BritishJournal ofOphthalmology, 1990,74,321-322 321

BRITISH JOURNAL OF Br J Ophthalmol: first published as 10.1136/bjo.74.6.321 on 1 June 1990. Downloaded from

Editorial CHARD W. LUNG MEMRIAL DICAL UBRARY

Lyme disease

Lyme disease takes its name from a town in New England chronic arthritis a progressive encephalomyelitis and a skin where an outbreak ofchronic arthritis in children was studied disorder known as acrodermatitis chronica atrophicans can and reported in 1977. Epidemiology suggested a tick borne occur at this time. Congenital infection has been reported, infection, and in 1982 the causative organism, a previously usually with a fatal outcome for the fetus. unrecognised spirochaete, was found and named Borrelia Ocular involvement can be seen as in stage I burgdorferi.- Since then the disease has become more widely but occurs more commonly in stage II; a may be seen recognised as a result ofclinical awareness, better diagnostic in stage III. Ocular involvement appears to be relatively tests, and an increase in deer stocking.' It is now the infrequent. The commonest findings are a or commonest tick borne infection in the USA, with over 6000 , oculomotor palsy, or papilloedema from reported cases in 1987. The tick is widely distributed, and meningeal involvement. variants of the disease have been described in Europe since Most descriptions of ocular disease concern sporadic case early this century. A rise in cases is now being reported in reports, but Kinward et al have recently reported a series of

Britain for similar reasons as in the USA.2 six cases with ocular involvement.3 The patients' ages ranged http://bjo.bmj.com/ Borrelia burgdorferi is transmitted by ixodes ticks. The from 11 to 71 years; five of the six had visited endemic areas tick's life cycle is not fully documented, but in New England for Lyme disease but only two had a positive history of a tick it depends on the white footed mouse for its larval and bite. Five of the six patients had a bilateral vitritis, with nymphal stages and the white tailed deer as the preferred similarities in one to pars planitis; the other patient had a adult host, though West Coast ticks are apparently happy to fourth nerve palsy. Three ofthe six patients had a substitute lizards for mice. The spirochaete lives in the gut of palsy, the commonest cranial neuropathy found with Lyme

the tick and is injected into the unfortunate host through disease. The most important lesson from these cases is that on September 27, 2021 by guest. Protected copyright. its saliva. Ixodes ticks are widely distributed throughout recognition of Lyme disease led to appropriate antibiotic America, Europe, and Asia, and the spirochaete can be found treatment and a good visual outcome. Other ocular manifes- in mosquitoes and deer flies as well, though the importance of tations are ischaemic , , and these to human disease is unknown. swelling with or without raised intracranial pres- Lyme disease is a multisystem disease with major cutane- sure, as well as oculomotor palsies. These are reviewed in the ous, neurological, cardiac, and rheumatological manifesta- discussion of a patient with unilateral endophthalmitis from tions. For a complete and authoritative review of the disease Lyme disease in this issue ofthe B7O. and all its ramifications readers should consult the review by The various manifestations appear to be related to direct Steere,' who described the original cases in 1977. The disease infection with the spirochaete, which can be recovered has similarities to syphilis, with stages oflocalised infection, histologically or cultured with varying degrees of success dissemination, and late persistent infection. Ocular involve- from involved organs. Most cases are, however, diagnosed ment is uncommon and occurs mainly in the second stage. serologically using an ELISA test. This becomes positive for Following inoculation of the spirochaete by a tick bite IgM during the first few weeks ofinfection, during this time patients develop a characteristic skin lesion, erythema false negative results can occur. An IgG response occurs later. migrans (stage I), usually centred on the tick bite, and they Seronegative cases can occur; in these cases the diagnosis was may develop fever, lymphadenopathy, and constitutional made by finding a specific T cell blastogenic response,4 and it symptoms. Conjunctivitis has been reported in 11% of has recently been shown that in these cases the antigen is patients. Dissemination (stage II) is by blood or lymphatic sequestered in immune complexes.5 spread. Secondary annular skin lesions appear, and the In Britain Lyme disease usually occurs in people from a patient may be quite ill with fever, malaise, and fleeting rural or agricultural background. In a study of serological musculoskeletal pains. After several weeks or months 15- titres in 101 patients from Dumfries chosen because of 20% of patients in the USA have developed neurological potential exposure 12 were found to give positive results from symptoms, ofwhich chronic lymphocytic meningitis, cranial serological tests; all were farmers, six exclusively working polyneuropathy, or radiculitis are the commonest; 4-8% with dairy cattle, the others working with cattle and sheep. develop cardiac symptoms, with arrhythmias or myopericar- No patient had typical features ofLyme disease, but 11 ofthe ditis. After six months about 60% ofpatients develop arthritis 12 had symptoms such as arthritis, which might have been ofmajor joints (stage III), particularly the knees. Apart from relevant.6 No ocular Lyme disease has yet been reported in 322 Spalton Britain, though thegardener ofa London ophthalmologist has avoided in the management ofpatients with intraocular Lyme apparently suffered cardiac manifestations. disease. D J SPALTON Borrelia burgdorferi is sensitive to tetracyclines and Br J Ophthalmol: first published as 10.1136/bjo.74.6.321 on 1 June 1990. Downloaded from erythromycin. These appear to be the best antibiotics for the 1 Steere AC. Lyme disease. New EnglJ Med 1989; 321: 586-%. treatment of the systemic infection, as the spirochaete is 2 Muhlemann MF, Wright DJM. Emerging pattern ofLyme disease in the United apparently less sensitive than Kingdom and Irish Republic. Lancet 1987; i: 260-2. Treponema pallidum to peni- 3 Kinward KE, Lawton Smith J, Culbertson WW, Paris-Hamelin A. Ocular cillin, but the best treatment for intraocular disease is not yet Lyme borreliosis. AmJ Ophthlamol 1989; 108: 651-7. known. The Bascom Palmer patients with 4 Dattwyler RJ, Volkman DJ, Luft BJ. Seronegative Lyme disease - dissociation early disease did ofspecific T and B lymphocyte responses to Borrelia burgdorferi. N EnglJ Med well with doxycycline, and good results in the others were 1988; 319: 1441-6. obtained with intravenous ceftriaxone. The 5 Schutzer SE, Coyle PK, Belman AL, et al. Sequestration ofantibody to Borrelia disease may burgdorferi in immune complexes in seronegative Lyme disease. Lancet 1990; relapse after treatment, and in this series all three patients 335: 312-5. who did relapse had had prior treatment with oral 6 Baird AG, Gillies JCM, Bone Fj, Dale BAS, Miscampbell NT. Prevalence of steroids. antibody indicating Lyme disease in farmers in Wigtownshire. BrMedJ 1989; The role of steroids in systemic infection is controversial, in 299: 836-7. one series 7 Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ. Treatment of late Lyme predisposing patients to antibiotic failure.7 borreliosis. Randomized comparison of ceftriaxone and penicillin. Lancet Systemic steroids are therefore probably at present best 1988;i: 1191-4. http://bjo.bmj.com/ on September 27, 2021 by guest. 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