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Lyme borreliosis
Comp. Immun. Microbiol. infect. Dis. Vol. 13, No. 3, pp. 111-117, 1990 Printed in Great Britain. All rights reserved
0147-9571/90 $3.00+0.00 Copyright © 1990 Pergamon Press plc
REVIEW
LYME BORRELIOSIS G. BARANTON Unit6 des Leptospires, Institut Pasteur, 28 rue du Dr Roux, 75724 Paris, Cedex 15, France
INTRODUCTION Lyme arthritis, Lyme disease, Lyme borreliosis. The different terminologies successively used to designate this pathological complex express both the symptomatologic diversity and the recent advances in etiological research in the U.S.A. which resulted in the discovery of the bacterium responsible for this infectious syndrome. Despite their common disadvantage of suggesting that all began in Lyme, a small county of Connecticut, these three descriptions illustrate the enlarging of the nosological frame following the integration of previously described symptoms. The third and most frequently used description, Lyme borreliosis, refers to the etiological agent and links the past, present and perhaps the future to the disease spectrum. A brief historical review detailing the findings preceding the description of Lyme disease is presented in Table 1. The publications concerning the three symptoms of cutaneous manifestations, which were the first symptoms to be described, are reviewed in chronological order. Gradually the causative influence of tick bites was recognised as well as the notions of transmissibility and of the bacterial nature of the agent which was eventually suspected to belong the Order Spirochaetales. It must be emphasized that even as early as 1922, Garin and Bujadoux in Lyon, who were first to describe the neurological syndrome, suggested that a spirochete could be responsible for this "tick paralysis" [1] based upon Wassermann's positive reaction and efficiency of anti-syphilitic treatment. Therefore, between the fifties when a possible association and common origin of these neurological syndromes was discussed, and the seventies when Lyme arthritis was described, there was only a fragmentary knowledge of the disease. No appropriate culture medium was available before that described by an American biologist named Kelly in 1971 [2] and without bacterial isolation, no serology was possible, and only hypotheses could be expressed regarding a possible common origin. However, in 1980, Ackerman, a German biologist, performed a serology with Borrelia duttoni (an African Borrelia responsible for recurrent fever) [3]. It was in 1977 that Steere, an American clinician, was confronted with a number of simultaneous cases--rather than an epidemic--all occurring in the county of Lyme. After an excellent epidemiological study of the disease [4], Steere described its symptomatology extensively [5]. Five years later in 1982, Willy Burgdorfer, an American-based Swiss medical entomologist who was looking for Rickettsiae in the tick Ixodes dammini, observed spirochetes [6]. Linking European findings and the American advances, he compared, under indirect immunofluorescence, smears of these spirochetes with sera from Lyme CIMID i3/3~A
111
112
G . BARANTON
Table 1. Chronology of the main characteristics of Lyme borreliosis ECM
ACA
LBC
Description
Afzelius
Buchwald
Burckhardt
Tick bite notion
19119
1883
1911
Afzelius
Hauser
1909
1954
Neurological symptoms
Garin and Bujadoux
Hopf
Paschoud
1922
1966
1954
Joints symptoms
Bannwarth
Jessner
1941
1924
Cardiac symptoms
Steere
Human experimental transmission Penicillin et~ciency
Binder
G6tz
1955
1955
1957
Hollstr6m
Swartz
Bianchi
1951
1946
1950
Spirochetes
Garin and Bujadoux
Kahle
1977
1922
1942
Lenhoff
Griineberg 1954 Weber 1983
1948
Borrelia burgdorferi
Burgdorfer 1982
Paschoud
Weber 1983
ECM: Erythema Chronicum Migrans. ACA: Acrodermatitis Chronicum Atrophicans.
LBC: Lymphoma Benigna Cutis.
disease and concluded that this bacterium could be responsible for Lyme disease. With Barbour, he isolated the spirochete which was classified within genus Borrelia. In 1983, similar work was performed by Barbour with the tick Ixodes ricinus from Switzerland [7].
SYMPTOMATOLOGY
Although now well known, the clinical picture will be briefly outlined. The disease is generally divided into three stages (Table 2) [8]: --The primary stage begins a few days or weeks after tick bite. The main sign is Erythema migrans, generally fiat with radial evolution. The central part becomes normal again, whereas the active circle widens. Accompanying signs are generally atypical and most often consist of slight transient fever, influenza, with a particular acute algesic symptom (articular pains), asthenia, and sometimes adenopathy. --The secondary stage (a few weeks or months) is characterized by neurological symptoms such as chronical or subacute meningitis, occasional radiculoneuritis with sensitive signs (radicular pains) and motricity hindrance: palsies (particularly facial palsy). At this stage cardiac signs are sometimes observed--mainly atrioventricular blocks but also myocarditis or pericarditis. The skin may also show secondary Erythema lesions or, rarely, mild lymphome-like lesions generally localized on the ear, nipple or nose. It is an inflammatory tumefaction histologically characterized by lymphohistiocytes infiltration. --During the third stage, a few months or years after tick bite, chronic manifestations appear: chronic arthritis, generally mono-articular (mainly in large joints, especially the knee). On the skin a specific syndrome may be observed: Acrodermatitis Chronicum Atrophicans or Pick-Herxheimer disease. Finally, various neurological syndromes, from central syndrome, cerebellar lesions, myelitis to psychic disorders may be related to Lyme borreliosis, but their diagnosis is only based on serology which is not totally reliable.
113
Lyme borreliosis Table 2. Clinical features (modified from Steere [8])
System Skin
Early localized (Stage I)
Infection disseminated (Stage II)
Erythema migrans
2ndary lesions, rash Urticaria, LBC
Musculoskeletal system
joints and muscles, pains, myositis
Neurological system Lymphatic system
radiculoneuritis, mrningitis generalized adenopathies splenomegaly
regional adenopathies
Heart
atrioventricular nodal Block myocarditis, pancarditis conjunctivitis, iritis retinal detachment panophtalmitis mild hepatitis sore throat, cough
Eye Liver Respiratory system Kidney Genital system Constitutional symptoms
Late infection (Stage 1II) ACA localized Scleroderma chronic arthritis sometime severe encephalomyelitis various disorders
keratitis
microscopic hematuria, proteinuria orchitis minors
severe
fatigue
THE BACTERIUM
The morphology is typical of all spirochetes [9], the helically shaped protoplasmic cylinder is coiled around the axial filaments (from 7 to 11 at each end) which overlap in the middle of the cell. The cell is encased in an outer membrane. The cell is 3-30/a m long and 0.2-0.3/zm wide. The spires (4-10) are loosely coiled and irregular. The narrow diameter allows the bacteria to pass through 0.45 and even 0.22 ~tm filters. The motility is typical of spirochetes with rotation, translation and flexion motions.
Identification After the first isolation, whole D N A - D N A hybridations confirmed this spirochete was a Borrelia and a new species, Borrelia burgdorferi [41]. If the growth and morphological characteristics are typical enough, the formal identification is achieved by the observation of the main outer proteins (OspA and OspB) in electrophoresis [10] and reactivity with monoclonal antibodies [11]. Other means, particularly genomic ones, are also used [12, 13], hybridization with specific plasmidic probes, the systematic presence of which has yet to be confirmed, or by hybridization of fragments after restriction, electrophoresis and Southern blot with a polyvalent probe of E. coli RNA according to Grimont [14], as performed by D. Postic and C. Edlinger in the Lab, allowing the determination of sub-groups. This technique showed that Borrelia burgdorferi possesses only one set of rDNA genes. Pulse field gel electrophoresis is another promising method: intact bacteria are included in agarose plugs, therefore DNA is extracted and restricted by endonuclease enzymes under perfect conditions (without any denaturation). This method has other applications: it can be used for physical studies of the genome, such as those performed by C. Baril and
114
G. BARANTON
C. Richaud with the assistance of D. Margarita in the Laboratory of I. Saint Girons. The presence of both circular and linear plasmids and more importantly the linearity and small size (1000 kb) of the chromosome of Borrelia burgdorferi (B.b.) were confirmed [15, 39],
Growth [16] This small genome similar in size to that of Mycoplasma and the single set of rRNA genes may be explained by the strictly parasitic nature of B. burgdorferi which is characterized by its nutritional requirements. The BSK II medium is composed of an eucaryotic cells medium base (containing N-acetyl glucosamine, a constituant of chitin), with addition of bovine serum albumin, yeast extract, gelatin and rabbit serum. BIOLOGICAL DIAGNOSIS Growth is slow. Four to six days are necessary to obtain a density of 4 × 108 bacteria per ml under microaerophilic conditions. Isolation (from blood at the very beginning of the disease, from CSF, synovial fluid or skin biopsies) is problematical and fastidious. It cannot be considered as a diagnostic means, however, it has to be attempted as it was recently published that it would be more frequently successful when serology is negative. Detection of antibodies in serum, CSF and synovial fluid remains the best means of biological confirmation [11] but is limited in sensitivity as well as in specificity. During the first weeks, about 50% of serological tests are negative [17]. Furthermore, in addition to cross reactions with leptospires or treponemes, positive results which are difficult to explain may occur: subclinical infections, long term antibodies persistence and also false positive reactions. Among isolates, mainly European ones, a large antigenic diversity seems to exist [18]. Antigens of a cloned strain may also vary during growth [19]. Furthermore, antigenic specificities against which antibodies develop may vary throughout the course of the disease. The most frequently recognized antibody epitopes are the ones common to other spirochetes. This is the case for 41 d protein, a flagellin which has common epitopes with T. pallidum flagellin [20]. It was shown that western blot facilitates the interpretation but cannot solve all problems [21]. Paradoxically, two different approaches for the same purpose (to increase serology reliability) are suggested. In Denmark [22], the use of a 41 kd protein is proposed to increase sensitivity. Other authors suggest the use of a 41 kd depleted antigen for a better specificity. ELISA or IFA [23] are the methods generally chosen. As an alternative to serology which is sometimes unreliable, other methods were recently proposed: --iymphocytes transformation test [24] ~ e t e c t i o n of antigen in urine [25]. PATHOGENESIS
The pathogenic mechanism of B. burgdorferi remains unknown. Always extracellular and rarely observed, the bacteria were found in all target organs. Because of that scarceness, a pathogenic amplification mechanism was suspected. Interleukine-1 [26], endotoxin [27], anti-myelin antibodies [28], immune-complexes [29] were generally involved. The problem remains unsolved. Adhesion to fibroblasts and recently the ability of B.b. to penetrate within endothelial cells and through them to migrate into tissues were demonstrated [30].
Lyme borreliosis
115
Table 3. Treatment regimens (modified from Steere [8]) Early infection + Facial palsy + I st degree AV block + ACA (oral 1 month)
Tetra 2 5 0 m g 4 x daily 10--30 days 2 Doxy 100mg 2 x daily 10-30 days 2"3 Amox 500rag 4 x daily 10-30 days 2'3
Children < 8 years If peni allergy
Amox or Peni V 250mg 3 x or 20mg/kg 3 : 1 0 - 3 0 days Eryth 250 mg 3 x or 30 mg/kg 3 : 1 0 - 3 0 days 3
Neurological abnormalities ~ Early or late + AV block > 1st If allergy
C e f t r i a 2 g I V I x 14 days Peni G 2 0 M IV 6 : 1 4 days 4 Doxy 100mg 2 x 30 days 3 or Chloram 2 5 0 m g 4 x 14 days 3
Arthritis "~
Doxy 100mg 2 x 30 days Amox ( + Probenecid) 500 mg 4 x 30 days C e f t r i a 2 g I V 1 x 14 days Peni G 2 0 M 6 : 1 4 days
~Treatment failures have occurred whatever the regimen. 2 Duration based on clinical response. 3No clinical trials available. 4Neurological tertiary stage, duration possibly > 14 days.
EPIDEMIOLOGY
In 1975, in Lyme, a small county of Connecticut, the mother of an adolescent suffering from juvenile rhumatoid arthritis informed the CDC that many young people in this area had this usually rare syndrome. Allan C. Steere [4, 5, 8, 31], an epidemiologist and rhumatologist, investigated this "epidemic". He concluded that these cases of arthritis were in fact infectious although not contagious and were probably transmitted by non-flying arthropods. He called this disease Lyme arthritis and later, after recognizing former European descriptions (mainly erythema migrans), and also cardiac symptoms, "Lyme disease". Now, it is known that many wild animals [32] (even birds) or domestic ones may be subclinically infected. The usual host reservoirs are rodents, Peromyscus leucopus in U.S.A., Apodemus in Europe [33]. Auricular biopsy could allow the isolation of strains in these reservoirs. Some animals may exhibit arthritis, dogs [34], in exceptional cases, horses [35], and experimentally Lewis rats [36] and irradiated and foot pad inoculated LSH hamsters
[40]. Ixodes ticks (L dammini and L pacificus in U.S.A., L ricinus in Europe) are responsible for transmission [37], but it was observed that fleas and parasitic flies could harbour B. burgdorferi. Experimentally, it was shown that B. burgdorferi could survive 24 h within horse flies and mosquitoes. TREATMENT
In vitro, minimal inhibitory concentrations of antibiotics were by decreasing order: erythromycin [38], cyclins, amoxillin or ampicillin and penicillin G. In vivo, experimentally as well as clinically, erythromycin had a low efficiency and penicillin G, the most frequently used antibiotic, had some disappointing results. For example, a strain was isolated from the CSF of a meningoradiculitis patient who had been treated for 10 days with penicillin (20 million units per day) [35]. In fact, results of unsuccessful treatments were published whatever the antibiotic used. The protocols now in force (Table 3) [8] are to give 1-2 g per day of doxacyclin during 10-15 days for cutaneous and recent forms, or amoxillin for more advanced forms and in serious cases ceftriaxone for which no relapse has, as yet, been described.
116
G. BARANTON
Acknowledgement--We wish to express our thanks to Dr I. Old for thoroughly reviewing the manuscript.
REFERENCES 1. Garcia-Monco J. C., Coleman J. L. and Benach J. L. Antibodies to myelin basic protein in Lyme disease. J. Infect. Dis. 1511, 667~68 (1988), 2. Kelly R. Cultivation of Borrelia hermsii. Science 173, 443 (1971). 3. Ackermann R., Runne U., Klenk W. and Dienst C. Erythema chronicum migrans mit Arthritis. Dtsch Med. Wschr. 105, 1779-1781 (1980). 4. Steere A. C., Malawista S. E., Snydman D. R. et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis Rheum. 20, 7 17 (1977). 5. Steere A. C., Malawista S. E., Hardin J. A., Ruddy S., Askenase W. and Andiman W. A. Erythema chronicum migrans and Lyme arthritis: the enlarging clinical spectrum. Ann. Int. Med. 86, 685~598 (1977). 6. Burgdorfer W., Barbour A. G., Hayes S. F., Benach J. L., Grunwaldt E. and Davis J. P. Lyme disease--a tick-borne spirochetosis? Science 216, 1317-1319 (1982). 7. Barbour A. G., Burgdorfer W., Hayes S. F., Peter O. and Aeschlimann A. Isolation of a cultivable spirochete from Ixodes ricinus ticks of Switzerland. Curr. Microbiol. 8, 123 126 (1983). 8. Steere A. C. Lyme disease. N. Engl. J. Med. 321, 586-596 (1989). 9. Hovind-Hougen K., Asbrink E., Stiernstedt G., Steere A. C. and Hovmark A. Ultrastructural differences among spirochetes isolated from patients with Lyme disease and related disorders, and from lxodes ricinus. Zbl. Bakt. Mikrobiol. Hyg. A 263, 103 111 (1986). 10. Barbour A. G. Immunochemical analysis of Lyme disease spirochetes. Yale J. Biol. Med. 57, 581 586 (1984). 11. Barbour A. G. Laboratory aspects of Lyme borreliosis. Clin. Microbiol. Rev. 1, 399-414 (1988). 12. Schwan T. G. and Barbour A. G. Efficacy of nucleic acid hybridization probes for the detection and identification of Borrelia burgdorferi. Ann. N.Y. Acad. Sci. 539, 419-421 (1988). 13. Schwan T. G., Simpson W. J., Schrumpf M. E. and Karstens R. H. Identification of Borrelia burgdorferi and B. hermsii using DNA hybridization probes. J. clin. Microbiol. 27, 1734-1738 (1989). 14. Grimont F. and Grimont P. A. D. Ribosomal ribonucleic acid gene restriction patterns as potential taxonomic tools. Ann. Inst. Pasteur/Microbiol 137B, 165-175 (1986). 15. Ferdows M. S. and Barbour A. G. Megabase-sized linear DNA in the bacterium Borrelia burgdorferi, the Lyme disease agent. Proc. natn. Acad. Sci. U.S.A. 86, 5969-5973 (1989). 16. Barbour A. G. Isolation and cultivation of Lyme disease spirochetes. Yale J. Biol. Med. 57, 521 525 (1984). 17. Shrestha M., Grodzicki R. L. and Steere A. C. Diagnosing early Lyme disease. Am. J. Med. 78, 235 240 (1985). 18. Wilske B., Preac-Mursic V., Schierz G. and Busch K. V. Immunochemical and immunological analysis of European Borrelia burgdorferi strains. Zbl. Bakt. Parasitenkd. Infektionskr. Hyg. Abt. I Orig. Reihe A 263, 92-102 (1986). 19. Schwan T. G., Burgdorfer W. and Garon C. F. Changes in infectivity and plasmid profile of the Lyme disease spirochete. Borrelia burgdorferi, as a result of in vitro cultivation. Infect. lmmun. 56, 1831 1836 (1988). 20. Grodzicki R. L. and Steere A. C. Comparison of immunoblotting and indirect Enzyme-Linked Immunosorbent Assay using different antigen preparations for diagnosing early Lyme disease. J. Infect. Dis. 157, 790-797 (1988). 21. Raoult D., Hechemy K. E. and Baranton G. Cross-reaction with Borrelia burgdorferi antigen of sera from patients with human immunodeficiency, virus infection, syphilis, and leptospirosis. J. olin. Microbiol. 27, 2152-2155. 22. Hansen K., Hindersson P. and Pedersen N. S. Measurement of antibodies against the Borrelia burgdor]eri flagellum improves serodiagnosis in Lyme borreliosis. J. clin. Microbiol. 26, 338-346 (1988). 23. Baranton G. and Postic D. M~thodes de laboratoire. Leptospirose---Borrkliose de Lyme, Vol. 1. Collect. Inst. Pasteur (1989). 24. Dattwyler R. J., Volkman D. J., Luft B. J., Halperin J. J., Thomas J. and Golightly M. G. Seronegative Lyme disease dissociation of the specific T- and B-lymphocyte responses to Borrelia burgdorferi. N. Engl. J. Med. 319, 1441-1446 (1988). 25. Hyde F. W., Johnson R. C., White T. J. and Shelburne C. E. Detection of antigens in urine of mice and humans infected with Borrelia burgdorferi, etiologic agent of Lyme disease. J. clin. Microbiol. 27, 5841 (1989). 26. Habicht G. S., Beck G., Benach J. L., Coleman J. L. and Liechthling K. D. Lyme disease spirochetes induce human and murine interleukin 1 production . J. Immun. 134, 3147-3154 (1985). 27. Beck G., Habicht G. S., Benach J. C. and Coleman J. L. Chemical and biologic characterizations of a lipopolysaccharide extracted from the Lyme disease spirochete (Borrelia burgdorferi). J. Infect. Dis. 152, 108-I 17 (1985). 28. Garin-Bujadoux C. Paralysie par les tiques. J. Mkd. Lyon 71, 765 767 (1922).
Lyme borreliosis
117
29. Hardin J. A., Steere A. C. and Malawista S. E. Immune complexes and the evolution of Lyme arthritis: dessemination and localization of abnormal Clq binding activity. N Engl. J. Med. 301, 1358-1363 (1979). 30. Thomas D. D. and Comstock L. E. Interaction of Lyme disease spirochetes with cultured eucaryotic cells. Infect. Immun. 57, 1324-1326 (1989). 31. Steere A. C. and Malawista S. E. Cases of Lyme disease in the United States: locations correlated with distribution of lxodes dammini. Ann. Int. Med. 91, 730--733 (1979). 32. Anderson J. F. Mammalian and avian reservoirs for Borrelia burgdorferi. Ann. N. Y. Acad. Sci. 539, 180-191 (1988). 33. Hovmark A., Jaenson G. T., Asbrink E., Forsman A. and Jansson E. First isolations ofBorrelia burgdorferi from rodents collected in Northern Europe. A P M I S 96, 917-920 (1988). 34. Kornblatt A. N., Urband P. H. and Steere A. C. Arthritis caused by Borrelia burgdorferi in dogs. J. Am. Vet. Med. Assoc. 186, 960-964 (1985). 35. Burgess E. C. Borrelia burgdorferi infection in Wisconsin horses and cows. Ann. N. Y. Acad. Sci. 539, 235-243 (1988). 36. Barthold S. W., Moody K. D., Terwilliger G. A., Duray P. H., Jacoby R. O. and Steere A. C. Experimental Lyme arthritis in rats infected with Borrelia burgdorferi. J. Infect. Dis. 157, 842-846 (1988). 37. Magnarelli L. A. and Anderson J. G. Ticks and biting insects infected with the etiologic agent of Lyme disease. Borrelia burgdorferi. J. clin. Microbiol. 26, 1482-1486 (1988). 38. Johnson R. C., Kodner C. and Russell M. In vitro and in vivo susceptibility of the Lyme disease spirochete, Borrelia burgdorferi, to four antimicrobial agents. Antimicrob. Agents Chemother. 31, 164-167 (1987). 39. Baril C., Richaud C., Baranton G. and Saint Girons I. A linear chromosome of Borrelia burgdorferi. Res. Microbiol. 140, 507 516 (1989). 40. Hejka A., Schmitz J. L., England D. M., Callister S. M. and Schell R. F. Histopathology of Lyme arthritis in LSH hamsters. Am. J. Path. 134, 1113-1123 (1989). 41. Hyde F. W. and Johnson R. C. Genetic relationship of Lyme disease spirochetes to Borrelia, Treponema, and Leptospira spp. J. clin. Microbiol. 20, 151-154 (1984).
0147-9571/90 $3.00+0.00 Copyright © 1990 Pergamon Press plc
REVIEW
LYME BORRELIOSIS G. BARANTON Unit6 des Leptospires, Institut Pasteur, 28 rue du Dr Roux, 75724 Paris, Cedex 15, France
INTRODUCTION Lyme arthritis, Lyme disease, Lyme borreliosis. The different terminologies successively used to designate this pathological complex express both the symptomatologic diversity and the recent advances in etiological research in the U.S.A. which resulted in the discovery of the bacterium responsible for this infectious syndrome. Despite their common disadvantage of suggesting that all began in Lyme, a small county of Connecticut, these three descriptions illustrate the enlarging of the nosological frame following the integration of previously described symptoms. The third and most frequently used description, Lyme borreliosis, refers to the etiological agent and links the past, present and perhaps the future to the disease spectrum. A brief historical review detailing the findings preceding the description of Lyme disease is presented in Table 1. The publications concerning the three symptoms of cutaneous manifestations, which were the first symptoms to be described, are reviewed in chronological order. Gradually the causative influence of tick bites was recognised as well as the notions of transmissibility and of the bacterial nature of the agent which was eventually suspected to belong the Order Spirochaetales. It must be emphasized that even as early as 1922, Garin and Bujadoux in Lyon, who were first to describe the neurological syndrome, suggested that a spirochete could be responsible for this "tick paralysis" [1] based upon Wassermann's positive reaction and efficiency of anti-syphilitic treatment. Therefore, between the fifties when a possible association and common origin of these neurological syndromes was discussed, and the seventies when Lyme arthritis was described, there was only a fragmentary knowledge of the disease. No appropriate culture medium was available before that described by an American biologist named Kelly in 1971 [2] and without bacterial isolation, no serology was possible, and only hypotheses could be expressed regarding a possible common origin. However, in 1980, Ackerman, a German biologist, performed a serology with Borrelia duttoni (an African Borrelia responsible for recurrent fever) [3]. It was in 1977 that Steere, an American clinician, was confronted with a number of simultaneous cases--rather than an epidemic--all occurring in the county of Lyme. After an excellent epidemiological study of the disease [4], Steere described its symptomatology extensively [5]. Five years later in 1982, Willy Burgdorfer, an American-based Swiss medical entomologist who was looking for Rickettsiae in the tick Ixodes dammini, observed spirochetes [6]. Linking European findings and the American advances, he compared, under indirect immunofluorescence, smears of these spirochetes with sera from Lyme CIMID i3/3~A
111
112
G . BARANTON
Table 1. Chronology of the main characteristics of Lyme borreliosis ECM
ACA
LBC
Description
Afzelius
Buchwald
Burckhardt
Tick bite notion
19119
1883
1911
Afzelius
Hauser
1909
1954
Neurological symptoms
Garin and Bujadoux
Hopf
Paschoud
1922
1966
1954
Joints symptoms
Bannwarth
Jessner
1941
1924
Cardiac symptoms
Steere
Human experimental transmission Penicillin et~ciency
Binder
G6tz
1955
1955
1957
Hollstr6m
Swartz
Bianchi
1951
1946
1950
Spirochetes
Garin and Bujadoux
Kahle
1977
1922
1942
Lenhoff
Griineberg 1954 Weber 1983
1948
Borrelia burgdorferi
Burgdorfer 1982
Paschoud
Weber 1983
ECM: Erythema Chronicum Migrans. ACA: Acrodermatitis Chronicum Atrophicans.
LBC: Lymphoma Benigna Cutis.
disease and concluded that this bacterium could be responsible for Lyme disease. With Barbour, he isolated the spirochete which was classified within genus Borrelia. In 1983, similar work was performed by Barbour with the tick Ixodes ricinus from Switzerland [7].
SYMPTOMATOLOGY
Although now well known, the clinical picture will be briefly outlined. The disease is generally divided into three stages (Table 2) [8]: --The primary stage begins a few days or weeks after tick bite. The main sign is Erythema migrans, generally fiat with radial evolution. The central part becomes normal again, whereas the active circle widens. Accompanying signs are generally atypical and most often consist of slight transient fever, influenza, with a particular acute algesic symptom (articular pains), asthenia, and sometimes adenopathy. --The secondary stage (a few weeks or months) is characterized by neurological symptoms such as chronical or subacute meningitis, occasional radiculoneuritis with sensitive signs (radicular pains) and motricity hindrance: palsies (particularly facial palsy). At this stage cardiac signs are sometimes observed--mainly atrioventricular blocks but also myocarditis or pericarditis. The skin may also show secondary Erythema lesions or, rarely, mild lymphome-like lesions generally localized on the ear, nipple or nose. It is an inflammatory tumefaction histologically characterized by lymphohistiocytes infiltration. --During the third stage, a few months or years after tick bite, chronic manifestations appear: chronic arthritis, generally mono-articular (mainly in large joints, especially the knee). On the skin a specific syndrome may be observed: Acrodermatitis Chronicum Atrophicans or Pick-Herxheimer disease. Finally, various neurological syndromes, from central syndrome, cerebellar lesions, myelitis to psychic disorders may be related to Lyme borreliosis, but their diagnosis is only based on serology which is not totally reliable.
113
Lyme borreliosis Table 2. Clinical features (modified from Steere [8])
System Skin
Early localized (Stage I)
Infection disseminated (Stage II)
Erythema migrans
2ndary lesions, rash Urticaria, LBC
Musculoskeletal system
joints and muscles, pains, myositis
Neurological system Lymphatic system
radiculoneuritis, mrningitis generalized adenopathies splenomegaly
regional adenopathies
Heart
atrioventricular nodal Block myocarditis, pancarditis conjunctivitis, iritis retinal detachment panophtalmitis mild hepatitis sore throat, cough
Eye Liver Respiratory system Kidney Genital system Constitutional symptoms
Late infection (Stage 1II) ACA localized Scleroderma chronic arthritis sometime severe encephalomyelitis various disorders
keratitis
microscopic hematuria, proteinuria orchitis minors
severe
fatigue
THE BACTERIUM
The morphology is typical of all spirochetes [9], the helically shaped protoplasmic cylinder is coiled around the axial filaments (from 7 to 11 at each end) which overlap in the middle of the cell. The cell is encased in an outer membrane. The cell is 3-30/a m long and 0.2-0.3/zm wide. The spires (4-10) are loosely coiled and irregular. The narrow diameter allows the bacteria to pass through 0.45 and even 0.22 ~tm filters. The motility is typical of spirochetes with rotation, translation and flexion motions.
Identification After the first isolation, whole D N A - D N A hybridations confirmed this spirochete was a Borrelia and a new species, Borrelia burgdorferi [41]. If the growth and morphological characteristics are typical enough, the formal identification is achieved by the observation of the main outer proteins (OspA and OspB) in electrophoresis [10] and reactivity with monoclonal antibodies [11]. Other means, particularly genomic ones, are also used [12, 13], hybridization with specific plasmidic probes, the systematic presence of which has yet to be confirmed, or by hybridization of fragments after restriction, electrophoresis and Southern blot with a polyvalent probe of E. coli RNA according to Grimont [14], as performed by D. Postic and C. Edlinger in the Lab, allowing the determination of sub-groups. This technique showed that Borrelia burgdorferi possesses only one set of rDNA genes. Pulse field gel electrophoresis is another promising method: intact bacteria are included in agarose plugs, therefore DNA is extracted and restricted by endonuclease enzymes under perfect conditions (without any denaturation). This method has other applications: it can be used for physical studies of the genome, such as those performed by C. Baril and
114
G. BARANTON
C. Richaud with the assistance of D. Margarita in the Laboratory of I. Saint Girons. The presence of both circular and linear plasmids and more importantly the linearity and small size (1000 kb) of the chromosome of Borrelia burgdorferi (B.b.) were confirmed [15, 39],
Growth [16] This small genome similar in size to that of Mycoplasma and the single set of rRNA genes may be explained by the strictly parasitic nature of B. burgdorferi which is characterized by its nutritional requirements. The BSK II medium is composed of an eucaryotic cells medium base (containing N-acetyl glucosamine, a constituant of chitin), with addition of bovine serum albumin, yeast extract, gelatin and rabbit serum. BIOLOGICAL DIAGNOSIS Growth is slow. Four to six days are necessary to obtain a density of 4 × 108 bacteria per ml under microaerophilic conditions. Isolation (from blood at the very beginning of the disease, from CSF, synovial fluid or skin biopsies) is problematical and fastidious. It cannot be considered as a diagnostic means, however, it has to be attempted as it was recently published that it would be more frequently successful when serology is negative. Detection of antibodies in serum, CSF and synovial fluid remains the best means of biological confirmation [11] but is limited in sensitivity as well as in specificity. During the first weeks, about 50% of serological tests are negative [17]. Furthermore, in addition to cross reactions with leptospires or treponemes, positive results which are difficult to explain may occur: subclinical infections, long term antibodies persistence and also false positive reactions. Among isolates, mainly European ones, a large antigenic diversity seems to exist [18]. Antigens of a cloned strain may also vary during growth [19]. Furthermore, antigenic specificities against which antibodies develop may vary throughout the course of the disease. The most frequently recognized antibody epitopes are the ones common to other spirochetes. This is the case for 41 d protein, a flagellin which has common epitopes with T. pallidum flagellin [20]. It was shown that western blot facilitates the interpretation but cannot solve all problems [21]. Paradoxically, two different approaches for the same purpose (to increase serology reliability) are suggested. In Denmark [22], the use of a 41 kd protein is proposed to increase sensitivity. Other authors suggest the use of a 41 kd depleted antigen for a better specificity. ELISA or IFA [23] are the methods generally chosen. As an alternative to serology which is sometimes unreliable, other methods were recently proposed: --iymphocytes transformation test [24] ~ e t e c t i o n of antigen in urine [25]. PATHOGENESIS
The pathogenic mechanism of B. burgdorferi remains unknown. Always extracellular and rarely observed, the bacteria were found in all target organs. Because of that scarceness, a pathogenic amplification mechanism was suspected. Interleukine-1 [26], endotoxin [27], anti-myelin antibodies [28], immune-complexes [29] were generally involved. The problem remains unsolved. Adhesion to fibroblasts and recently the ability of B.b. to penetrate within endothelial cells and through them to migrate into tissues were demonstrated [30].
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Table 3. Treatment regimens (modified from Steere [8]) Early infection + Facial palsy + I st degree AV block + ACA (oral 1 month)
Tetra 2 5 0 m g 4 x daily 10--30 days 2 Doxy 100mg 2 x daily 10-30 days 2"3 Amox 500rag 4 x daily 10-30 days 2'3
Children < 8 years If peni allergy
Amox or Peni V 250mg 3 x or 20mg/kg 3 : 1 0 - 3 0 days Eryth 250 mg 3 x or 30 mg/kg 3 : 1 0 - 3 0 days 3
Neurological abnormalities ~ Early or late + AV block > 1st If allergy
C e f t r i a 2 g I V I x 14 days Peni G 2 0 M IV 6 : 1 4 days 4 Doxy 100mg 2 x 30 days 3 or Chloram 2 5 0 m g 4 x 14 days 3
Arthritis "~
Doxy 100mg 2 x 30 days Amox ( + Probenecid) 500 mg 4 x 30 days C e f t r i a 2 g I V 1 x 14 days Peni G 2 0 M 6 : 1 4 days
~Treatment failures have occurred whatever the regimen. 2 Duration based on clinical response. 3No clinical trials available. 4Neurological tertiary stage, duration possibly > 14 days.
EPIDEMIOLOGY
In 1975, in Lyme, a small county of Connecticut, the mother of an adolescent suffering from juvenile rhumatoid arthritis informed the CDC that many young people in this area had this usually rare syndrome. Allan C. Steere [4, 5, 8, 31], an epidemiologist and rhumatologist, investigated this "epidemic". He concluded that these cases of arthritis were in fact infectious although not contagious and were probably transmitted by non-flying arthropods. He called this disease Lyme arthritis and later, after recognizing former European descriptions (mainly erythema migrans), and also cardiac symptoms, "Lyme disease". Now, it is known that many wild animals [32] (even birds) or domestic ones may be subclinically infected. The usual host reservoirs are rodents, Peromyscus leucopus in U.S.A., Apodemus in Europe [33]. Auricular biopsy could allow the isolation of strains in these reservoirs. Some animals may exhibit arthritis, dogs [34], in exceptional cases, horses [35], and experimentally Lewis rats [36] and irradiated and foot pad inoculated LSH hamsters
[40]. Ixodes ticks (L dammini and L pacificus in U.S.A., L ricinus in Europe) are responsible for transmission [37], but it was observed that fleas and parasitic flies could harbour B. burgdorferi. Experimentally, it was shown that B. burgdorferi could survive 24 h within horse flies and mosquitoes. TREATMENT
In vitro, minimal inhibitory concentrations of antibiotics were by decreasing order: erythromycin [38], cyclins, amoxillin or ampicillin and penicillin G. In vivo, experimentally as well as clinically, erythromycin had a low efficiency and penicillin G, the most frequently used antibiotic, had some disappointing results. For example, a strain was isolated from the CSF of a meningoradiculitis patient who had been treated for 10 days with penicillin (20 million units per day) [35]. In fact, results of unsuccessful treatments were published whatever the antibiotic used. The protocols now in force (Table 3) [8] are to give 1-2 g per day of doxacyclin during 10-15 days for cutaneous and recent forms, or amoxillin for more advanced forms and in serious cases ceftriaxone for which no relapse has, as yet, been described.
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Acknowledgement--We wish to express our thanks to Dr I. Old for thoroughly reviewing the manuscript.
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