BC Baker, AM Croft, CR Winfield. Hospitalisation Due to Lyme
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J R Army Med Corps 2004; 150: 182-186 J R Army Med Corps: first published as 10.1136/jramc-150-03-05 on 1 September 2004. Downloaded from CASE REPORT Hospitalisation Due To Lyme Disease: Case Series In British Forces Germany BC Baker, AM Croft, CR Winfield ABSTRACT into both arms and into the neck, and of Lyme disease is a tick-transmitted diffuse paraethesiae. He felt generally infection with disabling sequelae unwell, weak and apathetic. and important occupational health He gave a history of a tick bite some 5 to implications for a military workforce. It 6 weeks earlier, while off-duty, resulting in is likely that some military patients localised reddening which persisted for with typical clinical signs remain several weeks. undiagnosed and untreated. Prompt Physical examination showed localised treatment with an antibiotic is essential, reddening on the left upper arm. besides targeted education on preventing Auscultation of the heart and lungs was infection through avoiding exposure to normal, and there was no focal neurological tick bites. We describe four British deficit, and no peripheral, sensory or motor Forces Germany personnel (two serving military personnel, one adult civilian, one child) who during 2002–2003 required hospital inpatient treatment for Lyme disease. The epidemiology, pathogenesis, clinical features, diagnosis and treatment of the disease are discussed. Fig1. Developmental stages of the Ixodes tick (EUCALB). Key words: Lyme Disease, British deficits. Army,Borrelia burgdorferi,Occupational Investigations Health Serology and CSF testing were both positive for B. burgdorferi IgG and IgM. Introduction ECG showed normal sinus rhythm of 70 Lyme disease is a multi-system illness beats per minute, with left axis deviation but http://militaryhealth.bmj.com/ resulting from the bite of an Ixodes or hard- no significant repolarisation abnormalities, bodied tick (Figure 1) infected with and no blocks. spirochaetes of the genospecies Borrelia burgdorferi sensu lato (1). The disease takes Treatment and progress its name from the town of Lyme in A diagnosis was made of radiculoneuritis Connecticut, USA. secondary to Lyme disease. The patient Lyme disease is rare in Britain, with a was treated with intravenous cefuroxime. Lt Col B C Baker mean of about 50 new cases reported in His symptoms had improved by the fifth MB ChB MRCGP day of antibiotic treatment, and his rash DipSport&TI RAMC England and Wales each year (2). In mainland Europe the infection is more had disappeared. Discharged after 11 on September 25, 2021 by guest. Protected copyright. Regional Clinical days. Director, Paderborn, common, with especially high endemicity in Talbot Barracks, southern Scandinavia, the Netherlands, BFPO 16 parts of Germany and in eastern European Case Two states such as Austria and Slovenia (3). History and initial findings Lt Col A M Croft Lyme disease is, therefore, a threat to Admitted in October 2002 to Allgemeines MA MBBS MSc MIL British troops and their families stationed in Krankenhaus, Viersen. The patient was a DMCC DTM&H continental Europe. 46-year old female British Army officer. FFPHM RAMC She had no previous illnesses of note, and Director of Public We describe four British Forces Germany Health, Headquarters personnel who required hospital inpatient no prior hospitalisations. She gave a history British Forces Germany treatment for Lyme disease. of dysaesthesia in both arms, with pins Health Service, and needles and paraesthesiae in both BFPO 40 Case One hands. She complained of concentration History and initial findings difficulties and visual disturbances, and felt Brig C R Winfield MA Admitted in September 2002 to ill, tired and exhausted. BCh DCH FRCP There was no history of tick bite, but L/RAMC Allgemeines Krankenhaus, Viersen. The patient was a 46-year old male non- physical examination showed typical erythema Director of Secondary migrans on the right side of the chest, in the Healthcare, Secondary commissioned British Army officer. He Healthcare Admin complained of recent-onset neuroradicular mid-axillary line. She was admitted with Centre, BFPO 39 symptoms in the shoulder girdle, radiating clinically suspected Lyme disease. BC Baker, AM Croft, CR Winfield 183 J R Army Med Corps: first published as 10.1136/jramc-150-03-05 on 1 September 2004. Downloaded from Investigations Krankenhaus, Viersen. The patient was a Serology and CSF testing were negative for 48-year old female UK-based civilian, B. burgdorferi IgG and IgM. Western resident in Germany. She had made a blotting was negative. ECG showed normal complete recovery from a left-sided stroke sinus rhythm of 70 beats per minute, with one year previously, and complained now of no significant repolarisation abnormalities, recent-onset left-sided facial paresis, with and no blocks. Echocardiography showed a diffuse neuroradicular symptoms in her normal sized heart, for her age. shoulder girdle area. She felt ill, weak and tired. Treatment and progress She gave a history of a tick bite some 6 to The patient’s symptoms, together with the 8 weeks earlier. classic erythema migrans rash, pointed to a Physical examination was normal except clinical diagnosis of Stage 2 Lyme disease. for a facial palsy on the left. The patient was treated with intravenous ceftriaxon, later changed to oral Investigations doxycycline. Discharged after 8 days. Serology was negative for B. burgdorferi IgG but positive for IgM. CSF testing was Case Three positive for B. burgdorferi IgG and IgM. History and initial findings Two consecutive admissions, in February Treatment and progress and March 2003, to Zentrum fur Kinder- The symptoms and laboratory findings und-Jugendmedizin, Krefeld. The patient pointed to Lyme disease. The patient was was a 12-year old female, the daughter of a treated with intravenous ceftriaxone for 14 non-commissioned British Army officer. days, and this led to resolution of her She was investigated and diagnosed during neuroradicular symptoms, and complete the first admission, and treated during the remission of her facial paresis. second. The patient gave a 6-month history of Discussion pain in her right hip, knee and ankle joints, Epidemiology of Lyme disease with a more recent monoparesis of her right Humans acquire Lyme disease by leg She also complained of blurred vision in cutaneous inoculation of spirochaete- her right eye. There was no history of tick infected saliva, after being bitten by an bite. infective vector tick. In Europe, the natural Physical examination showed a drop-foot reservoir hosts of B. burgdorferi s.l. comprise gait and reduced right gluteal muscular nine small mammals (including several mass, with paresis of the right peroneal mice, the bank vole and shrews), seven nerve. The patient was unable to lift her medium-sized mammals (especially http://militaryhealth.bmj.com/ right foot, and had a dull feeling in the foot. squirrels) and a number of birds (4). The right plantar reflex could not be The global distribution of Lyme disease elicited. closely matches the worldwide distribution of ticks of the Ix. ricinus complex, although Investigations the disease is often highly focal within Normal values for full blood screen, liver endemic regions (5). High-risk areas are enzymes, electrolytes, creatinine, urea. characterised by a combination of forest Polio antibodies were detected but the and forest-edge habitats that support the results were consistent with previous natural reservoir hosts, and humid, immunisation. Serology was positive for B. temperate microclimatic ground-level burgdorferi IgG on ELISA and Western blot, conditions that favour Ixodes spp. ticks in all on September 25, 2021 by guest. Protected copyright. but negative for IgM. CSF testing was stages of their development (6). In Europe, positive for B. burgdorferi IgG and IgM. Lyme disease risk is associated with forestry Fundoscopy normal. MRI images of the work and with residence and leisure cervical, thoracic and lumbar spines showed activities in rural areas, but not in those no evidence of an intraspinal or intracranial areas devoted to intensive agriculture (7). cause of the paresis. In Germany, rates of tick infectivity range from 10% to 40% (8). One survey in south- Treatment and progress east Bavaria found that 11% of blood On the first admission, a diagnosis of Lyme donors harboured antibodies to B. disease was made. During a second, two- burgdorferi s.l., indicating previous exposure week admission the patient was treated to the bacterium (9). It is estimated that in with intravenous cefotaxime, together highly endemic areas of Germany, every with intensive physiotherapy. Outpatient tenth tick bite could lead to infection with physiotherapy in a rehabilitation unit was B. burgdorferi s.l (8). recommended. Human Lyme disease can affect all age groups of both sexes. Age-adjusted attack Case Four rates show a bimodal distribution, with the History and initial findings greatest risk of acquiring the disease being Admitted in July 2003 to Allgemeines in children and middle-aged adults (10). 184 Lyme Disease In British Forces Germany J R Army Med Corps: first published as 10.1136/jramc-150-03-05 on 1 September 2004. Downloaded from Table 1. Principal clinical manifestations of Lyme disease (adapted from Reference 10). System Stage 1 disease Stage 2 disease Stage 3 disease (Constitutional) Malaise, fatigue, headache, Severe malaise and fatigue Persistent fatigue fever, arthralgias Skin Erythema migrans Secondary annular lesions Acrodermatitis chronica atrophicans