Van alles over Erythema Migrans

[vonneke]

Clin Infect Dis. 1995 Aug;21(2):380-9.Links

Persistence of Borrelia burgdorferi sensu lato in resolved erythema migrans lesions.

Strle F, Cheng Y, Cimperman J, Maraspin V, Lotric-Furlan S, Nelson JA, Picken MM, Ruzic-Sabljic E, Picken RN.
Department of Infectious Diseases, University Medical Centre, University of Ljubljana, Slovenia.

Erythema migrans skin lesions resulting from a tick bite and infection with Borrelia burgdorferi sensu lato eventually resolve, even without antibiotic therapy. The aim of the present study was to gauge the frequency of persistence of B. burgdorferi sensu lato in such lesions. Thus, the site of a previous lesion was biopsied and cultured in 48 patients: 39 with systemic or localized symptoms/signs and nine with no symptoms. B. burgdorferi sensu lato was isolated from biopsied skin from three symptomatic patients. Cultures of other tissues and fluids were negative. By genospecies-specific polymerase chain reaction (PCR) and pulsed-field gel electrophoretic (PFGE) analysis, two isolates were classified as Borrelia afzelii. The remaining isolate was a member of an unusual group of strains that type as B. burgdorferi sensu stricto by genospecies PCR but possess an atypical PFGE profile. All three patients had a dramatic clinical response to antibiotic treatment. These findings demonstrate the capacity of viable B. burgdorferi sensu lato organisms to persist in clinically normal-appearing skin at the site of a resolved erythema migrans rash for periods ranging from 2 months to 3.5 years. This observation may provide new insight into the organisms' ability to evade the host's immune response.

PMID: 8562748

[vonneke]

1: Epidemiol Mikrobiol Imunol. 2008 Aug;57(3):97-100.

Reccurent erythema migrans as a persistent infection.

Svecová D, Gavornik P.
Dpt.of Dermatovenerology, Faculty of Medicine, Comenius University, Bratislava, Slovak Republic. danka.svecova@faneba.sk

BACKGROUND: Effective antibiotic therapy administered early in the course of the clinical presentation of erythema migrans (EM) prevents further progression of infection and dissemination of the agent to internal organs. CASE REPORT: A 73-year old woman was referred with a history of five episodes of recurrent EM after repeated adequate antibiotic treatment. The patient who had visited an endemic area only once before the disease recalled no tick bite either prior to the first episode or later. After the first episode, the serological examination was negative (IFA, ELISA, Western blot). In the second episode, not preceded by her visit to any endemic area, the patient showed borderline positivity. Western blot confirmed Borrelia burgdorferi sensu lato. The following episodes were observed again without a prior visit to any endemic area. The most recent EM episode was accompanied by nonspecific moderate symptoms such as fatigue and malaise without involvement of internal organs, with the same serological result as found previously. Peripheral blood PCR assay detected Borrelia burgdorferi specific DNA. Intravenous cephalosporin was effective in treating both the skin and extracutaneous signs of the disease. CONCLUSION: Recurrent episodes of appropriately treated EM may occur as a result of either reinfection due to contact with another vector tick or persistent infection. Intravenous cephalosporin is likely to be appropriate therapy for recurrent borrelial infection in the skin, in particular when accompanied by general extracutaneous signs and symptoms that might indicate dissemination of the spirochetes.

PMID: 18767376

[vonneke]

: Int J Med Microbiol. 2009 Jan 8. [Epub ahead of print] Links

Antibody responses to borrelia IR(6) peptide variants and the C6 peptide in Swedish patients with erythema migrans.

Tjernberg I, Sillanpää H, Seppälä I, Eliasson I, Forsberg P, Lahdenne P.
Department of Clinical Chemistry, Kalmar County Hospital, S-391 85 Kalmar, Sweden; Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Linköping, Linköping, Sweden.

The aim of this study was to evaluate the antibody responses to different VlsE protein IR(6) peptide variants and the synthetic C6 peptide in acute and convalescent (2-3 and 6 months) serum samples from Swedish patients with clinical erythema migrans (EM). Serum samples were prospectively collected from 148 patients with EM and compared to serum samples obtained from 200 healthy blood donors. The IgG responses to 3 IR(6) peptide variants originating from Borrelia burgdorferi (B. burgdorferi) sensu stricto, B. garinii, and B. afzelii were measured by enzyme-linked immunosorbent assays (ELISAs) and compared to a commercial C6 peptide ELISA. Seropositivity rate in the IR(6) or C6 peptide ELISAs ranged from 32% to 58% at presentation, 30-52% after 2-3 months, and 20-36% after 6 months. At presentation, positive antibodies in any of the 4 ELISAs were found in 66%. In 7/52 (13%), C6-negative EM cases, serological reaction was found to the B. burgdorferi sensu stricto-derived IR(6) peptide. In patients reporting previous LB compared to those without previous LB, significantly higher seropositivity rates were noted for all IR(6) peptides, but not for the C6 peptide. In the serology of EM in Europe, C6 ELISA does not seem to cover all cases. An ELISA using a mixture of B. burgdorferi sensu stricto IR(6) peptide and the C6 peptide could be of value in the serodiagnosis of LB in Europe. Further studies on combinations of variant IR(6) peptides and the C6 peptide in other manifestations of LB are needed to address this issue.

PMID: 19138558

[vonneke]

Serologische follow-up onderzoeken worden vaak uitgevoerd bij patiënten met erythema migrans, borrelia lymphocytoma en acrodermatitis chronica atrophicans om de werkzaamheid van een behandeling te evalueren.
Er is echter substantieel bewijs in de literatuur dat antilichaam titer ontwikkeling na de therapie onvoorspelbaar en variabel is, en het bovendien grotendeels niet in verhouding staat met het klinische verloop en de wijze van antibiotische behandeling.
Bijvoorbeeld, aanhoudend positieve IgG en / of IgM antilichaam titers duiden niet op falen van de behandeling. Dus herhaalde serologische testen zijn van zeer beperkte waarde voor de beoordeling van de therapie werkzaamheid, en daarom niet aanbevolen in de follow-up van dermatoborreliose patiënten. Aangezien PCR ook onvoldoende adequaat is voor dit doel, berust de beoordeling van patiënten met cutane manifestaties van Lyme Borreliose in de follow-up voornamelijk op het klinische beeld.

Curr Probl Dermatol. 2009;37:178-182. Epub 2009 Apr 8.Links
Is Serological Follow-Up Useful for Patients with Cutaneous Lyme Borreliosis?Mullegger RR, Glatz M.
Department of Dermatology, State Hospital Wiener Neustadt, Wiener Neustadt, Austria.

Serologic follow-up examinations are frequently performed in patients with erythema migrans, borrelial lymphocytoma, and acrodermatitis chronica atrophicans (the 3 dermatoborrelioses) to evaluate treatment efficacy. There is, however, substantial proof in the literature that antibody titer development after therapy is unpredictable and variable, and moreover it is largely uncorrelated with the clinical course and mode of antibiotic treatment. For example, persistent positive IgG and/ or IgM antibody titers do not indicate treatment failure. Thus, repeated serologic testing is of very limited value for assessing therapy efficacy, and therefore not recommended in the follow-up of dermatoborrelioses patients. Since cultivation of the etiologic agent, Borrelia burgdorferi sensu lato, and polymerase chain reaction are also inadequate for this purpose, the assessment of patients with cutaneous manifestations of Lyme borreliosis in the follow-up rests primarily on the clinical picture

PMID: 19367102

[vonneke]

De meeste bacteriële huidinfecties kunnen worden gediagnosticeerd op basis van de anamnese en de klinische bevindingen. Huidkweken en serologisch onderzoek (bijvoorbeeld bij erythema migrans) zijn niet nodig.

Bij een patiënt met erythema migrans kort na een tekenbeet is serologisch onderzoek niet zinvol. Dit geldt ook als er vlak na een tekenbeet twijfel bestaat over de diagnose, omdat de sensitiviteit van serologisch onderzoek op dat moment laag is. De standaard adviseert bij twijfel aan de diagnose om de patiënt na één week opnieuw te onderzoeken. Voor de beslissing om al dan niet met antibiotica te behandelen is het klinische beeld doorslaggevend.

http://www.ntvg.nl/node/315166/print

[vonneke]

Erythema migrans
Het erytheem kan zich vanaf enkele dagen tot ongeveer drie maanden na de tekenbeet ontwikkelen.17) Het erytheem wordt gekenmerkt door een rode of blauwrode plek die meestal langzaam groter wordt. De doorsnede varieert afhankelijk van de infectieduur van enkele centimeters tot tientallen centimeters. Naast een rond of, door centrale verbleking, ringvormig erytheem worden ook ovale of meer rechthoekige vormen gezien. Erythema migrans is vaak de eerste presentatie van lymeborreliose. Onbehandeld kan het erytheem binnen één tot vier maanden spontaan verdwijnen. Erythema migrans kan gepaard gaan met een branderig gevoel of jeuk ter plaatse van het erytheem of met algemene ziekteverschijnselen zoals koorts, lymfadenitis en moeheid

http://nhg.artsennet.nl/kenniscentrum/k ... 68_std.htm

[vonneke]

De 'zonnebrand' van de patiënt is in werkelijkheid een ongewone vorm van een EM.

Het vesiculopustular(blaasjes/met pus gevulde blaasjes) onderdeel van de uitslag van de patiënt is een ongewoon hoewel goed gedocumenteerde variant van het karakteristieke" bulls-eye laesie " die wordt gezien in het begin van Lyme .

EMS kunnen worden verward met een spinnebeten wanneer er een vesiculaire of necrotisch midden is in de plek.

(Necrose: http://nl.wikipedia.org/wiki/Necrose)

Zie afbeelding op pagina 2 links onderaan :

http://www.jabfm.org/cgi/reprint/22/2/219.pdf

The patient’s “sunburn” was in actuality an uncommon
form of the EM lesion. The vesiculopustular
component of the patient’s rash is an uncommon
although well-documented variant of the
characteristic bulls-eye lesion found in early Lyme
disease (Figure 2).

The majority of rashes are uniform
in color, with the famous “bulls eye” appearing
in only 20% of patients in the United States and
the vesiculopustular lesions in 1% to 2% of cases.6,7

EMs may be mistaken for a spider bite when there
is a vesicular or necrotic center to the lesion.8 In
North America, rashes diagnostically indistinguishable
from EM may be caused by Lyme disease or a
newly described infection of unknown cause called
southern tick-associated rash illness.

Therefore, the positive predictive value of EM for Lyme disease is
expected to be highly dependent on the prevalence
of Lyme disease in a particular geographic region.6
The negative predictive value of EM is poor because
no rash is present in up to 10% of patients
with early Lyme disease.9,10

[vonneke]

Borrelia infectie wordt gekenmerkt door verschillende huid uitingen die meestal ingedeeld in de drie voornaamste soorten: ECM, borrelia lymphocytoma en acrodermatitis chronica atrophicans.

Wij melden een ongewoon geval van borrelia cutane infectie gepresenteerd als een medio faciaal erytheem die niet paste in een van deze drie categorieën.

CASE REPORT: Een 51-jarige vrouw die met geïnfiltreerd erytheem vanuit het midden van het gezicht en uitgebreidt tot de hals en kin.

Anamnese en lichamelijk onderzoek toonde geen tekenen van Rosaceae. Infectie met Borrelia werd vermoed op de huid biopsie onderzoek, die een inflammatoire dermale infiltratie met talrijke plasma cellen liet.

De diagnose van B.afzelii infectie werd bevestigd door serologie en PCR op de huid biopsie, die beide positief waren voor B.afzelii.

Discussie: Borrelia erytheem van het gezicht kan een bijzondere vorm zijn van cutane borrelia infectie, die beschouwd moet worden in de differentiaal diagnose van faciaal erytheem, vooral in gebieden met endemische Borreliose

Ann Dermatol Venereol. 2008 Dec;135(12):852-4. Epub 2008 Oct 26. Links

[Borrelial erythema of the face]
[Article in French]


de Heller-Milev M, Peter O, Panizzon RG, Laffitte E.
Service de dermatologie et vénérologie, centre hospitalier universitaire Vaudois (CHUV), Lausanne, Suisse.

BACKGROUND: Borrelial infection is characterized by various skin manifestations that are usually classified into three main types: chronic migratory erythema, borrelial lymphocytoma and acrodermatitis chronica atrophicans. We report an unusual case of borrelial cutaneous infection presenting as a mediofacial erythema that cannot be included in any of these three categories. CASE REPORT: A 51-year-old woman presented with infiltrated erythema of the middle of the face extending to the neck and chin. Medical history and physical examination revealed no signs of rosaceae. Infection with Borrelia was suspected on skin biopsy examination, which showed an inflammatory dermal infiltrate containing numerous plasma cells. The diagnosis of B.afzelii infection was confirmed by serology and polymerase chain reaction on the skin biopsy, both of which were positive for B.afzelii. DISCUSSION: Borrelial erythema of the face may represent a special form of cutaneous borrelial infection, which must be considered in the differential diagnosis of facial erythema, especially in areas of endemic borreliosis.

PMID: 19084697

[vonneke]

Lyme Literate Physician Recommends Taking a Photograph of Any Unusual or Bulls-Eye Rash to Assist in Proper Lyme Disease Diagnosis and Testing :

http://www.prweb.com/releases/lyme/test ... 827184.htm

According to Dr. Braccia, a Lyme literate physician, "Many people don't realize that a "bulls-eye" or other "non-specific" rashes resulting from a deer tick bite can "disappear", depriving a physician of important clinical evidence for Lyme disease testing and diagnosis. "If you see a rash, grab your cell phone and take digital photographs for your physician", he advises.

Here are Dr. Braccia's recommendations on what to be on the alert for.
1. The Lyme rash is usually at the site of the tick bite. And since ticks like to hide, the rash is often behind the knee, groin, waistline, armpit, or scalp.
2. Don't dismiss a rash just because it's not the classic "bulls-eye", Many times, the rash is nonspecific, or appears as multiple rashes (see photo)
3. The rash of Lyme disease does not occur immediately at the time of tick bite, but somewhere within 3 days to 3 weeks after the bite

"The Lyme rash typically lasts 2 to 4 weeks and disappears on its own", counsels Dr. Braccia, "It is important to take a picture of the rash before it disappears. The photograph may help your physician make an accurate diagnosis. Getting a proper medical diagnosis for Lyme disease has always been tricky. Lyme disease often starts with flu-like feelings of headaches, muscle and joint aches, neck stiffness, low-grade fever and fatigue. Some will develop classic Lyme arthritis Normally, this involves painful swollen joints that predominantly involve the knees, hands and wrists".

"The good news," according to Dr. Braccia, a Lyme literate physician in Havertown, PA, "is that in the early stages of Lyme disease, oral antibiotics given appropriately for thirty days will cure over 85% of cases. In fact, in my day-to-day practice, which specializes in Lyme disease testing and treatment, I often recommend that patients who have a deer tick bite in an endemic area should receive preventive antibiotic therapy".

"Unfortunately, if individuals are not treated, after a few days to weeks, the tell-tale rash will disappear, as well as their initial symptoms, but they are still infected," continues Dr. Braccia.

[vonneke]

http://www.ntvg.nl/publicatie/lyme-dise ... 0/volledig

Het ECM is zo kenmerkend dat daarop alleen al de diagnose B. burgdorferi-infectie gesteld kan worden. Daarbij is de gevoeligheid van de immunofluorescentietest zodanig, dat bij een negatieve uitslag een infectie niet kan worden uitgesloten, te meer daar het positief worden van de testuitslag maanden op zich laat wachten of uitblijft