the long-term prognosis of definite NB seems to be good.
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Affiliation(s)
- Randi Eikeland
- Department of Pediatrics, Sørlandet Hospital Trust, Arendal, Norway.,The Norwegian National Advisory Unit on Tick-borne Diseases, Arendal, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Helgeland
- Department of Neurology, Møre and Romsdal Hospital Trust, Molde, Norway
| | - Geir Sand
- Department of Infectious Diseases, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Ludmila Nordaa
- Department of Neurology, Helse Fonna Trust, Haugesund, Norway
| | - Jone Furulund Owe
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Rehabilitation, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Åslaug Rudjord Lorentzen
- The Norwegian National Advisory Unit on Tick-borne Diseases, Arendal, Norway.,Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
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27
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Nordberg CL, Bodilsen J, Knudtzen FC, Storgaard M, Brandt C, Wiese L, Hansen BR, Andersen ÅB, Nielsen H, Lebech AM. Lyme neuroborreliosis in adults: A nationwide prospective cohort study. Ticks Tick Borne Dis 2020; 11:101411. [PMID: 32178995 DOI: 10.1016/j.ttbdis.2020.101411] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/23/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
Abstract
The goal of this paper is to characterize the clinical presentation, serological results, current antibiotic treatment practice, including compliance with current European guidelines, and outcome in adults with Lyme neuroborreliosis (LNB) diagnosed at departments of infectious diseases in Denmark. Using a nationwide prospective cohort of patients with central nervous system infections, we identified all adults (≥ 18 years of age) treated for LNB at departments of infectious diseases in Denmark from 2015 through 2017. The database contains information on baseline demographics, history of tick bite, erythema migrans, clinical presentation, laboratory results of blood samples, and cerebrospinal (CSF) biochemistry (e.g. specific Borrelia burgdorferi sensu lato (s.l.) antibodies in serum, B. burgdorferi s.l. intrathecal antibody index) as well as antibiotic therapy. Outcome was assessed by the Glasgow Outcome Scale (GOS) and the presence of residual symptoms at follow-up one month after discharge. We included 194 LNB patients with a median age of 59 years (range 18-85 years, interquartile range [IQR] 47-69 years). The female-to-male ratio was 0.8. A total of 177 of 191 (93 %) of patients had early (second stage) LNB. A history of tick bite or erythema migrans was registered in 75 (39 %) and 49 (25 %) patients, respectively. The median duration of neurological symptoms before first hospital contact was 21 days (range 0-600 days, IQR 10-42 days). Predominant symptoms consisted of radicular pain in 135 of 194 (70 %), cranial nerve paresis in 88 of 194 (45 %), headache in 71 of 185 (38 %), and extremity paresis in 33 of 194 (17 %) patients. Serum-B. burgdorferi s.l. IgM and/or IgG antibodies were detectable in 166 of 181 (92 %) patients at the time of first CSF investigation. Median duration of antibiotic treatment was 14 days (range 10-35 days, IQR 14-21 days) and 59 (39 %) of the patients received intravenous ceftriaxone and/or benzylpenicillin G throughout treatment. At the 1-month follow-up, GOS was unfavorable (< 5) in 54 of 193 (28 %) patients. An unfavorable GOS score was more often registered in patients with ≥ 45 days of symptom duration (20 of 45 (44 %) vs. 34 of 145 (23 %); P = 0.006). In conclusion, a European cohort of adult patients with LNB diagnosed between 2015-2017 presented with classic symptoms and CSF findings. However, a substantial diagnostic delay was still observed. In disagreement with current guidelines, a substantial part of LNB patients were treated with antibiotics longer than 14 days and/or intravenously as route of administration.
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Affiliation(s)
- Cecilie Lerche Nordberg
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Fredrikke Christie Knudtzen
- Clinical Centre for Emerging and Vector-borne Infections, Department of Infectious Diseases, Odense University Hospital, Denmark.
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands University Hospital, Hillerød, Denmark.
| | - Lothar Wiese
- Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark.
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark.
| | - Åse Bengård Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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28
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Infectious causes of peripheral facial nerve palsy in children-a retrospective cohort study with long-term follow-up. Eur J Clin Microbiol Infect Dis 2019; 38:2177-2184. [PMID: 31372902 DOI: 10.1007/s10096-019-03660-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022]
Abstract
The aim of this study was to analyze the clinical and laboratory characteristics of children with peripheral facial nerve palsy (pFP) with a focus on identifying infectious etiology and long-term outcome. We conducted an ICD-10-based retrospective chart review on children hospitalized with pFP between January 1, 2006, and December 31, 2016. Furthermore, a telephone-based follow-up survey was performed. A total of 158 patients were identified, with a median age of 10.9 years (interquartile range 6.4-13.7). An infectious disease was associated with pFP in 82 patients (51.9%); 73 cases were classified as idiopathic pFP (46.2%). Three cases occurred postoperatively or due to a peripheral tumor. Among the infectious diseases, we identified 33 cases of neuroborreliosis and 12 viral infections of the central nervous system (CNS), caused by the varicella-zoster virus, human herpesvirus 6, herpes simplex virus, enterovirus, and Epstein-Barr virus. Other infections were mainly respiratory tract infections (RTIs; 37 cases). Children with an associated CNS infection had more often headache and nuchal rigidity, a higher cerebrospinal fluid cell count, and a longer length of hospital stay. Long-term follow-up revealed an associated lower risk of relapse in CNS infection-associated pFP. Among all groups, permanent sequelae were associated with female sex, a shorter length of hospitalization, and a lower white blood cell count at presentation. pFP is frequently caused by an CNS infection or is associated with concurrent RTIs, with a potential impact on the short- and long-term clinical course.
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29
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Gocko X, Lenormand C, Lemogne C, Bouiller K, Gehanno JF, Rabaud C, Perrot S, Eldin C, de Broucker T, Roblot F, Toubiana J, Sellal F, Vuillemet F, Sordet C, Fantin B, Lina G, Sobas C, Jaulhac B, Figoni J, Chirouze C, Hansmann Y, Hentgen V, Caumes E, Dieudonné M, Picone O, Bodaghi B, Gangneux JP, Degeilh B, Partouche H, Saunier A, Sotto A, Raffetin A, Monsuez JJ, Michel C, Boulanger N, Cathebras P, Tattevin P. Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies. Med Mal Infect 2019; 49:296-317. [PMID: 31257066 DOI: 10.1016/j.medmal.2019.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/31/2019] [Indexed: 12/19/2022]
Affiliation(s)
- X Gocko
- Département de médecine générale, faculté de médecine, 42000 Saint-Étienne, France
| | - C Lenormand
- Dermatologie, hôpitaux universitaires de Strasbourg et faculté de médecine, université de Strasbourg, 67000 Strasbourg, France
| | - C Lemogne
- Psychiatrie, hôpital européen Georges-Pompidou, AP-HP.5, Inserm U1266, université Paris, 75015 Descartes, Paris, France
| | - K Bouiller
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, UMR CNRS 6249 université Bourgogne Franche Comté, 25000 Besançon, France
| | - J-F Gehanno
- Médecine du travail, centre hospitalo-universitaire, 76000 Rouen, France
| | - C Rabaud
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 54100 Nancy, France
| | - S Perrot
- Centre d'étude et de traitement de la douleur, hôpital Cochin, 75014 Paris, France
| | - C Eldin
- Maladies infectieuses et tropicales, IHU Méditerranée infection, centre hospitalo-universitaire Timone, 13000 Marseille, France
| | - T de Broucker
- Neurologie, hôpital Delafontaine, 93200 Saint-DenisFrance
| | - F Roblot
- Inserm U1070, Maladies infectieuses et tropicales, centre hospitalo-universitaire, 86000 Poitiers, France
| | - J Toubiana
- Service de pédiatrie générale et maladies infectieuses, hôpital Necker-Enfants malades, AP-HP, 75014 Paris, France
| | - F Sellal
- Département de neurologie, hôpitaux Civil, 68000 Colmar, France
| | - F Vuillemet
- Département de neurologie, hôpitaux Civil, 68000 Colmar, France
| | - C Sordet
- Rhumatologie, centre hospitalo-universitaire, 67000 Strasbourg, France
| | - B Fantin
- Médecine interne, hôpital Beaujon, université Paris Diderot, Inserm UMR 1137 IAME, 92110 Clichy, France
| | - G Lina
- Laboratoire de bactériologie et CNR des Borrelia, faculté de médecine et centre hospitalo-universitaire, 67000 Strasbourg, France
| | - C Sobas
- Microbiologie, centre hospitalo-universitaire, 69000 Lyon, France
| | - B Jaulhac
- Laboratoire de bactériologie et CNR des Borrelia, faculté de médecine et centre hospitalo-universitaire, 67000 Strasbourg, France
| | - J Figoni
- Maladies infectieuses et tropicales, hôpital Avicenne, 930222 Bobigny, France; Santé publique France, 94410 St.-Maurice, France
| | - C Chirouze
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, UMR CNRS 6249 université Bourgogne Franche Comté, 25000 Besançon, France
| | - Y Hansmann
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 67000 Strasbourg, France
| | - V Hentgen
- Pédiatrie, centre hospitalier, 78000 Versailles, France
| | - E Caumes
- Maladies infectieuses et tropicales, hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - M Dieudonné
- Centre Max-Weber, CNRS, université Lyon 2, 69000 Lyon, France
| | - O Picone
- Maternité Louis-Mourier, 92700 Colombes, France
| | - B Bodaghi
- Ophtalmologie, hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - J-P Gangneux
- Laboratoire de parasitologie-mycologie, UMR_S 1085 Irset, université Rennes1-Inserm-EHESP, centre hospitalo-universitaire, 35000 Rennes, France
| | - B Degeilh
- Laboratoire de parasitologie-mycologie, UMR_S 1085 Irset, université Rennes1-Inserm-EHESP, centre hospitalo-universitaire, 35000 Rennes, France
| | - H Partouche
- Cabinet de médecine générale, 93400 Saint-Ouen, département de médecine générale, faculté de médecine, université Paris Descartes, 75006 Paris, France
| | - A Saunier
- Médecine interne et maladies infectieuses, centre hospitalier, 24750 Périgueux, France
| | - A Sotto
- Maladies infectieuses et tropicales, centre hospitalo-universitaire, 30000 Nîmes, France
| | - A Raffetin
- Maladies infectieuses et tropicales, centre hospitalier intercommunal, 94190 Villeneuve-St-Georges, France
| | - J-J Monsuez
- Cardiologie, hôpital René-Muret, 93270 Sevran, France
| | - C Michel
- Médecine générale, 67000 Strasbourg, France
| | - N Boulanger
- Laboratoire de bactériologie et CNR des Borrelia, faculté de médecine et centre hospitalo-universitaire, 67000 Strasbourg, France
| | - P Cathebras
- Médecine interne, hôpital Nord, centre hospitalo-universitaire, 42000 Saint-Étienne, France
| | - P Tattevin
- Maladies infectieuses et reanimation médicale, hôpital Pontchaillou, centre hospitalo-universitaire, 35000 Rennes, France.
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Di Domenico EG, Cavallo I, Bordignon V, D'Agosto G, Pontone M, Trento E, Gallo MT, Prignano G, Pimpinelli F, Toma L, Ensoli F. The Emerging Role of Microbial Biofilm in Lyme Neuroborreliosis. Front Neurol 2018; 9:1048. [PMID: 30559713 PMCID: PMC6287027 DOI: 10.3389/fneur.2018.01048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/19/2018] [Indexed: 01/04/2023] Open
Abstract
Lyme borreliosis (LB) is the most common tick-borne disease caused by the spirochete Borrelia burgdorferi in North America and Borrelia afzelii or Borrelia garinii in Europe and Asia, respectively. The infection affects multiple organ systems, including the skin, joints, and the nervous system. Lyme neuroborreliosis (LNB) is the most dangerous manifestation of Lyme disease, occurring in 10-15% of infected individuals. During the course of the infection, bacteria migrate through the host tissues altering the coagulation and fibrinolysis pathways and the immune response, reaching the central nervous system (CNS) within 2 weeks after the bite of an infected tick. The early treatment with oral antimicrobials is effective in the majority of patients with LNB. Nevertheless, persistent forms of LNB are relatively common, despite targeted antibiotic therapy. It has been observed that the antibiotic resistance and the reoccurrence of Lyme disease are associated with biofilm-like aggregates in B. burgdorferi, B. afzelii, and B. garinii, both in vitro and in vivo, allowing Borrelia spp. to resist to adverse environmental conditions. Indeed, the increased tolerance to antibiotics described in the persisting forms of Borrelia spp., is strongly reminiscent of biofilm growing bacteria, suggesting a possible role of biofilm aggregates in the development of the different manifestations of Lyme disease including LNB.
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Affiliation(s)
- Enea Gino Di Domenico
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Ilaria Cavallo
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Valentina Bordignon
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Giovanna D'Agosto
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Martina Pontone
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Elisabetta Trento
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Maria Teresa Gallo
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Grazia Prignano
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Fulvia Pimpinelli
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Luigi Toma
- Department of Research, Advanced Diagnostics, and Technological Innovation, Translational Research Area, Regina Elena National Cancer Institute IRCCS, Rome, Italy
| | - Fabrizio Ensoli
- Clinical Pathology and Microbiology Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
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