> Lyme borreliosis

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Name and nature of infecting organism Clinical features yme borreliosis (LB) is a tick-transmitted bacterial infection caused by some burgdorferi infection can be members of the spirochete group sensu lato. It is the asymptomatic. most prevalent tick-transmitted infection in temperate areas of , North • Early manifestation AmericaL and Asia, and its geographic distribution is ever-increasing. Erythema migrans, the early skin rash of loca- lised infection, occurs in about 70–80% of The B. burgdorferi complex comprises of at least 19 cases. It is an erythematous rash that gradually genospecies worldwide; only five are significantly expands from the site of a tick bite and is not si- pathogenic to . A common symptom caused gnificantly raised or painful. Some patients may by the pathogenic genospecies is erythema migrans, also have systemic ‘flu-like’ illness but without the early skin rash of LB. and B. garinii significant respiratory symptoms. are the major pathogenic genospecies found in Borrelial lymphocytoma is an uncommon skin Europe and are associated with skin and neurological manifestation of early infection, usually affecting complications respectively. B. burgdorferi sensu the earlobe, nipple or scrotum. It may persist for ©S. Kaulitzki ©S. Kaulitzki stricto (the only pathogenic genospecies found in Ricinus some months if left untreated, and can be mis- North America) is present in some parts of Europe taken for cutaneous lymphoma because of its and can cause neurological and arthritic complications. Two other pathogenic associated intense lymphocytic infiltrate. genospecies have been identified in Europe: B. bavariensis, associated with • Late manifestations neurological complications and B. spielmanii. Additionally B. valaisiana and Neuroborreliosis is the main complication, seen B. lusitaniae rarely cause disease in humans. in.up to 12% of patients with Lyme borreliosis. The regions with highest tick infection rates (nymphs > 10%; adult > 20%) are Acute neuroborreliosis can present: facial pal- located in central Europe and include Austria, Czech Republic, southern Germany, sy, lymphocytic meningitis, radiculoneuritis. It Switzerland, Slovakia and Slovenia. usually occurs within about six to twelve weeks of infection. Meningoencephalitis is a less com- mon feature. Occasional cases of more indo- Transmission lent radiculopathy can develop over a period of months, mainly in older people. Radicular pain Reservoir can be very severe, but usually reduces rapidly In Eurasian endemic areas B. burgdorferi genospecies circulate between hard following antibiotic treatment. Other uncommon ticks of the Ixodes ricinus complex and vertebrate hosts, including many species features of disseminated infection include mul- of small and ground-feeding , which are the principal feeding hosts tiple erythema migrans, intermittent arthritis for and nymphs. and carditis, which can cause rhythm abnorma- Adult ticks usually feed on larger such as , and other large lities. These also present within a few weeks to size ungulates, which are not reservoir-competent for several months of infection. borrelia, but help to maintain the ticks’ reproductive Presentations of late (previously untreated) Lyme stage. borreliosis can affect the skin, nervous or muscu- The most suitable microhabitats for tick development loskeletal systems. Manifestations include acro- and survival have > 85% relative humidity. Optimal dermatitis chronica atrophicans, a persistent habitats are represented by deciduous or mixed skin infection usually affecting the extremities, woodland, but I. ricinus ticks can also be found in causing inflammation and eventually thinning heathland, open grassy meadows and in suburban of the affected skin with an associated neuro-

© Trimming Peter Zanone © Ferruccio and urban environments, including urban parklands pathy. Late neuroborreliosis usually presents as and gardens. an encephalomyelitis and can resemble multiple sclerosis. Lyme arthritis usually affects a large Transmission mode joint, most commonly the knee. All are caused by Transmission of B. burgdorferi to humans occurs through a bite from an infected active infection which will respond to antibiotic tick, mainly a nymph or an adult. Larval tick bites do not pose a significant risk, therapy, but recovery may be incomplete depen- as it is rare for larvae to carry infection. Infected ticks are unlikely to transmit the ding on the degree of underlying tissue damage organisms in the early hours of feeding, but the risk rises steadily with increasing prior to treatment.

> For more information on tick-borne diseases, please consult the ECDC website www.ecdc.europa.eu Factsheet for health practitioners > Lyme borreliosis

duration of the blood meal, so early removal of attached ticks within the first hours is very useful in reducing transmission risk. Risk groups All persons exposed to risk of tick bites are at risk of becoming infected. Prevention measures No licensed vaccine is currently available, so the main methods of preventing infection are avoiding tick bites and early removal of attached ticks. The most effective tick-bite avoidance strategies include wearing protective clothing (long trousers and long-sleeved shirts) and using repellents on skin and clothes. Skin should be checked periodically for attached ticks and these References should be removed with tweezers or fine-pointed forceps, grasping the tick • Factsheet for health professionals – Lyme borreliosis as closely as possible to the skin, pulling gently upwards and trying not to [website]. ECDC; 2010 (http://www.ecdc.europa.eu/en/ break off the mouth parts. The risk of borrelial infection is not increased if tick healthtopics/emerging_and_vector-borne_diseases/ mouth parts are left behind. A skin disinfectant should be applied afterwards tick_borne_diseases/lyme_disease/factsheet-health- to prevent localised pyogenic infection. professionals/Pages/factsheet_health_professionals. aspx). Areas to check for ticks that should have particular attention include skin-folds – groins, armpits, under breasts, waist band area, backs of knees – as ticks • Derdáková D, Lencaková D. Association of genetic seek out more humid areas for attachment. The head (including scalp) and variability within the Borrelia burgdorferi sensu lato with the ecology, epidemiology of Lyme borreliosis in neck area of young children should also be checked carefully, as tick bites are Europe. Ann Agric Environ Med 2005;12(2):165-172. relatively more common at these sites in this age group. • Hofhuis A et al. A prospective study among patients presenting at the general practitioner with a tick Diagnosis bite or erythema migrans in The Netherlands. PLoS No laboratory tests are required in the diagnosis of erythema migrans, which One. 2013 May 16;8(5):e64361. doi: 10.1371/journal. depend on a clinical evaluation and an assessment of tick exposure risk. pone.0064361. Laboratory tests are necessary to confirm a diagnosis of later stage infection. • Ixodes ricinus [website]. Stockholm: ECDC; 2014 Antibodies to B. burgdorferi are usually detectable within 4-8 (http://www.ecdc.europa.eu/en/healthtopics/vectors/ weeks of infection. Patients with late-stage infection are rarely ticks/Pages/ixodes-ricinus.aspx). seronegative and usually have very strongly positive antibody • Medlock JM et al. Driving forces for changes in tests. However, the occurrence of false-positive tests in patients geographical distribution of Ixodes ricinus ticks in with other infections or conditions such as autoimmune Europe. Parasites & Vectors. 2013;6:1 doi: 10.1186/1756- diseases, can lead to misdiagnosis and inappropriate treatment. 3305-6-1. Other specialised investigations can be helpful in certain cases, • Pitches DW. Removal of ticks: a review of the literature. for example antibody testing and borrelial DNA detection studies Euro Surveill 2006;11(33):3027.

© J. Gathany - US-CDC Library - US-CDC © J. Gathany on CSF from patients with suspected neuroborreliosis. Borrelia • Randolph SE. Tick ecology: processes and patterns DNA detection can also be useful on skin biopsies from patients behind the epidemiological risk posed by ixodid ticks as with suspected erythema migrans and acrodermatitis chronica atrophicans vectors. Parasitology. 2004;129(S):37-65.

and on synovial fluid from patients with suspected Lyme arthritis. • Rizzoli A et al. Lyme borreliosis in Europe. Eurosurveillance. 2011;16(27):pii=19906. (http://www.eurosurveillance.org/ViewArticle. Management and treatment aspx?ArticleId=19906). All patients with symptomatic B. burgdorferi infection should be treated with appropriate antibiotics (amoxicillin and cephalosporin and macrolides for • Stanek G, et al. Lyme borreliosis. Lancet. 2012 Feb disseminated infections). Early treatment can prevent the risk of developing 4;379(9814):461-73. doi: 10.1016/S0140-6736(11)60103-7. late stage complications, but even patients with late stage Lyme can benefit • Stanek G, et al. Lyme borreliosis: Clinical case from antibiotics, although clinical recovery may be incomplete if severe tissue definitions for diagnosis and management in damage had occurred prior to treatment. Europe. Clin Microbiol Infect. 2011, 17(1):69-79. doi: 10.1111/j.1469-0691.2010.03175.x.

• Study Group for Lyme Borreliosis – ESGBOR [website]. Key areas of uncertainty Basel: European Society of Clinical Microbiology and Areas for further research include more detailed knowledge of the ecological Infectious Diseases; 2014 (https://www.escmid.org/ aspects of Lyme borreliosis on a local, regional and EU scale, including research_projects/study_groups/esgbor/ distribution and prevalence of pathogenic and non-pathogenic genospecies • Vázquez M et al. Effectiveness of personal protective and more data on the epidemiology of Lyme borreliosis. Further improvements measures to prevent Lyme borreliosis. Emerging in diagnostic tests are also required. Infectious Diseases. 2008;14:210-216.

> For more information on tick-borne diseases, please consult the ECDC website www.ecdc.europa.eu

Information contained in this factsheet may change as new evidence becomes available.