Duration of antibiotic treatment in disseminated Lyme borreliosis: a double-blind, randomized, placebo-controlled, multicenter clinical study

Despite rather strict recommendations for antibiotic treatment of disseminated Lyme borreliosis (LB), evidence-based studies on the duration of antibiotic treatment are scarce. The aim of this multicenter study was to determine whether initial treatment with intravenous ceftriaxone (CRO) for 3 weeks should be extended with a period of adjunct oral antibiotic therapy. A total of 152 consecutive patients with LB were randomized in a double-blind fashion to receive either amoxicillin (AMOX) 1 g or placebo (PBO) twice daily for 100 days. Both groups received an initial treatment of intravenous CRO 2 g daily for 3 weeks, followed by the randomized drug or PBO. The outcome was evaluated using the visual analogue scale at the follow-up visits. The final analysis included 145 patients, of whom 73 received AMOX and 72 PBO. Diagnoses of LB were categorized as either definite or possible, on the basis of symptoms, signs, and laboratory results. The diagnosis was definite in 52 of the 73 (71.2%) AMOX-treated patients and in 54 of the 72 (75%) PBO patients. Of the patients with definite diagnoses, 62 had neuroborreliosis, 45 arthritis or other musculoskeletal manifestations, and 4 other manifestations of LB. As judged by the visual analogue scale and patient records, the outcome after a 1-year follow-up period was excellent or good in 114 (78.6%) patients, controversial in 14 (9.7%) patients, and poor in 17 (11.7%) patients. In patients with definite LB, the outcome was excellent or good in 49 (92.5%) AMOX-treated patients and 47 (87.0%) PBO patients and poor in 3 (5.7%) AMOX-treated patients and 6 (11.1%) PBO patients (difference nonsignificant, p = 0.49). Twelve months after the end of intravenous antibiotic therapy, the levels of antibodies against Borrelia burgdorferi were markedly decreased in 50% of the patients with definite LB in both groups. The results indicate that oral adjunct antibiotics are not justified in the treatment of patients with disseminated LB who initially receive intravenous CRO for 3 weeks. The clinical outcome cannot be evaluated at the completion of intravenous antibiotic treatment but rather 6-12 months afterwards. In patients with chronic post-treatment symptoms, persistent positive levels of antibodies do not seem to provide any useful information for further care of the patient.

Prevalence of tick-borne encephalitis virus in Ixodes ricinus ticks in Finland

Approximately 20 cases of tick-borne encephalitis (TBE) occur annually in Finland. The known endemic areas are situated mainly in the archipelago and coastal regions of Finland, with highest incidence in Aland islands. Ixodes ricinus panels collected in 1996-1997 from two endemic areas were screened for the presence of RNA. Two distinct RT-PCR methods were applied, and were shown to have an approximate detection limit of 10 focus forming doses (FFD)/100 microl. One out of 20 pools (a total of 139 ticks) from Helsinki Isosaari Island and one out of 48 pools (a total of 450 ticks) from Aland were positive with both methods, whereas the remaining pools were negative. The observed overall frequency (0.34%) in ticks in endemic areas of Finland, was similar to the low incidence found by virus isolation in mice in the 1960s (0.5%). Viral RNA was detectable in a diluted sample representing 0.005% of a positive pool of ten nymphs suggesting that the viral RNA load within an infected tick pool was approximately equivalent to 20,000-200,000 FFD. Sequence analysis did not show geographical clustering of the Finnish strains, suggesting an independent emergence of different TBE foci from the south. TBE virus RNA positive ticks were not found in I. ricinus panels consisting of 130 pools (726 ticks) from Helsinki city parks or 41 pools (197 ticks) from Võrmsi Island in Estonia.

Lyme borreliosis, an etiological factor in sensorineural hearing loss?

The incidence of Lyme borreliosis was studied prospectively in 165 patients with acute idiopathic sensorineural hearing loss. The prevalence of positive levels of antibodies against Borrelia burgdorferi was sixfold higher in patients with sensorineural hearing loss than in the general population in Finland. Four patients fulfilled the criteria for Lyme borreliosis. No specific risk factors were found with which to predict the occurrence of Lyme borreliosis among patients with hearing loss. In logistic regression modeling the poor outcome of hearing loss was best explained by advanced age, high-frequency or flat-type hearing loss, and absence of positive levels of antibodies against B. burgdorferi. Although the causal relationship between Lyme borreliosis and sensorineural hearing loss is difficult to verify, we suggest that Lyme borreliosis is a rare but potentially treatable cause of sudden deafness. We propose that in endemic areas antibodies against Lyme borreliosis should be determined in patients with idiopathic sensorineural hearing loss.

Intratympanic and systemic dexamethasone for Ménière's disease

Intratympanic and systemic dexamethasone treatment of Ménière's disease (MD) was evaluated in a prospective study. Seventeen patients (6 men and 11 women) with MD (5 right-sided, 11 left-sided and 1 bilateral) were treated with three 0.2- to 0.4-ml injections of intratympanic dexamethasone hyaluronate (16 mg/ml) during a week and with an initial intramuscular dexamethasone injection of 15 mg. Most of patients were in stage 3, and the mean duration of MD was 5. 3 years. Pure-tone and speech audiometry and the symptom scale of the patients were followed up for 1 year after the treatment. Symptoms of aural fullness, hearing loss, tinnitus and vertigo did not improve significantly. However, sufficient control of vertigo was achieved in 76% of the patients. In conclusion, no definite treatment effect has yet been shown for intratympanic and systemic dexamethasone treatment. Therefore, the clinical use of dexamethasone in MD needs further investigation.

Prevalence of Borrelia burgdorferi in Ixodes ricinus ticks in urban recreational areas of Helsinki

Lyme borreliosis, an infection caused by the tick-borne spirochete Borrelia burgdorferi, is a major health problem for populations in areas of endemicity in the Northern Hemisphere. In the present study we assessed the density of ticks and the prevalence of B. burgdorferi sensu lato among ticks in popular urban recreational areas of Helsinki, Finland. Altogether 1,688 Ixodes ricinus ticks were collected from five areas located within 5 km of the downtown section of Helsinki, and 726 of them (303 nymphs, 189 females, and 234 males) were randomly chosen for laboratory analysis. The midguts of the ticks were divided into three pieces, one for dark-field microscopy, one for cultivation in BSK-II medium, and one for PCR analysis. Ticks were found in all the study areas; their densities varied from 1 to 36 per 100 m along which a cloth was dragged. The rate of tick infection with B. burgdorferi sensu lato varied from 19 to 55%, with the average being 32%. Borellia afzelii was the most predominant genospecies in all the areas, and no B. burgdorferi sensu stricto isolates were detected. Only two ticks were concurrently infected with both B. afzelii and Borrelia garinii. Dark-field microscopy gave more positive results for B. burgdorferi than did cultivation or PCR analysis. However, the agreement between all three methods was fairly good. We conclude that Lyme borreliosis can be contracted even in urban environments not populated with large mammals like deer or elk. The disease should be taken into account in the differential diagnosis of certain symptoms of patients from these areas, and the use of measures to improve the awareness of the general population and health care officials of the risk of contracting the disease is warranted.

Paediatric facial paralysis caused by Lyme borreliosis: a prospective and retrospective analysis

The incidence of Lyme borreliosis (LB) was studied prospectively in 49 children (< 17 years of age) with 50 episodes of acute FP. In addition, 43 children with a history of FP (average follow-up of 5.2 y) were studied retrospectively for the outcome of FP and for the symptoms and signs of late LB. In the prospective study, 17 (34%) patients with FP proved to have acute LB. They all received antibiotic treatment and their FP had a favourable outcome. In the retrospective study the patients had had FP before the diagnostic tests for LB were available. Thus, none of the 43 patients had been diagnosed to have, or treated for, LB. The outcome of their FP had generally been favourable. None of them had any signs of late LB at the follow-up visit. Our results indicate that LB is a frequent cause of acute paediatric FP in an endemic area. In addition our data suggests that FP caused by LB in children has a favourable prognosis, even when left untreated.

Lyme borreliosis--an unusual cause of vertigo

A total of 2055 consecutive vertigo patients were examined in a prospective study in an area endemic for Lyme borreliosis for clinical signs of Lyme borreliosis or serum antibodies against Borrelia burgdorferi. Of these, 41 patients (2%) had positive levels of serum antibodies against B. burgdorferi. The incidence of seropositivity against B. burgdorferi among the vertigo patients did not differ from the incidence of the normal Finnish population. In addition to seropositivity the criteria used for Lyme borreliosis included previous erythema migrans, a positive polymerase chain reaction (PCR) or positive serum immunoblot. Eight patients were diagnosed as having Lyme borreliosis. This disease is a rare but possible cause of vertigo. Seropositivity alone is an insufficient finding for the diagnosis of Lyme borreliosis and should be supported by the clinical findings, the patient's history and other laboratory findings, such as immunoblotting or PCR. Although Lyme borreliosis seems to be a rare cause of vertigo, it must be kept in mind in the differential diagnosis of vertigo.

Impaired interferon production by leukocytes from patients with Bell palsy and lack of findings suggestive for a systemic viral involvement

HYPOTHESIS

This study aimed to test the hypothesis that viral and other microbial infections cause Bell palsy and to use the interferon (IFN) alpha/beta-induced MxA protein as an indicator of systemic viral infection.

BACKGROUND

Bell palsy has been previously associated with several viral infections. Recently, after this study was completed, herpes simplex virus DNA was detected in the endoneurial fluid of some patients with Bell palsy.

METHODS

Serum and blood mononuclear cells were obtained from 30 patients with Bell palsy and 12 control subjects. The sera were tested for antibodies to 21 microbes. Mononuclear cells were assayed for (a) MxA protein using immunoblotting and (b) capacity to produce IFN in short-term culture after stimulation with influenza A virus.

RESULTS

No significant differences were seen in serum antibodies or MxA protein between the patients and controls. The geometric mean of leukocyte IFN production in the convalescent phase of Bell palsy patients was higher than in the acute phase but remained still at significantly lower levels as compared with the control group (p < 0.05). In three patients there was no detectable IFN production.

CONCLUSIONS

These results provide no evidence for a systemic viral involvement in Bell palsy, but the observed decreased IFN-producing capacity at the onset of Bell palsy could be a sign of transient immunosuppression or of an abnormal frequency of leukocyte subpopulations in the disease.

Pediatric facial paralysis--a spirochetal infection with good prognosis?

The aim of the study was to investigate the possible signs of chronic spirochetal infection in 27 children with a history of facial paralysis with onset of symptoms during May-October 1985-1993. These children had not been studied at the time of facial paralysis for possible Lyme borreliosis and none of these children had received antimicrobial therapy at that time. The patients were interviewed with special reference to symptoms and signs of Lyme borreliosis and thereafter examined clinically and with laboratory tests. None of the patients showed signs or symptoms of chronic Lyme borreliosis. One child-now a 14-year old girl-had a 4-fold rise in serum Borrelia burgdorferi antibodies as a sign of a recent infection. According to our prospective studies on pediatric facial paralysis in Finland (over 50% of children presenting with facial paralysis during May-October have Lyme borreliosis), we have a reason to assume that at least some in our study group had a facial paralysis caused by Borrelia burgdorferi infection. The results of our study indicate that facial paralysis has a favorable prognosis and in short-term follow-up the children do not have symptoms or signs of chronic Lyme borreliosis.

Azathioprine with cortisone in treatment of hearing loss in only hearing ear

A sudden or progressive hearing loss in the only hearing ear is an otologic emergency, in which therapeutic possibilities are limited. We describe results of immunosuppressive therapy in 10 patients with one deafened ear either due to cochlear hydrops or Meniere's disease, who developed progressive or fluctuant hearing loss in the only hearing ear. The perilymphatic fistula was excluded with tympanoscopy. Azathioprine (25 mg t.i.d.) with prednisone (initial dose 20-40 mg with daily dose of 5-15 mg/day) was used. The hearing of 6 subjects responded to treatment. The initial pure tone audiogram (PTA) at speech frequencies of the "only hearing ear" was 57.3 dB HL with speech discrimination score (SDS) of 85%. The hearing improvement occurred successively within days or weeks. The average improvement of PTA was 22.4 dB HL after the mean treatment period of 5 weeks. In contralateral ear (the average PTA and SDS were 72.5 dB HL and 28%, respectively) the mean improvement in PTA was insignificant (4.4 dB). In 5 patients with vertigo it was improved in 3 cases. Cortisone alone or with combination of cyclophosphamide or ciclosporine was not effective in our hands.

Proton-induced X-ray emission analysis of atherosclerotic plaques of the carotid bifurcation

The trace elements of both calcified atherosclerotic plaques and plaque-free vessel walls of the carotid bifurcation from 31 autopsies were investigated using the proton-induced X-ray emission (PIXE) method. The trace elements studied were phosphorus (P), calcium (Ca), chrome (Cr), iron (Fe), copper (Cu), zinc (Zn), lead (Pb), selenium (Se), bromine (Br), strontium (Sr), and rubidium (Rb). All samples contained Fe and Zn. Mercury (Hg) was not detected in any of the samples studied. All plaque-free samples contained Cu and almost all Br and Ca, none Sr. All calcified atherosclerotic plaques contained Ca and almost all Br and Sr. The relative levels of Ca were higher in the calcified plaques than in the plaque-free vessel walls. The relative value of Ca in calcified and uncalcified samples was greatest in the group who had died because of cardiovascular disorders and smallest in the group who had died from other causes. There was a strong positive correlation between the Ca and Sr of the plaque samples and between the P and Br of the plaque-free samples.