Infectious Disease

Focus on Lyme-Borreliosis

FOR OUTSIDE THE US AND CANADA ONLY II l Authors Dr. Thomas W. Talaska, Specialist in Microbiology and Infection Epidemi- ology. Since 1992, his work has been focused on tick-borne diseases, especially on epidemiological and diagnostic projects related to Lyme borreliosis and other infections caused by parasites (i.e. babesiosis, ehrlichiosis and rickettsiosis). Dr. Talaska coordinates the Interdisciplinary Consulting Group for Lyme borreliosis organized by the Brandenburg Medical Association. He is the Director of the Institute for Tick-Borne Diseases, whose activity was addressed to the prevention and on informing the population about the possible risks of such insect bites. Thomas Talaska

Prof. Andreas Krause, Specialist in Internal Medicine and Rheumatology, has conducted studies about the pathogenesis of Lyme borreliosis and the immune response of cells related to this disease. He has also worked on studies concerning arthritic diseases associated with infections and psychoneuroimmunology. Until 2002, Prof. Krause was Director of the Day Clinic for Rheumatology at the Charité University Hospital. Since then, he has been Head of the department of the Internal Medicine/Rheumatology and Clinical Immunology Department, Rheumatology Institute, Imman- uel-Krankenhaus, Berlin-Wannsee, and since October 2005 he has also been Head of the department of the Rheumatology Clinic, Berlin-Buch.

Andreas Krause

Prof. Elisabeth Aberer is specialized in dermatology and venereal diseases. She has a Master’s Degree in Dermohistopathology. Since April 1995 she has been Senior Consultant of the Dermatology Clinic, University of Graz. Her studies have mainly focused on clinical signs and symptoms, treatment and diagnostic issues related to Lyme borreliosis. Prof. Aberer has formed a research center specialized in Lyme borreliosis at the Vienna General Hospital. She has directed two projects designed to promote scientific research: “Die pathogenetische Bedeutung von B. burgdorferi in der Haut” (The pathogenic meaning of B. burgdorferi on the skin, 1989-1992) and “Harn - PCR zur Routinediagnose der Lyme-Borreliose” (Urine PCR in rou- tine screening for Lyme borreliosis, 1999-2002). She is the Director of the Elisabeth Aberer Research Center specialized in General and Self-Immune Pathology and, Director of the Quality Control Department, University Clinic of Derma- tology and Venereology, Graz. Laboratory diagnostics mainly focus on immunodiagnostics in autoimmune dermatological and primary systemic diseases and on specialized diagnostics for Lyme borreliosis.

1 Authors

Since July 2000 Prof. Reinhard Kaiser has been the Director of the Neur- ology Clinic, Pforzheim Hospital. After following experimental training at the Institute of Virology and Immunology, University of Würzburg, Pro- fessor Kaiser has been involved, since 1989 in the diagnostics, treatment and clinical observation of patients suffering from neuroborreliosis and tick-borne meningoencephalitis (FSME). His clinical studies have focused on differential diagnostics, on the treatment of patients with acute and chronic inflammation of the nervous system and of those suffering from neurological disorders who are serologically positive for borreliosis, even in absence of evident symptoms of neurological form.

Reinhard Kaiser

Dr. Volker Fingerle - Specialist in Microbiology and Infectious Epidemi- ology - has worked at the Max von Pettenkofer Institute of Hygiene and Medical Microbiology, Ludwig Maximilians Universität (LMU), Munich, since 1990. He works at the National Reference Center (NRZ) for Borreliae and oversees the consiliary lab for Ehrlichea. His studies have mainly focused on training and consulting activities targeted at colleagues and dealing with the epidemiology, diagnostics and treatment of Lyme borreliosis and of anaplasmosis (ehrlichiosis). His fields of research are epidemiol­ogy, diagnostics and pathogenesis of Lyme borreliosis and granulocytic anaplasmosis in humans.

Volker Fingerle

Prof. Bettina Wilske is Microbiologist at the Max von Pettenkofer-Institute of Hygiene and Medical Microbiology, Ludwig Maximilians Universität (LMU), Munich. She is also the head of the National Reference Center (NRZ) for Borreliae and carries out medical consulting assignments on the prophylaxis, diagnostics and treatment of Lyme borreliosis. She has been studying Lyme borreliosis since the early ‘80s, especially focusing on the microbiology, diagnostics, epidemiology and analysis of the pathogenic agent’s antigen structure. She has authored the MiQ 12 Lyme borreliosis (quality standard for the microbiological diagnosis of Lyme borreliosis) edited by the DGHM (German Association for Hygiene and Microbiology), whose English version can be found on the homepage of the DGHM (http://www. Bettina Wilske dghm.org/red/index.html?cname=MIQ).

2 l Index

Epidemiological, biological, and ecological aspects of Lyme borreliosis...... 5 • Thomas Talaska

Rheumatological and other internal manifestations of Lyme borreliosis...... 25 • Andreas Krause

Dermatological manifestations of Lyme borreliosis...... 37 • Elisabeth Aberer

Neuroborreliosis...... 51 • Reinhard Kaiser

Lyme borreliosis diagnostics...... 67 • Volker Fingerle, Bettina Wilske

Contacts...... 83

3 4 Epidemiological, biological, and ecological aspects of Lyme borreliosis l Thomas Talaska

s the science of disease pre­ realised without knowledge of disease Avention, epidemiology plays a prevalence, incidence, and risk factors. significant role in the planning and Such epidemiological information is evaluation of public health and health also essential to gauging the success politics. It is used in conjunction of any preventive measures. Although with laboratory research to identify Lyme borreliosis has an extremely risk factors for disease, elucidate the low mortality rate, its frequency alone mechanisms by which they develop, has a significant economic effect. This and finally to formulate prevention “economical impact” is defined by the strategies. In Germany, the instrument World Health Organisation (WHO) for epidemiological evaluation of as the total cost of visits to physicians, infectious diseases is the Infectious laboratory diagnostics, drugs, hospital Diseases Control Law (IfSG), which stay, lost work time, additional health came into force on January 1, 2001; care and, in certain cases, invalidity [5]. however, this law applies only to Personal suffering, reduced quality of infections transmitted directly from life and ability to perform should not be person to person or food-borne, and ignored, even though these are difficult does not, cover Lyme borreliosis, by to quantify. In occupations with high far the most common vector-borne exposure rates, Lyme borreliosis has disease in central Europe. However, all considerable significance as a work- of the former East German states and related disease. Berlin have laws regarding registration The WHO European regional office of both occurrence and positive in Copenhagen published a report laboratory results of the disease. An in 2004 on vector-borne diseases, effective, affordable, regionally tailored including tick-borne diseases, and their prevention programme including significance in Europe. The incidence immunisation schemes cannot be of such illness is significantly higher

5 Epidemiological, biological, and ecological aspects of Lyme borreliosis

than has been assumed by medical Fig. 1. A mouse with Ixodes ricinus larvae and nymphs practitioners and public health departments – often diagnoses are not made and treatment is delayed. This requires action! In the absence of the public interest associated with dramatic outbreaks, the need for surveillance and control of not only the disease but also its vectors is easily overlooked, resulting in insufficient support for epidemiological research, even by the public health authorities [4].

Borrelia: ticks – hosts The epidemiology of Lyme borreliosis burgdorferi genospecies was isolated in humans is closely associated with from erythema migrans lesions [7]: the tick’s life cycle, its habitat, and - Borrelia spielmanii (also designated the interaction between tick, host – A14S). including humans – and the particular For Borrelia, humans are dead-end species of Borrelia involved. Thus hosts. it is necessary here to make a short The main vector of Lyme borreliosis excursion into the world of ticks in in central Europe is Ixodes ricinus order to understand this zoonosis. (Fig. 1). This tick species has a very Borrelia are obligate parasites with no broad spectrum of vertebrate hosts free-living stages, and their propagation (reptiles, birds, especially migratory relies on complex zoonotic transmission species, and mammals), compared with cycles involving rodents as the main other native tick species, and is thus reservoir hosts and ticks as vectors. well suited for transmitting pathogens In Europe there are three species to a wide variety of species. confirmed pathogenic to humans: - Borrelia afzelii How does a tick bite? - Borrelia garinii Once a tick finds a suitable attachment - Borrelia burgdorferi sensu stricto site on a host, it uses its mouthparts, the Two other species show evidence of chelicerae, to cut through the host’s skin. pathogenicity: The tick pushes its hypostome, a chitin - Borrelia valaisana tube with recurved teeth, into the small - Borrelia lusitaniae wound created. In effect, the tick stabs Recently an additional Borrelia or pricks its host. The tick hypostome is

6 however not a completely closed tube, the host (a nonpermissive system). as in insects, and to facilitate suction, If, however, the tick is systemically the hypostome must be cemented into infected, deactivation in the midgut the skin by a salivary secretion at the occurs, but the tick remains infected site of penetration. While feeding, the and trans-stadial transmission occurs, tick is stuck fast to the host – thus the while the bird host is protected by its generic name Ixodes (from Greek ixos, complement system (a semipermissive meaning “glue” [13]). system). The bird has no reservoir competence for this strain. Reservoir- Transmission of Borrelia to ticks incompetent host species can have a is required for human infection and zooprophylactic effect through which can take place in various ways. Trans- the dissemination of Borrelia can be ovarial transmission to offspring in hindered. Nuncio et al. describe an systemically infected ticks is relatively example of this effect on the Portuguese uncommon, affecting less than 5% island of Madeira, where the native of Ixodes ricinus larvae. A more common route of transmission occurs Fig. 2. Teira dugesii, Funchal, Madeira (photo: Robert Klose) when larvae are infected by feeding on blood, usually from infected forest mice. Trans-stadial transmission is then possible to nymphs and finally adult ticks. This cross-stage transmission is highly dependent on the Borrelia species involved, the distribution of Borrelia in the tick (midgut only or systemic, including salivary glands), and on the host species. It also depends on the sensitivity of Borrelia species to the lytic action of the host’s innate immune defences, the complement system. hosts are lizards (Madeira wall lizard, If a tick infected with Borrelia afzelii Teira dugesii) in either non- or semi- draws a bird’s blood, the complement permissive systems (Fig. 2) [12, 15]. system in this liquid “meal” is able The circulation of Borrelia on Madeira to destroy the Borrelia in the tick’s can be maintained by introduced mice midgut. If the tick is infected only and rats [16]. in the midgut, then the Borrelia can neither be transferred to the next Co-feeding is an additional transmission tick developmental stage nor to route between ticks. Borrelia can be

7 Epidemiological, biological, and ecological aspects of Lyme borreliosis

transmitted through cofeeding when with Borrelia, while ticks in a Prague ticks are infected systemically. Ticks city park showed a low prevalence are pool feeders, meaning that their of 4.9% over a four-year period. biting and the activity of enzymes Although some risk of contracting secreted in their saliva cause a pool of Lyme borreliosis by tick bite exists blood to accumulate at the base of the throughout Germany, with the hypostome, from which the blood meal exception of vegetation-free areas in is drawn. This “washing” of the tick’s the mountains and Baltic and North Sea feeding apparatus with saliva leads to beaches, the risk varies dramatically the transfer of Borrelia into the wound. within regions and depends strongly Ticks have preferred attachment sites on local conditions. From the many where they congregate close together studies in German states, we find to feed. In the process, Borrelia can mean prevalences of 7.7% in Hessen, be transferred to neighbouring ticks 14.4% in Baden-Wuerttemberg, 14% without the host becoming infected in Bavaria, 15.11% in Thuringia, 16.5% or needing to be reservoir-competent in Saxony, and 22% in Brandenburg. (Fig. 3). However, the incidence of infection in The above transmission mechanisms a whole state cannot be used to predict are responsible for the local and life the actual risk in a particular part of stage-dependent variations in infection that state. In areas with optimal tick rates of Ixodes ricinus. An extremely habitat, local prevalence can approach high prevalence was found in a part 40%, a fact that is not obvious if only of Croatia, with 45% of ticks infected the mean prevalence is considered. Optimal tick habitats have two Fig. 3. White-tailed deer with a heavy tick infestation (photo: USDA Northeast Area-Wide Tick Control Project, essential requirements: sufficient USA) moisture to maintain the ticks’ sensitive water balance and a mixture of sufficiently numerous hosts for tick larva, nymphs, and adults. It is interesting to note that tick behaviour is also influenced by Borrelia. Such phenomena are well known from other host-parasite systems (e.g. trypanosomes and tsetse flies, rat fleas and Yersinia pestis, Leishmania and Phlebotomus sandflies). Drs Perret and Guerin and Prof. Gern of the University of Neuchatel in Switzerland

8 demonstrated that, in dry atmospheric - Ground moisture and geological conditions, infected ticks move farther characteristics and more often from their original - Long-term temperature develop­ments location than uninfected ticks. This - Risk and recreational behaviour of increases the likelihood of finding humans new hosts on which to feed – and thus - Certainty of the diagnosis of Lyme of new infections with Borrelia [10]. borreliosis Prevalence rates also vary according to tick life stage; for example in Thuringia Epidemiology a study of ticks found attached to Worldwide, epidemiological data on patients showed infection in 0% of Lyme borreliosis as an “emerging larvae, about 15% of nymphs, and infectious disease” are inadequate, about 19% of adult females [6]. with the exception of those from the USA (Centers of Disease Control, The diversity of interactions between or CDC, and the Division of Vector- Borrelia, ticks, and hosts outlined here Borne Diseases). In Europe there demonstrates the need for sophisticated are currently very few national biological and epidemiological analyses notification or registration systems. of Lyme borreliosis. In addition, one The epidemiological data available must also include ecological factors for Germany are based mostly on such as vegetation, geology, hydrology, studies aimed at only a single clinical temperature, and rainfall. At present, manifestation or are limited to very we are only able to give a descriptive small regions within a German account of the epidemiology of Lyme state. Other countries have regional borreliosis in humans. registration systems, such as in Austria and France. Russia has the beginnings of Factors influencing the epidemiology a regional notification system based on a of Lyme borreliosis in humans highly centralised diagnosis of Borrelia. - Tick species Slovenia probably has the oldest - Borrelia species epidemiological databank in Europe, - Presence/density of reservoir- based on a notification system for Lyme competent hosts borreliosis originating in 1998 [21]. - Presence/density of tick habitats which What actually is borreliosis? Borrelia humans enter are not new pathogens – typical clinical - Use of forest and agricultural land cases were described as early as the end - Forest structure and kinds of biotopes of the 1800s (acrodermatitis chronica - Seasonal changes in temperature, atrophicans, erythema chronicum sunshine, and rainfall migrans, Bannworth’s syndrome).

9 Epidemiological, biological, and ecological aspects of Lyme borreliosis

In 1996 Ohlenbusch confirmed the borreliosis. The significance of infection presence of Borrelia in ticks more with Rickettsia slovaca and Rickettsia than 100 years old from museum helvetica is still largely unclear. collections in Berlin and Vienna What explains the increase in Lyme (Borrelia burgdorferi sensu stricto, disease? Socio-ecological factors Borrelia garinii, Borrelia afzelii [17]). are implicated in a study of an area The significant increase in borreliosis, with endemic Lyme disease in the considered a rarity with unknown northeastern USA where the movement aetiology but well-defined symptoms as of large numbers of people from recent as 20 years ago, is surprising. The populated urban centres to forested establishment of clinical case definitions rural areas increased the risk of of Lyme borreliosis was an important exposure to tick bites [8]. At the same requirement for collecting valid data. time, this area experienced a decrease Those created by the CDC were very in agricultural land use, and an increase stringent and developed specifically for in bushes and trees abutting directly epidemiological purposes. However, a to inhabited areas, with a concomitant number of European manifestations of increase in tick hosts. The WHO Report the disease were not included because on Europe also describes massive they are practically unknown in the ecological changes that have taken place USA. In 1996 the European Union for since the end of the Second World War. Concerted Action on Risk Assessment In particular, intensive reforestation in Lyme Borreliosis (EUCALB) has brought (and continues to bring) established valid case definitions for changes in the flora and fauna. The Europe that allow standardisation of population densities of wild boar and registered, defined clinical cases [20]. deer have increased, leading to greater The existence of yet undefined and tick density. Similar developments can hence unregistered clinical manifes­ also be seen in Germany, but specific tations must be considered. studies on this problem are lacking. The possibility of simultaneous It is probable that continued climatic transmission of multiple tick-born change will influence the frequency of diseases necessitates differential vector-borne diseases. The distribution diagnosis. In fact, simultaneous infection and seasonality of diseases transmitted with Borrelia and the pathogens causing by ectothermic insects and ticks human granulocytic ehrlichiosis (HGE), are particularly sensitive to global Anaplasma phagocytophilum, or temperature changes. Warmer winters Babesia spp. are documented. These favour tick survival and movement into present a clinical picture that differs new areas where they were previously from the course typical for Lyme rare or absent. Global warming also

10 leads to longer active periods for ticks auspices of the 1994 WHO Consultation in spring and autumn and probably on the Development and Application increases human recreational activities of Geographical Methods in the in these periods, resulting in higher risk Epidemiology of Zoonoses [3]. In that of exposure to ticks. Examples include year, the “Geographical Epidemiology Sweden, where the distribution of tick- of Borreliosis in Brandenburg” project borne encephalitis (TBE) has expanded was started, in which a voluntary northward, and the Czech Republic, notification schedule was introduced where (TBE) expansion has occurred and the Lyme Disease Case Report over the last 30 years into higher areas Form adapted from the American Case of the Bohemian Forest [25]. How the Report Questionnaire in conjunction situation with Lyme borreliosis will with the CDC. Starting in November develop remains to be determined, 1996 the German Federal Infectious although it is likely to follow the pattern Diseases Law was extended to require of TBE. The first data confirming this that all clinical occurrences of Lyme came from the Czech Republic [5]. borreliosis in Brandenburg be reported A temperature-related lengthening of using the notification schedule and the tick season in the presence of a large all positive laboratory results to be number of reservoir-competent hosts registered. This was the first opportunity can also lead to faster tick develop­ to collect and analyse a data set covering mental cycles and thus greater tick an entire German state. In the same year, density; transit from egg to adult can be the Lyme Borreliosis Interdisciplinary shortened from 54 to 18 months. Advisory Group was established by the In November of 2004, the European Brandenburg State Medical Board to Union project “Emerging Diseases in a advise medical practitioners, patients Changing European Environment” was and self-help groups. In 2001, the started. Prof. Sarah Randolph of Oxford Brandenburg State Ministry for Work, University is leading the “Tick-Borne Social Affairs, Women, and Health Diseases” section. Its aim is to explain founded the Regional Counselling the increase in tick-borne diseases on a Centre for Tick-Borne Diseases. In European scale and to create predictive addition to its advisory role, this service statistical and biological models. coordinates and carries out studies, evaluates tests, and makes additional The development of borreliosis analyses of registered cases of Lyme epidemiology in Brandenburg borreliosis. In addition, issues involving The first studies on the epidemiology HGE, Rickettsia helvetica, and babesiosis of Lyme borreliosis in Germany began are considered there in cooperation in the state of Brandenburg under the with, among others, the Robert Koch

11 Epidemiological, biological, and ecological aspects of Lyme borreliosis

Institute (RKI) in Berlin, the WHO in Geographic information systems and Geneva, the CDC Division of Vector- Lyme disease Borne Diseases at Fort Collins, the Computer-based geographic in­- University of Frankfurt/Main, and formation­ systems (GIS) represent a Tulane University in New Orleans. modern tool for analysing risk factors and producing risk maps for the epidemiology of infectious diseases, Fig. 4. Distribution of borreliosis cases in particularly tick-borne diseases [3]. Brandenburg 2003 (database: EpiInfo 3.3; created using ArcView 3.2 [23]) This in turn can provide the basis for locally adapted prevention strategies similar to the time-tested methods used in veterinary medicine and veterinary disease control. The GIS systems are based on area-related databases with parameters that include cases of infection, geographic coordinates, administrative structures, and population density. They contain digital coordinate reference maps showing, for example, administrative boundaries, biotopes, geology, hydrology, weather, and other relevant factors [14, 18, 19].

The computer programme “EpiInfo”, freeware for epidemiological Fig. 5. Example of satellite-supported biotope carto­ graphy – alder sections (marked blue) in the Spree forest surveillance originally developed by (photos: Landsat TM; processed with ArcView 3.2; A. the CDC, includes databases, analytical Ober 2003) tools, and EpiMap, a component program that can produce cartographic representations of epidemiological data. The databases are compatible with the GIS system ArcView, which allows coordinates from study areas or new distribution areas to be recorded locally using global positioning systems (GPS) and precisely located on coordinate reference maps. Other geographic parameters such as vegetation and

12 watercourses can be superimposed on factor optimistically to Brandenburg these maps for analysis (Fig. 4). (ignoring undiagnosed cases and those EpiInfo is also useful for evaluating not presenting erythema migrans, as satellite photographs, in which for these can only be speculated) would example different vegetation types predict 4,000 clinically relevant cases produce different patterns of reflection of borreliosis. Developments in spectra. The ability to precisely the USA show that the number of superimpose satellite photographs onto Fig. 6. Lyme borreliosis in Brandenburg – registered digital maps permits on-site biotope clinical cases per month until 31.12.2004 (graphic: T. searching and analysis using GPS. Talaska) Computer searches for biotypes with similar characteristics are also facilitated 350 Cases (Fig. 5). 300

Areas with a potentially higher risk of 250

Lyme borreliosis can be located on the 200 computer screen and related to data 150 from regions with a higher incidence of 100 borreliosis – a major prerequisite for the 50 development of risk maps. 0 1997 1998 1999 2000 2001 2002 2003 2004 Epidemiological data on Lyme borreliosis in Brandenburg The first incidence data on Lyme borreliosis in Brandenburg were Fig. 7. Clinical cases of Lyme borreliosis from 1995 to collected on a volunteer basis from 2004 (graphic: T. Talaska) 1994 to 1996, i.e. until introduction of the notification requirement. The incidence was ten cases per 100,000 2500 Cases inhabitants but with marked regional 1,981 2000 differences, which may, however, have 1,823 1,355 1,410 1500 been strongly related to notification 1,240 behaviour. In 1997, 400 clinical cases 1000 783 were registered. Two studies in 819 451 Maryland and Connecticut, USA shortly 500 198 after the introduction of a notification 164 0 requirement showed that only 10–15% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004* of cases fitting the CDC case definition * preliminary data were actually registered. Applying this

13 Epidemiological, biological, and ecological aspects of Lyme borreliosis

Fig. 8. Borreliosis in individual German states (graphic: infections are reported (D.T. Dennis, G. Hesse, Erfurt 2004) personal communication). If this is the case, Brandenburg’s 1,240 registered borreliosis cases in 2000 represent an 2000 Thuringia Brandenburg actual value of about 4,200. Such high 1800 Mecklenburg- Saxony 1600 estimates suggest that the increased West Pomerania Berlin 1400 Saxony-Anhalt incidence of borreliosis is probably only 1200 a function of the notification changes, 1000 800 and that the actual estimates for the last 600 four years were much lower. 400 200 Nevertheless, one cannot ignore that 0 subsequent years have shown a steady

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 increase in registered cases of 10–15% annually. This trend has also been found in other German states with notification requirements, as G. Hesse reported at Fig. 9. Borreliosis morbidity from 1994 to 2003 (graphic: G. Hesse, Erfurt 2004) the 2004 Thuringia Workshop on Tick- Borne Diseases in Erfurt (Figs. 6, 7, 8, 9, 10). 80 Thuringia 70 Mecklenburg-West Pomerania Regional variability in the state 60 Saxony-Anhalt of Brandenburg 50 Brandenburg As already indicated, there are 40 Saxony significant differences between districts Morbidit y 30 in the registered incidence of borreliosis. 20 The highest incidence in Brandenburg 10 was reached in 2000 in the Oder-Spree 0 district (89.3/100,000 inhabitants), the 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Uckermark (89.0/100,000), and the Barnim (74.6/100,000). In general, there has been a trend toward higher registered cases increased markedly incidence in eastern Brandenburg since in the years following introduction of 1996. This appears to depend not on the notification system, especially when risk behaviour but rather on the density the notifying physician was informed of suitable biotopes for the ticks. It is on regional epidemiological data. It still necessary to determine whether is assumed that with an established more and smaller habitat areas with notification system, about a third of higher contact for humans exist in

14 the eastern part of Brandenburg Fig. 10. Registered cases and incidence of borreliosis in those German states with required notification (graphic: than the west. A typical such case is T. Talaska) the municipality of Scharmuetzelsee in the Oder-Spree district, a densely forested recreational centre for people Age-specific incidence of Lyme Borreliosis in Brandenburg Total 2001-2003 500 visiting the lake area. Inhabitants of Incidence the town of Bad Saarow stated they are 400 regularly bitten by ticks in their gardens, in which mice are very common and 300 visits by wild animals (e.g. roe deer) are 200 not uncommon. Scharmuetzelsee had 100 the highest incidence in Brandenburg in 2000, with 237 cases per 100,000 0 1150 00 inhabitants. This figure does not include Age (years) visitors from Berlin who were affected. This example shows considerable similarities to observations made in Fig. 11. Incidence of borreliosis in 2003 in municipalities and communities (database: EpiInfo 3.3 created using the USA [8]. Considering the Oder- ArcView 3.2 [23]) Spree district more closely, one finds immense differences in incidence at the local level. These ranged from 10/100,000 inhabitants in Beeskow to the previously mentioned 237/100,000 in adjacent Scharmuetzelsee. Mapping cases in the Oder-Spree district on a satellite photograph, most of the registered cases were localised close to forested wetlands. Sections with very low incidence included large agricultural areas, but even there, the few registered cases were associated with small lakes or water courses. These are best provided by several In general Brandenburg is rich in forest annual layers of slowly decomposing and wetlands, but not all forested land leaf cover, especially beech and oak. is suitable tick habitat. Ticks require Such deciduous and mixed forest tracts a moist microclimate for survival [11] together comprise less than 5% of forest and protection from the cold in winter. cover in the state. There are large areas

15 Epidemiological, biological, and ecological aspects of Lyme borreliosis

of commercial pine monoculture. Areas 1997 to 2004 shows that its proportion forested in this way are poor habitats increased from 61.7% to 84.5% over for ticks because pine needle layers that period. It is now higher than in retain less humidity directly over the soil Austria (77.7%) and the USA (76.0%) surface than deciduous leaf layers in the [24]. It is also evident that the growing warmer part of the year. Recent changes proportion of erythema migrans cases in forestry practice in this region have accompanies significant reductions in aimed at increasing the deciduous and the proportions of reported cases of mixed forest components to 40% over both the more advanced disseminated a 10-year period to return the forest borreliosis (19.2% in 1997 vs 5.6% to its original natural make-up. It is in 2004) and cases which cannot be anticipated that the extent of suitable clearly clinically classified into the tick habitat will also increase, and EUCALB case definitions (19.1% therefore provisions have been made in 1997 to 8.7% in 2004). Given the to monitor tick density and thus the notification requirement from 1996 potential risk of Lyme borreliosis in and continuing education organised by these areas (Fig. 11). the Interdisciplinary Lyme Borreliosis Advisory Group, a possible explanation Clinical data for this trend is that the early stage Erythema migrans, an early clinical of borreliosis is more frequently and manifestation, is the most common accurately diagnosed and treated due registered sign of borreliosis in all to increasing physician and patient states of Germany, and the trend from awareness. This would reduce the number of patients developing late Fig. 12. Different clinical manifestations in percentages manifestations such as disseminated borreliosis. However, these cannot be completely avoided, as a significant 100% Other proportion of infected individuals K/L 80% ACA present with the disseminated form at NB anamnesis. Only 21% of cases of Lyme 60% LA EM arthritis registered in 1999 and 2000 40% had been previously diagnosed with

20% erythema migrans. The decreasing proportion of “unclear” cases is an 0% 1997 1998 1999 2000 2003 2004 indication that Lyme borreliosis is

K/L = Karditis/Lymphadenosis cutis benigna; generally being diagnosed with more ACA = Acrodermatitis chronica atrophicans; NB = Neuroborreliosis; LA = Lyme arthritis; EM = Erythema migrans certainty. However, it is still necessary to analyse these ambiguous clinical

16 cases and if possible expand the current Fig. 13. Estimates of borreliosis occurrence in Branden- burg with and without preventive measures (highest case definitions. When analysing cases estimates) for 1997 and 2000 from 2003 and 2004, it is necessary to consider a certain bias in registered 250 manifestations toward erythema 1000 EM LA migrans due to the RKI case definition 200 800 LA/Prev of Lyme borreliosis (Fig. 12). NB -820,000 150 Considering the conservatively estima­ 600 NB/Prev Euro 100 ted cost of 10,000 Euro per case of dis­ 400 -260,000 Euro seminated borreliosis and the relatively 50 certain relationship between erythema 200 0 migrans and development of dis­ 0 1997 2000 seminated borreliosis in the absence of EM-Cases Disseminated Borreliosis intervention, the economic importance EM = Erythema migrans; LA = Lyme arthritis; NB = Neuroborreliosis of information distribution and con­ tinuing education is evident. According to this very simplified model, Fig. 14. Typical “tick biotope” in the Oder-Spree district: a garden adjacent to the forest kept close to natural about 1 million Euros could have been condition saved by the prevention campaign in Brandenburg over the last few years. (Fig. 13).

Model system in the Oder-Spree district The Oder-Spree district was chosen as a study area to analyse risk factors for borreliosis and the prevalence of Borrelia in ticks due to the high incidence of Lyme borreliosis found there. The study was carried out in conjunction with the RKI from June to December 1999. In addition, the geographic distribution of cases was One significant risk factor, as predicted, calculated to determine whether it was was activity in private gardens, random or there were indeed high- particularly those bordering the forest risk areas within the district (which, as (Fig. 14). indicated previously, is very hetero­ This is probably due to a lack of geneous). awareness of the risk, which most

17 Epidemiological, biological, and ecological aspects of Lyme borreliosis

Fig. 15. Registered cases of Lyme borreliosis in 1998 and individuals seem to associate only with 1999 in the Oder-Spree district showing the proportion of municipalities on the cluster index (Borreliosis Study, activities in the woods. Light clothing Oder-Spree District; A. Ammon, RKI 1999) is often worn while gardening and, if nobody search for ticks follows, there is a distinct risk of infection. Unfor­tunately it was also determined that, in spite of familiarity with personal pre­vention measures, they were actually carried out by only 40% of those questioned.­ This requires action by the health authorities and additional prevention strategies directed not only at individual activities. It showed that personal prevention can be very effective, when actually carried out. Our experience from the Oder-Spreewald district shows that it is

Table 1. Model system in the Oder-Spree district: incidence of registered Lyme borreliosis 2003 (Compare with incidence in Old Lyme municipality, USA 2001, 297, and 2002, 391) Municipality Mean age N clinical cases Incidence Cases/100,000 inhabitants Beeskow 34 9 100 Brieskow-Finkenheerd 55 26 311 Eisenhüttenstadt 53 62 149 Erkner 38 2 16 Friedland 63 5 146 Fürstenwalde 51 25 73 Grünheide 54 13 184 Neuzelle 55 8 111 Odervorland 47 4 68 Rietz-Neuendorf 52 5 109 Scharmützelsee 49 25 298 Schlaubetal 54 5 58 Schöneiche bei Berlin 57 11 45 Spreenhagen 44 11 142 Steinhöfel 24 1 24 Storkow 51 12 127 Tauche 63 1 23 Woltersdorf 39 4 59

18 frequently ignored [2, 9]. usually well-suited to preventing tick In the USA a comprehensive analysis of bites. practical prevention methods requiring Our study was carried out on a volunteer minimal effort was done. From the basis and included immunoglobulin-G point of view of practicability, acaricide- (IgG) examinations for seroprevalence impregnated feeding stations for wild against Borrelia burgdorferi sensu lato, animals, like those used in the USA, are as well as the pathogens causing HGE a realistic alternative. Their application (human granulocytic ehrlichiosis): requires minimal administrative effort, Anaplasma phagocytophilum, Babesia and the case reduction achieved in microtii and Rickettsia helvetica. models is very good. Unfortunately, at The risk group as a whole showed present this is not possible in Germany 29% Borrelia burgdorferi prevalence, due to the difficulty in coordinating the although borreliosis was allegedly areas of responsibility of the various diagnosed and treated in only 10.2% authorities involved. of cases. This discrepancy indicates a The geographic distribution shows significant number of asymptomatic a clear aggregation of cases in the and previously undiagnosed cases. In Oder-Spree district in particular, and fact, a questionnaire filled out after Brandenburg as a whole (Fig. 15). serodiagnosis showed that an additional Analyses of notification records show 24% of seropositive subjects described that differences in notification beha­ symptoms compatible with Lyme viour by physicians can be eliminated borreliosis. as a possible cause. Thus we can assume that the geographic factors previously A significant aggregation of sero­ discussed are responsible for this positive cases occurred in the Barnim variation in risk (Table 1) [2]. region northeast of Berlin. This population showed 6.2% positivity for Forestry workers: a risk group IgG antibodies to Anaplasma phago­ The seroprevalence of tick-borne cytophilum (FAT, Western blot). In diseases in forestry workers was the subsequent case control study, examined in a study carried out in no statistical relationship could be Berlin and Brandenburg [22]. Forestry found between HGE-positive cases workers, hunters, and forest managers and potential symptoms. Thus there is are more commonly exposed to such evidence of contact with the pathogen, diseases than the general population; but the course of infection appears to be however, they are also better informed either asymptomatic or mild. on the risks and their prevention and There are only limited data on the hence their typical working clothing is frequency of Babesia microtii antibodies

19 Epidemiological, biological, and ecological aspects of Lyme borreliosis

in humans in Europe. Our study showed bite, but we found no antibodies against a 1.4% IgG-positive prevalence (FAT, HGE or Borrelia. Western blot). Only one individual­ Rickettsia helvetica has been found complained at anamnesis of symptoms in ticks from Switzerland, Sweden, consistent with babesiosis after a tick France, and Slovenia. Clinical cases with prolonged fever, weakness, and myalgia were recorded in France. Fig. 16. Rickettsia helvetica IgG seroprevalence in Brandenburg (study from 2005) In Scandinavia, the deaths of two young athletes were attributed to perimyocarditis from training during Rickettsia helvetica IgG seroprevalence Rickettsia helvetica infection. A sample in Brandenburg 30 from the forestry worker group was Children 25 therefore tested for Rickettsia helvetica Blood donors Elderly IgG using an in-house FAT (Raoult, 30 Patients with borreliosis 28,3 Rolain, Marseilles University). A total Forestry workers 25 27,7 25 of 28.3% of individuals tested were IgG- 20 positive. Infection with other Rickettsia 15 species were found in only two cases. 0 13,3 0 These results are in agreement with IgG seroprevalence in %, n = 217 Swedish studies; Rickettsia helvetica is apparently endemic and dominant in central and northern Europe. In a current study, we are examining the Fig. 17. Map showing HGE and babesiosis sero- prevalence of Rickettsia helvetica positivity in Brandenburg IgG in children and the elderly. Our results to date show 0% prevalence for children less than 10 years old (without borreliosis). This increases to 25% in the elderly (>65 years, without borreliosis) (Figs. 16, 17). In a third group of patients with clinically and serologically proven borreliosis, this level increased to 27.7%, with co-infections probable. The clinical significance of these results still needs clarification.

Outlook Considering the borreliosis situation

20 over the past 8 years, it is apparent paralysis, by definition requires that interest in this illness, originally registration under neuroborreliosis only considered a “fashionable disease” in in cases where intrathecal antibodies are Europe, has increased markedly and present, even though it is known that that the problem of vector-associated these are not found in all cases because diseases in general is being taken more central nervous system involvement is seriously. Collection of the epidemio­ not necessary. Accurate analyses of the logical data from Brandenburg, which clinical spectrum of Lyme borreliosis according to the CDC are among the and the efficiency of prevention best available worldwide for Lyme programs are not possible using the borreliosis, would not have been present case definitions. Since these are possible without the active help of still under discussion, it is hoped that physicians, public health officials, and more inclusive versions will be forth­ the Brandenburg state Department of coming. In 2004, the RKI wrote in a Public Health and Ministry of Health. publication on zoonoses in humans: “An We hope the German federal govern­ improved database on the frequency­ of ment will also become active in the Lyme borreliosis in Germany is to be prevention of Lyme borreliosis. A posi­ strived for. A contribu­tion to improved tive signal can be see in the publication epidemiolo­gical data collection would in 2002 of the RKI Bulletin of case be achieved by including Lyme borre­ definitions for this disease conforming liosis in the list of pathogens requiring to the new IfSG. However, the inclusion official registration according to the of only erythema migrans and what IfSG” [1]. We hope this will not remain was previously termed neuroborreliosis only a dream. remains an obstacle to effective epide­ Another unsolved problem is the miological work. Lyme arthritis, development of a safe, efficacious Borrelia-related lymphocytoma, vaccine against Lyme borreliosis. The chronic neuro­borreliosis, acrodermatitis monovalent OspA vaccine approved chronica atrophicans, and Lyme carditis for use in the USA showed good immu­ were not included, in contrast with both nogenicity, but was later removed from the CDC and EUCALB definitions. We the market. A polyvalent OspC vaccine know from our own epidemiological failed to gain approval due to problems data that about 15–20% of cases fall with side effects. The development outside of the RKI definitions. This of therapeutically useful polyvalent biases the actual picture. For example, vaccines based on chimeric antigens is erythema migrans is found in only currently underway. However, it will be 21.5% of Lyme arthritis cases. Cranial some time before they are available. nerve paralysis, such as facial nerve

21 Epidemiological, biological, and ecological aspects of Lyme borreliosis

Legal bases in those - Mecklenburg-West Pomerania: State German states with Decree on the Extension of the Noti­ notification requirements for fication Requirements for Transmissible­ Lyme borreliosis Diseases According to the Federal - Thuringia: Thuringian Decree on the Epidemic Law of 5 February 1992 (a new Adjustment of Notification Requi­ version for protection against infection is rements for Infectious Diseases currently being produced) (Thüringer Infektionskrankhei­ - Berlin: Decree on the Extension of Noti­ tenmeldeverordnung, or ThürIfKr­MVO) fication Requirements for Transmissible of 15 February 2003 Diseases according to the Federal - Saxony: Decree of the Saxon State Epidemic Law of 13 January 1997 Ministry for Social Affairs on the - Brandenburg: Decree on the Extension of the Notification Requi­ Extension of Notification Requi­re­ rements for Transmissible Diseases and ments for Infectious Diseases (Infek­ Pathogens According to the Infectious tionskran­kheitenmeldeverordnung, Diseases Control Law (IfSGMeldeVo) of or InfKrankMV) of 14 December 3 June 2002 2001 (succeeding the SeuchMV of 1 - Saxony-Anhalt: Decree on the November 1996) Extension of Notification Requi­ rements for Transmissible Diseases in There is no notification requirement for the State of Saxony-Anhalt of 24 April Lyme borreliosis or positive laboratory 1997 results in the other German states.

22 l References Lyme-borreliosis: a German case-control 1. Alpers K, Stark K, Hellenbrandt study. Poster. VII. International Postdam W, Ammon A (2004) Zoonotische symposium on tick-borne diseases Infektionen beim Menschen – Übersicht 10. Gern L, Humair P-F (2002) Ecology über die epidemiologische Situation of Borrelia burgdorferi sensu lato in in Deutschland. Bundesgesundheitsbl- Europe. In: Gray JS, Kahl O, Lane Gesundheitsforsch-Gesundheitsschutz RS, Stanek G (eds) Lyme borreliosis – 47:611‑622 biology, epidemiology and control. CABI 2. Ammon A (2001) Risikofaktoren für International 149‑174 Lyme-Borreliose: Ergebnisse einer Studie 11. Kahl O (1995) Betrachtungen zur in einem Brandenburger Landkreis. RKI Ökologie der Lyme-Borreliose in der Epidemiol Bull 21:147‑149 Region Berlin-Brandenburg. In: Talaska 3. Anonymous (1994) WHO Consultation T (ed) Borreliosen in Brandenburg. on development and application of Tagung Berufsverband Med Mikrobiol. geographical methods in the epidemiology Brandenburg, pp 6‑7 of zoonoses. WHO/CDS/VPH/94.139 12. Kahl O, Gern L, Eisen L, Lane RS 4. Anonymous (2004) The vector-borne (2002) Ecological research on Borrelia human infections of Europe – their burgdorferi sensu lato: terminology and distribution and burden on public health. some methodological pitfalls. In: Gray JS, WHO Regional Office for Europe, Kahl O, Lane RS, Stanek G (eds) Lyme Copenhagen borreliosis – biology, epidemiology and 5. Danielova V (2005) The risk of tick-borne control. CABI International 29‑46 diseases rises in higher altitudes in central 13. Kimmig P (2000) Biologie von Zecken. Europe (Czech Republik). Abstract. VIII In: Kimmig P, Hassler D, Braun R (eds) International Potsdam symposium on tick- Zecken – Kleiner Stich mit bösen Folgen. borne diseases, Jena, March 2005 Ehrenwert, Munich, pp 11‑21 6. Dorn W, Flügel C, Grübner I (2002) Data 14. Kistemann T, Schweickart J, Exner M on human-biting Ixodes ricinus ticks in a (2003) Geographische Information­ region of Thuringia (Germany). Abstract. ssysteme. In: Krämer A, Reintjes R (eds) Int J Med Microbiol 291 [Suppl 33]:219 Infektionsepidemiologie. Springer, Berlin 7. Fingerle V, Schulte-Spechtel U, Göttner Heidelberg, pp 109‑116 G, Hizo-Teufel C, Hofmannn H, Pfister 15. Kurtenbach K, Schäfer SM, Michaelis K, Leonhard S, Weber K, Wilske B (2005) S de, Etti S, Sewell H-S (2002) Borrelia Detection of a new Borrelia burgdorferi s.l. burgdorferi sensu lato in the vertebrate genospecies A14S from patient material host. In: Gray JS, Kahl O, Lane RS, and ticks. Abstract. VIII International Stanek G (eds) Lyme borreliosis – Potsdam symposium on tick-borne biology, epidemiology and control. CABI diseases, Jena, March 2005 International pp 117‑148 8. Fish D (1997) Ecoepidemiology of tick- 16. Nuncio MS, Schouls LM, Pool I van borne pathogens (Borrelia burgdorferi, de, Almeida V, Filipe AR (2002) Ecoe­ Ehrlichia) in the northeastern United pidemiology of Borrelia spp. on Madeira States: implications for Europe? In: Süss J, Island, Portugal. Abstract. Int J Med Kahl O (eds) Tick-borne encephalitis and Microbiol 291 [suppl 33]:212 Lyme borreliosis. Pabst Science Publishers, 17. Ohlenbusch A (1996) Beiträge zur pp 15‑20 Diagnostik und Pathogenese der Lyme- 9. Fitzner J, Ammon A, Baumann I, Talaska Borreliose und zur Transmission des T, Schönberg A, Stöbel K, Fingerle V, Erregers Borrelia burgdorferi. Cuvillier, Wilske B, Petersen L (2001) Risk factors in Göttingen

23 Epidemiological, biological, and ecological aspects of Lyme borreliosis

18. Schöder W (2005) GIS, geostatistics, 22. Talaska T, Bätzing-Feigenbaum J (2001) metadatabanking and tree-based Waldarbeiterstudie Berlin-Brandenburg models for data analysis and mapping 2000 zu zeckenübertragenen und anderen in environmental and epidemiology. Zoonosen. RKI Epidemiol Bull 16:109‑110 Abstract. VIII International Potsdam 23. Talaska T, Ober A, Hoffmann C, symposium on tick-borne diseases, Jena, Schweickart J, Pieper J, Dreissig M March 2005 (2005) Epidemiological analysis of 19. Schweickart J, Kistemann T, Leisch H Lyme borreliosis in the Federal Land (1998) Der Arbeitskreis “Medizinische Brandenburg with GIS. Abstract. VIII Geographie”. Eine interdisziplinäre International Potsdam symposium on tick- Antwort auf gesundheitsrelevante borne diseases, Jena, March 2005 Fragestellungen. HHG-J 12:245‑250 24. Tylewska-Wierzbanowsk S (1995) Country 20. Stanek G, O’Connell S, Cimmino M, Reports/WHO Workshop on Lyme Aberer E, Kristoferitsch W, Granström borreliosis – diagnosis and surveillance. M, Guy E, Gray J (1996) European Union WHO/CDS/VPH/95.141-1 concerted action on risk assessment in 25. Zeman P, Benes C (2004) A tick-borne Lyme borreliosis: clinical case definitions encephalitis ceiling in central Europe has for Lyme borreliosis. Wiener Klin moved upwards during the last 30 years: Wochenschr 106:741‑747 possible impact of global warming? Int J 21. Strle F (1999) Lyme borreliosis in Slovenia. Med Microbiol 293 [suppl 37]:48‑54 Zentralbl Bakteriol 289:643‑652

24 Rheumatological and other internal manifestations of Lyme borreliosis l Andreas Krause

yme arthritis is one of the most arthritis is Borrelia burgdorferi sensu Lcommon and clinically important stricto. The fact that this is the only manifestations of Lyme borreliosis. It species known to cause Lyme borre­ was discovered and first described about liosis in the USA explains why Lyme 30 years ago due to a local aggregation arthritis occurs more frequently there of cases in children in the municipalities than in Europe or Asia. Although of Lyme and Old Lyme in Connecticut, Borrelia garinii and Borrelia afzelii are USA. In addition, systemic infection considerably more common in Europe with Lyme borreliosis can lead to than Borrelia burgdorferi sensu stricto, numerous other rheumatological various studies of patients with Lyme and generalised internal symptoms, arthritis have found either comparable knowledge of which is of particular frequencies of all three species or importance for differential diagnosis of predominantly Borrelia burgdorferi the various clinical pictures. sensu stricto. These data confirm the particularly athritogenic significance of All three species of Borrelia burgdorferi Borrelia burgdorferi sensu stricto while sensu lato known to be human patho­ indicating that Borrelia garinii and gens (Borrelia burgdorferi sensu stricto, Borrelia afzelii play an important role Borrelia garinii, Borrelia afzelii) can in causing Lyme arthritis in Europe [1, cause internal symptoms. Whether the 3, 4, 9, 10, 15]. other Borrelia species recently isolated from patients with Lyme borreliosis Clinical picture (e.g. Borrelia valaisiana, Borrelia It is impractical to divide the clinical lusitaniae, Borrelia bissettii) are patho­ course of Lyme borreliosis into three gens remains unclear. stages, as was previously common, as this incorrectly suggests that victims The most important cause of Lyme must go through all these stages and

25 Rheumatological and other internal manifestations of Lyme borreliosis

that chronic infections become more Lyme arthritis patients with antibiotic disseminated with the involvement of treatment need not fear developing more and more organ systems. In truth, chronic neuroborreliosis. A possible Lyme borreliosis follows a variable explanation for this is the organ course with a wide variety of symptoms. specificity of the different Borrelia It can spontaneously heal at any phase burgdorferi species, which attack organ or be arrested through the action systems preferentially. of antibiotics. Except for the early It has proven clinically valuable, however, cutaneous manifestation, erythema to divide Lyme borreliosis into an early or migrans, Lyme borreliosis usually acute stage (with the pathogenic stages affects a single organ system, presuming of local and disseminated infection), and a antibiotic treatment has followed the late or chronic stage (persistent infection) diagnosis. Thus for example a patient showing different clinical pictures and suffering from acute neuroborreliosis variable degrees of response to antibiotic usually does not get Lyme arthritis, and treatment (Table 1).

Table 1. Rheumatological and other internal manifestations of Lyme borreliosis (from [3, 8]) Organ system/phase Symptoms Comments General symptoms Early phase Feeling of illness, headache, Can be pronounced, no respiratory subfebrile temperatures, or gastrointestinal symptoms lymph node swelling Chronic phase As in the acute phase Mostly less distinct Heart Early phase Perimyocarditis Uncommon, typical AV block with changing grade, usually complete recovery Chronic phase Dilated cardiomyopathy, Questionable, individual cases ventricular extrasystoles Musculoskeletal system Early phase Arthralgia and myalgia Rarely fleeting arthritis Chronic phase Arthritis, myositis, Intermittent, uncommon chronic bursitis, enthesitis persistent arthritis, mainly in the knee joint, not the axis skeleton, myositis is uncommon Other Early phase Hepatomegaly, hepatitis, Practically never clinically relevant splenomegaly Chronic phase Vasculitis Uncommon, can lead to ischaemia

26 Particularly in the early phase, many clinical significant. Hepato- and spleno­ patients have the feeling of being ill. megaly, increased hepatic enzyme levels, Swollen lymph nodes and subfebrile and pathological urine results in Lyme temperatures are also possible. These borreliosis patients have been described, symptoms can be especially evident at but relevant functional disturbances of the beginning of the infection. Respiratory the corresponding organs have not been or gastrointestinal symp­ toms,­ however, documented. are not part of the symptomatology of Lyme disease and are therefore helpful Rheumatological symptoms can occur in differentiating it from other infectious relatively early in the course of the disease diseases. During the chronic phase, these (within weeks), with arthralgia, myalgia, or unspecific signs of infection are less mild short-term arthritides of individual common and weaker. joints. The typical manifestation of Lyme arthritis occurs however in the chronic Lyme carditis is rare, occurring in less phase (several weeks to months after that 5% of patients. As heart invol­ infection). Due to its variable latency, there vement is often subclinical or only is no seasonal aggregation of new cases. accompanied by unspecific symptoms, Arthritis usually manifests as mono- or it is possible for transitory rhythm oligoarthritis,­ with 85% of cases involving disturbances or partial atrioventricular at least one knee joint. The ankle and (AV) block to go unnoticed if they are elbow joints can also be involved, while not consciously sought. Dramatic and involvement of finger joints, especially potentially lethal complete AV blocks, as polyarthritis, has only rarely been which can require temporary pacemaker­ recorded. Individual exceptions are the treatment, are rare and usually are arthropathies that appear in association rapidly cured with antibiotic and steroid with acrodermatitis chronica atrophicans therapy. Whether Lyme borreliosis leads and often involve toe or finger joints. Due to dilated cardiomyopathy­ (DCMP) to the frequency with which these occur in the late phase is still controversial. together, they are commonly referred to On the one hand, sporadic borrelia- as arthrodermatitis. like structures have been detected in The course of Lyme arthritis is usually myocardial biopsies, while on the other, sporadic, with recurring inflammation serological studies do not suggest an interrupted by intervals in which the association between dilated cardio­ intensity of symptoms is reduced or they myopathy and Lyme borreliosis. disappear completely. Over time, these intervals may shorten and the arthritis The involvement of other internal becomes chronic. Synovial analysis organs is possible but is usually not shows acute arthritis with dramatically

27 Rheumatological and other internal manifestations of Lyme borreliosis

increased white cell counts of up to a special rheumatological problem. In 50,000/µl, predominantly neutrophils. spite of regression of inflammatory Histological findings for the synovial manifestations with antibiotic therapy, membrane in chronic Lyme borreliosis some patients show persistent unspecific cannot be distinguished from those in symptoms such as arthralgia, myalgia, rheumatoid arthritis. sleep disturbances, and fatigue, while Accompanying manifestations related to others report headache as well as memory the musculoskeletal system are bursitis and concentration disturbances. Some and tenosynovialitis. Important for the patients show only transient symptoms in differentiation from other, clinically the previously inflamed joints. In children, similar spondylarthritides is that the axial both cognitive and psychiatric changes skeleton, as for example in sacroiliitis, is such as fear and depression have been not involved in Lyme arthritis. Moreover, recorded. Late start of therapy is a risk there are no typical symptoms clearly factor associated with these problems. differentiating Lyme arthritis from other Many patients with post-Lyme syndrome inflammatory joint diseases. are severely handicapped by the In addition to the myalgia frequently continuing symptoms and suffer from found in the early phase, chronic Lyme significantly reduced quality of life. The arthritis can on rare occasions develop course is similar in many ways to that into manifest, proximally accentuated of chronic fatigue syndrome and fibro­ myositis leading to muscle weakness myalgia. Recent studies have shown and atrophy. that, contrary to the fear nourished With early diagnosis and treatment, by uncertainty and information from Lyme arthritis has good prognosis less authoritative sources, the risk of and usually heals without further con­ contracting this syndrome is very low. A sequences. Erosive courses with chronic comparison of previous Lyme borreliosis arthritis have been reported but are patients and an age-matched control rare. For some patients with Lyme group showed good health in both arthritis, cure is not achieved even after groups and similar frequency of common multiple antibiotic treatments. In the unspecific symptoms. Only those patients USA this proportion is estimated at 10% with, for example, neuroborreliosis who of patients; the epidemiological data had received inadequate or late antibiotic for Europe are not adequate for such treatment were more likely to suffer from an estimate. Evidence suggests that residual neurological symptoms and pain. these antibiotic-resistant cases involve Patients with Lyme arthritis at anamnesis infection-triggered immunopathological complained more of knee pain. mechanisms [1, 3, 5, 14]. In two placebo-controlled studies, So-called post-Lyme syndrome represents symptoms showed a variable course

28 that was not influenced by antibiotic anamnesis, and corroborated by positive therapy. It is hypothesised that serology. Because direct detection of Borrelia infection triggers autoimmune the pathogen is uncommon, generally or neurohormonal processes which Lyme arthritis can be diagnosed with continue some time after the pathogen certainty only after the elimination of itself has been eradicated, and which in many differential diagnoses. turn cause the symptoms experienced. Thus, although an optimal pathogen- Differential diagnosis for Lyme oriented treatment is still lacking, arthritis (most important examples) irrational use of antibiotic therapy, includes: with its potentially severe side effects - Gout should be avoided [1, 2, 3, 6, 7, 15]. - Pseudogout - Septic arthritis Diagnosis and differential - Löfgren’s syndrome diagnosis - Reactive arthritis General symptoms, fever and lymph - Psoriatic arthritis node swelling, are not specific to - Enteropathic arthritis Lyme disease, opening up a range of - Rheumatoid arthritis (atypical onset) differential diagnoses which must be eliminated through anamnesis and Typical for Lyme arthritis is uni- or looking for more specific manifestations bilateral involvement of the knee joint of the disease. with synovialitis and usually voluminous Any myocarditis can be a manifestation effusion (Fig.1). This frequently leads of Lyme borreliosis, especially when to extended Baker’s cysts, which often a high-grade AV block is present. As additional specific symptoms are Fig. 1. Lyme arthritis of the right knee lacking, anamnesis with tick bite, erythema migrans, and Lyme serology are of particular diagnostic importance. Other causes of myocarditis must be eliminated as well, since positive Borrelia serology cannot prove the presence of Lyme borreliosis (see below). Lyme arthritis must be considered in the differential diagnosis of new cases of mono- or oligoarthritis. The diagnosis must be based on clinical findings and

29 Rheumatological and other internal manifestations of Lyme borreliosis

rupture. In addition, there is also a acrodermatitis chronica atrophicans frequent discrepancy between pro­ can be diagnostically suggestive. Lyme nounced local findings and only limited arthritis, however, is often the first and pain. Other large joints of the upper and only manifestation of Borrelia infection lower extremities are less commonly and it is precisely these cases that make involved. In contrast to infection-reactive diagnosis so difficult [1, 4]. arthritides, isolated hand and arm joint involvement is quite possible in Lyme The diagnostic gold standard for an arthritis. Otherwise, the symptoms of this infectious disease is demonstration disease are ambiguous and unspecific of the pathogen’s presence. Due to when considered alone. Polyarthritis this pathogen’s characteristics and its of smaller joints suggests either a low density, determining the presence viral or autoimmune-based disease, of Borrelia burgdorferi using culture and involvement of the axis skeleton methods is difficult, time-consuming, and, indicates one of the spondylarthritides. with Lyme arthritis, of low sensitivity and Important anamnestic clues to the hence unsuitable for clinical diagnostics. presence of Lyme arthritis include Therefore, polymerase chain reaction increased risk of exposure to ticks (PCR) is increasingly used for direct (occupational or especially recreational determination of the pathogen. This gardening), previous tick bite, and method can detect the presence of obviously, a recent untreated or Borrelia DNA in synovia and synovial inadequately treated erythema migrans. membrane from untreated patients with a It is highly unlikely that Lyme arthritis sensitivity approaching 80% (Table 2) [9, will develop after adequately treated 12, 13, 16]. Information on its sensitivity erythema migrans, however if anamnesis with muscle biopsies from myositis indicates exposure to ticks and increased patients is not available. False positive risk of tick bites, the possibility of results are uncommon, so this test has a new infection should be taken into high specificity. It is important to note consideration. Unfortunately, less however that PCR does not demonstrate than 50% of Lyme arthritis patients the presence of viable pathogens, remember a tick bite, and decidedly only pathogen DNA. Nevertheless, a fewer, a previous erythema migrans. positive PCR result is now interpreted Previously untreated erythema migrans as a demonstration of the presence of and neuroborreliosis are now less the pathogen and thus as an indication common due to increased knowledge for therapy. Various protocols and test of the disease and therefore of adequate systems are now available; however, their antibiotic therapy. Occasionally suitability to routine diagnostics needs the association of arthritis with to be validated. PCR is fast becoming

30 an established component of laboratory Due to the high sensitivity of the test, diagnostics, particularly for Lyme a false negative serology for Lyme arthritis [9, 11, 12, 16]. arthritis is very unlikely. However, the lack of IgM antibodies does not The most common laboratory method exclude a current infection or active for routine diagnosis is serology, i.e. illness. The main problem here lies determining the presence of specific in the interpretation of serological antibodies against Borrelia burgdorferi findings: positive IgG values in the (see the relevant chapter in this book). chronic phase of Lyme borreliosis are In the early phase of infection, Borrelia indistin­guishable from positive titres serology is often still negative, as after an acute illness or infection (so- measurable concentrations of anti­ called serum scar). This means that bodies develop slowly over weeks. the banding pattern on immunoblot Given continued clinical suspicion, a does not allow determination of the short-term serological examination time of infection or inference of a of disease progression demonstrating possible ongoing infection. Immune seroconversion will confirm the responses are individual, in part diagnosis. In chronic phases of the genetically determined and dependent illness such as Lyme arthritis, serology on, for example, extruded pathogen is less problematic, as in general there antigens. The antibody response is are clearly positive antibody values therefore also variably strong and in for a whole series of Borrelia antigens. some cases nonexistent. The value of Significantly elevated IgG levels can a positive Borrelia serology is thus be found but, in spite of pathogen dependent on the clinical symptoms. persistence, specific IgM antibodies are Only in cases with sufficient clinical seldom detected. In other cases, IgM evidence does positive serology have antibodies can persist for years after high diagnostic value. In those with successful treatment and thus cannot unspecific symptoms however, positive be used as an indication for therapy or serology is of limited diagnostic value. evidence of persistence of the infection. Due to the high sensitivity of the test,

Table 2. Sensitivity of methods for direct proof of B. burgdorferi (from [16]) Material Sensitivity Skin biopsy (erythema migrans, acrodermatitis) 50–70% in culture or PCR Liquor (acute neuroborreliosis) 10–30% in culture or PCR Synoviaa 50–70% in PCR aEven higher sensitivity (up to 80%) by examination of the synovial tissue

31 Rheumatological and other internal manifestations of Lyme borreliosis

negative serology practically eliminates - Positive Borrelia PCR for the synovia the diagnosis of Lyme arthritis. or synovial membrane Given the slowness of changes in immune response during the chronic Depending on the constellation of phase, successive examinations over findings, it is possible to distinguish time are seldom helpful, as they produce between certain, probable, and significant findings only at intervals of possible Lyme arthritis. This also helps several months. In such cases, chronic indicate the possible need for critical borreliosis can often be surmised with re-examination of the diagnosis during only a limited probability but seldom the course of the disease. If the first proven [3, 5, 13, 16]. four criteria are fulfilled, e.g., when An additional difficulty stems from the fact the arthritis is associated with obvious that serological tests are not standardised; acrodermatitis chronica atrophicans tests performed in different laboratories in a patient with highly positive often provide different results, which Borrelia serology, then the findings are could be mistakenly interpreted as the unequivocal and allow definite diagnosis. titre course or an effect of therapy. This The same is true for gonarthritis patients commonly leads to false diagnosis, with positive serology, and positive unnecessary fears of continued disease Borrelia PCR result from synovial fluid progression, and unnecessary treatment. once the differential diagnoses have Thus Lyme arthritis can be diagnosed been excluded. In practice however, with sufficient certainty either by standard the suspected diagnosis is based only anamnesis and clinical symptoms together on criteria 2 and 4, leaving diagnostic with positive serology or, in case of less uncertainty, and even after eliminating typical symptoms, by demonstrating other possible diagnoses, one can only the presence of the pathogen. A careful speak of a probable diagnosis; or, for rheumatological differential diagnosis is example, if there is also psoriasis that also always necessary. cannot be excluded by other cause, only a diagnosis of possible Lyme arthritis Criteria for the diagnosis of Lyme remains [2, 4, 8, 10]. arthritis - Association with pathognomonic Therapy extra-articular manifestations Antibiotic therapy should be started as - Typical pattern of joint involvement soon as possible after diagnosis in order - Exclusion of possible differential to shorten the course of the disease, diagnoses cure it, and prevent progression or - IgG antibodies against Borrelia the development of chronic disease. burgdorferi Treatment is stage- and symptom-

32 oriented, with doxycycline, amoxicillin, pulse therapies, combination treatment, and ceftriaxone being the drugs of and the use of antibiotics other than choice. The current internationally valid those listed [6,7]. Therapy-resistant standard treatment recommendations Lyme arthritis occurs in about 10% of are listed in Table 3. patients in the USA but is probably less common in Europe. Useful treatment The success rate of antibiotic therapy can include intra-articular steroid is high, and therapy-resistant cases injections (only after antibiotic therapy!), are rare. In the acute phase, a single radiosyno­viorthesis, and synovectomy. treatment cycle almost invariably leads Otherwise, symptom-oriented treatment to a cure, although general, unspecific is recommended together with an symptoms sometimes take a long time explanation to the patient that the to disappear. The success rate of the disease will not spread and usually first therapy for Lyme arthritis is about improves slowly over time, possibly 80%. If patients still have symptoms many months. The general prognosis after several weeks, a second and later for Lyme arthritis and the other forms at most a third treatment with parenteral of Lyme borreliosis discussed is very antibiotics should be carried out. good [1, 2, 3, 4, 17]. Early studies on Recent studies have shown that further Lyme arthritis have shown that 10% antibiotic treatment is inefficacious, of cases heal spontaneously within a as are long-term therapies, high-dose year, and that antibiotic therapy initiated

Table 3. Therapy for Lyme borreliosis [1, 2, 3, 4, 10, 17] Manifestation Drug Dose/day Duration (dose for childrena) (days) General symptoms, Doxycycline 1x200 mg or 2x100 mg orally 14-21 acute phase Amoxicillin 3x500-750 mg or 2x1,000 mg orally 14-21 (corresponds to (50 mg/kg) therapy for Azithromycinb 2x500 mg orally 1 erythema migrans) 500 mg 2-5 Cefuroxime Axetilb 2x500 mg orally 14-21 Carditisc Ceftriaxone 1x2 g i.v. 14 Cefotaxim 3x2 g i.v. 14 Penicillin G 4x5 million U i.v. 14 Arthritis, myositis Doxycycline 1x200 mg or 2x100 mg oral 30 (-40) Amoxicillin 3x500-750 mg or 2x1,000 mg oral 30 (-40) Ceftriaxone 1x2 g i.v. 14-21 Cefotaxim 3x2 g i.v. 14-21 aAdult dose corresponds to maximum dose bOnly in case of allergies or contraindications against doxycyline and amoxicillin cIn patients with 1st grade AV Block, the oral therapy (14-21 days) is indicated

33 Rheumatological and other internal manifestations of Lyme borreliosis

even several years after disease onset is Laboratory findings showed limited effective [14]. humoral inflammatory activity with increased erythrocyte sedimentation Case studies rate and elevated C-reactive protein First case description (CRP). All other routine parameters A 38-year-old male patient had were normal. The patient was human complained for 4 months of painful leukocyte antigen (HLA)-B27- swelling in the right knee. As this negative. Borrelia serology was highly problem first occurred after a skiing positive for IgG antibodies against holiday, trauma was suspected, although Borrelia burgdorferi using enzyme- the patient could not remember such linked immunosorbent assay (ELISA). incident. Magnetic resonance imaging Immunoglobulin-M antibodies were not showed minor chondropathy and present. These results were confirmed degenerative changes to the outer by immunoblot using antibodies against, meniscus. Symptomatic treatment among others, the proteins OspC, p39, with diclofenac led to only short-term flagellin, VlsE, and p83/100. Analysis of improvement. Further anamnesis synovial fluid from the right knee joint showed no significant previous illness. showed a highly inflamed knee effusion About a year previously, the patient had with 10,000 leukocytes/mm3 (90% been bitten on the left side of the chest neutrophils).­ Probable Lyme arthritis by a tick probably while working in the was diagnosed that likely resulted from garden. The tick had been removed with the reported tick bite. Whether the a tweezers. Shortly thereafter, erythema erythema following the tick bite was occurred which lasted 1 day and then erythema migrans remains unclear. spontaneously disappeared. Indications Its regression after only 1 day suggests for another cause of the arthritis, that this was not the case, although additional rheumatological symptoms, erythema migrans is sometimes very and extra-articular manifestations pale and can go unnoticed by patients. were neither reported nor found on Oral treatment with 200 mg/day of clinical examination. The latter was doxycycline was initiated. Acemetacin unre­markable with the exception (60 mg) as required was given as an of florid, left-sided gonarthritis with anti-inflammatory in addition to cold substantial synovitis. Arthrosonography treatment and physiotherapy. The confirmed this finding and showed arthritis healed slowly under this partly edematous, partly proliferative treatment, with symptomatic treatment synovialitis, and joint swelling with a continuing 4 weeks after the antibiotic poor echo (estimated volume 50 ml) but therapy was finished. The patient was no popliteal cyst. symptom-free after 3 months.

34 Second case description A diagnosis of active right-sided valgus A 55-year-old, obese female had gonarthritis was made, with probable complained for several months of pain psoriatic spondylarthritis associated in the right knee. Additionally, she had with HLA-B27, and Lyme borreliosis with had lumbar back pain for “as long as she erythema migrans 6 years previously. could remember”. Anamnesis indicated There was no evidence of florid Lyme psoriasis vulgaris from early adulthood disease. and typical erythema migrans on the Sacroiliitis does not manifest in Lyme left upper thigh 6 years previously that arthritis. Synovial analysis clearly had been treated for 2 weeks with an showed that the knee problems, which unknown antibiotic. She suffered tick could also be related to psoriatic bites every year. Having changed her arthritis in differential diagnosis, general practitioner shortly before, did not result from Lyme arthritis the new physician conjectured that but, taken together with the other her rheumatological problems were clinical and radiological findings, caused by Lyme arthritis. A serological were apparently caused by active examination was positive. arthritis. The serological findings also From the clinical rheumatological point speak against Lyme arthritis, as the of view, both iliosacral joints were typical clearly positive IgG antibody markedly swollen and painful when response against numerous Borrelia moved, and the right knee joint showed proteins, e.g. VlsE and p38/100, was malposition of the valgus with light not present. The findings suggest inflammation. Subsequent anamnesis a serum scar after Lyme borreliosis indicated, at least for earlier years, an some years previously. The erythema inflammatory character to the back pain migrans 6 years earlier helps to explain with a distinct maximum in the early this serological result. An association morning and reduction with movement. between Borrelia and the current Radiology showed bilateral sacroiliitis rheumatological problems could not be and right-sided gonarthritis. made due to the time span involved. In Laboratory findings showed increased addition, the development of a disease values for erythrocyte sedimentation rate course involving an organ cannot be and CRP. Human leukocyte antigen-B27 expected after adequate antibiotic was present. Borreliosis serology was treatment of erythema migrans. This positive, with low titres of IgG against case shows how carefully a serological OspC, flagellin, p58, and p60. Analysis of finding must be interpreted in relation synovial fluid from the knee showed less to clinical symptoms and other results. than 1,000 leukocytes/mm3, as seen in arthritic irritation.

35 Rheumatological and other internal manifestations of Lyme borreliosis

l References 10. Nationales Referenzzentrum für Borrelien 1. Burmester GR, Kamradt T, Krause am Max von Pettenkofer-Institut München. A (2004) Lyme disease. In: Isenberg http://pollux.mpk.med.uni-muenchen.de/ DA, Maddison PJ, Woo P, Glass D, alpha1/nrz-borrelia/lb/frame-lb.html Breedveld FC (eds) Oxford textbook of 11. Nocton JJ, Dressler F, Rutledge BJ, Rys rheumatology. pp 613-620 N, Persing DH, Steere AC. Detection of 2. European Union concerted action on Lyme B. burgdorferi DNA by polymerase chain borreliosis (EUCALB). http://www.dis. strath. reaction in synovial fluid in Lyme arthritis. ac.uk/vie/LymeEU/index.htm N Engl J Med 330: 229-234, 1999 3. Franz JK, Krause A: Lyme disease (Lyme 12. Priem S, et al. Detection of Borrelia borreliosis). Best Practice & Research Clinical burgdorferi by polymerase chain reaction Rheumatology 17: 241-264, 2003 in synovial membrane, but not synovial 4. Herzer P, Krause A. Lyme-Borreliose. In: fluid from patients with persisting Lyme Classen M et al. (Hrsg.) Rationelle Diagnostik arthritis after antibiotic therapy. Ann und Therapie in der Inneren Medizin, Rheum Dis 57: 118-121, 1998 Urban&Fischer, München, 2006, in press 13. Quality standards for the microbiological 5. Huppertz HI, Krause A. Lyme-Borreliose. diagnosis of infectious diseases: Internist 44: 175-183, 2003 Lyme-Borreliose (MiQ 12 2000 Lyme 6. Kalish RA, et al. Evaluation of study patients Borreliosis). with Lyme disease, 10-20-year follow-up. J http://pollux.mpk.med.uni-muenchen.de/ Infect Dis 183: 453-460, 2001 alpha1/nrz-borrelia/miq-lyme/frame-miq- 7. Klempner MS, et al. Two controlled trials lyme.html of antibiotic treatment in patients with 14. Steere AC, Schoen RT, Taylor E. The clinical persistent symptoms and a history of Lyme evolution of Lyme arthritis. Ann Intern Med disease. N Engl J Med 34: 85-92, 2001 107: 725-731, 1987 8. Krause A, Herzer P. Frühdiagnostik der Lyme- 15. Steere AC, Coburn J, Glickstein L. The Arthritis. Z f Rheumatol 2005 (in press) emergence of Lyme disease. J Clin Invest 9. Lünemann J, et al. Rapid typing of Borrelia 113: 1093-1101, 2004 burgdorferi sensu lato species in specimens 16. Wilske B. Diagnosis of Lyme borreliosis in from patients with different manifestations Europe. Vector-Borne Zoonotic Dis 3: 215- of Lyme borreliosis. J Clin Micrbiol 39: 227, 2003 1130-1133, 2001 17. Wormser GP, et al. Practice guidelines for the treatment of Lyme disease. Clin Infect Dis 31: 1-14, 2000

36 Dermatological manifestations of Lyme borreliosis l Elisabeth Aberer

s the organ contacting the What happens after a tick bite? Aenvironment, the skin is exposed The transmission of Lyme borreliosis to many external influences. It is by ticks, in Europe predominantly by also a point of entry for pathogens, the Ixodes ricinus species, is reported which spread via the skin if the in only about 60% of patients [30]. barrier function or immune system Studies have shown that insects such is no longer intact. In contrast, the as mosquitoes, horse flies, sandflies, transmission of pathogens such as gnats, and wasps have no organ Borrelia spp. by arthropods can occur suitable for survival of the Borrelia in fully healthy individuals. pathogen as exists in the tick gut [13]. Whether Lyme borreliosis (LB) manifests, leading to a specific clinical Unspecific arthropod reactions picture, depends on the genetic After a tick has attached to the skin for an disposition of the patient, duration extended time, a local immune reaction of the tick bite and virulence of the occurs that, however, may go unnoticed. pathogen [20, 22, 26, 28]. An itchy swelling or lump may then form Cutaneous symptoms of LB were at the site of the bite, from which a tick already recognized many decades granuloma can develop. An inflamed before discovery of the pathogen, patch several centimetres in diameter can Borrelia burgdorferi, by W. Burgdorfer also develop and then disappears over a in 1983. It has also been known since number of days. the 1950s that erythema migrans (EM), Borrelia lymphocytoma (BL), and Classic cutaneous symptoms of acrodermatitis chronica atrophicans Lyme borreliosis (Table 1) (ACA) can be successfully treated Erythema migrans with penicillin [19, 21]. Erythema migrans can develop from an

37 Dermatological manifestations of Lyme borreliosis

unspecific reaction to a tick bite after Children often show a unilateral only 1–2 days. It is characterised by a reddening of a cheek or a stripe that is slowly expanding inflamed patch. In only visible on some days. Temporary most cases however there is a latent disappearance followed by reappearance phase of 4–20 days before the formation of the erythema has been reported. of this patch. If not treated, it can Rubbing a suspect location with increase to 50 cm or more in diameter. a wooden spatula can lead to re- The erythema can vary in form from appearance of the erythema. round to oval to irregular. Subjectively it can lead to slight itching. Local lymph node swelling is possible [11, 28]. Fig. 2.

Clinical forms of erythema migrans - The color can be bluish in the center while the edge is bright red. There are often streaky or patchy radial branches at the periphery (Fig. 1). - A bright red, moving ring can form, with healing in the center (Fig. 2). - A small vesiculous variant can appear (Fig. 3). - A homogenous erythema without a marked border can form (Fig. 4).

Fig. 1. Fig. 3.

38 Fig. 4. Disseminated early infection While only about two thirds of patients have only cutaneous infection (erythema migrans minor), the remaining third have simultaneous, generalised symptoms as a sign of haematogenic dissemination [34]. Patients with this EM major form report flu-like symptoms, light fever, headache, joint and muscle pain, swollen lymph nodes, and fatigue. Occasionally, rapid heartbeat and cardiac rhythm disturbances are observed [23]. Multiple EM lesions can also result from haema­ togenic dissemination as well as from

Table 1. Differential diagnosis of Lyme borreliosis Cutaneous manifestation Differential diagnosis Erythema migrans Bluish center Fixed drug eruption Morphea Homogenous reddening Fixed drug eruption Erysipeloid Subacute cutaneous lupus erythematosus Vesicular form Contact dermatitis Herpes simplex Multiple erythemata Urticaria

Borrelia lymphocytoma On the ear Othaematoma Erysipelas Relapsing polychondritis On the mamilla Breast cancer In other places Malignant lymphoma

Acrodermatitis chronica atrophicans Light red discoloration of the distal extremities Stasis dermatitis Diffuse livid discoloration Chronic venous insufficiency Venous thrombosis of the leg Acral form: fingers/toes Acrocyanosis Livid reticular discoloration on the extremities Phospholipid antibody syndrome Livedo reticularis/racemosa

39 Dermatological manifestations of Lyme borreliosis

simultaneous infection from multiple the helix, and a flat node one or more tick bites. centimetres in size in the scrotal area. BL may also occur on one mammilla Erythema chronicum migrans or areola mammae as an enlargement If not treated, EM can last several weeks or nodular lesion (Fig. 6). These nodes or months while growing continuously. can start in an expanding EM that the Spontaneous healing is possible, but its patient may or may not remember. frequency is difficult to determine. As EM often occurs on the heads of children, the redness frequently goes Borrelia lymphocytoma unnoticed and a lymphocytoma on the Borrelia Lymphocytoma (BL) was ear is the first recognised symptom. first described as lym­phadenosis cutis benigna (Bäfverstedt’s disease), a Acrodermatitis chronica pseudolymphoma with mixed polyclonal atrophicans B and T cell proli­feration [6]. After Acrodermatitis chronica atrophicans a latent period of several weeks, BL begins as an inconspicuous, poorly most commonly manifests in children defined reddening of the skin (Fig. 7), as a reddish to bluish node in the area subjectively without symptoms, which of the earlobe (Fig. 5), livid reddish becomes slowly darker. It occurs on discoloration­ or swelling in the area of the distal extremities, elbows, extensor

Fig. 5. Fig. 6.

40 Fig. 7. tick bite, the patient noted a burning sensation and weakness in both thighs as well as a bright red discoloration with undefined borders and light swelling in the left ankle region. This led her to visit a dermatologist, where finally ACA was diagnosed clinically and verified with a biopsy and serology (Fig. 7). The dermatological changes healed under antibiotic treatment with 2 g of ceftriaxone daily for 15 days. The accompanying neuropathy improved slowly.

Comments The clinical course of ACA can rarely be studied so clearly. This patient distinctly shows the clinical persistence of the disease as described in the literature [14, 29]. Reactivation sides of the upper arms, back of the of Borrelia burgdorferi and the hand, and upper and lower legs. development of ACA were also found in two other patients, one injured on Case reports a rose thorn while gardening and the The development of ACA with other on a metal spike at home. This neuropathy. A 57-year-old female indicates that latent infections occur observed an EM on her lower leg after in the extremities where temperature a tick bite. Correct diagnosis was not is lower, the optimum Borrelia growth made, and the erythema spread to temperature being 33–34°C. the upper thigh and buttocks over Bluish, cushion-like swellings also the next 2 years. After 3 years an develop in ACA. Sometimes individual enlarged lymph node was removed fingers are swollen and discolored blue from the right inguinal area which (Fig. 8). Swelling of the feet can lead to showed unspecific lymphadenitis. The the patient’s requiring a larger shoe size. patient reported intermittent redness More reticulate discoloration can occur on the buttocks. Two years later, left- on the extensor sides of the upper arms sided bartholinitis appeared and later and thighs. The skin gradually becomes disappeared. Twelve years after the thin and wrinkled, and the bluish

41 Dermatological manifestations of Lyme borreliosis

Fig. 8. discoloration decreases. A thin, almost transparent skin remains, with blood vessels visible underneath (Fig. 9). The neuropathy often reported by patients does not respond to antibiotics as well as the dermatological changes do [12]. Solid, extra-articular (fibrous) nodes form over the elbows, knees, and finger joints. These can easily be lifted in a fold of the skin and, unlike rheu­ matic nodes, are not painful. Skin sclerosis is possible in shin and underarm extensor regions (tibial and ulnar bands) where ACA is present. This can be differentiated from linear scleroderma by its undefined edges. In addition to classic ACA, anetodermic­ lesions can occur also. Fig. 9. Genospecies-specific courses of Lyme borreliosis The species Borrelia burgdorferi sensu lato is subdivided into three genospecies: Borrelia burgdorferi sensu stricto, Borrelia afzelii, and Borrelia garinii; all three of these can cause EM. Various genospecies-specific courses of EM have been reported [7]. Of these, only Borrelia burgdorferi sensu stricto is found in the USA. This species causes the least number of Borrelia infections in Europe. In our study in the Vienna area, Borrelia burgdorferi sensu lato was isolated from the skin of 28 patients. Of these, 23 had Borrelia afzelii (17 with EM, six with ACA), three had Borrelia garinii (all with EM), and two had Borrelia burgdorferi sensu stricto

42 infection (one with EM, one positive Generalised and local symptoms occur blood culture in disseminated LB). In in three quarters of Borrelia garinii and around the city of Graz, Austria patients but only a third of Borrelia 11 strains were isolated, of which five afzelii patients [5, 17]. were Borrelia garinii from EM and six Borrelia afzelii (four EM, one ACA, Symptoms after one morphea). A similar pattern has erythema migrans been found in other studies [25]. For A case of EM is clinically cured with the other cutaneous symptoms, BL is 2–3 weeks of antibiotic treatment, most commonly caused by Borrelia sometimes within a few days and afzelii (eight of nine cases) [18] and sometimes towards the end of the ACA almost exclusively by Borrelia therapy period. Occasionally there afzelii [24], with mixed infections is still a livid erythema after 3 weeks also possible. This explains why no that fades several weeks later. If secondary cutaneous clinical courses severe symptoms exist at the start of (e.g. BL or ACA) of LB have been therapy, they may continue after the found in the USA, with the exception of end of medication and completely patients who were infected in Europe. disappear several weeks later. Severe Differences between EM caused by symptoms can also arise during therapy Borrelia burgdorferi sensu stricto and (Herxheimer-like reaction) and should EM caused by Borrelia afzelii are: not be interpreted as treatment failure. shorter incubation time (4 days vs 14), The prescribed antibiotic must not be more frequent localisation in the trunk stopped. Duration of therapy should be area (50% vs 27%), central lightening increased to 3 weeks if originally set at of colour in only a third of patients 2 weeks based on apparently localised compared with two thirds of Borrelia EM. About 7% of patients suffer afzelii infections, and more frequent relapse in the following weeks (for up to systemic signs and seropositivity­ (89% 6 months) with repeated wandering joint vs 30%) [30]. In addition, EM caused by and muscle pain and headaches that Borrelia afzelii differs from that caused can last for days. These symptoms also by Borrelia garinii–infections with the disappear after several weeks. In severe former occurring more often in June cases, an additional course of antibiotics and with Borrelia garinii in September, is usually prescribed. The occurrence of while Borrelia afzelii EM appears more arthritis or neuroborreliosis has not been often on the extremities and less often observed in LB patients with correctly on the trunk. Growth of the reddened treated EM over an observation period area by Borrelia afzelii reaches 3 cm/ of 20 years. In two patients, erythema day and by Borrelia garinii 12.5 cm/day. nodosum (EN) accompanied the EM.

43 Dermatological manifestations of Lyme borreliosis

Case report of erythema migrans with eliminated as a cause of the EN and erythema nodosum (EN) bilateral lymphadenopathy. There were A 34-year-old male had a 7 x 5 cm also no fever or unusual laboratory annular erythema on the right leg for values such as leukopenia. The 2 months and painful, bright red nodes conclusion is that the EN is associated on both shins for a week. He could not with the EM. Arthralgia, myalgia, remember being bitten by a tick. He memory disturbances, fatigue syndrome, also complained of joint pain that had conjunctivitis, febrile periods, headache, lasted for a year. X-ray of the thorax tinnitus, and acute loss of hearing are showed bilateral lymphadenopathy referred in the literature as symptoms (Löfgren’s syndrome). Pathological of post-Lyme syndrome. Seltzer et al. findings included C-reactive protein of [27] examined the symptom profiles 89, erythrocyte sedimentation rate of 44, of 212 patients 1–11 years after LB and angiotensin-converting enzyme of and compared them to a group with 57.4 U (normal range 18.0–55.0 Units). equivalent age and place of residence. Immunoblot for Borrelia antibodies No differences were found between was negative before and after therapy. the groups. It is still unclear how to Polymerase chain reaction (PCR) for classify this clinical picture. Perhaps Borrelia in the urine was positive on the symptoms are overrated and were five occasions from the 5th to 150th day of influenced by fear of further organ treatment but negative on days 210 and involvement from the LB. 360 [2]. Anti IgM and IgG antibodies specific for Ehrlichia were positive (1:64) Culture and polymerase over 5 months without a change in titre, chain reaction confirmed but PCR for Ehrlichia in the blood atypical forms was negative. A pulmonary specialist Clinical observations have shown that diagnosed pulmonary sarcoidosis I. the potency of Borrelia burgdorferi Bronchoscopy and bronchoalveolar infection lies in immune stimulation of lavage showed no evidence of B cells and the induction of cutaneous pulmonary involvement. A double sclerosis. therapy cycle of 200 mg of doxycyline for 3 weeks and glucocorticosteroid Cutaneous lymphoma treatment led to cure of the EM, EN, The role of Borrelia burgdorferi in and lymph node swelling. atypical cutaneous proliferation, pseudolymphoma, and malignant Comments lymphoma has been confirmed in Due to the steady titre values and many publications. As a cause of negative PCR, ehrlichiosis could be malignant lymphoma, it acts similarly

44 to Helicobacter pylori or Epstein-Barr significance of Borrelia to the emergence virus. A targeted antibiotic (virostatic) of this disease is not yet clear. Borrelia therapy can lead to cure in some cases. serology using immunoblot and Borrelia Comparative studies with lymphoma PCR of a skin biopsy are recommended patients in the USA or Asia showed no for diagnosis. The IgG ELISA titres association with Borrelia burgdorferi are often negative, but specific bands [16, 32], while those in Austria, France, appear on immunoblot. In Borrelia Scotland, Denmark, and Germany associated skin sclerosis it is likely that clearly did [9, 15]. cellular immune reactions predominate, as shown by lymphocyte proliferation Circumscribed scleroderma tests. Stimulation of lymphocytes by (morphea) and lichen sclerosis Borrelia burgdorferi was also observed in Starting in 1985, an association between seronegative patients with morphea and Borrelia infection and the development ACA patients with fibrous nodules [3]. of morphea was described in Switzerland, Patients with morphea react better to Germany, and Austria by various systemic therapy with ceftriaxone (for authors from Basel, Munich, Berlin, 20 days) than to oral treatment; the same and Vienna. According to PCR results has been observed in seronegative patients. and positive Borrelia cultures from skin This is the treatment of choice for all patients biopsies and their typing, aggregation with progressive morphea and distinct lilac of Borrelia-induced morphea cases rings, particularly in children. was geographic in nature [4, 10]. Only Borrelia afzelii could be isolated from Dermatoses in which Borrelia both morphea and lichen sclerosis. burgdorferi infection must be considered Diagnostic and therapeutic All patients with unexplained management of these patients sclerosis [31], myositis, and especially In principle, circumscribed scleroderma dermatomyositis must be examined for has a variety of causes. It can occur after the presence of Borrelia burgdorferi insect bites, immunisations, and trauma. infection. In the literature this infection Independently of this, a childhood and has also been associated with cases of early adolescent form exists which is livid erythema with myopathy, relapsing localised to the lines of Blaschko (e.g. febrile panniculitis, annular erythema, linear forms, morphea en coup de sabre) trigger-finger, Schönlein-Henoch and and therefore could be induced during thrombocytopenic purpura, granu­ embryonal development. Congenital lomatous thrombophlebitis, temporal atrophic morphea has been cured by arteritis, sarcoidosis, pityriasis rosea, treatment with ceftriaxone [1]. The pityriasis lichenoides, anetoderma,

45 Dermatological manifestations of Lyme borreliosis

Buschke’s scleroderma, eosinophilic here. Biopsy shows polyclonal B and fasciitis (Shulman’s syndrome), facial T cell proliferation. In children, biopsy hemiatrophy, granuloma annulare, and can be avoided if there is a classic interstitial granulomatous dermatitis. manifestation. In cases of lymphocytoma of the mammilla or other localised areas, Diagnosis of Lyme borreliosis a skin biopsy should be carried out. In Consult the European Union for about 70% of patients, antibodies can be Concerted Action on Risk Assessment demon­strated. Healing after antibiotic in Lyme Borreliosis guidelines at http:// therapy can be slow, taking several weeks. www.oeghmp.at/eucalb/. Acrodermatitis chronica Erythema migrans atrophicans Erythema migrans is usually diagnosed Positive IgG titre, typical clinical picture, on purely clinical criteria! Anamnesis and histological examination are crucial of a growing red patch is the most to diagnosing this manifestation of important feature; patients frequently do LB. Histology shows atrophy of the not remember a bite. This patch should epidermis and dermis, telangiectasia, be >5 cm. The patch may have to be and occasionally band-like lympho­ observed over the course of a week, with a histiocytic infiltrates with plasma control examination sometimes required. cells. The cure by therapy is very slow, Histological examination is unspecific, requiring months. Follow-up after a showing perivascular lymphohistiocytic year is recommended, possibly also a infiltrate with sparse eosinophils. Biopsy repeat biopsy to determine whether is needed only when the clinical picture inflammatory infiltrates are present. is unclear. Serological examination can show positive IgM antibodies, which Serology should however be confirmed by Borrelia serology will be dealt with in immunoblot. Depending on the duration detail in the chapter on diagnosis. Here of the erythema, IgG antibodies may also only a possible serological picture for be present. These could also result from EM is presented (Table 2). an earlier infection of known or unknown origin (seroprevalence in healthy Therapy individuals 10–30%). Since only 50% Treatments of LB with oral penicillin, of patients have antibodies, serological tetracycline, cefuroxime axetil, and examination is not required for diagnosis. azithromycin are equally effective (Table 3). With antibiotic treatment, EM Borrelia lymphocytoma with or without accompanying symptoms The clinical diagnosis is also decisive heals without complications in >90% of

46 Table 2. Serological picture in erythema migrans (Borrelia antibodies) ELISA IgM ELISA IgG IB IgM IB IgG Interpretation - - - - EM/no borreliosis? + - - - EM/unspecific + - + - EM Confirmation/antibody persistence from older infections + + + +/- EM Confirmation/reinfection - + - + Older infections +/- - + + EM Confirmation/older infections cases. If treatment fails, headaches, joint case of severe symptoms. The choice and muscle pain, and fatigue can occur of antibiotic depends on patient for a period of 6 months but usually compatibility­ and possible allergies. disappear within a few weeks. Secondary Tetracyclines should be avoided if manifestations are extremely rare after exposure to sun is likely, and are also appropriate treatment. The most recent contraindicated during pregnancy, while publications on duration of therapy breast-feeding, and for children <8 years show that post-Lyme syndrome occurs old. In cases accompanied by fever, in 5-10% of patients independently of severe general symptoms, or when co- whether treatment lasts 2 or 3 weeks [33]. infection with ehrlichiosis is suspected, Three-week treatment is recommended tetracycline is the treatment of choice if the erythema lasts >2 months and in (Table 3).

Table 3. Antibiotic therapy for Lyme borreliosis Erythema migrans Penicillin V 3x1 1,5 Mio 14-20 days Amoxicillin 3x1 500-750 mg 14-20 days Doxycycline 1x1 200 mg 14-20 days Azithromycin 2x1 500 mg 1st day 1x1 500 mg 7 days Borrelia lymphocytoma Oral therapy 20 days Acrodermatitis chronica atrophicans Oral therapy 30 days Or ceftriaxone 1x1 2g 20 days A second treatment with an alternative antibiotic is recommended for the following findings: Positive serology Severe suffering and unspecific symptoms EM Continuing arthralgia, headaches for >3 months BL No cure within 3 months ACA Histologically verified infiltrate after 1 year

47 Dermatological manifestations of Lyme borreliosis

Prognosis developing LB when EM is properly Pathogen persistence was found in treated. Therapy can fail however, three of 48 patients with late symptoms when less efficacious antibiotics such [29]. Re-infection is possible. It is as first-generation cephalosporins, noteworthy that chronic Borrelia roxithromycin, or erythromycin infections stimulate lymphocytes, are used in an irregular manner; for with the possibility of monoclonal example if therapy is interrupted on lymphocytic proliferation. Persistent, weekends, as sometimes happens severe disease courses could be due to with ceftriaxone therapy. Uncertainty infection with exceptionally pathogenic concerning serology remains, as the Borrelia burgdorferi clones (RST1 variable prevalence in the population isolate [8]). In addition to interspecies and persistence of antibodies after variation, additional genetic factors can therapy complicate the assessment lead to organ-specific manifestations. of serology results, making diagnosis In general, there is no danger of difficult.

48 l References of Borrelia burgdorferi DNA (B garinii or B 1. Aberer E, Weissenbacher G (1997) Congenital afzelii) in morphea and lichen sclerosus et anetoderma induced by intrauterine atrophicus tissues of German and Japanese infection? Arch Dermatol 133(4):526-527 but not of US patients. Arch Dermatol 2. Bergmann AR, Schmidt BL, Derler AM, Aberer 133(1):41–44 EJ (2002) Importance of sample preparation 11. Hengge UR, Tannapfel A, Tyring SK, Erbel R, for molecular diagnosis of lyme borreliosis Arendt G, Ruzicka T (2003) Lyme borreliosis. from urine. J Clin Microbiol 40(12):4581– Lancet Infect Dis 3(8):489-500; Erratum in: 4584 Lancet Infect Dis 3(12):815 3. Breier P, Klade H, Stanek G, Poitschek C, 12. Kindstrand E, Nilsson BY, Hovmark A, Kirnbauer R, Dorda W, Aberer E (1996) Pirskanen R, Asbrink E. Peripheral neuropathy Lymphoproliferative responses to Borrelia in acrodermatitis chronica atrophicans - burgdorferi in circumscribed scleroderma. effect of treatment. Acta Neurol Scand. 2002 Br J Dermatol 134(2):285–291 Nov;106(5):253 4. Breier FH, Aberer E, Stanek G, Khanakaha 13. Kosik-Bogacka D, Kuzna-Grygiel W, Bukowska G, Schlick A, Tappeiner G (1999) Isolation K (2004) The prevalence of spirochete of Borrelia afzelii from circumscribed Borrelia burgdorferi sensu lato in ticks Ixodes scleroderma. Br J Dermatol 140(5):925–930 ricinus and mosquitoes Aedes spp. within 5. Carlsson SA, Granlund H, Jansson C, Nyman D, a selected recreational area in the city of Wahlberg P (2003) Characteristics of erythema Szczecin. Ann Agric Environ Med 11(1):105– migrans in Borrelia afzelii and Borrelia garinii 108 infections. Scand J Infect Dis 35(1):31–33 14. Kuiper H, Dam AP van, Spanjaard L, Jongh 6. Colli C, Leinweber B, Müllegger R, Chott BM de, Widjojokusumo A, Ramselaar TC, A, Kerl H, Cerroni L (2004) Borrelia Cairo I, Vos K, Dankert J (1994) Isolation of burgdorferi-associated lymphocytoma cutis: Borrelia burgdorferi from biopsy specimens clinicopathologic, immunophenotypic, and taken from healthy-looking skin of patients molecular study of 106 cases. J Cutan Pathol with Lyme borreliosis. J Clin Microbiol 31(3):232–240 32(3):715–720 7. Dam AP van, Kuiper H, Vos K, Widjojokusumo 15. Leinweber B, Colli C, Chott A, Kerl H, Cerroni A, Jongh BM de, Spanjaard L, Ramselaar (2004) Differential diagnosis of cutaneous AC, Kramer MD, Dankert J (1993) Different infiltrates of B lymphocytes with follicular genospecies of Borrelia burgdorferi growth pattern. Am J Dermatopathol are associated with distinct clinical 26(1):4–13 manifestations of Lyme borreliosis. Clin 16. Li C, Inagaki H, Kuo TT, Hu S, Okabe M, Infect Dis 17(4):708–717 Eimoto T (2003) Primary cutaneous marginal 8. Dolan MC, Piesman J, Schneider BS, Schriefer zone B-cell lymphoma: a molecular and M, Brandt K, Zeidner NS (2004) Comparison clinicopathologic study of 24 asian cases. of disseminated and nondisseminated strains Am J Surg Pathol 27(8):1061–1069 of Borrelia burgdorferi sensu stricto in mice 17. Logar M, Ruzic-Sabljic E, Maraspin V, Lotric- naturally infected by tick bite. Infect Immun Furlan S, Cimperman J, Jurca T, Strle F (2004) 72(9):5262–5266 Comparison of erythema migrans caused by 9. Fouchardiere A de la, Vandenesch F, Berger F Borrelia afzelii and Borrelia garinii. Infection (2003) Borrelia-associated primary cutaneous 32(1):15–19 MALT lymphoma in a nonendemic region. 18. Maraspin V, Cimperman J, Lotric-Furlan Am J Surg Pathol 27(5):702–703 S, Ruzic-Sabljic E, Jurca T, Picken RN, Strle 10. Fujiwara H, Fujiwara K, Hashimoto K, F (2002) Solitary borrelial lymphocytoma Mehregan AH, Schaumburg-Lever G, Lange in adult patients. Wien Klin Wochenschr R, Schempp C, Gollnick H (1997) Detection 31;114(13-14):515–523

49 Dermatological manifestations of Lyme borreliosis

19. Miescher G, Storck H (1951) Successful outcomes of persons with Lyme disease. penicillin therapy of acrodermatitis JAMA 2;283(5):609–616 atrophicans. Dermatologica 102(4-6):370– 28. Stanek G, Strle F (2003) Lyme borreliosis. 371 Lancet 15;362(9396):1639–1647 20. Nahimana I, Gern L, Blanc DS, Praz G, Francioli 29. Strle F, Cheng Y, Cimperman J, Maraspin P, Peter O (2004) Risk of Borrelia burgdorferi V, Lotric-Furlan S, Nelson JA, Picken MM, infection in western Switzerland following Ruzic-Sabljic E, Picken RN (1995) Persistence a tick bite. Eur J Clin Microbiol Infect Dis of Borrelia burgdorferi sensu lato in resolved 23(8):603–608 erythema migrans lesions. Clin Infect Dis 21. Paschoud JM (1958) Lymphadenosis 21(2):380–389 benigna cutis as a communicable disease. IV. 30. Strle F, Nadelman RB, Cimperman J, Discussion of study results. Part B: penicillin Nowakowski J, Picken RN, Schwartz I, therapy; lymphadenosis benigna cutis & Maraspin V, Aguero-Rosenfeld ME, Varde erythema chronicum migrans, connections S, Lotric-Furlan S, Wormser GP (1999) & etiology; summary. Der Hautarzt 9(7):311– Comparison of culture-confirmed erythema 315 migrans caused by Borrelia burgdorferi 22. Piesman J (1993) Dynamics of Borrelia sensu stricto in New York State and by burgdorferi transmission by nymphal Ixodes Borrelia afzelii in Slovenia. Ann Intern Med dammini ticks. J Infect Dis 167(5):1082–1085 5;130(1):32–36 23. Pikelj-Pecnik A, Lotric-Furlan S, Maraspin 31. Wackernagel A, Bergmann AR, Aberer E V, Cimperman J, Logar M, Jurca T, Strle (2005) Acute exacerbation of systemic F (2002) Electrocardiographic findings in scleroderma in Borrelia burgdorferi infection. patients with erythema migrans.Wien Klin J Eur Acad Dermatol Venereol 19(1):93–96 Wochenschr 31;114(13-14):510–514 32. Wood GS, Kamath NV, Guitart J, Heald P, 24. Rijpkema SG, Tazelaar DJ, Molkenboer Kohler S, Smoller BR, Cerroni L (2001) MJ, Noordhoek GT, Plantinga G, Schouls Absence of Borrelia burgdorferi DNA LM, Schellekens JF (1997) Detection of in cutaneous B-cell lymphomas from Borrelia afzelii, Borrelia burgdorferi sensu the United States. J Cutan Pathol 28(10):502– stricto, Borrelia garinii and group VS116 507 by PCR in skin biopsies of patients with 33. Wormser GP, Ramanathan R, Nowakowski erythema migrans and acrodermatitis J, McKenna D, Holmgren D, Visintainer P, chronica atrophicans. Clin Microbiol Infect Dornbush R, Singh B, Nadelman RB (2003) 3(1):109–116 Duration of antibiotic therapy for early 25. Schaarschmidt D, Oehme R, Kimmig P, Hesch Lyme disease. A randomized, double-blind, RD, Englisch S (2001) Detection and molecular placebo-controlled trial. Ann Intern Med typing of Borrelia burgdorferi sensu lato in 6;138(9):697–704 Ixodes ricinus ticks and in different patient 34. Wormser GP, McKenna D, Carlin J, Nadelman samples from southwest Germany. Eur J RB, Cavaliere LF, Holmgren D, Byrne DW, Epidemiol 17(12):1067–1074 Nowakowski J (2005) Brief communication: 26. Seinost G, Dykhuizen DE, Dattwyler RJ, hematogenous dissemi­nation in early Lyme Golde WT, Dunn JJ, Wang IN, Wormser GP, disease. Ann Intern Med 3;142(9):751–755 Schriefer ME, Luft BJ (1999) Four clones of Borrelia burgdorferi sensu stricto cause invasive infection in humans. Infect Immun 67(7):3518–3524 27. Seltzer EG, Gerber MA, Cartter ML, Freudigman K, Shapiro ED (2000) Long-term

50 Neuroborreliosis l Reinhard Kaiser

or laymen the terms Borrelia a natural affinity for cells of the central Finfection, borreliosis, and neuro­ and peripheral nervous systems, where borreliosis are commonly used as it concentrates in the region of the synonyms. The reason for this confusion is meninges and nerve roots. This because the incorrect assumption that unspecific, these cells have surface proteoglycans generalised symptoms are usually caused and galactocerebrosides, which provide by a disease of the nervous system, and binding sites for the outer surface that a borrelial infection discovered by protein Osp A of Borrelia burgdorferi chance during examination is causing sensu lato [2]. The OspA lipoprotein these symptoms. Here the uncritical is also of particular importance in the request for Borrelia serology analysis in pathogenesis of neuroborreliosis. Initially response to unspecific symptoms has a it induces proliferation of astrocytes and high a priori chance of returning positive lymphocytes­ via the synthesis of pro­ results due to the high seroprevalence in inflammatory cytokines (e.g. IL-1, IL-6, the population. Even using an optimal and IL-8). Later however, it causes their test method, such as ELISA using apoptosis from increased production of recombinant proteins from three Borrelia tumour necrosis factor alpha [30]. The spp., only a negative result provides useful general feeling of illness and, in cases information. The following is a critical of acute neuroborreliosis, frequently discussion of the typical neurological pain can be explained by the increased symptoms of neuroborreliosis, the synthesis of immunotransmitters problem of unspecific symptoms, and and their attachment to neuronal post-Lyme syndrome. receptors, but the mechanisms leading to the disturbance of neurological Pathogenesis function in chronic forms are not yet Laboratory investigations have shown known. Antibodies and auto-reactive that Borrelia burgdorferi sensu lato has T lymphocytes specific for neuronal

51 Neuroborreliosis

and glial proteins are commonly found, by demonstrating pleocytosis in the but their significance is also unclear. A CSF and an elevated Borrelia-specific correlation between these la­boratory antibody index. findings and the clinical course and prognosis of the disease has not been Radiculitis established [14, 18]. The symptoms of radiculitis develop on average within 4–6 weeks (range Clinical picture 1–12 weeks) after the tick bite. The Borrelia infection of the nervous system first symptoms are predominantly night is usually acute, and seldom chronic. time radicular pain in the extremities Symptoms lasting for ≥6 months are and circling pain in the trunk that do criteria for the chronic form. not respond to simple analgesics. Maximum pain is often reached within Diseases affecting the peripheral a few hours or days. It reaches an nervous system intensity that patients report not having Meningopolyradiculoneuritis previously experienced, is constantly (Bannwarth’s syndrome) present, and often prevents sleep. After erythema migrans, meningopoly­ As there is usually no demonstrable radiculoneuritis (Bannwarth’s neurological deficit during this phase, syndrome) is the second most common the possibility of borreliosis is often manifestation­ of acute Borrelia infection not considered. Most patients however in Europe [19, 34]. Diagnosis is charac­ show sensory neurological irritation terised by the effects of Borrelia-induced and neurological deficits within a few inflammation in the meninges (menin­ weeks: symptoms involving sensitivity gitis), spinal cord root (radiculitis), and to stimulus are commonly reported cranial nerves, which may occur concur­ although corresponding deficits are rently or consecutively but also alone. rare. Occasionally the segment with the most intense pain later becomes Meningitis numb. Paresis is more common than Meningitis is relatively uncommon in sensitivity disturbances and is typically adult Europeans but can be a major distributed asymmetrically, more problem in children [4, 7]. Headaches commonly affecting the limb bitten by often are only moderately pronounced, the tick or where the erythema migrans however their intensity can fluctuate occurred. In cases of radiculitis, the pain substantially within a few days or usually decreases within a few days weeks. Meningitis, fever, nausea, after beginning antibiotic treatment. vomiting, and vertigo are uncommon. Differential diagnoses for such extreme Suspected diagnosis is confirmed pain and pleocytosis are Varicella zoster

52 virus reactivation and carcinomatous is abducens paresis, which is bilateral in meningitis. Pathological findings about 10% of cases. All the other cranial on magnetic resonance imaging are nerves are affected much less often. uncommon for radiculitis. The significance of Borrelia infection in vestibulocochlear nerve or vestibular Cranial nerve paresis organ diseases is still unconfirmed. A About 60% of patients with number of large epidemiological studies Bannwarth’s syndrome have cranial were unable to show a definite causal nerve paresis. With the exception of the relationship between acute vertigo and olfactory nerve, reports indicate that any serologically determined borreliosis brain region can be affected. In most infection [27]. Only in a single study cases, the paresis occurs within a few of patients with acute hearing loss did weeks after the erythema migrans. The analysis of CSF by lumbar puncture facial nerve paresis is by far the most reveal inflammatory changes. It is common, affecting about 80% of cases, noteworthy that patients with such and is bilateral in 40% of these (acute inflammatory CSF signs and positive > chronic course). Facial paresis in Borrelia serology responded better to neuroborreliosis is occasionally isolated, treatment and/or had better prognoses in which case it cannot be differentiated than those with acute idiopathic hearing from idiopathic cases. Clarification loss [13]. These findings suggest a is best made by analysis of the CSF. recommendation not only for Borrelia If pleocytosis is absent–even with serology but also for lumbar puncture the presence of Borrelia-specific IgG in cases of acute hearing loss. Chronic antibodies in the serum–an idiopathic neuroborreliosis can occasionally also case is most likely. If Borrelia-specific be associated with a significant loss in IgM antibodies are found in the serum, it hearing. is not possible to exclude borreliosis as a cause of the paresis, even in the absence Polyneuritis/polyneuropathy of pleocytosis and antibodies in the CSF. The term polyneuritis is used to describe In such cases (particularly if there are cases in which there is evidence of an also Borrelia-specific IgG antibodies inflammatory cause of a polyneuropathy in the serum), a 14-day oral course of (PNP). In PNP, disturbances in antibiotics (e.g. 1x200 mg doxycycline neurological function or dysaesthesia or 3x750 mg amoxicillin per day) is are usually distal, affecting the recommended. As with idiopathic facial extremities. In European patients distal paresis, about 5–10% of patients suffer polyneuritis resulting from Borrelia from subsequent disturbances [5, 17]. infection is almost always found in Second in frequency after facial paresis association with acrodermatitis chronica

53 Neuroborreliosis

atrophicans (ACA) [16]. All other show no characteristics pointing to cases of Borrelia-induced polyneuritis such aetiology. Reported disturbances should be considered with scepticism, have included quantitatively and as most publications on the subject qualitatively reduced states of lack sufficient proof and an adequate consciousness, focal and generalised differential diagnosis is not defined. The seizures, mono- and hemiparesis, major hindrances to collecting evidence hemianopsia, aphasia, dysarthria and are the large number of possible causes coordination disturbances. Individual of PNP combined with the very high cases have presented with choreiform seroprevalence of Borrelia antibodies and dystonic motor disturbances, in the general population (between transitory Parkinson’s disease-like 10% and 30% depending on region). symptoms, pseudotumour cerebri in Additionally, only a small proportion association with autoimmune thyroiditis, of Borrelia infections (<5%) manifest obstructive hydrocephalus, temporary clinically. Thus the association of PNP organic brain syndrome with memory and serum Borrelia antibodies is more and concentration disturbances, coincidental than causal in most patients. opsoclonus, and cerebral “pseudo­ Only with additional evidence of lymphoma” (lymphocytic infiltrate as pathological CSF changes can causality a consequence of local collection of be accepted. This however, would Borrelia in the cerebrum). suggest a diagnosis of radiculitis, because CSF involvement is not generally Myelitis associated with the predominantly The clinical symptoms of the rare, acute distal changes seen in a typical PNP. Borrelia myelitis include transverse Using such diagnostic and therapeutic sensory and motor symptoms as methods, we have been unable to find well as bladder disturbances, usually a proven Borrelia-induced PNP in the accompa­nied by fever. These cannot last 15 years. be differentiated from myelitis of viral aetiology. Chronic myelitis, which was Diseases of the central diagnosed more frequently in the past, is nervous system now relatively rare and usually develops Encephalitis slowly over months to years. At first, Clinical symptoms of borreliosis the patients notice increased fatigue involving the central nervous system while walking, more frequent stumbling, have seldom been observed. When progressive reduction in walking present, they occur more frequently distance and finally the development of in the chronic than the acute course. a spastic-ataxic gait disorder and urinary Cases of encephalitis involving Borrelia dysfunction. Two thirds of such patients

54 with para- or tetraparesis described in magnetic resonance angiography. Due the literature showed severe clinical to its rare aetiology, regular checks for symptoms [1, 9]. In about 60% of antibodies in cases of cerebral insult are patients with myelitis, there were also not necessary. signs of encephalitis, and of these, 40% had additional cranial nerve paresis. Myositis Magnetic resonance imaging seldom Myositis is considered a very rare mani­ showed signal changes in the spinal cord. festation of borreliosis affecting the Borrelia-induced inflammation of the musculoskeletal system. The pain and spinal cord and nerve roots (myelora­ paresis are usually focal, and muscle diculitis) can sometimes be painless or enzyme levels are seldom elevated. lack changes in sensitivity such as those Histopathology shows nodular or in a motor neuron illness. The causal interstitial myositis with little degene­ relationship between Borrelia infection ration of the muscle fibres and few and the development of amyotrophic macrophage but many CD4-positive lateral sclerosis suggested by some T-lymphocytes [31]. This finding authors is based only on seroprevalence, differentiates Borrelia myositis from and no case has been confirmed using other inflammatory myopathies in which appropriate diagnostic tests. B-lymphocytes usually predominate. Diagnosis is supported by electromyo­ Cerebral vasculitis graphy, clinical symptoms conforming In rare cases, cerebral symptoms are to the serology, and immunological and caused by Borrelia-induced cerebral molecular demonstration of Borrelia vasculitis. More than a third of the burgdorferi sensu lato in the biopsy. reported cases occur in patients younger than 30 [24, 32]. Its course is usually acute, involving an infarct in the Fig. 1. Brainstem infarct as a result of cerebral vasculitis due to posterior basin (thalamus, brainstem) Borrelia (Fig. 1), and can be fatal. Autopsies have revealed obliterative vasculitis with substantial intima swelling and only discrete fibrosis of the media but marked thickening of the adventitia with numerous lymphocytic infiltrates. Additionally, chronic lymphocyte infiltration of the meninges was present. Diagnosis is based on positive serology, pathological CSF findings, MRI, and

55 Neuroborreliosis

Problem cases in clinical practice one group without persistent symptoms Borrelia encephalopathy and the other without. Fibromyalgia was diagnosed in seven patients with PLS, This diagnosis comes predominantly three had chronic fatigue syndrome, from the American literature and shows and ten had “other” mild symptoms. various unspecific symptoms such as Patients with PLS showed conspicuous reduced performance, increased fatigue, deficits in concentration and memory irritability, emotional instability, as well tests and complained more frequently as disturbances in sleep, concentration, of sleep disturbances and mood changes and memory [22]. A causal relationship than the control population. It was between these symptoms and concluded from these results that Lyme serologically determined Borrelia borreliosis could lead to persistent infection is hardly conceivable without complaints in a proportion of patients evidence of inflammatory signs in the despite antibiotic treatment. It was not CSF and the persistence of symptoms possible to show what factors, other than after antibiotic therapy. The positive the Borrelia infection, were responsible Borrelia serology in patients lacking for development of these symptoms. inflammatory changes in the CSF, should Elkins et al. examined 30 patients be interpreted instead as resulting from with PLS using psychological and a clinically unapparent past infection neuropsychological tests [12]. Unlike (seroprevalence), and possible causes for other authors, they could not find these symptoms other that Borrelia must relevant deficits compared with a normal be sought in the differential diagnostic. group. The only feature observed was a When, a positive Borrelia serology is reduced proportion of positive emotions. associated with inflammatory changes However, such conspicuous emotional in the CSF and other neurological features are also found in chronic fatigue deficits, all of these indications, singly syndrome patients with no history of or in combination, can be interpreted as Lyme borreliosis, calling into question symptoms of neuroborreliosis. the credibility of PLS as a cause. Klempner et al. examined 78 Borrelia Post-Lyme syndrome antibody-positive and 51 antibody- Post-Lyme syndrome (PLS) was defined negative patients with a history of in 1996 as a complex of symptoms borreliosis and PLS in a double-blind, that persist more than 6 months after placebo-controlled study to test the appropriately treated Lyme disease [6]. value of long-term antibiotic therapy Two groups of 23 patients of comparable (2 g ceftriaxone for 30 days plus age and gender who had received 200 mg doxycycline for 60 days or antibiotic treatment were compared, placebo). The study had to be stopped

56 prematurely, as an interim analysis In 1992 Dinerman and Steere described showed that symptoms such as muscle the appearance of fibromyalgic pain, fatigue, and dysaesthesia could not symptoms during acute Lyme arthritis or be eliminated by such treatment [25]. up to 5 months after acute Lyme disease Similar results were found in two other [10]. Additional antibiotic therapy led to large-scale antibiotic studies, of which temporary improvement that lasted only neither showed a positive effect on the a few months. The authors attributed unspecific symptoms [23, 26]. this temporary success to a suggestive A critical review of this literature or placebo effect of the antibiotic, shows no plausible evidence for a since sleep deficit, lack of training, and chronic Lyme disease or PLS without changed muscle metabolism can act as proof of presence of the pathogen. trigger functions, as can infections with In particular, immunological and various pathogens, head trauma, and microbiological findings that could emotional factors. Steere discussed the explain the persistence of these clinical differentiation between Lyme unspecific symptoms are lacking. arthritis and fibromyalgia in his 1995 review article. Local joint inflammation Fibromyalgia syndrome predominates in Lyme arthritis; whereas The diagnostic criteria of fibromyalgia patients with fibromyalgia show are: generalised symptoms such as increased - Generalised pain by anamnesis (i.e. fatigue, head, joint, and muscle pain, left- and right-sided, upper and lower diffuse paraesthesia, and concentration body, axis skeleton) disturbances [35]. The appearance of - Pain on at least 11 of 18 tender points fibromyalgia weeks or months after with finger pressure (nine on each Lyme disease will be discussed in a body side) subsequent article by a panel of experts - Insertion point of the cisternal muscles who are however quite critical of any - Transverse processes of the spine C5–7 causal relationship to previous Borrelia - Central upper edge of the M. trapezius infection. and M. supraspinatus A retrospective study conducted by - Cartilage/bone boundary of the Shadick et al. compared the long-term second rib results of 186 patients with clinically - Radial epicondyle probable Lyme disease with those - Regio glutaea lateralis of 167 control individuals with no - Trochanter major evidence of earlier Borrelia infection - Medial fat pad of the knee proximal to [33]. Six years after the acute illness, the line of the joint the frequency of neurological and cognitive deficits in the Lyme disease

57 Neuroborreliosis

patients was not higher than that of fatigue and for diagnosis must persist for the controls. During the initial illness, at least 6 months: patients in the borreliosis group - Neck pain complained mostly of fever, headache, - Painful cervical or axillary lymph nodes photophobia, and neck stiffness - Muscle pain (symptoms of meningitis). The authors - Wandering, noninflammatory arthralgia deduce from their results that the long- - Newly developed headaches term prognosis for borreliosis is usually - Concentration problems and good and that fibromyalgia is not a disturbances in short-term memory typical residual effect. - No recovery after sleep As neither the pathogenesis nor - Increased, generalised fatigue aetiology of fibromyalgia is known, the persisting >24 h after a previously cause of the syndrome by some earlier tolerated activity event, e.g. a Borrelia infection, cannot be determined. This needs to be taken Coyle et al. (1994) questioned the into consideration when expert opinion importance of Borrelia infection is given. Most authors agree that to the development of CFS. They additional antibiotic treatment does examined 13 patients who had had not lead to a cure of the symptoms. borreliosis and 12 controls without A proportion of patients do however previous clinical evidence of such benefit from anti-depressive therapy disease [8]. The only remarkable with serotonin re-uptake inhibitors. result was notable variations in the cerebrospinal fluid of one third of Chronic fatigue syndrome subjects in both groups; however, a Diagnostic criteria for chronic fatigue specific influence of Borrelia infection syndrome (CFS). on the cerebrospinal fluid could not The main criterion of CFS is persistent be found. A similar result was found fatigue or rapid tiring for at least by Pollark et al., who examined 6 months which: 138 CFS patients for antibodies to - Cannot be explained by another illness Borrelia burgdorferi sensu lato in a and is recent risk area for this disease [29]. Only - Does not result from a chronic stress eight serum samples were borderline situation and can not be significantly positive, but using immunoblot they improved by bed rest were negative. In various case control - Is so pronounced that average studies a large number of pathogens, performance is distinctly reduced including Borrelia burgdorferi sensu At least four secondary criteria of CFS lato, and various other factors (gender, must be present at or after the onset of number of childbirths, silicon implants,

58 tendency to depression) have been appropriate questionnaires patterned investigated as possible causes of after that of Burrascano. Even when CFS, however no aetiology has been there is no doubt about the presence identified. of chronic Borrelia infection, as with To summarise, the aetiology and ACA or chronic neuroborreliosis pathogenesis of CFS as well as (with appropriate inflammatory fibromyalgia are still unknown, and indications in the CSF), persistent a causal relationship with previous health problems cannot be assumed Borrelia infection has not been to stem from chronic borreliosis in the demonstrated. absence of organ-specific pathology consistent with this diagnosis, despite Pain syndrome positive Borrelia serology. Cost-benefit Pain of unknown origin. Such pain, analyses speak against speculative with no cause found by differential treatment of unspecific symptoms in diagnosis, could indicate the beginning cases of positive Borrelia serology. of Borrelia radiculitis if Borrelia antibodies are present in the serum. Differential diagnosis The next step is lumbar puncture in In cases of neuroborreliosis it is order to test this possible diagnosis. necessary, in principle, to consider If the CSF findings are normal, it is other pathogens (bacterial and viral), highly unlikely that the pain is related autoimmunity (multiple sclerosis, lupus to a Borrelia infection, and the search erythematosus), and granulomatous for other causes must be intensified. diseases of the nervous system Borrelia infections can cause, in (neurosarcoidosis) in the differential rare cases, a complex regional pain diagnosis. In the USA it is necessary, syndrome (previously called Sudeck’s in rare cases of polyneuropathy after a dystrophy). Treatment involves tick bite, to consider a toxic or allergic eliminating the infection (e.g. by 1x2 g neuropathy caused by tick saliva. ceftriaxone/day for 14 to 21 days) and symptomatic therapy of the Diagnostics sympathetic nervous system-supported The diagnosis of neuroborreliosis pain syndrome. is initially determined clinically, then confirmed by serology and CSF analysis. Health disturbances The probability of correct diagnosis A whole spectrum of health problems can be divided into difference grades are attributed to chronic borreliosis by depending on clinical and laboratory patients with positive Borrelia serology. findings [19]. This self-diagnosis is supported by

59 Neuroborreliosis

Possible neuroborreliosis: specific antibody concentrations­ in the - Typical clinical picture (cranial CSF and serum with respect to the nerve deficits, meningitis/ total immunoglobulin concentrations meningoradiculitis, focal neurological in both compartments [21]. An antibody deficits) concentration at least 1.5 times higher - Borrelia-specific IgG and/or IgM per unit of immu­noglobin in the antibodies in serum CSF indicates intrathecal synthesis. - CSF findings not available Pathogen-specific intrathecal antibody synthesis can also be demonstrated Probable neuroborreliosis is as by different banding patterns using “possible borreliosis” but also with: immunoblot when the immunoglobulin - Positive CSF findings with lympho­ concentrations in the CSF and serum cytic pleocytosis, blood/CSF barrier are equivalent. Intrathecal Borrelia disturbances, and/or intrathecal burgdorferi-specific antibody immunoglobin synthesis and production can persist for many years - Elimination of other possible causes of or decades. the symptoms present Therapy Certain neuroborreliosis is as “probable Ceftriaxone and cefotaxim, given for borreliosis” but also includes: sufficient duration, are equally effective - Intrathecal synthesis of Borrelia- for treating neuroborreliosis [28]. The specific antibodies (IgG and/or IgM) former shows very good in vitro results in the CSF or for minimum inhibitory concentration - Positive PCR for the CSF and availability in brain tissue. Both antibiotics reach CSF concentrations Typical CSF findings for up to ten times higher than required neuroborreliosis show lymphocytic to inhibit bacterial growth, even under pleocytosis with numerous plasma the physiological conditions of the cells and a definite barrier disruption blood/CSF barrier. The clinical value (increased albumin and total protein of ceftriaxone for the treatment of levels). In addition, the acute form also erythema migrans, Lyme arthritis, and displays pronounced intrathecal IgM neuroborreliosis has been described that progresses to include synthesis in numerous studies and case reports. of both IgG and IgA in the chronic As a general rule, a dosage of 1x2 g form. The diagnosis can be confirmed ceftriaxone/day given over 30 min is by demonstration of Borrelia-specific adequate. If the infusion is too rapid and/ intrathecal antibody synthesis. This or the dose higher, then precipitation can be done most easily by comparing of a calcium salt of ceftriaxone in the

60 gallbladder may occur (accumulation of sludge); its disadvantage is a shorter biliary sludge). Such precipitates usually half-life with the resulting need of more do not cause symptoms and disappear at frequent application. Study results the conclusion of therapy. If the therapy demonstrate cefotaxime’s efficiency lasts more than 2 weeks, sonography in both acute and chronic forms of of the gallbladder should be done to borreliosis. check for biliary sludge. The effect of Penicillin has a similar efficiency to treatment duration on outcome has doxycycline for certain forms of acute been clearly shown in several studies. borreliosis. In a Danish prospective In one case, Borrelia burgdorferi sensu study, 170 neuroborreliosis patients lato could be isolated from the CSF were successfully treated with 2x10 of a patient 7 months after a 10-day mega penicillin G over 10 days [15]. ceftriaxone treatment regimen [28, 36]; Doxycycline is probably the most while another study showed a substantial commonly used antibiotic for borreliosis. number of patients complaining of Studies testing a new antibiotic normally unspecific problems weeks after short use doxycycline for comparison. In most duration treatment. Our own study of these studies, it was as effective as with 101 patients diagnosed with certain the alternative test substances. It has neuroborreliosis­ showed no such findings been tested using various doses and or problems after 14-day–21-day for durations of treatment, and it is generally chronic neuroborreliosis–treatment with agreed that the minimum dose is ceftriaxone­ [20]. There are no criteria 200 mg/day, with a minimum duration suppor­ting a longer duration. Thus a of 14 days. In cases of uncomplicated minimum 14-day treatment should be meningopolyneuritis, 300 mg/day of given. doxycycline over 21 days is a possible alternative to 2 g/day ceftriaxone over Although ceftriaxone showed clinical 14 days [11]. Controlled tests determining efficacy equivalent to that of penicillin the optimal dose of doxycycline are not G in comparative studies, some authors available. find significant advantage in the once- a-day drug application and the higher Ophthalmological diseases bactericidal CSF concentrations attained Clinical picture by the former. Pharmacological data on In certain cases, Borrelia infection ceftriaxone can be found at www.rxlist. can also lead to ophthalmological com/cgi/generic3/ceftriax_cp.htm. manifestations: follicular conjunctivitis, The advantage of cefotaxim over interstitial keratitis, vitritis, iridocyclitis, ceftriaxone lies in its lower biliary episcleritis, anterior uveitis, choroiditis, excretion (no accumulation of biliary and retinal vasculitis [3]. Visual

61 Neuroborreliosis

deterioration in cases of optic neuritis suspected a slipped disk and ordered usually develops sub-acutely over several MRI of the lumbar spine. A small lateral weeks and only with early treatment can protrusion was found at L4/5 but there a good prognosis be given. was no nerve compression. Primary therapy therefore included analgesics, Diagnostics physiotherapy, and application of Anamnesis, the clinical picture, and warmth. Despite these measures, the evidence of specific IgM and IgG pain increased and the patient was antibodies support the diagnosis. unable to sleep at night. Ten days after However, they seldom demonstrate the pain began, he developed facial causality between Borrelia infection and paralysis. The physician prescribed the ophthalmological illness. Only in cortisone (100 mg prednisolone), which the case of papillitis can CSF findings did not affect the paralysis, but the confirm the diagnosis. Culture of the other symptoms improved. Four days pathogen and PCR do not play a role in after beginning this treatment, the pain confirming diagnosis. increased again, this time to the extent that the patient was admitted to hospital. Therapy Neurological examination showed Prospective studies are lacking due peripheral, bilateral facial paralysis and to the rarity of these diseases. For mild impairment of foot lifting. Borrelia treatment, primarily third-generation serology was positive for IgM and IgG cephalosporins are recommended (e.g. antibodies, and CSF analysis showed 2 g/day of ceftriaxone or 3x2 g/day of lymphocytic pleocytosis with 200 cells/ cefotaxime) due to their favourable µl, an increased albumin quotient of penetration. 10x10-3, and intrathecal synthesis of IgM. At 1.3, the Borrelia-specific antibody Case report index was still within normal limits. Case 1: acute neuroborreliosis In spite of this, acute neuroborreliosis A 45-year old male programmer first was suspected based on anamnesis and experienced mild back pain about symptoms. Treatment with 2 g/day 3 weeks after a long hike in the Black of ceftriaxone i.v. was started. After Forest. Within a few days the pain had 3 days the patient reported marked disseminated to include the right leg, reduction in pain and at the end of the and its intensity increased to such an 14-day treatment it had disappeared extent that he visited his local physician. completely. In addition, the leg paralysis The patient showed a positive nerve was no longer apparent on discharge stretch reflex, but neurological findings from the hospital. The bilateral facial were otherwise normal. The physician paralysis disappeared completely about

62 6 weeks after the end of treatment. well as light spastic paraparesis in the Follow-up CSF examination at legs. Magnetic resonance imaging of 3 months showed normal cell count and the brain and spinal cord for suspected an intact blood/CSF barrier, decreasing multiple sclerosis was pathologically IgM synthesis, and low IgG synthesis unremarkable. Subsequent lumbar with evidence of oligoclonal bands. A puncture showed pleocytosis at year later, the Borrelia-specific antibody 100 cells/µl, total protein of 2500 mg/l, index was significantly higher at 2.5, and intrathecal IgG synthesis of indicating previous Borrelia infection 70%. Test results for sarcoidosis, of the nervous system, but CSF findings vasculitis, neurolysis, and HIV remain normal. The patient was infection were negative. However, symptom-free 6 weeks after the end of the high Borrelia-specific antibody treatment. index of 5.8 was occasion for initiating a 3-week treatment regimen with Case 2: chronic neuroborreliosis 2 g of ceftriaxone per day. Control A 40-year-old female resumed jogging examination of the patient’s CSF 1 year in March 2000 after a 3-month winter later was unremarkable except for the pause and noticed a considerable clear presence of oligoclonal bands, and reduction in her normal running both general and Borrelia-specific IgG distance. Despite training three times synthesis. a week, she remained unable to reach her previous year’s distance, 5 km at a stretch. She also noted an increased tendency to stumble not only in the forest but also on any uneven or rough surface. In June 2000 she noticed light urinary incontinence and increased micturition, which could not be explained through urinalysis. The following August she stumbled over a curb in the darkness, fell to the ground, and broke her lower arm after an evening of dancing, when she had also noticed a certain “stiffness”. On admittance to hospital, she mentioned instability while walking, so a neurologist was consulted. Further examination showed pronounced ataxia while standing and walking as

63 Neuroborreliosis

l References 12. Elkins LE, Pollina DA, Scheffer SR, Krupp 1. Ackermann R, Gollmer E, Rehse- LB (1999) Psychological states and Kupper B (1985) [Progressive Borrelia neuropsychological performances in chronic encephalomyelitis. Chronic manifestation Lyme disease. Appl Neuropsychol 6:19–26 of erythema chronicum migrans disease of 13. Finizia C, Jonsson R, Hanner P (2001) Serum the nervous system] Progressive Borrelien- and cerebrospinal fluid pathology in patients Enzephalomyelitis. Chronische Manifestation with sudden sensorineural hearing loss. Acta der Erythema-chronicum-migrans-Krankheit Otolaryngol 121:823–830 am Nervensystem. Dtsch Med Wochenschr 14. Garcia-Monco JC, Benach JL (1997) 110:1039–1042 Mechanisms of injury in Lyme neuro­ 2. Bay I, Narayan K, Dail D, Sondey M, Hodzic E, borreliosis. Semin Neurol 17:57–62 Barthold SW, Pachner AR, Cadavid D (2004) 15. Hansen K, Lebech AM (1992) The clinical Spinal cord involvement in the nonhuman and epidemiological profile of Lyme primate model of Lyme disease. Lab Invest neuroborreliosis in Denmark 1985–1990. 84:160–172 A prospective study of 187 patients with 3. Balcer LJ, Winterkorn JM, Galetta SL (1997) Borrelia burgdorferi specific intrathecal Neuro-ophthalmic manifestations of Lyme antibody production. Brain 115 (Pt 2):399– disease. J Neuroophthalmol 17: 108–121 423 4. Belman AL, Iyer M, Coyle PK, Dattwyler 16. Hopf H (1975) Peripheral neuropathy in R (1993) Neurologic manifestations in acrodermatitis chronica atrophicans children with North American Lyme disease. (Herxheimer). J Neurol Neurosurg 38:458 Neurology 43:2609–2614 17. James DG (1997) Differential diagnosis of 5. Berglund J, Stjernber L, Ornstein K, Tykesson- facial nerve palsy. Sarcoidosis Vasc Diffuse Joelsson K, Walter H (2002) 5-y Follow-up Lung Dis 14:115–120 study of patients with neuroborreliosis. 18. Kaiser R (1995) Intrathecal immune response Scand J Infect Dis 34:421–425 in patients with neuroborreliosis: specificity 6. Bujak DI, Weinstein A, Dornbush, RL (1996) of antibodies for neuronal proteins. J Neurol Clinical and neurocognitive features of the 242:319–325 post Lyme syndrome. J Rheumatol 23:1392– 19. Kaiser R (1998) Neuroborreliosis. J Neurol 1397 245:247–255 7. Christen HJ (1996) Lyme neuroborreliosis in 20. Kaiser R (2004) [Clinical courses of acute and children. Ann Med 28:235–240 chronic neuroborreliosis following treatment 8. Coyle PK, Krupp LB, Doscher C, Amin K (1994) with ceftriaxone]. Nervenarzt 75:553–557 Borrelia burgdorferi reactivity in patients 21. Kaiser R, Lucking CH (1993) Intrathecal with severe persistent fatigue who are from synthesis of specific antibodies in a region in which Lyme disease is endemic. neuroborreliosis. Comparison of different Clin Infect Dis 18 [Suppl 1]:S24–S27 ELISA techniques and calculation methods. 9. Depre A, Sindic CJ, Bukasa K, Bigaignon J Neurol Sci 118:64–72 G, Laterre C (1988) [Borrelia burgdorferi 22. Kaplan RF, Jones-Woodward L (1997) Lyme encephalomyelitis] Formes encephalo­ encephalopathy: a neuropsychological­ myelitiques de l’infection a Borrelia burgdorferi. perspective. Semin Neurol 17:31–37 Rev Neurol (Paris ) 144:416–420 23. Kaplan RF, Trevino RP, Johnson GM, Levy 10. Dinerman H, Steere AC (1992) Lyme disease L, Dornbush R, Hu LT, Evans J, Weinstein A, associated with fibromyalgia. Ann Intern Schmid CH, Klempner MS (2003) Cognitive Med 117:281–285 function in post-treatment Lyme disease: 11. Dotevall L, Hagberg L (1999) Successful oral do additional antibiotics help? Neurology doxycycline treatment of Lyme disease- 60:1916–1922 these are out of alphabetical associated facial palsy and meningitis. Clin order Infect Dis 28:569–574 24. Keil R, Baron R, Kaiser R, Deuschl G (1997) 64 [Vasculitis course of neuroborreliosis with Pathogenesis of Lyme neuroborreliosis: thalamic infarct] Vaskulitische Verlaufsform Borrelia burgdorferi lipoproteins induce einer Neuroborreliose mit Thalamusinfarkt. both proliferation and apoptosis in rhesus Nervenarzt 68:339–341 monkey astrocytes. Eur J Immunol 33:2539– 25. Klempner MS, Hu LT, Evans J, Schmid CH, 2550 Johnson GM, Trevino RP, Norton D, Levy 31. Reimers CD, Koning J de, Neubert U, L, Wall D, McCall J, Kosinski M, Weinstein Preac-Mursic V, Koster JG, Muller-Felber A (2001) Two controlled trials of antibiotic W, Pongratz DE, Duray PH (1993) Borrelia treatment in patients with persistent burgdorferi myositis: report of eight patients. symptoms and a history of Lyme disease. N J Neurol 240:278–283 Engl J Med 345:85–92 32. Schmiedel J, Gahn G, Kummer R von, 26. Krupp LB, Hyman LG, Grimson R, Coyle PK, Reichmann H (2004) Cerebral vasculitis with Melville P, Ahnn S, Dattwyler R, Chandler B multiple infarcts caused by lyme disease. (2003) Study and treatment of post Lyme Cerebrovasc Dis 17:79–81 disease (STOP-LD): a randomized double 33. Shadick NA, Phillips CB, Sangha O, Logigian masked clinical trial. Neurology 60:1923– EL, Kaplan RF, Wright EA, Fossel AH, Fossel 1930 K, Berardi V, Lew RA, Liang MH (1999) 27. Peltomaa M, Pyykko I, Seppala I, Viljanen M Musculoskeletal and neurologic outcomes (1998) Lyme borreliosis – an unusual cause in patients with previously treated Lyme of vertigo. Auris Nasus Larynx 25:233–242 disease. Ann Intern Med 131:919–926 28. Pfister HW, Preac-Mursic V, Wilske B, Schielke 34. Stanek G, Flamm H, Groh V, Hirschl A, E, Sorgel F, Einhaupl KM (1991) Randomized Kristoferitsch W, Neumann R, Schmutzhard E, comparison of ceftriaxone and cefotaxime in Wewalka G (1987) Epidemiology of borrelia Lyme neuroborreliosis. J Infect Dis 163:311– infections in Austria. Zentralbl Bakteriol 318 Mikrobiol Hyg [A] 263:442–449 29. Pollark RJ, Komaroff AL, Telford SR, Gleit, 35. Steere AC (1995) Musculoskeletal Fagioli L, Brunet LR, Spielman A (1995) manifestations of Lyme disease. Am J Med Borrelia burgdorferi infection is rarely found 98:44S–48S in patients with chronic fatigue syndrome. 36. Treib J, Fernandez A, Haass A, Grauer Clin Infect Dis 20:467–468 MT, Holzer G, Woessner R (1998) Clinical 30. Ramesh G, Alvarez AL, Roberts ED, Dennis and serologic follow-up in patients with VA, Lasater BL, Alvarez X, Philipp MT (2003) neuroborreliosis. Neurology 51:1489–1491

65

Lyme borreliosis diagnostics l Volker Fingerle, Bettina Wilske

Introduction analysing 242 isolates from European Lyme borreliosis is the most common patients (Fingerle and Wilske, tick-borne disease in the northern unpublished data). In contrast, Borrelia hemisphere. It does not occur in the burgdorferi sensu stricto is the only southern hemisphere. As a multisystem Borrelia spp. pathogenic to humans disease it affects many organs, in in the USA [76]. The three most particular the skin, nervous system, important human pathogenic species in joints, and heart [58, 69, 70]. Due to the Europe comprise at least seven outer wide variety of symptoms, testing for antibodies against Borrelia spp. is the most commonly requested serological Fig. 1. Heterogeneity of Borrelia burgdorferi sensu lato. Yellow rectangles, known human pathogens; green rectangle, human test. In Europe, microbiological pathogenicity unclear; orange rectangle nonpathogenic for diagnostics must take into account the humans heterogeneity of the pathogen.

Heterogeneity of Borrelia B. bissettii burgdorferi sensu lato and its B. japonica B. spielmanii significance for the diagnostics of B. andersonii B. turdi Lyme borreliosis B. afzelii B. tanukii At least four Borrelia species cause B. sinica B. burgdorferi Lyme disease in Europe, Borrelia s. l. complex burgdorferi sensu stricto, Borrelia B. garinii afzelii, Borrelia garinii, and the till now rarely found Borrelia spielmanii B. valaisiana B. burgdorferi s.s. (Fig. 1). Up to now, we have found B. lusitaniae Borrelia spielmanii four times (all from patients with erythema migrans) after

67 Lyme borreliosis diagnostics

surface protein A (OspA) serotypes the development of diagnostic reagents [83]. Skin isolates are predominantly such as PCR primers and antigens. Thus Borrelia afzelii (OspA type 2), when considering the frequently used particularly those from patients with OspA PCR, it is important that not only acrodermatitis chronica atrophicans, representatives of all human pathogenic which incidentally is also not found species be detected but also the various in the USA [10, 53, 83]. Isolates from OspA types of the heterogeneous CSF and ticks are variable but show a Borrelia garinii group [18]. In addition, predominance of Borrelia garinii (OspA PCR should also distinguish Borrelia types 3-7) [18, 72, 79, 83]. Sequence valaisiana and Borrelia lusitaniae analysis of OspA amplicons using because both are potential human polymerase chain reaction (PCR) on pathogens, as indicated by a number arthrocentesis from patients with Lyme of PCR and culture results [63, 75, 78]. arthritis are distinctly heterogeneous We recently developed a powerful [17, 73]. Other PCR studies showed OspA PCR assay to determine and mostly Borrelia burgdorferi sensu stricto differentiate the various European (5S/23S rRNA intergenic spacer PCR species and OspA subtypes [49]. In [48] or flagellin PCR [35, 36]). serodiagnostic procedures, the strains’ Borrelia afzelii and Borrelia garinii are hetergeneity must also be taken into the most common European species. account, as certain important diagnostic The third most common, Borrelia proteins are decidedly heterogeneous burgdorferi sensu stricto, is particularly and thus differ in their reactivity with rare in eastern Europe (see review by patient sera. For example, among Hubalek and Halouzka 1997 [32]). A representative strains of Borrelia great deal of heterogeneity can occur burgdorferi sensu stricto, Borrelia even in very small areas [18, 21, 49, afzelii, and Borrelia garinii (B31, 61, 64] however, distinct regional PKo, and PBi), amino acid sequence accumulations of certain species or identities for DbpA (Osp17) are 40– subspecies have also been observed 44%, and those for OspC are 54–68%. [45, 49, 55]. Multispecies infections DbpA in particular has much greater in ticks have also been reported [32], amino acid sequence heterogeneity than although such infections are less DNA heterogeneity, which indicates commonly found in humans [14, 73, immunoselection. Interestingly, highly 79]. The heterogeneity of the pathogen heterogeneous proteins can still (Fig. 1) makes the diagnostics of Lyme show highly conserved immunogenic borreliosis in Europe substantially epitopes (e.g. the C6 peptide from more difficult than in the USA and VlsE) [46, 47]. must be taken into consideration in

68 Microbiological diagnostics [59, 85], which expends considerable Quality standards for the time and material, can help in special microbiological diagnosis of Lyme cases when the clinical picture strongly borreliosis suggests Lyme borreliosis despite The German Society for Hygiene and negative serology (seronegative Microbiology (DGHM) has published Lyme borreliosis) [86]. Such cases may quality standards for the diagnosis involve atypical erythema migrans, of Lyme borreliosis formulated by a especially acute neuroborreliosis with committee of experts (MiQ 12 Lyme- short disease duration and no proof Borreliose) [86]. The free English version of antibodies in the CSF, or patients is available at http://www.dghm.org/ red/ with immunodeficiency. The sensitivity index. html?cname=MIQ. of pathogen detection in culture is Except for the pathognomic clinical generally poor (Table 1). manifestation of erythema migrans, the diagnosis of Lyme borreliosis normally Detection using PCR requires microbiological confirmation. Currently no standard procedures are For this purpose, determination of the available for either sample preparation presence of antibodies is usually used, or the PCR itself. Borrelia PCR should while demonstration of the pathogen enable diagnosis of the Borrelia using culture or PCR is limited to special species, i.e. the laboratory report cases, for example with ambiguous should supply information on which serological test results or difficult clinical human pathogenic species is present. cases. Demonstration of the pathogen’s The diagnostic sensitivity of PCR is presence should be made only in approximately the same as for culture, specialised laboratories. whereas it is distinctly easier to detect Borrelia in tissue than in body fluids [2, Detection of the pathogen 6, 35, 39, 44, 71, 87]. Only in the case Detection using culture of synovial fluid is PCR appreciably Culture using modified Kelly medium better than culture (Table 1; [52]).

Table 1. Sensitivity of culture and PCR methods for detecting Borrelia burgdorferi Sample Sensitivity Skin (erythema migrans, acrodermatitis) 50–70% with culture or PCR Cerebrospinal fluid (acute neuroborreliosis) 10–30% with culture or PCR Synovial fluid* (Lyme arthritis) 50–70% with PCR (culture is extremely seldom positive) *higher sensitivity with synovial biopsy compared to synovial fluid

69 Lyme borreliosis diagnostics

Detection of antibodies e.g. enzyme-linked immunosorbent to Borrelia burgdorferi assay (ELISA) or a similar procedure such It is generally accepted that serological as chemiluminescence immunoassay examination should follow a two- (CLIA), which can be confirmed by step approach [12, 37, 85, 86]: (1) immunoblot if reactivity is present. serological screening which, only if reactive, should be followed by (2) a Screening procedure. At least an confirmatory examination. A sensitive improved second-generation test (using screening procedure is recommended, for example recombinant material

Table 2. Reactivity of the various homologues of VlsE and DbpA using line immunoblot for early manifestations. Data from Goettner et al. 2005 A. IgG reactivity DbpA from DbpA VlsE from VlsE Quantity PBie PBr PKo B31e reactive PBie PKoe PKa2 reactive (n) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) EMa 15 0 2 4 1 5 12 9 6 12 (0,0) (13,3) (26,7) (6,7) (33,3) (80,0) (60,0) (40,0) (80) NBb 50 19 20 17 6 39 44 41 41 46 (38,0) (40,0) (34,0) (12,0) (78,0) (88,0) (82,0) (82,0) (92,0) Controlsc 110 2 2 0 0 4 1 3 0 4 (1,8) (1,8) (0,0) (0,0) (3,6) (0,9) (2,7) (0,0) (3,6)

B. IgM reactivity DbpA from DbpA VlsE from VlsE Quantity PBie PBre PKoe B31e reactived PBie PKoe PKa2e reactived (n) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) EMa 15 0 0 1 0 1 8 4 3 8 (0,0) (0,0) (6,7) (0,0) (6,7) (53,3) (26,7) (20,0) (53,3) NBb 50 9 13 2 0 22 26 7 6 28 (18,0) (26,0) (4,0) (0,0) (44,0) (52,0) (14,0) (12,0) (56,0) Controlsc 110 0 1 0 0 1 6 0 0 6 (0,0) (0,9) (0,0) (0,0) (0,9) (5,4) (0,0) (0,0) (5,4) aErythema migrans bNeuroborreliosis cSera from blood donors were used as controls n=60, patients with syphilis n=10, patients with fever of unknown origin n=30, rheumatic factor-positive sera n=10 dAt least one homologous protein reactive eThe Borrelia strains belong to the following species: PBi to Borrelia garinii OspA type 4, PBR to B. garinii OspA type 3, PKo to Borrelia afzelii, and B31 and PKa2 to Borrelia burgdorferi

70 as antigen) should be used for the 29]. Different rules for interpretation screening procedure [86] due to possible must therefore be established in order cross-reactions with other bacteria. to achieve equivalent sensitivity and The strains used as a source of antigens specificity using different Borrelia should express OspC, the dominant strains for immunoblot antigens. The antigen of the IgM immune response, criteria for interpreting immunoblots and DbpA, an immunodominant recommended by the DGHM were antigen of the IgG response [86]. published in “MiQ 12 Lyme-Borreliose” Recently, specific recombinant antigens [86]. (e.g VlsE) or synthetic peptides (e.g. the C6 peptide derived from VlsE) Patients with early manifestations were used successfully on samples from have an immune response based on American [4, 43, 47] and European only a few proteins, while those with patients [20, 22, 46, 54]. Moreover, late manifestations (acrodermatitis or DbpA which, like VlsE, is often hard arthritis) have IgG antibodies against a to extract from Borrelia in culture, has broad spectrum of antigens (Fig. 2). also proved to be a sensitive antigen [22, Using recombinant antigens has a 54] (Table 2). number of advantages over the use of whole cell lysate antigen: (a) specific Confirmatory test (immunoblot). As a antigens can be selected (e.g. p83/100, confirmatory test, immunoblot requires BmpA), (b) homologous antigens a high specificity of at least 95%. Using from various strains can be combined recombinant antigens, the identification (e.g. DbpA [Osp17], OspC, BmpA), of diagnostic bands is substantially easier (c) truncated antigens with a higher than with lysate blots. specificity can be produced (internal The American immunoblot criteria flagellin fragment), and (d) antigens recommended by the centers for disease expressed primarily in vivo but not control cannot be applied in Europe in culture are available (e.g. DbpA [28, 29, 65]. Dressler et al. [16] have and in particular VlsE [30, 67, 81]). shown that the immune response of Commercial recombinant blots can European patients is confined to a be better standardised than whole cell markedly narrower spectrum of Borrelia lysate blots. proteins than that of American patients. The sensitivity of immunoblots based In a study using sera from Germany on recombinant antigens has been and another using sera from various improved considerably in the last few European countries, Hauser et al. have years by additional antigens and the shown that strain-specific criteria for establishment of line immunoblots interpretation must be defined [28, [22, 67, 81]. For the first time, this has

71 Lyme borreliosis diagnostics

Fig. 2. Line immunoblot: IgG immune response in patients with various manifestations of Lyme borreliosis. Late Lyme borreliosis: sera from patients with acrodermatitis chronica atrophicans or Lyme arthritis. The Borrelia strains belong to the species: PBi to Borrelia garinii OspA type 4, PBR to Borrelia garinii OspA type 3, 20047 to Borrelia garinii unknown OspA type, PKo to Borrelia afzelii, and B31 and PKa2 to Borrelia burgdorferi sensu stricto

Early LB Late LB Controls Antigen (Strain) Erythema migrans Neuroborreliosis

allowed significantly higher sensitivity clinical findings. For this, case with recombinant immunoblots definitions are helpful [60, 68, 86]. than with whole cell lysate blots In stage I (erythema migrans), only Recombinant immunoblot technology is 20–50% of patients are seropositive an essential step towards standardising for IgM and/or IgG antibodies [3, 26, and increasing sensitivity, as homologous 77] (Table 3), and IgM antibodies antigens from various strains (especially are prevalent. A possible exception those with low sequence identity such is the immune response to VlsE. In as DbpA) and antigens that are only American patients with erythema expressed in vivo (e.g. VlsE) can be used. migrans, VlsE IgG antibodies were detectable before the Borrelia-specific Serological results at various IgM response (44% vs 19% of patients stages of the disease in acute erythema migrans and 59% vs Serological test results must always 43% in convale­scent erythema migrans) be interpreted in relation to the [4]. In European patients with erythema

72 Table 3. Sensitivity for the presence of antibodies in cases of Lyme borreliosis Stage Sensitivity Antibody class I 20-50% Predominantly IgM II 70-90% With short-term illness predominantly IgM, with longer-term illness predominantly IgG III Near 100% Usually only IgGa aThe presence of IgM antibodies without IgG is not diagnostic for late manifestation migrans, earlier IgG response against cytosis and barrier disturbance, this VlsE was observed in 20 of 23 cases provides decisive diagnostic evidence. confirmed by culture (87%). The IgM For diagnosing chronic borreliosis of response was not studied [46]. In stage the central nervous system, a positive II (acute neuroborreliosis), the rate IgG CSF/serum index is essential (see of seropositivity increases (IgM and/ EUCALB case definitions [68, 86]), or IgG antibodies) to 70–90% [24, 25, whereas chronic peripheral neuropathy 80, 82]. In principle, patients with early usually displays no intrathecal antibody manifestations can be seronegative, production [42]. particularly those with short-term illness. As serological results can vary A check of the serological course should substantially and antibodies can persist be done in such cases. At 6 weeks or for a long time even in successfully more after onset of the disease, 100% treated patients, serological course of stage II neuroborreliosis patients controls are not suitable for determining are seropositive [24]. In cases with late therapy failure. Until recently, a fall in manifestations (stage III, acrodermatis VlsE specific antibodies was considered and arthritis), IgG antibodies could be an indicator for the success of therapy demonstrated in all patients examined [57]. This could not however be [26, 37, 80, 82]. A negative IgG test confirmed in a European study [56]. therefore speaks against diagnosis of The presence of specific antibodies does late-stage Lyme borreliosis. A positive not indicate the presence of a clinical IgM test with negative IgG is likewise manifestation. Antibody tests can also not diagnostically relevant for late-stage be positive due to previous clinical or Lyme borreliosis [86]. subclinical infection. The less specific For the diagnosis of neuroborreliosis, the patients’ symptoms are, the less is evidence of intrathecal antibody the positive predictive value. In normal, production (i.e. in the CSF/serum healthy individuals, seropositivity varies index) is particularly important [84]. with age and outdoor activity (e.g. in a Combined with additional changes study from Bavaria between 5% and in the CSF such as lymphocytic pleo­ 20% [62]).

73 Lyme borreliosis diagnostics

Methods not recommended globin or scutum of the tick), for the diagnosis of Lyme laboratory contamination and the borreliosis genetic heterogeneity of Borrelia Evidence of borreliosis from a tick burgdorferi sensu lato. removed from a patient 4. The great majority of the resulting Examination of ticks for the presence illnesses are simple to diagnose and of Borrelia burgdorferi is valuable only efficiently to treat [34]. if (1) with a negative test result there 5. No European study has been able is sufficient certainty that no infection to demonstrate that antibiotic with Borrelia burgdorferi has occurred prophylaxis or therapy following or (2) with a positive result there is a bite by an infected tick has more sufficient likelihood of a clinical advantages than disadvantages. manifestation of the infection. The following points must be To summarise, examining ticks considered for evaluating this method removed from humans for Borrelia of examination: burgdorferi sensu lato cannot be 1. Not every tick bite is discovered. recommended. The reasons are the Ixodes ricinus larvae and nymphs low infection and manifestation rates, can hardly be recognised by normal insufficient negative and positive vision and are often unconsciously predictive value of the method, good removed with a fingernail. Thus, disease prognosis, and no evidence of negative results can lead to a false a reasonable prophylactic treatment. sense of security, and infection can be Action useful after tick bites has been contracted through the unrecognised proposed by a group of experts [38]. bite. 2. Infected ticks usually do not transmit Significance of the lymphocyte the pathogen through biting, and, transformation test should an infection result, only some In principle, the lymphocyte cases become clinically relevant (e.g. transformation test (LTT) measures Nahimana et al. [51] in which only proliferation of lymphocytes in patient three of 17 individuals who sero­ blood after stimulation with an antigen converted became clinically ill). (e.g. sonicated Borrelia, recombinant 3. The diagnostic sensitivity and Borrelia antigens). The test is therefore specificity of the various methods an attempt to determine cellular for analysing ticks is largely unclear. immunity against specific antigens. Influencing factors include transport In 1988, Dattwyler et al. showed that time, DNA extraction, presence of LTT could be positive even in cases of inhibitory substances (e.g. haemo­ seronegative chronic borreliosis that

74 developed after prompt treatment for The sensitivity of the test was 77% an early manifestation [13]. However, with a specificity of 78%. For eight of a series of studies published since then the children with Lyme arthritis, the have shown no advantage of LTT over stimulation index was negative before serology in routine Lyme borreliosis therapy but positive after therapy. diagnostics [5, 9, 15, 19, 31, 33, 40, 66, In the authors’ opinion, their study 74]. demonstrates that the test is valuable Krause et al. used LTT to examine 24 for neither prognosis nor control of patients with various manifestations of the disease course. They concluded: Lyme disease and 30 patients with arthritis “Lymphocyte proliferation assay of unrelated aetiology as a control group, will rarely aid in finding the correct including also 20 healthy individuals [40]. diagnosis when clinical presentation For proof of antibodies, the sensitivity was and anti-borrelial serology do not 83% and specificity 92%. For LTT with a match.” specificity of 92%, the sensitivity was 71%, The studies of LTT to date show that it while for a sensitivity of 83% the specificity is not well standardised and, compared was 72%. Krause recently questioned with serology, is less sensitive and whether LTT could contribute to routine particularly less specific. Therefore, LTT clinical diagnostics. In addition, due to the is not suited for routine diagnosis of test’s low specificity, he re-emphasised the Lyme borreliosis. high likelihood of false positive results and Meanwhile, the ELISPOT test (a concluded that LTT should not be used for commercially available LTT modifi­ the diagnosis of Lyme borreliosis [41]. cation) has been recommended for Dressler et al. examined 42 patients human granulocytic ehrlichiosis, with chronic Lyme borreliosis and 77 including an indication that co-infection control individuals [15]. A sonicated has considerable significance for the Borrelia burgdorferi sensu stricto strain prognosis and course of infection with was used as antigen. The sensitivity of Borrelia. Here we would point out that the test was given at 45% (serology to date no case of autochthonous human 93%) with specificity of 95%. (No data granulocytic ehrlichiosis in Germany were provided for serology.) Four of has been published and therefore use nine laboratory personnel examined of this test is already questionable on also were positive using LTT. epidemiological grounds. In 1996 Huppertz et al. examined 55 children with Lyme arthritis and 48 The significance of cystic forms of control patients [33]. Two unsonicated Borrelia burgdorferi Borrelia burgdorferi sensu stricto So-called cystic forms, also known as strains were used as the antigen source. spheroblasts, forms without cell walls,

75 Lyme borreliosis diagnostics

or L forms, can be induced in vitro by symptoms such as myalgia, muscle various stress factors such as culture twitching, joint pain, low energy, in CFS, extreme changes in pH value, fatigue, diarrhea, constipation, and and increased temperature [1, 7, 8, 50]. similar symptoms [27]. This test is Purely L forms proved infectious to based on the hypothesis that Borrelia mice [23]. Whether these forms are burgdorferi produces a lipophilic significant for pathogenesis of the neurotoxin which, among other disease or to diagnostics is however activities, binds to the optic nerves, still unclear. In the meantime, assays making the disease detectable using allegedly specific for the Borrelia a VCS test due to reduced function, burgdorferi sensu lato form without i.e. a deficit in recognising grey cell walls are available. However, they tones [27]. We do not know of any have not been adequately evaluated scientific publication that supports and thus cannot be recommended for the suppositions on which this test is Lyme borreliosis diagnostics [11]. based. As the neurotoxin is subject to the enterohepatic circulation, it is also The visual contrast recommended that cholestyramine­ be sensitivity test used to break the toxic cycle. The visual contrast sensitivity test From our point of view, we urgently (VCS) has been recommended by advise against therapy with cholesty­ Hartmann and Müller-Marienburg for ramine and the use of VCS tests for the chronically ill patients with unspecific diagnosis of Lyme borreliosis.

76 l References for generating cystic forms of Borrelia 1. Alban, PS, Johnson, PW, Nelson, DR. burgdorferi and their reversal to mobile Serum-starvation-induced changes spirochetes. APMIS 106 (1998)1131-1141 in protein synthesis and morphology 9. Buechner, S. A.; Lautenschlager, S.; Itin, P.; of Borrelia burgdorferi. Microbiol Bircher, A.; Erb, P. Lymphoproliferative 146(2000)119-127 responses to Borrelia burgdorferi 2. Arnez M, Ruzic-Sabljic E, Ahcan J, Radsel- in patients with erythema migrans, Medvescek A, Pleterski-Rigler D, Strle F. acrodermatitis chronica atrophicans, Isolation of Borrelia burgdorferi sensu lymphadenosis benigna cutis, and lato from blood of children with solitary morphea. Arch. Dermatol.: 131(1995)673- erythema migrans. Pediatr Infect Dis J 677 2001; 3:251-255 10. Canica, MM, Nato, F, Du Merle, L, 3. Åsbrink, E.; Hovmark, A.; Hederstedt, B. Mazie, JC, Baranton, G, Postic, D. Serologic studies of erythema chronicum Monoclonal antibodies for identification migrans Afzelius and acrodermatitis of Borrelia afzelii sp. nov. associated with chronica atrophicans with indirect late cutaneous manifestations of Lyme immunofluorescence and enzyme-linked borreliosis. Scand J Infect Dis 1993; 25:441- immunosorbent assays. Acta Derm Venereol 448. 1985; 65:509-514 11. Centers for Disease Control and Prevention. 4. Bacon, RM, Biggerstaff, BJ, Schriefer, Caution regarding testing for Lyme disease. M, Gilmore, RD, Philipp, MT, Steere, Morbid Mortal Wkly Rprt 2005; 54:125 A, Wormser, GP, Marques, AR, and 12. Centers for Disease Control and Prevention. Johnson, BJB. Improved serodiagnosis Recommendations for Test Performance of Lyme disease by kinetic ELISAs using and Interpretation from the Second National recombinant VlsE1 or peptide antigens of Conference on Serologic Diagnosis of Borrelia burgdorferi compared with two- Lyme Disease. Morbid Mortal Wkly Rprt tiered testing. J Infect Dis; 2003; 187:1187- 1995;44:590 1199 13. Dattwyler, R. J.; Volkman, D. J.; Luft, B. J.; 5. Bauer, Y.; Hofmann, H.; Jahraus, O.; Halperin, J. J.; Thomas, J.; Golightly, M. G. Mytilineos, J.; Simon, M. M.; Wallich, R. Seronegative Lyme disease: Dissociation Prominent T cell response to a selectively of specific T- and B-lymphocyte responses in vivo expressed Borrelia burgdorferi to Borrelia burgdorferi. N. Engl. J. Med.: outer surface protein (pG) in patients 319(1988)1441-1446 with Lyme disease. Eur. J. Immunol.: 14. Demaerschalck, I, Messaoud, AB, De Kesel, 31(2001)767-776 M, Hoyois, B, Lobet, Y, Hoet, P, Bigaignon, 6. Brettschneider, S.; Bruckbauer, H.; G, Bollen, A, Godfroid, E. Simultaneous Klugbauer, N.; Hofmann, H. Diagnostic presence of different Borrelia burgdorferi value of PCR for detection of Borrelia genospecies in biological fluids of Lyme burgdorferi in skin biopsy and urine disease patients. J Clin Microbiol: 1995; samples from patients with skin borreliosis. 33:602-608 J. Clin. Microbiol.: 36(1998)2658-2665 15. Dressler, F, Natalino, H, Yoshinari, Steere, 7. Brorson, O.; Brorson, S. H. In vitro A C. The T-cell proliverative assay in the conversion of Borrelia burgdorferi to cystic diagnosis of lyme borreliosis. Ann Int Med forms in spinal fluid, and transformation 115(1991)533-539 to mobile spirochetes by incubation in 16. Dressler, F, Ackermann, R, Steere, BSK-H medium. Infection: 26(1998)144- AC. Antibody responses to the three 150 genomic groups of Borrelia burgdorferi in 8. Brorson, O.; Brorson, S. H. A rapid method European Lyme borreliosis. J Infect Dis

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1994; 169:313-318 assay for intrathecal sythesis of Borrelia 17. Eiffert, H, Karsten, A, Thomssen, R, burgdorferi - specific immunoglobulin G, Christen H-J. Characterization of Borrelia A, and M. Ann. Neurol.: 30(1991)197-205 burgdorferi strains in Lyme arthritis. Scand 26. Hansen, K.; Åsbrink, E. Serodiagnosis J Infect Dis 1998; 30:265-268 of erythema migrans and acrodermatitis 18. Eiffert, H, Ohlenbusch, A, Christen, H-J, chronica atrophicans by the Borrelia Thomssen, R, Spielman, A, Matuschka, F-R. burgdorferi flagellum enzyme-linked Nondifferentiation between Lyme disease immunosorbent assay. J Clin Microbiol spirochetes from vector ticks and human 1989; 27:545-551 cerebrospinal fluids. J Infect Dis 1995; 27. Hartmann und Müller-Marienburg. 171:476-479 Indirekter Neurotoxinnachweis durch 19. Ekerfelt, C.; Forsberg, P.; Svenvik, M.; Roberg, den “Visual Contrast Sensitivity” Test M.; Bergström, S.; Ernerudh, J. Asymptomatic bei Patienten mit chronischer Borreliose. Borrelia-seropositive individuals display Neurologie 2003. 248-251 the same incidence of Borrelia-specific 28. Hauser, U, Lehnert, G, Lobentanzer, interferon-gamma (IFN-y)-secreting cells R, Wilske, B. Interpretation criteria for in blood as patients with clinical Borrelia standardized western blots for three infection. Clin. Exp. Immunol.: 115(1999)498- european species of Borrelia burgdorferi 502 sensu lato. J Clin Microbiol 1997. 35:1433- 20. Fingerle, V, Schulte-Spechtel, U, Wilske, 1444 B. Evaluation of an ELISA based on the 29. Hauser, U, Lehnert, G, Wilske, B. C6-peptide of VlsE for diagnosis of early Diagnostic value of proteins of three neuroborreliosis. Int J Med Microbiol 2002; Borrelia species (Borrelia burgdorferi sensu 292 (Suppl. 34): 217 lato) and implications for development 21. Gern, L, Hu CM, Kocianova E, and use of recombinant antigens for Vyrestekova V, Rehacek J. Genetic serodiagnosis of Lyme borreliosis in diversity of Borrelia burgdorferi sensu lato Europe. Clin Diagn Lab Immunol 1998; isolates obtained from Ixodes ricinus ticks 5:456-462 collected in Slovakia. Europ J Epidemiol 30. Heikkilä, T, Seppälä, I, Saxen, H, (1999)15, 665-669 Panelius, J, Yrjänäinen, H, Lahdenne, 22. Goettner, G., U. Schulte-Spechtel, R. P. Speciesspecific serodiagnosis of Lyme Hillermann, G. Liegl, B. Wilske, and V. arthritis and neuroborreliosis due to Fingerle. 2005. Improvement of Lyme Borrelia burgdorferi sensu stricto, B. afzelii, borreliosis serodiagnosis by a newly and B. garinii by using decorin binding developed recombinant IgG and IgM line protein A. J Clin Microbiol 2002; 40:453- immunoblot and addition of VlsE- and DbpA 460 homologues. J.Clin.Microbiol. in press 31. Horowitz, HW, Pavia, CS, Bittker, S, 23. Gruntar, I, Malovrh, T, Murgia, R, Cinco, Forseter, G, Cooper, D, Nadelman, RB, M. Conversion of Borrelia garinii cystic Byrne, D, Johnson, RC, Wormser, GP. forms to motile spirochetes in vivo. APMIS Sustained cellular immune response to 105(2001)383-388 Borrelia burgdorferi: Lack of correlation 24. Hansen, K, Hindersson, P, Pedersen, with clinical presentation and serology. NS. Measurement of antibodies to the Clin Diagn Lab Immunol 1(1994)4:373-378 Borrelia burgdorferi flagellum improves 32. Hubalek, Z. Halouzka, J. Distribution of serodiagnosis in Lyme disease. J Clin Borrelia burgdorferi sensu lato genomic Microbiol 1988; 26:338-346 groups in Europe, a review. Eur J 25. Hansen, K, Lebech, A-M. Lyme Epidemiol 1997; 13: 951-957 neuroborreliosis: a new sensitive diagnostic 33. Huppertz, H.-I.; Mösbauer, S.; Busch,

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82 l Contacts

Dr. med. Thomas Talaska Praxis für Mikrobiologie und Infektionsepidemiologie Rudolf-Breitscheid-Str.10 15295 Groß Lindow [email protected]

Prof. Dr. med. Andreas Krause Immanuel Krankenhaus GmbH Rheumakliniken Berlin-Wannsee und Berlin-Buch Königstr.63 Karower Str.11 14109 Berlin 13125 Berlin [email protected]

Prof. Dr. med. Elisabeth Aberer Universitätsklinik für Dermatologie Medizinische Universität Graz A-8036 Graz [email protected]

Prof. Dr. med. Reinhard Kaiser Neurologische Klinik Klinikum Pforzheim GmbH Kanzlerstraße 2-6 75175 Pforzheim [email protected]

Dr. med. Volker Fingerle Max von Pettenkofer-Institut, LMU München Nationales Referenzzentrum für Borrelien Pettenkofer-Strasse 9a 80336 Munich [email protected]

Prof. Dr. med. Bettina Wilske Max von Pettenkofer-Institut, LMU München Nationales Referenzzentrum für Borrelien Pettenkofer-Strasse 9a 80336 Munich [email protected]

83

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