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Hulshof MM, Starink MV, Lokin ASHJ, Hovius JW. [Cutaneous Lyme disease: not always a rash with a central clearing]. Ned Tijdschr Geneeskd 2024; 168:D7863. [PMID: 38568004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
During the past four decades the number of reported Lyme disease diagnoses in the Netherlands has increased to 27.000 a year, with a yearly incidence of Lyme disease between 111 (95% CI 106-115) to 131 (95% CI 126-136) per 100,000 person years. A large part of all Lyme disease diagnoses concern the skin; in the Netherlands, 77-89% erythema migrans, 2-3% borrelia lymfocytoom and 1-3% acrodermatitis chronica atrophicans. These skin manifestations have a variable clinical expression, reason why they can be difficult to diagnose. Early recognition and treatment is important to prevent the development of systemic manifestations.
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Affiliation(s)
| | | | | | - Joppe W Hovius
- Amsterdam UMC, Amsterdam. Afd. Inwendige Geneeskunde en Infectieziekten
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2
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Diaconeasa A, Voicu C, Ivaniciuc M, Miulescu R, Birsan C, Chiriac AE, Chiriac A, Schönlebe J, Wollina U. Cutaneous borreliosis in children - a challenging problem. Eur J Dermatol 2024; 34:18-25. [PMID: 38557454 DOI: 10.1684/ejd.2024.4611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Borreliosis, also known as Lyme disease, is a vector-borne disease caused by different species of the Borrelia burgdorferi complex. It is frequent in Europe and Northern America. The major vectors are ixodoid ticks. Paediatric borreliosis is common and peaks in children between five to nine years. In Europe, the leading symptom of early infection is erythema migrans, in contrast to Northern America where arthritis is the dominating clinical finding. In this review, we focus on Europe, where cutaneous borreliosis is mainly caused by infection with B. afzelii. The cutaneous symptoms include erythema migrans, lymphocytoma, chronic atrophic dermatitis and juxta-articular nodules. In children, lymphocytoma is very common but chronic atrophic dermatitis is rare. Clinical symptoms, diagnosis, peculiarities of childhood disease and treatment are also reviewed. It is important to note that after haematogeneic spread, signs of infection may be non-specific, and this is a challenge for diagnosis.
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Affiliation(s)
- Adriana Diaconeasa
- Dermatology Ambulatory Care Center, "Grigore Alexandrescu" Clinical Emergency Hospital for Children, Bucharest, Romania
| | - Cristiana Voicu
- Department of Dermatology, MedLife Medical System, Bucharest, Romania
| | | | | | - Cristina Birsan
- Nicolina Medical Center, Department of Dermatology, Iasi, Romania
| | - Anca E Chiriac
- Nicolina Medical Center, Department of Dermatology, Iasi, Romania
| | - Anca Chiriac
- Nicolina Medical Center, Department of Dermatology, Iasi, Romania, P. Poni Institute of Macromolecular Chemistry, Romanian Academy
| | | | - Uwe Wollina
- Department of Dermatology and Allergology, Municipal Hospital Dresden, Dresden, Germany
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3
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Repiska V, Gutaiova B, Humplikova S, Shawkatova I. Challenges of laboratory diagnosis of Lyme disease ‒ Questionnaire survey results. BRATISL MED J 2024; 125:360-364. [PMID: 38757592 DOI: 10.4149/bll_2024_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Lyme disease. Our second goal was to identify bacterial and viral co-infections occurring concurrently with Lyme disease. Furthermore, it was our intention to also analyze the correlation of laboratory testing with the occurrence of erythema migrans (EM). BACKGROUND The accuracy in diagnostic testing for Lyme disease in the early stages of infection is an important factor necessary for delivering proper treatment to patients. METHODS A total of 173 individuals with confirmed Lyme disease or with laboratory testing underway participated in the quantitative survey. RESULTS ELISA was the first test conducted in 51% of the respondents, 28% of whom yielded positive findings of both IgM and IgG antibody classes. The positivity of ELISA test findings was confirmed by Western blot in 100% of results. Negative results of ELISA were consistent with Western blot only in less than half of the patients. More than half of the respondents had not been tested for any bacterial or viral co-infections. The results of serological testing were not consistent with clinical findings in all cases, including those with clinically discernible skin manifestation of erythema migrans. CONCLUSION The comparison of results obtained by ELISA and Western blot revealed significant discrepancies. Simultaneous infections by vectors with several pathogens were detected (Tab. 3, Fig. 2, Ref. 15).
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Del Giudice P, Freychet F, Kopec L, Fenollar F, Eldin C, Velin M, Hubiche T, Raoult D, Mediannikov O. Erythema Migrans Caused by Borrelia spielmanii, France. Emerg Infect Dis 2023; 29:2366-2369. [PMID: 37877610 PMCID: PMC10617338 DOI: 10.3201/eid2911.230149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
We describe a rare case of early Lyme borreliosis in France caused by Borrelia spielmanii, which manifested as a large erythema chronicum migrans rash. The patient completely recovered after a 15-day course of amoxicillin. Absence of pathognomonic signs prevented distinguishing B. spielmanii from other etiologies as cause in this case-patient.
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Ozcan Y, Gunes Takir S, Karagun E, Uyar B. Dermatoscopic Features of Early Erythema Chronicum Migrans. Acta Dermatovenerol Croat 2023; 31:110-112. [PMID: 38006374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Dear Editors, A 37-year-old man from a Lyme disease-endemic area presented with a one-week old rapidly expanding rash on his right calf. He lacked other comorbidities or symptoms such as fever, weakness, lack of appetite, or joint pain, but recalled removing a tick from the same region three weeks earlier. Inspection revealed a round, bluish-red erythematous patch with a central clearing (Figure 1). The patient experienced no discomfort, but the rash was warm and faded easily when palpated. Dermatoscopic inspection revealed collarette-shaped white scales encircling the punctum of the tick bite in the center (Figure 2, left inset). There were three distinct background zones towards the periphery: skin-colored, bluish-red, and bright red. The transitions between the zones were not fully discernable. Red purpuric dots and clods were randomly distributed over these backgrounds, gradually increasing towards the periphery (Figure 2). The rash was diagnosed as erythema chronicum migrans (ECM), and the patient was started on doxycycline 100 mg BID. The expansion of the rash was stopped, while the speed of central clearing was increased. Half of the rash had healed by the third day (Figure 1, left inset), and it had completely disappeared by the seventh (Figure 1, right inset). Anti-Borrelia burgdorferi antibodies were initially negative for IgM and positive for IgG, but both tested positive two weeks later. ECM is the hallmark of early-stage lyme disease, but it is not always present. In addition to the classically described bull's eye appearance, ECM may appear as homogenous erythematous patches, interrupted annular patches, or patches with hemorrhagic or purpuric components (1). It can manifest anywhere except in the palmoplantar region, but it is more common around large joints. Despite the morphological variations of ECM, the clinical presentation is often clear and distinct enough for dermatologists to correctly diagnose more than 90% of patients (1). Diagnostic procedures such as ELISA or Western blot are employed in cases when the ECM is absent or atypical. However, their reliability is low due to the lack of standardization, limited coverage of Borrelia spp., and significant false-positive and false-negative rates (1). Seropositivity owing to previous asymptomatic infection in individuals residing in endemic areas may result in incidental positive findings. Alternative methods, including isolating the pathogen or PCR testing from biopsy samples have similar drawbacks (1). Histopathological investigations are another practical method that yields supportive findings. ECM exhibits diffuse perivascular and interstitial inflammation, including lymphocytes, eosinophils, and plasma cells (2), which corresponds to background erythema in dermatoscopy. As the inflammation develops, the newly-developed regions are superficial and brilliant red, but the surface inflammation fades over time, leaving bluish erythema, which correlates to deeper inflammation (2,3) dermoscopy is gaining appreciation in assisting the diagnosis of nonneoplastic diseases, especially inflammatory dermatoses (inflammoscopy). Extravasated erythrocytes combined with perivascular inflammation (2) generate purpuric pinkish-red dots and clods. Given the greater efficacy of early treatment and the ambiguity surrounding diagnostic methods, clinical findings should be deemed adequate to commence therapy, particularly in endemic regions (1). Dermatoscopic examination of ECM offers a quick and low-cost alternative approach for supporting the diagnosis. However, as emphasized by Errichetti, dermatoscopic examination in non-neoplastic diseases should be regarded as the second step of a "2-step procedure", with differential diagnoses established first by history and clinical examination (3). A systematic investigation of early and late, typical and atypical lesions would improve the reliability and utility of this method.
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Affiliation(s)
- Yunus Ozcan
- Yunus Ozcan, Duzce Ataturk State Hospital, Duzce, Turkey;
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Thompson AD, Balamuth F, Neville DN, Chapman LL, Levas MN, Kharbanda AB, Branda JA, Ladell MM, Loiselle C, Nigrovic LE. Sensitivity of Two-Tiered Lyme Disease Serology in Children With an Erythema Migrans Lesion. J Pediatric Infect Dis Soc 2023; 12:553-555. [PMID: 37756491 DOI: 10.1093/jpids/piad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
In our prospective cohort of 192 children with a physician-diagnosed erythema migrans (EM) lesion, two-tier Lyme disease serology had higher sensitivity in children with multiple EM lesions (76.8% multiple lesions vs. 38.1% single EM; difference 38.7%, 95% confidence interval 24.8%-50.4%). The diagnosis of cutaneous Lyme disease should be based on careful physical examination rather than laboratory testing.
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Affiliation(s)
- Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware, USA
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Desiree N Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura L Chapman
- Division of Pediatric Emergency Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meagan M Ladell
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claire Loiselle
- Department of Research, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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7
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Bonnet C, Figoni J, Souty C, Septfons A, de Martino S, de Valk H, Fournier L, Hanslik T, Jaulhac B, Blanchon T. Prevalence and factors associated with a prescription of a Lyme borreliosis serology for erythema migrans diagnosis in general practice: a study from the French sentinel network, 2009-2020. BMC Prim Care 2023; 24:163. [PMID: 37620763 PMCID: PMC10464237 DOI: 10.1186/s12875-023-02108-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/18/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Serological testing of patients consulting for typical erythema migrans (EM) is not recommended in European recommendations for diagnosis of Lyme borreliosis (LB). Little is known on the level of adherence of French general practitioners to these recommendations. The objectives were to estimate the proportion of Lyme borreliosis serological test prescription in patients with erythema migrans seen in general practice consultations in France, and to study the factors associated with this prescription. METHODS LB cases with an EM reported by the French general practitioners (GPs) of the Sentinelles network between January 2009 and December 2020 were included. To assess the associations with a prescription of a serological test, multilevel logistic regression models were used. RESULTS Among the 1,831 EM cases included, a prescription for a LB serological test was requested in 24.0% of cases. This proportion decreased significantly over the study period, from 46.8% in 2009 to 15.8% in 2020. A LB serological prescription was associated with patients with no reported tick bite (Odds Ratio (OR): 1.95; 95% confidence interval [1.23-3.09]), multiple EM (OR: 3.82 [1.63-8.92]), EM of five centimeters or more (OR: 4.34 [2.33-8.08]), and GPs having diagnosed less than one EM case per year during the study period (OR: 5.28 [1.73-16.11]). CONCLUSIONS Serological testing of patients consulting for EM is not recommended in European recommendations for diagnosis of Lyme borreliosis. Therefore, the significant decrease in the rate of LB serological test for EM over the study period is encouraging. The factors identified in this study can be used to improve messaging to GPs and patients. Further efforts are needed to continue to disseminate diagnostic recommendations for LB to GPs, especially those who rarely see patients with EM.
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Affiliation(s)
- Camille Bonnet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France.
| | - Julie Figoni
- Santé publique France, Saint-Maurice, F94410, France
| | - Cécile Souty
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
| | | | - Sylvie de Martino
- CNR des Borrelia et Institut de Bactériologie, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, CHRU Strasbourg, UR7290, ITI InnoVec, Strasbourg, 67000, France
| | | | - Lucie Fournier
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
| | - Thomas Hanslik
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
- Service de Médecine Interne, APHP, Hôpital Ambroise Paré, Assistance Publique - Hôpitaux de Paris, Boulogne-Billancourt, France
- Université Versailles Saint-Quentin-en-Yvelines, UVSQ, UFR de Médecine Simone Veil, Versailles, France
| | - Benoît Jaulhac
- CNR des Borrelia et Institut de Bactériologie, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, CHRU Strasbourg, UR7290, ITI InnoVec, Strasbourg, 67000, France
| | - Thierry Blanchon
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Paris, F75012, France
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Rebman AW, Yang T, Yoon I, Powell D, Geller SA, Aucott JN. Initial Presentation and Time to Treatment in Early Lyme Disease. Am J Trop Med Hyg 2023; 108:734-737. [PMID: 36746657 PMCID: PMC10077021 DOI: 10.4269/ajtmh.22-0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/01/2022] [Indexed: 02/08/2023] Open
Abstract
The erythema migrans (EM) rash is an important initial diagnostic sign of early Lyme disease. We tested the hypothesis that patients who noticed EM first differed from those who noticed viral-like symptoms first. "EM First" participants (167/271, 61.6%) had shorter illness duration before treatment (5.0 versus 6.2 days, P = 0.019), were more likely to have seen or removed a tick (P = 0.048) and to be non-Hispanic White (P = 0.025), and were less likely to present with disseminated lesions at the time of diagnosis (P = 0.003) than "Symptoms First" participants (104/271, 38.4%). In multivariate analyses, EM First participants had a 22% decrease in time to treatment (P = 0.012) compared with Symptoms First participants, suggesting that initial presentation affects time to treatment. In a large minority of patients, EM may not be the initial sign or symptom of early Lyme disease. There is a need for rapid diagnostics and improved physician awareness of the varied manifestations of early Lyme disease.
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Affiliation(s)
- Alison W. Rebman
- Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ting Yang
- Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Debra Powell
- Tower Health Reading Hospital, West Reading, Pennsylvania
| | | | - John N. Aucott
- Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Stupica D, Collinet-Adler S, Blagus R, Gomišček A, Cerar Kišek T, Ružić-Sabljić E, Velušček M. Treatment of erythema migrans with doxycycline for 7 days versus 14 days in Slovenia: a randomised open-label non-inferiority trial. Lancet Infect Dis 2023; 23:371-379. [PMID: 36209759 DOI: 10.1016/s1473-3099(22)00528-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lyme borreliosis is the most prevalent vector-borne disease in Europe and the USA. Doxycycline for 10 days is the primary treatment recommendation for erythema migrans. To reduce potentially harmful antibiotic overuse by identifying shorter effective treatments, we aimed to assess whether oral doxycycline for 7 days is non-inferior to 14 days in adults with solitary erythema migrans. METHODS In this randomised open-label non-inferiority trial, we enrolled patients with a solitary erythema at the University Medical Centre in Ljubljana, Slovenia. Patients were excluded if they were pregnant or lactating, immunosuppressed, allergic to doxycycline, or had received antibiotics with anti-borrelial activity within 10 days preceding enrolment or had additional manifestations of Lyme borreliosis Adults were randomly allocated 1:1 to receive oral doxycycline 100 mg twice a day for 7 days or 14 days. The primary efficacy endpoint was the difference in proportion of patients with treatment failure, defined as persistent erythema, new objective signs of Lyme borreliosis, or borrelial isolation on skin re-biopsy at 2 months, in a per-protocol analysis (the population that completed the assigned doxycycline regimen according to the study protocol and did not receive any other antibiotics with anti-borrelial activity until the 2-month visit). The non-inferiority margin was 6 percentage points. Safety was assessed in all randomly assigned patients who followed the study protocol and were evaluable at the 14-day visit. This study is registered with ClinicalTrials.gov, NCT03153267. FINDINGS Between July 3, 2017, and Oct 2, 2018, we enrolled 300 patients (150 per group: median age 56 years [IQR 47-65]; 126 [45%] of 300 male; skin culture positive 72 [30%] of 239 assessed). 295 patients completed antibiotic therapy as per protocol and 294 (98%) patients were evaluable 2 months post-enrolment. Five (3%) of 147 patients from the 7-day group versus 3 (2%) of 147 patients from the 14-day group (one patient did not attend the 2-month visit and was unreachable by telephone) had treatment failure manifesting as persistence of erythema (difference 1·4 percentage points; upper limit of one-sided 95% CI 5·2 percentage points; p=0·64). No patients developed new objective manifestations of Lyme borreliosis during follow-up or had positive repeat skin biopsies. Two (1%) of 150 patients in the 7-day and one (1%) of 150 patients in the 14-day group discontinued therapy due to adverse events. INTERPRETATION Our data support 7 days of oral doxycycline for adult European patients with solitary erythema migrans, permitting less antibiotic exposure than current guideline-driven therapy. FUNDING Slovenian Research Agency and the University Medical Centre Ljubljana.
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Affiliation(s)
- Daša Stupica
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Slovenia and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Stefan Collinet-Adler
- Department of Infectious Diseases, Park Nicollet/Health Partners, Methodist Hospital, Saint Louis Park, MN, USA
| | - Rok Blagus
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Faculty of Sports, University of Ljubljana, Ljubljana, Slovenia; Slovenia and Faculty of Mathematics, Natural Sciences and Information Technologies, University of Primorska, Koper, Slovenia
| | | | - Tjaša Cerar Kišek
- National Laboratory of Health, Environment and Food, Maribor, Slovenia
| | - Eva Ružić-Sabljić
- Institute for Microbiology and Immunology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maša Velušček
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
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10
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Abstract
Annular configuration is conspicuous in the clinical manifestation of many skin diseases and can be helpful for the diagnosis and differential diagnosis. Variations may include arciform, ring-form, annular, circinate, serpiginous, gyrated, polycyclic, targeted or figurate forms, in different colors, sizes, and numbers, with various textures and surfaces. In infectious dermatoses, the annular reactions can be specific or nonspecific, while the underlying mechanisms remain largely unknown. In the specific reactions caused by direct invasion of the pathogens, the contest between the centrifugal outspread of the infectious agents and the centripetal impedance of the host immune response is supposed to determine the final conformation. Examples include erythema infectiosum, orf, erythema multiforme, and pityriasis rosea of viral origin. Bacterial infections that may display annular lesions include erythrasma, erythema (chronicum) migrans of Lyme borreliosis, secondary syphilis, cutaneous tuberculosis, and leprosy. Superficial mycosis, such as dermatophytosis, candida intertrigo, tinea imbricata, and subcutaneous mycosis, such as chromoblastomycosis, and algae infection protothecosis, are characterized by annular progression of the skin lesions. The creeping serpiginous extension is an alarming sign for the diagnosis of cutaneous larva migrans. A better understanding of the virulence and pathogenicity of the pathogens and the way and type of immune response will help to clarify the pathogenesis.
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Affiliation(s)
- Wei-Ting Liu
- Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Lun Sun
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kusmarinah Bramono
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Mohammad Ezmerli
- Department of Dermatology, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Chao-Chun Yang
- Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; International Center for Wound Repair and Regeneration, National Cheng Kung University, Tainan, Taiwan.
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technische Universität München, Munich, Germany.
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11
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Brem CE, Goldberg LJ. Early Erythema Migrans: Do Not Count on Plasma Cells. Am J Dermatopathol 2022; 44:e23-e25. [PMID: 35076434 DOI: 10.1097/dad.0000000000002058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Three hundred thousand new cases of Lyme disease are diagnosed annually in the United States. The earliest manifestation of the disease, erythema migrans, occurs earlier than serologic conversion, and skin biopsies can be very helpful in suggesting the diagnosis. Histopathologic findings vary depending on where in the lesion the specimen is taken, but typically consist of a superficial and deep perivascular and interstitial lymphocytic infiltrate with eosinophils centrally and with histiocytes and plasma cells at the periphery. Rare cases with interstitial histiocytes and rare-to-sparse plasma cells exist. We present a 67-year-old man whose skin biopsy, taken on day 2 of his eruption, demonstrated a subtle perivascular and interstitial infiltrate of histiocytes without plasma cells. Dermatopathologists need to be aware of this pattern and consider the diagnosis of erythema migrans, despite negative initial serologic testing.
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Affiliation(s)
- Candice E Brem
- Section of Dermatopathology, Department of Dermatology, Boston University School of Medicine, Boston, MA
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12
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Branda JA, Lemieux JE, Blair L, Ahmed AA, Hong DK, Bercovici S, Blauwkamp TA, Hollemon D, Ho C, Strle K, Damle NS, Lepore TJ, Pollock NR. Detection of Borrelia burgdorferi Cell-free DNA in Human Plasma Samples for Improved Diagnosis of Early Lyme Borreliosis. Clin Infect Dis 2021; 73:e2355-e2361. [PMID: 32584965 PMCID: PMC8492203 DOI: 10.1093/cid/ciaa858] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/22/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Laboratory confirmation of early Lyme borreliosis (LB) is challenging. Serology is insensitive during the first days to weeks of infection, and blood polymerase chain reaction (PCR) offers similarly poor performance. Here, we demonstrate that detection of Borrelia burgdorferi (B.b.) cell-free DNA (cfDNA) in plasma can improve diagnosis of early LB. METHODS B.b. detection in plasma samples using unbiased metagenomic cfDNA sequencing performed by a commercial laboratory (Karius Inc) was compared with serology and blood PCR in 40 patients with physician-diagnosed erythema migrans (EM), 28 of whom were confirmed to have LB by skin biopsy culture (n = 18), seroconversion (n = 2), or both (n = 8). B.b. sequence analysis was performed using investigational detection thresholds, different from Karius' clinical test. RESULTS B.b. cfDNA was detected in 18 of 28 patients (64%) with laboratory-confirmed EM. In comparison, sensitivity of acute-phase serology using modified 2-tiered testing (MTTT) was 50% (P = .45); sensitivity of blood PCR was 7% (P = .0002). Combining B.b. cfDNA detection and MTTT increased diagnostic sensitivity to 86%, significantly higher than either approach alone (P ≤ .04). B.b. cfDNA sequences matched precisely with strain-specific sequence generated from the same individual's cultured B.b. isolate. B.b. cfDNA was not observed at any level in plasma from 684 asymptomatic ambulatory individuals. Among 3000 hospitalized patients tested as part of clinical care, B.b. cfDNA was detected in only 2 individuals, both of whom had clinical presentations consistent with LB. CONCLUSIONS This is the first report of B.b. cfDNA detection in early LB and a demonstration of potential diagnostic utility. The combination of B.b. cfDNA detection and acute-phase MTTT improves clinical sensitivity for diagnosis of early LB.
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Affiliation(s)
- John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob E Lemieux
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lily Blair
- Karius Inc, Redwood City, California, USA
| | | | | | | | | | | | - Carine Ho
- Karius Inc, Redwood City, California, USA
| | - Klemen Strle
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nitin S Damle
- South County Internal Medicine Inc, Wakefield, Rhode Island, USA
| | | | - Nira R Pollock
- Department of Laboratory Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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13
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Nilsson K, Skoog E, Jones V, Labbé Sandelin L, Björling C, Fridenström E, Edvinsson M, Mårtensson A, Olsen B. A comprehensive clinical and laboratory evaluation of 224 patients with persistent symptoms attributed to presumed tick-bite exposure. PLoS One 2021; 16:e0247384. [PMID: 33735220 PMCID: PMC7971513 DOI: 10.1371/journal.pone.0247384] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/05/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Persistent symptoms attributed to presumed tick-bite exposure constitute an unresolved medical controversy. We evaluated whether Swedish adults who met the criteria for post-treatment Lyme disease syndrome (PTLDS) exhibited characteristics distinguishable from adults who did not, but who displayed similar symptoms and disease course after suspected previous tick-bite infection (TBI). METHODS AND FINDINGS During 2015-2018, 255 patients-referred to the Centre for Vector-borne Infections, Uppsala University Hospital, Sweden with symptoms lasting longer than six months-were recruited. Of this group, 224 completed the study. Each patient was examined by an infectious disease specialist and, besides a full medical history, underwent a panel of blood and cerebrospinal fluid laboratory tests including hematological, biochemical, microbiological and immunological analyses, and the RAND-36 scale to measure quality of life. For analysis purposes, patients were divided into five subgroups, of which one represented PTLDS. According to serological results indicating TBI and documented/ reported objective signs of Lyme disease, 85 (38%) patients fulfilled the criteria for PTLDS and were compared with the other 139 (62%) serologically classified patients. In the PTLDS group, erythema chronicum migrans (ECM) was documented/reported in 86% of patients, previous neuroborreliosis in 15%, and acrodermatitis chronica atroficans (ACA) in 3.5%. However, there were no significant differences regarding symptoms, laboratory results or disease course between patients with PTLDS and those without laboratory evidence of Borrelia exposition. Most reported symptoms were fatigue-related (70%), musculoskeletal (79%), neurological (82%) and neurocognitive (57%). Tick bites were recalled by 74%. The RAND-36 score was significantly below that of the general Swedish population. Signs of immunological/inflammatory reactivity with myositis antibodies were detected in 20% of patients, fibrinogen levels were moderately increased in 21% and elevated rheumatoid factor in 6%. CONCLUSIONS The PTLDS group did not differ exclusively in any respect from the other subgroups, which either lacked previously documented/reported evidence of borreliosis or even lacked detectable serological signs of exposure to Lyme disease. The results suggest that symptoms often categorized as Chronic-Lyme-Disease (CLD) in the general debate, cannot be uniquely linked to Lyme disease. However, approximately 20% of the total group of patients showed signs of autoimmunity. Further studies are needed to elucidate the underlying causes and mechanisms of PTLDS and there is reason to consider a multifactorial approach.
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Affiliation(s)
- Kenneth Nilsson
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Section of Clinical Microbiology, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Zoonosis Science Centre, Uppsala University, Uppsala, Sweden
| | - Elisabet Skoog
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Viktor Jones
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Lisa Labbé Sandelin
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
- Department of Communicable Diseases and Disease Control, Kalmar County Hospital, Kalmar, Sweden
| | - Christina Björling
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Ester Fridenström
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Marie Edvinsson
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Andreas Mårtensson
- Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Björn Olsen
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Zoonosis Science Centre, Uppsala University, Uppsala, Sweden
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14
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Szep Z, Majtan J. Annular erythema as a cutaneous sign of recurrent ductal breast carcinoma, misdiagnosed as erythema chronicum migrans. Dermatol Online J 2020; 26:13030/qt4bq4t7tm. [PMID: 33054939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 06/11/2023] Open
Abstract
Annular erythema as a clinical manifestation of locoregional recurrence of breast cancer is extremely rare. Only three papers with the description of five cases have been published in the current literature to our knowledge. Herein, we describe two additional cases of annular erythema as a cutaneous sign of recurrent ductal breast carcinoma; both were misdiagnosed as erythema chronicum migrans.
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Affiliation(s)
| | - Juraj Majtan
- Institute of Molecular Biology, Slovak Academy of Sciences, Bratislava.
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15
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Voitey M, Bouiller K, Chirouze C, Fournier D, Bozon F, Klopfenstein T. Functional signs in patients consulting for presumed Lyme borreliosis. Med Mal Infect 2019; 50:423-427. [PMID: 31722861 DOI: 10.1016/j.medmal.2019.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/24/2018] [Accepted: 10/16/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Little is known about the functional symptoms associated with Lyme borreliosis (LB) in Europe. We aimed to assess functional symptoms associated with presumed LB and to compare patients with and without confirmed LB. MATERIALS AND METHODS We performed a retrospective monocenter study. Patients consulting for presumed LB were included. RESULTS Between November 2015 and June 2018, 355patients were included (mean age: 51years, 52% of women) of which 48had LB: erythema migrans (42%), early disseminated LB (50%; 35% of neuroborreliosis cases), and late disseminated LB (8%). The most frequently reported functional symptoms were neuropathic pain (23%), arthralgia (23%), and asthenia (17%). Other functional symptoms were rare (≤10%). Three hundred and seven (86%) patients did not have LB. Patients with confirmed LB reported fewer functional symptoms than patients without LB (1.8 (±1.7) vs. 3.6 (±2.5), P<0.001) with a shorter duration of symptoms (< 3 months in 48% vs. 16% of cases, P<0.001). They less often reported asthenia (17% vs. 59%, P<0.001), widespread pain (10% vs. 31%, P=0.003), myalgia (10% vs. 32%, P=0.002), memory disorders (4% vs. 16%, P=0.03), irritability (2% vs. 23%, P±0.001), and sadness (0% vs. 16%, P=0.003). CONCLUSION In patients consulting for presumed LB, patients diagnosed with LB had fewer and shorter functional symptoms than patients without LB.
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Affiliation(s)
- M Voitey
- Service de maladies infectieuses et tropicales, CHRU Besançon, 25000 Besançon, France
| | - K Bouiller
- Service de maladies infectieuses et tropicales, CHRU Besançon, 25000 Besançon, France; UMR CNRS 6249 chrono-environnement, université de Bourgogne Franche-Comté, 25000 Besançon, France.
| | - C Chirouze
- Service de maladies infectieuses et tropicales, CHRU Besançon, 25000 Besançon, France; UMR CNRS 6249 chrono-environnement, université de Bourgogne Franche-Comté, 25000 Besançon, France
| | - D Fournier
- Laboratoire de bactériologie, CHRU Besançon, 25000 Besançon, France
| | - F Bozon
- Service de maladies infectieuses et tropicales, CHRU Besançon, 25000 Besançon, France
| | - T Klopfenstein
- Service de maladies infectieuses et tropicales, CHRU Besançon, 25000 Besançon, France
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16
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Stażyk K, Czepiel J, Gumulska M, Garlicki A, Biesiada G. Analysis of cases of Lyme arthritis in patients hospitalized in Infectious Diseases Department, University Hospital in Cracow. Folia Med Cracov 2019; 59:5-14. [PMID: 31180072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Lyme disease is an emerging problem in Poland. Analysis has been undertaken of the medical documentation of 86 patients hospitalized in the Infectious Diseases Department, University Hospital in Cracow in 2013-2016, suspected of Lyme arthritis. It has especially considered medical history including potential exposure to the infection, detailed characteristics of the symptoms, diagnostic challenges and results of the treatment. Only some patients had a history of erythema migrans and not all of them recalled tick-bite. The majority of the patients had affected large joints, especially knee joints, and polyarthritis was rarely observed. Symptoms were resolved completely or partially after antibiotic treatment in most patients. The diagnosis of Lyme arthritis in areas endemic for Lyme disease is still a diagnostic challenge in patients with other rheumatic diseases, including osteoarthritis.
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Affiliation(s)
- Katarzyna Stażyk
- Department of Infectious and Tropical Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Jacek Czepiel
- Department of Infectious and Tropical Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Martyna Gumulska
- Students' Scientific Society, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksander Garlicki
- Department of Infectious and Tropical Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Grażyna Biesiada
- Department of Infectious and Tropical Diseases, Jagiellonian University Medical College, Kraków, Poland.
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17
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Shah AS, Varatharaj Palraj BR. Multiple Erythema Migrans Rashes Characteristic of Early Disseminated Lyme Disease, Before and After Therapy. Mayo Clin Proc 2019; 94:172-173. [PMID: 30611447 DOI: 10.1016/j.mayocp.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Aditya S Shah
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
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18
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Affiliation(s)
- Eugene D Shapiro
- Department of Pediatrics, Yale University, New Haven, Connecticut
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, Connecticut
| | - Gary P Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla
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19
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Affiliation(s)
- Sze Ting Ivy Ngu
- Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David Bilsland
- Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, UK
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20
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Ocias LF, Jensen BB, Knudtzen FC, Skarphedinsson S, Dessau RB. [Clinical manifestations, diagnosis and treatment of Lyme borreliosis]. Ugeskr Laeger 2017; 179:V01170026. [PMID: 28473022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Lyme borreliosis is an infection caused by the Borrelia burgdorferi sensu lato complex and transmitted by Ixodes ricinus ticks in Denmark. It can manifest itself in several different forms of which erythema migrans is the most common and is diagnosed by clinical assessment of the characteristic erythema. Laboratory support for the clinical diagnosis of other manifestations rests on the measurement of Borrelia-specific antibodies. Treatment is straight-forward with antibiotics such as penicillin. This paper reviews the clinical manifestations, diagnosis and treatment of this infection.
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21
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Cerar T, Strle F, Stupica D, Ruzic-Sabljic E, McHugh G, Steere AC, Strle K. Differences in Genotype, Clinical Features, and Inflammatory Potential of Borrelia burgdorferi sensu stricto Strains from Europe and the United States. Emerg Infect Dis 2016; 22:818-27. [PMID: 27088349 PMCID: PMC4861522 DOI: 10.3201/eid2205.151806] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Strains from the United States are more virulent and have greater inflammatory potential. Borrelia burgdorferi sensu stricto isolates from patients with erythema migrans in Europe and the United States were compared by genotype, clinical features of infection, and inflammatory potential. Analysis of outer surface protein C and multilocus sequence typing showed that strains from these 2 regions represent distinct genotypes. Clinical features of infection with B. burgdorferi in Slovenia were similar to infection with B. afzelii or B. garinii, the other 2 Borrelia spp. that cause disease in Europe, whereas B. burgdorferi strains from the United States were associated with more severe disease. Moreover, B. burgdorferi strains from the United States induced peripheral blood mononuclear cells to secrete higher levels of cytokines and chemokines associated with innate and Th1-adaptive immune responses, whereas strains from Europe induced greater Th17-associated responses. Thus, strains of the same B. burgdorferi species from Europe and the United States represent distinct clonal lineages that vary in virulence and inflammatory potential.
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22
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von Ameln-Mayerhofer A. [In process]. Med Monatsschr Pharm 2016; 39:313-314. [PMID: 29953186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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23
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Stiefelhagen P. [A non-itching lesion on the stomach]. MMW Fortschr Med 2015; 157:5-96. [PMID: 26960834 DOI: 10.1007/s15006-015-7573-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Peter Stiefelhagen
- DRK-Krankenhaus, Alte Frankfurter Str. 12, D-57627, Hachenburg, Deutschland
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24
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Lyme disease. Recognising and treating erythema migrans. Prescrire Int 2015; 24:247-9. [PMID: 26594731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Lyme disease is a tick-borne bacterial infection caused by Borrelia spirochetes. The first stage of infection involves a characteristic skin lesion, erythema migrans. Erythema migrans is a ring-shaped skin lesion, centred on the bite, which expands outwards. It usually appears within two weeks after a bite from an infected tick. If left untreated, the infection sometimes extends or progresses over a period of months or years, leading to potentially severe neurological, articular, cutaneous and cardiac complications. How is erythema migrans associated with Lyme disease recognised and managed? We conducted a systematic review of the literature using the standard Prescrire methodology. This review does not address the complications of Lyme disease. Diagnosis of erythema migrans is based on clinical findings in a patient with a possible or confirmed recent tick bite. Serological tests are not useful at this stage of the infection. Antibiotics shown to be active in vitro also proved effective in non-comparative trials. In randomised trials, amoxicillin, doxycycline, cefuroxime and ceftriaxone had similar efficacy, clearing signs and symptoms in about 90% of patients, with a relapse rate of less than 5% at 6 months. Azithromycin, clarithromycin, erythromycin, three macrolide antibiotics, appear to have lower efficacy. Doxycycline should not be used to treat pregnant or breast-feeding women, or children under 8 years old, due to a risk of tooth and bone disorders in children. In practice, a diagnosis of erythema migrans should be borne in mind when a patient presents with recent history of a possible or confirmed tick bite and skin lesions suggestive of erythema migrans. Oral amoxicillin or doxycycline will prevent progression of the infection to the potentially severe, later stages of Lyme disease. Routine antibiotic prophylaxis is not justified after a tick bite, even in an endemic area, as the risk of infection is low. It is best to monitor the skin around the bite and to prescribe an antibiotic only if erythema migrans develops, thus avoiding unnecessary treatment and adverse effects.
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25
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Akın Belli A, Derviş E, Özbaş Gök S, Midilli K, Gargılı A. [Evaluation of 10 cases of Lyme disease presenting with erythema migrans in Istanbul, Turkey]. MIKROBIYOL BUL 2015; 49:525-531. [PMID: 26649410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Lyme disease (LD) is a tick-borne, multisystemic infection caused by Borrelia burgdorferi. Although variable rates of seropositivity for B.burgdorferi have been reported between 2% to 44% in Turkey, its actual prevalence is not well-understood. The aim of this retrospective study was to evaluate the characteristics of 10 cases of LD presenting as erythema migrans (EM) between 2009 and 2013 from Istanbul which is one of the metropolitan cities of Turkey. Of the patients, five were male and five were female, ages between 9-51 years (mean age: 34.5 years). Five of the patients were admitted in June, three in October, one in November and two in December and all have the history of tick bite in last 1-2 weeks. There were no clinical symptoms for systemic infection among the patients with normal level routine laboratory test (whole blood count and biochemical tests) results. Five of the cases had EM lesions in the trunk, three in the upper extremities, and two in the lower extremities. Four patients presented with annular, three with solitary macular, and three with target-like EM lesions. In all cases, the biopsy specimens were positive for B.burgdorferi sensu lato DNA with polymerase chain reaction and all were also positive in terms of B.burgdorferi IgM antibodies with ELISA. Nine patients were treated with oral doxycycline, 100 mg twice daily and one child patient was treated with oral amoxicillin 500 mg twice daily for 21 days. EM lesions disappeared within 2-4 weeks in all patients. There was no clinical evidence for systemic involvement in any of the patients like neurologic, cardiac, and joint involvement at the follow-ups on the third, sixth and 12(th) months. To our best knowledge, 10 patients in this study are the largest EM series reported from Turkey. The increase in the number of LD cases may be associated with increased tick bite and increased awareness due to the emergence of concurrent Crimean-Congo hemorrhagic fever epidemic in Turkey. As a result, when enlarged erythematous lesions on the skin were observed, LH must also be considered in differential diagnosis, history of tick bite should be questioned and etiological diagnostic test should be performed.
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Affiliation(s)
- Aslı Akın Belli
- Mugla Sitki Kocman University Training and Research Hospital, Dermatology Clinic, Mugla, Turkey.
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26
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Mazori DR, Orme CM, Mir A, Meehan SA, Neimann AL. Vesicular erythema migrans: an atypical and easily misdiagnosed form of Lyme disease. Dermatol Online J 2015; 21:13030/qt9cs1x7r5. [PMID: 26437159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/14/2015] [Indexed: 06/05/2023] Open
Abstract
Erythema migrans is the initial sign in the majority of patients infected with Borrelia, the genus of spirochetes that causes Lyme disease. Early identification and treatment decrease the risk of progression to later stages of disease. Although a "bull's eye" appearance owing to lesional clearing is considered classic for erythema migrans, this feature is surprisingly often lacking among patients in the United States. Furthermore, cutaneous Lyme disease can exhibit a wide range of morphologic variability in a minority of patients. Herein, we describe the case of a patient with Lyme disease in which the presence of atypical vesicular features, in conjunction with the initial absence of clearing, resulted in multiple misdiagnoses and delayed treatment. We also review the literature on the epidemiology and management of erythema migrans for cases in which the diagnosis may pose a challenge.
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Affiliation(s)
- Daniel R Mazori
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine.
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27
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Petersen BB, Møller JK, Vilholm OJ. Season is an unreliable predictor of Lyme neuroborreliosis. Dan Med J 2015; 62:A5084. [PMID: 26036883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Lyme neuroborreliosis (LNB) is a tick-borne infection of the nervous system caused by the spirochete Borrelia burgdorferi sensu lato. The primary symptoms are usually painful radiculitis, facial palsy and lymphocytic meningitis. The aim of this study was to provide data on the seasonal variation, anamnesis, symptoms, laboratory data and course of the disease in adults (≥ 16 years). METHODS The medical records of 69 patients with confirmed LNB who attended the Department of Neurology, Lillebaelt Hospital, Vejle, Denmark, were analysed. The diagnosis was confirmed by the presence of leucocytosis in the cerebrospinal fluid and intrathecal production of immunoglobulin M and/or G anti-B. burgdorferi antibodies. RESULTS Onset of neurological symptoms in LNB occurred year round in the Region of Southern Denmark. Only half of the patients had a history of a tick bite or erythema migrans (EM). Half of the patients who observed a tick bite subsequently reported EM. The duration from the onset of neurological symptoms to referral to hospital was remarkably long for patients with radiculoneuritis, whereas the onset of facial palsy led to a swift referral. Patients who were ≥ 50 years old had a significantly lower age-related risk of facial palsy without radicular symptoms. CONCLUSION In this study, winter as a low-risk season was not a reliable factor in ruling out LNB. This finding may be relevant when investigating the cause of facial palsy and radicular symptoms.
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Affiliation(s)
- Bo Bødker Petersen
- Neurologisk Afdeling, Vejle Sygehus, Kabbeltoft 25, 7100 Vejle, Denmark.
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28
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Landolt L, Kovari H. [CME. Larva migrans]. Praxis (Bern 1994) 2014; 103:1491-1498. [PMID: 25491049 DOI: 10.1024/1661-8157/a001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Lea Landolt
- Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich, Universität Zürich
| | - Helen Kovari
- Klinik für Infektionskrankheiten und Spitalhygiene, Universitätsspital Zürich, Universität Zürich
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Abstract
A 32-year-old pregnant woman from southeastern Connecticut presents to her physician in July at 26 weeks’ gestation because of a skin lesion. She reports she has had fatigue, arthralgia, and headache for 2 days and a rash in her left axilla for 1 day. She lives in a wooded area and works in her garden frequently. Six weeks earlier, she had removed a small tick that was attached behind her right knee. On physical examination, she is afebrile. She has an erythematous, oval macular lesion, 7 to 8 cm in diameter, in her left axilla, with enhanced central erythema; no other abnormalities are noted. How should her case be managed?
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30
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Abstract
A 32-year-old pregnant woman from southeastern Connecticut presents to her physician in July at 26 weeks' gestation because of a skin lesion. She reports she has had fatigue, arthralgia, and headache for 2 days and a rash in her left axilla for 1 day. She lives in a wooded area and works in her garden frequently. Six weeks earlier, she had removed a small tick that was attached behind her right knee. On physical examination, she is afebrile. She has an erythematous, oval macular lesion, 7 to 8 cm in diameter, in her left axilla, with enhanced central erythema; no other abnormalities are noted. How should her case be managed?
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Knoll JM, Ridgeway AC, Boogaerts CM, Burket GA. Appalachian Trail hikers' ability to recognize Lyme disease by visual stimulus photographs. Wilderness Environ Med 2014; 25:24-8. [PMID: 24433777 DOI: 10.1016/j.wem.2013.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 08/21/2013] [Accepted: 09/13/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lyme disease is the most common vector-borne infectious disease in North America. With nearly 2,500 Appalachian Trail (AT) hikers entering the endemic area for as long as 6 months, exposure to the disease is likely. The characteristic exanthem of erythema migrans (EM) should be a trigger for seeking medical treatment, and its recognition in this relatively isolated environment is important. OBJECTIVE The purpose of this study was to determine the ability of AT hikers to identify EM, the exanthem of Lyme disease. METHODS Hikers were administered a photographic stimulus in this Internal Review Board-approved pilot study. Historical hiking data, basic demographics, and self-reported treatment and diagnosis were collected. RESULTS In all, 379 responses were collected by 4 researchers at 3 geographically separate locations at or proximate to the AT from June 2011 to May 2012. Fifty-four percent of respondents (206 of 379) were able to recognize the photographs of EM/Lyme disease; 46% could not. Of those who did recognize EM, 23 (6%) had seen it either on themselves or on another hiker while on the AT. A total of 37 hikers stated that they had been diagnosed with Lyme disease while hiking, and of these, 89% were treated with antibiotics. Thirteen of these 37 hikers (35%) diagnosed with Lyme disease had visualized an embedded tick. Nine percent of all respondents reported they had been diagnosed with Lyme disease by a healthcare practitioner, whether from EM, symptomatology, or by titer. CONCLUSIONS This study suggests that hikers are poorly able to recognize the characteristic exanthem of Lyme disease but have a high exposure risk.
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Affiliation(s)
- Judith M Knoll
- Department of Emergency Medicine, Adena Health System, Chillicothe, OH (Dr Knoll).
| | - Andrea C Ridgeway
- Department of Emergency Medicine, York Memorial Hospital, York, PA (Drs Ridgeway and Boogaerts)
| | - Christine M Boogaerts
- Department of Emergency Medicine, York Memorial Hospital, York, PA (Drs Ridgeway and Boogaerts)
| | - Glenn A Burket
- Lake Erie College of Osteopathic Medicine, Erie, PA (Mr Burket)
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Abstract
Case definitions for European Lyme disease have been published. However, multiple erythema migrans may pose a diagnostic challenge. Therefore, we retrospectively reviewed the clinical and serological findings and response to therapy in a cohort of consecutive 54 patients with PCR-confirmed erythema migrans, referred to a university dermatology clinic. The proportion of patients with multiple erythema migrans lesions (usually 2 or 3) was almost equal (46%) to the proportion of patients with single erythema migrans lesions (54%). All patients, except for 2 multiple erythema migrans patients with a concomitant autoimmune disease, completely responded to treatment. In conclusion, multiple erythema migrans may be more common than anticipated, and since only 50% of the patients were seropositive when seeking medi-cal help, PCR testing of skin lesions is helpful to confirm the diagnosis in clinically atypical cases.
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Affiliation(s)
- Pernilla Eriksson
- Department of Dermatology and Allergology, Helsinki University Central Hospital, FIN-00029 HUS, Finland.
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33
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[Lyme borreliosis. A tick bite and its multiple sequelae]. MMW Fortschr Med 2013; 155:17. [PMID: 24006580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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34
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Spring P, Vernez M, Maniu CM, Hohl D. Localized interstitial granuloma annulare induced by subcutaneous injections for desensitization. Dermatol Online J 2013; 19:18572. [PMID: 24011321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 06/15/2013] [Indexed: 06/02/2023] Open
Abstract
We describe a patient with interstitial granuloma annulare associated with subcutaneous injection therapy (SIT) for desensitization to a type I allergy. Asymptomatic, erythematous, violaceous annular patches were located at the injection sites on both her arms. Medical history revealed perennial rhinoconjonctivitis treated with SIT (Phostal Stallergen® cat 100% and D. pteronyssinus/D.farinae 50%:50%).
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Affiliation(s)
- Philipp Spring
- Dermatology Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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35
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Huppertz HI. [Lyme borreliosis in children and adolescents]. Kinderkrankenschwester 2013; 32:108-113. [PMID: 23600115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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36
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Maurin O, de Régloix S, Babouraj N, Bon O, Jost D, Domanski L. [Erythema chronicum migrans]. Rev Prat 2013; 63:178. [PMID: 23513773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Olga Maurin
- Centre médical de Courbevoie, Brigade des sapeurs pompiers de Paris, 92400 Courbevoie, France.
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37
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Schatorjé EJH, van der Steeg H, Stelma F, Hebeda K, Warris A. [Borrelial lymphocytoma]. Ned Tijdschr Geneeskd 2013; 157:A6605. [PMID: 24382037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Borrelial lymphocytoma is a relatively rare but typical presentation of Lyme disease. Predilection sites are the ears in children and chest/nipples in adults. It is treated like an erythema migrans and has a good prognosis. CASE DESCRIPTION A 16-year-old boy presented with a swollen, red and painful right nipple since several months. An ultrasound showed normal breast tissue. The patient was referred to the pediatric surgeon who performed an incision biopsy. Histopathological examination revealed follicular hyperplasia without signs of malignancy. An infectious cause, most likely Lyme disease, was suspected. Serological analysis and PCR of the tissue confirmed the diagnosis of a borrelial lymphocytoma, and the patient was treated with doxycycline with good result. CONCLUSION Early recognition of the characteristic clinical presentation of borrelial lymphocytoma, supported by positive results from serologic testing for Lyme disease, avoids the need for additional and invasive diagnostic tests.
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38
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Atiq N, van Meurs T. [A boy with nail abnormalities]. Ned Tijdschr Geneeskd 2013; 157:A6429. [PMID: 23838405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A 12-year-old boy consulted the dermatologist for nail abnormalities. Three weeks earlier, he was treated with doxycycline 100 mg BID for 10 days because of erythema chronicum migrans. Following sun exposure, the patient had developed distal onycholysis surrounded by a hyperpigmented zone. He was diagnosed with doxycycline-induced photo-onycholysis.
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Affiliation(s)
- Nasirah Atiq
- Maasstad Ziekenhuis, afd. Dermatologie, Rotterdam, the Netherlands.
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39
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Krbková L, Náterová Z. [Erythema migrans]. Klin Mikrobiol Infekc Lek 2012; 18:172-179. [PMID: 23386506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The article summarizes the latest knowledge about the etiology, epidemiology, pathogenesis, clinical signs, diagnostic procedures and therapy of erythema migrans (EM), a cutaneous form of Borrelia infection. The sole focus on this clinical entity is intentional since EM is the most common clinical involvement in Lyme borreliosis (LB) in the Czech Republic (CR). New genospecies from the Borrelia burgdorferi sensu lato complex, B. lusitaniae and B. spielmanii, as etiologic agents are reported. Although there are no commercial tests available yet for their detection, ticks are demonstrably infected with them in Europe and probably even in the CR. Six pathogenic genospecies circulate among vertebrates and Ixodes ricinus ticks in Europe. The transmission cycle in nature, hosts identified as reservoirs and distribution of borreliae in Europe are presented. Clinical forms of EM are described in detail including accompanying features. Types of erythema in the USA and Europe are compared. In the part on differential diagnosis, allergies, skin and infectious diseases with similar appearance on the skin as EM are mentioned. Although the diagnosis of EM is exclusively clinical and serology is not indicated, methods of direct detection and two-tier testing of antibodies are discussed. There are therapeutic recommendations concerning the choice of antibiotics available in the CR.
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Affiliation(s)
- Lenka Krbková
- Clinic of Pediatric Infectious Diseases, The University Hospital Brno, Czech Republic.
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Ghayad Z, Hou C. Erythema migrans in early disseminated lyme disease. J Am Osteopath Assoc 2012; 112:748. [PMID: 23139346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Zeina Ghayad
- Garden State Infectious Disease Associates, Voorhees, NJ 08043-3715, USA.
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41
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Chappell DH, Jacobson NA, Jacobsen VL. Erythema chronicum migrans. J Am Osteopath Assoc 2012; 112:308. [PMID: 22582201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Filipiuk J, Nowicka-Ciełuszecka A, Tarasiuk J, Pancewicz S. [Occurrence of erythema migrans in Hajnowka district in years 2004-2009]. Przegl Epidemiol 2012; 66:19-23. [PMID: 22708293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The aim of the study was the analysis of epidemiology and clinical picture of early Lyme disease-erythema migrans (EM). There was analysed the medical documentation of 307 (126 men and 181 women) patients, who came to Outpatient Clinic of Infectious Diseases with EM in Hajn6wka in years 2004-2009. Most people (54%) lived in Hajnówka district. 51,8% of patients remembered the contact with a tick. The highest incidence of EM cases was observed in July. The average size of erythema was 10,5 cm2. In 59 cases skin lesion was accompanied by such symptoms as: itching, pain and inflammatory infiltration in the skin lesion, pain in muscles and joints, headaches, fever and cold syndroms. The most common localisation of EM were lower limbs (135 people), trunk (68) and upper limbs (29). Time of patients' visit in our Outpatient Clinic from EM notice lasted about 2 months. 6 people from analysed group were reinfected. There was used the month treatment by doxycycline in prevailing cases.
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Affiliation(s)
- Justyna Filipiuk
- 'Oddzial Obserwacyjno- Zakainy Samodzielnego Publicznego Zakladu Opieki Zdrowotnej w Hajnówce.
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Füssle HS. [Erythema migrans. Can borrelia be transmitted other than by ticks?]. MMW Fortschr Med 2011; 153:22. [PMID: 21991831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Füessl HS. [From tick bite to borreliosis: the dreaded small blood sucker]. MMW Fortschr Med 2011; 153:14-17. [PMID: 21688404 DOI: 10.1007/bf03368461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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45
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Andersen CL. [Picture of the month: erythema migrans]. Ugeskr Laeger 2011; 173:590. [PMID: 21333263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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46
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Pfister HW. [Clinical aspects of neuroborreliosis]. MMW Fortschr Med 2010; 152:31-35. [PMID: 20672660 DOI: 10.1007/bf03366785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Hans-Walter Pfister
- Neurologische Klinik und Poliklinik, Klinikum München-Grosshadern, LMU München.
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Affiliation(s)
- Frauke Benedix
- Department of Dermatology, University of Tuebingen, Liebermeisterstrasse 25, DE-72076 Tuebingen, Germany
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Kaminsky A. Erythema figuratum. Actas Dermosifiliogr 2009; 100 Suppl 2:88-109. [PMID: 20096167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
The term erythema figuratum is used to refer to erythematous lesions-with or without desquamation-that spread centrifugally in annular, arcuate, or polycyclic forms. Most of these conditions are reactions to unknown factors (immune, infectious, tumoral, and other processes), follow a chronic course with exacerbations and remissions, and are recurrent. They may disappear if the underlying cause is eradicated, but in general there are no specific treatments. They may appear at any time in life; some are more common in adults whereas others only present during childhood.
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Affiliation(s)
- A Kaminsky
- Profesora Titular Consulta de Dermatología. Facultad de Medicina. Universidad de Buenos Aires. Argentina. Area de Graduados y Estudios de Posgrado de la Facultad de Ciencias de la Salud. Universidad de Ciencias Empresariales y Sociales (UCES). Buenos Aires. Argentina.
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Werner U. [Apparent and real sequelae of a tick bite. Unbelievable what is on this "market"]. MMW Fortschr Med 2009; 151:7. [PMID: 19927907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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50
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Moravcová L, Pícha D, Vanousová D, Hercogová J. [Detection of borrelia DNA from patients with neuroborreliosis and erythema migrans]. Klin Mikrobiol Infekc Lek 2009; 15:160-165. [PMID: 19916154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
AIM Assessment of PCR procedure for proving of the Borrelia burgdorferi sensu lato DNA in nerve and skin forms of Lyme borreliosis. METHODS DNA from plasma, urine and CSF was isolated by QIAamp DNA mini kit. PCR was designed as two-step amplification (nested-PCR). Each sample was tested in PCR for five target sequences: two were specific for plasmide genes encoding OspA and OspC proteins and three correlated with genes for 16SrDNA, flagellin and p66 protein. RESULTS Borrelial DNA was proved in 41 patients suffering from neuroborreliosis out of 56 (77.4 %), among 48 patients with erythema migrans (EM) were found 26 positive (54.2 %). After treatment the specific DNA was detected in 22 patients with neuroborreliosis (41.5 %) and 16 patients with EM (38.1 %). Three months after the treatment 23 patients were positive in both of groups (28.7 %) and next 3 months later the specific DNA was found in 6 (9.5 %). The highest rate of positive results was manifested by 16SrDNA target, lower and comparable results were obtained by OspA, C and flagellin primers, the lowest rate was in p66 system. CONCLUSION The tested PCR proved specific DNA in all tested biological fluids in both of the clinical forms of Lyme borreliosis with a relatively high sensitivity. The proving of DNA can not be used for the assessment of the effect of treatment due to the long persistence of PCR positivity after antibiotic treatment. To achieve a sufficient diagnostic sensitivity of PCR it is desirable to use minimally two amplification systems in parallel.
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Affiliation(s)
- Lenka Moravcová
- Department of Infectious Diseases, Charles University Prague, Czech Republic.
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