Content uploaded by Sylvie De Martino
Author content
All content in this area was uploaded by Sylvie De Martino on Oct 13, 2014
Content may be subject to copyright.
Lyme Borreliosis
II Contents
Current Problems in Dermatology
Vol. 37
Series Editor
P. It i n Basel
Contents III
Lyme Borreliosis
Biological and Clinical Aspects
Basel • Freiburg • Paris • London • New York •
Bangalore • Bangkok • Singapore • Tokyo • Sydney
Volume Editors
Dan Lipsker Strasbourg
Benoît Jaulhac Strasbourg
13 figures, 8 in color, and 11 tables, 2009
Bibliographic Indices. This publication is listed in bibliographic services, including Pub Med/MEDLINE.
Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors
and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a
warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety.
The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas,
methods, instructions or products referred to in the content or advertisements.
Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accord with current recommendations and practice at the time of publication. However, in view
of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy
and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and
dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new
and/or infrequently employed drug.
All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any
form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any informa-
tion storage and retrieval system, without permission in writing from the publisher.
© Copyright 2009 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland)
www.karger.com
Printed in Switzerland on acid-free and non-aging paper (ISO 9706) by Reinhardt Druck, Basel
ISSN 1421–5721
ISBN 978–3–8055–9114–0
e-ISBN 978–3–8055–9115–7
Current Problems in Dermatology
Library of Congress Cataloging-in-Publication Data
Lyme borreliosis : biological and clinical aspects / volume editors, Dan
Lipsker, Benoît Jaulhac .
p. ; cm. -- (Current problems in dermatology ; v. 37)
Includes bibliographical references and index.
ISBN 978-3-8055-9114-0 (hard cover : alk. paper)
1. Lyme disease. I. Lipsker, Dan. II. Jaulhac, Benoît. III. Series: Current
problems in dermatology ; v. 37.
[DNLM: 1. Lyme Disease. W1 CU804L v.37 2009 / WC 406 L98531 2009]
RC155.5.L933 2009
616.9‘246--dc22
2009010643
Dan Lipsker
Clinique Dermatologique
1 Place de l’Hôpital
FR–67091 Strasbourg/France
Benoît Jaulhac
Laboratoire associé au Centre
National de Référence des Borrelia
3, rue Koeberlé
FR–67000 Strasbourg/France
V
VII Preface
Lipsker, D.; Jaulhac, B. (Strasbourg)
1 Borrelia burgdorferi sensu lato Diversity and Its Influence on Pathogenicity
in Humans
Baranton, G. (Paris); De Martino, S.J. (Strasbourg)
18 Life Cycle of Borrelia burgdorferi sensu lato and Transmission to Humans
Gern, L. (Neuchâtel)
31 Epidemiology of Lyme Borreliosis
Hubálek, Z. (Brno)
51 Clinical Manifestations and Diagnosis of Lyme Borreliosis
Strle, F. (Ljubljana); Stanek, G. (Vienna)
111 Treatment and Prevention of Lyme Disease
Hansmann, Y. (Strasbourg)
130 Other Tick-Borne Diseases in Europe
Bitam, I.; Raoult, D. (Marseille)
Frequently Asked Questions about Lyme Borreliosis
155 What Should One Do in Case of a Tick Bite?
Aberer, E. (Graz)
167 When Is the Best Time to Order a Western Blot and How Should It Be
Interpreted?
Hunfeld, K.-P.; Kraiczy, P. (Frankfurt am Main)
178 Is Serological Follow-Up Useful for Patients with Cutaneous Lyme
Borreliosis?
Müllegger, R.R. (Wiener Neustadt); Glatz, M. (Graz)
Contents
VI Contents
183 How Do I Manage Tick Bites and Lyme Borreliosis in Pregnant Women?
Maraspin, V.; Strle, F. (Ljubljana)
191 What Should Be Done in Case of Persistent Symptoms after Adequate
Antibiotic Treatment for Lyme Disease?
Puéchal, X. (Le Mans); Sibilia, J. (Strasbourg)
200 What Are the Indications for Lumbar Puncture in Patients with Lyme
Disease?
Rupprecht, T.A.; Pfister, H.-W. (Munich)
207 Author Index
208 Subject Index
‘Lyme disease’, so called since Steere et al. [1, 2] inquired into an arthritis epidemic
among young children in the community of Old Lyme, Conn., USA, in the late 1970s,
has a very long European history. Its cutaneous manifestations, the most frequent
signs of the disease, had already been described at the end of the 19th century and the
beginning of the 20th century by physicians like Buchwald, Pick, Herxheimer, Hart-
man, Afzelius and Lipschütz [3–5] . Additionally, two French physicians in a land-
mark paper published in 1922, Garin and Bujadoux [6] , reported a patient who devel-
oped erythema chronicum migrans followed by painful meningoradiculitis. Shortly
before the symptoms began, this patient was bitten by a tick and he had a positive
Bordet-Wasserman test, which was used at this time to diagnose syphilis. They stated,
however, that although this test was positive, this patient did not have syphilis, and
concluded that this patient had a tick-borne disease that induced cutaneous and neu-
rological manifestations caused by a spirochete different from Treponem a pallidum .
It was not until the early 1980s that their prediction proved to be correct, when Burg-
dorfer et al. [7] were able to isolate a bacterium belonging to the family of Spirochae-
taceae, first from ticks and then from humans. Interestingly, the first North Ameri-
can observation of Lyme disease, a patient with erythema migrans, was only pub-
lished in 1970 [8] .
In the years af ter the isolation of the causative bacterium, it was quickly shown that
there were significant differences in disease expression between North America and
Europe. Furthermore, it could be shown that there was 1 predominant species of Bor-
relia in North America, while there were at least 4 different pathogenic species in Eu-
rope [9, 10] .
Thus, this disease has a long European history, and therefore to us it seemed nec-
essary to speci fically address ‘Lyme disease’ in Europe (or should we call it ‘European
borreliosis’?).
Preface
VIII Preface
We have the great privilege in this volume of Current Problems in Dermatology to
coordinate a special overview of Lyme disease. The texts were written by some of the
top European experts in this field. Though this volume is published in a derma-
tological book series, all the aspects of Lyme disease are addressed. Microbiologists,
infectious disease specialists, neurologists, rheumatologists, internists and derma-
tologists all contributed to this volume. Indeed, our main goal was to cover a broad
range of the characteristics of the disease and to provide current state-of-the-art
guidelines on epidemiology, diagnosis, treatment, bacteriology and serology, rather
than focus exclusively on the skin disease.
In the last part of this volume, some important topics are addressed in the form of
questions. This part of the books deals with questions that are often asked of experts,
including ‘What should one do in case of a tick bite?’, ‘When is the best time to order
a Western blot and how should it be interpreted?’, ‘Is serological follow-up useful for
patients with cutaneous Lyme borreliosis?’, ‘How do I manage tick bites and Lyme
borreliosis in pregnant women?’, ‘What should be done in case of persistent symp-
toms after adequate antibiotic treatment for Lyme disease?’ and ‘What are the indica-
tions for lumbar puncture in patients with Lyme disease?’.
We sincerely hope that this book will be of help and interest to all physicians in-
volved in the diagnosis and care of patients with Lyme borreliosis.
Dan Lipsker
Benoît Jaulhac
References
1 Steere AC, Malawista SE, Snydman DR, Shope RE,
Andim an WA, Ross MR, Stee le FM: Lyme arthr itis:
an epidemic of oligoarticular arthritis in children
and adults in three Connecticut communities. Ar-
thritis Rheum 1977;
20: 7–17.
2 Steere AC, Boderick TF, Malawista SE: Erythema
chronicum migrans and Lyme arthritis: epidemio-
logic evidence for a tick vector. Am J Epidemiol
1978;
108: 312–321.
3 Lipschütz B: Über eine seltene Erythemform (ery-
thema chronicum migrans). Arch Dermatol Syph
1913;
118: 349–356.
4 Herxheimer K, Hartman K: Über acrodermatitis
chronica atrophicans. Arch Dermatol (Berlin)
1902;
61: 57–76.
5 Marchionini A: A propos de l’étiologie de l’acro-
dermatite chronique atrophiante de Pick-Herxhei-
mer. Ann Dermatol Venereol 1956;
83: 601–611.
6 Garin C , Bujadoux D: Para lysie par les tique s. J Med
(Lyon) 1922;
77: 765–767.
7 Burgdorfer W, Barbour AG, Hayes SF, Benach JL,
Grunwaldt E, Davis JP: Lyme disease: a tick-borne
spirochetosis? Science 1982;
216: 1317–1319.
8 Scrimenti RJ: Erythema chronicum migrans. Arch
Dermatol 1970;
102: 104–105.
9 Welsh J, Pretzman C, Postic D, Saint Girons I, Ba-
ranton G, McClelland M: Genomic fingerprinting
by arbitra rily prime d polymerase cha in reaction re-
solves Borrelia burgdorferi into three distinct phy-
letic groups. Int J Syst Bacteriol 1992;
42: 370–377.
10 Richter D, Postic D, Sertour N, Livey I, Matuschka
FR, Bar anton G: Delineat ion of Borrelia burgdorferi
sensu lato species by multilocus sequence analysis
and confirmation of the delineation of Borrelia
spielmanii sp. nov. Int J Syst Evol Microbiol 2006;
56: 873–881.
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 1–17
A b s t r a c t
Among the Spirochaetes, the Borrelia burgdorferi sensu lato complex is responsible for Lyme bor-
reliosis. This complex comprises more than 13 Borrelia species. Four of them are clearly pathogenic
for humans: B. burgdorferi sensu stricto, B. afzelii , B. garinii and B. spielmanii . They can generate er y-
thema migrans, an initial skin lesion, and can then spread deeply into the host to invade distant
tissues, especially the ner vous system, the joints or the skin. In humans , Borrelia pathogenicity seems
to be linked with taxonomic position, but in vitro studies show the role of plasmids in B. burgdorferi
s.l. pathogenesis. The inter- and intraspecies genetic diversity of B. burgdorferi s.l. evidences a clon-
al evolution of the chromosome, while p lasmid genes are quite variable, suggesting their major role
in Borrelia adaptability. The plasmid-encoded adhesins and vlse , crasps and osp genes determine
invasiveness and host immune evasion of B. burgdorferi s.l., and select the bacterial host spectrum.
The geographic distribution of B. burgdorferi s.l. is clos ely related to its vectors and competent hos ts,
and its development within these inf luences its diversity, taxonomy and pathogenesis, primar ily via
genetic lateral transfer. Copy right © 2009 S. Karger AG , Basel
Introduction
Borrelia Species and Speciation
The Spirochaetes phylum comprises several genera, but only 4 of them (Leptospira,
Tre ponem a, B rachyspira and Borrelia) contain human pathogens. Borrelia genus rep-
resentatives are characterized by both their strict parasitic way of life and a biphasic
cycle involving arthropod vectors and vertebrate hosts. Two distinct groups consti-
tute the Borrelia genus: the relapsing fever Borrelia group and the Borrelia burgdorferi
sensu lato complex; the latter is responsible for Lyme borreliosis. When it was discov-
Borrelia burgdorferi sensu lato Diversity and
Its Influence on Pathogenicity in Humans
Guy Baranton a ⭈ Sylvie J. De Martino b
a Centre National de Référence Borrelia, Institut Pasteur, Paris , et
b Laboratoire associé au CNR Borrelia,
Strasbourg , France
2 Baranton ⴢ De Martino
ered, B. burgdorferi was first considered to be a unique species responsible for Lyme
arthritis. Indeed the 12 isolates first studied (11 from the USA, 1 from Switzerland)
belonged to a single species [1] , later named Borrelia burgdorferi sensu stricto [2] . It
appeared that at least 3 pathogenic species could be delineated [2] . Finally, several
nonpathogenic species were discovered [3] . Up to now, 13 Borrelia species and 2 geno-
species have been identified as belonging to this B. b urgdorferi s.l. complex [4] . Geno-
species usually only differ from named species by a very small number of available
isolates [4] .
Ecological features associated with formal species (and speciation) are probably
diverse, complex and poorly understood; these are: the expansion area, host(s) spec-
trum, nature of vector(s) species and symptomatology of the disease in man (if this
exists).
For instance, B. burgdorferi s.s. is mostly present in North America and Europe,
and is transmitted by Ixodes scapularis, I. pacificus and I. ricinus to birds and multiple
mammals. In humans, it causes erythema migrans (EM) and arthritis, but also poly-
neuritis and in particular acrodermatitis chronica atrophicans (ACA) [3] . It coexists
with B. andersonii , which is restricted to the eastern part of the USA, nonpathogenic
for man and transmitted by a single vector (I. dentatus) to a single host (cotton tailed
rabbit) [5] . Therefore, conditions of speciation in Borrelia remain largely due to
chance: some sympatric species are narrowly specialized, while others are broadly
generalist. Similarly, in Europe, a single vector, I. ricinus , is competent for the 6 Bor-
relia species present, including B. b urgdorferi s.s. Therefore, in North America, 2 vec-
tors are both able to transmit B. b urgdorferi s.s., the only pathogenic species in the
USA.
It is noteworthy that another species, Borrelia lonestari , was identified as a caus-
ative agent of the southern tick-associated rash illness (STARI), an erythema mi-
grans-like rash observed in the southern USA [6] . However, its sequence analysis
showed that this species belongs to the relapsing fever group [7, 8] . The vector of B.
lonestari is the Amblyomma americanum tick, the lone star tick, distributed through-
out the southeast USA from central Oklahoma and Texas to the coast and northward
into Maine. However, B. lonestari has also been isolated in I. scapularis ticks, found
from the southeastern United States into both Massachusetts and New York [9] . Nev-
ertheless, in patients from Missouri, recent studies could implicate neither B. burg-
dorferi nor B. lonestari as the causative agent of STARI [10, 11] .
Methods to Evaluate the Genetic Diversity of B. burgdorferi s . l .
Since 1987, whole DNA/DNA hybridization (WDDH) was considered as the gold
standard in bacterial taxonomy [12] , and for 30 years no cultivable bacterial species
could be defined without WDDH data. It had been the case for Borrelia species up to
2006, when B. spielmanii became the first cultivable bacterial species to be delineated
B. burgdorferi s.l. Diversity and Pathogenicity 3
without being hybridized [13] . Multilocus sequencing analysis was accepted as an al-
ternative to WDDH by the editors of the leading journal in bacterial taxonomy, the
International Journal of Systematic and Evolutionary Microbiology .
However, many simpler methods allow an approach to the inter- and intraspecies
genetic diversity of bacteria: ribotyping, restriction fragment length polymorphism
analysis, multilocus enzyme electrophoresis and pulsed-field gel electrophoresis.
Other methods based on polymerase chain reaction (PCR) are usually faster, and
therefore frequently used: arbitrarily primed PCR, random amplification of polymor-
phic DNA, variable number tandem repeat analysis, etc. More recently, PCR and se-
quencing became popular because of their ease and sensitivity. Analysis of spacers
between ribosomal genes are particularly appreciated since the primers, hybridizing
on cons er ved s equences , a ll ow ampl if ic at ion of as ma ny b ac te ri a as w is hed for, where-
as the highly variable amplicons give a deep appreciation of species diversity. In the
case of Borrelia , the unusual topology of ribosomal genes ( rrl and rrf genes tandemly
repeated) allows a quite B. b urgdorferi s.l.-specific amplification of the rrl - rrf spacer
le ading to si multaneous detec tion, id ent if ica tion a nd ty ping [14] . One must be careful
when using sequencing of a single gene to identify species or subspecies because of
lateral transfer. Considering B. b urgdorferi s.l., for instance, genes coding outer mem-
brane proteins or virulence factors which are quite variable and plasmid encoded
(e.g. ospC, dbpAB genes) are often subjected to such lateral transfer. Conversely, the
chromosomally encoded genes are stable and present a clonal evolution. These are
conserved too much to be useful as markers of genetic diversity (intergenic spacers
excepted).
Multilocus sequences typing (MLST) is a method of studying the genetic diversity
in a bacterial group. A very early paper showed that the Borrelia chromosome clon-
ally evolves [15] . Three MLST studies have been used to elucidate the Borrelia popu-
lation structure [16–18] . They demonstrated a strong linkage between the multilocus
sequence genotypes, and a strong linkage between MLST allelic groups and the major
alleles of the ospC gene in spite of the high recombination rate in this gene. This sug-
gests a balancing selection of ospC as a dominant force to maintain diversity in local
populations of Borrelia . A similar conclusion had already been reached, showing that
OspC local diversity was equivalent to the global one [19] . However, except for ospC ,
sequence variation at plasmid-borne loci exhibits inconsistency with phylogeny, sug-
gesting plasmid transfers between isolates [17] , and ospC
phylogeny consistency in
spite of its high polymorphism suggests that ospC plays a major role in adaptive dif-
ferentiation of B. burgdorferi [18] .
Borrelia Pathogenicity
Pathogenicity stricto sensu and virulence of Borrelia comprise at least 2 phenomena
that are not independent of each other.
4 Baranton ⴢ De Martino
Borrelia Pathogenic Potential Seems to Be Linked to Taxonomic Position
Of course, since Borrelia are strict parasites, all species are able to invade a host. How-
ever, the host spectrum as well as the clinical expression differ greatly [20] . When
considering, by medical pragmatism, human sensitivity to Borrelia , the complex of
15 species is divided into 3 groups:
– 4 clearly pathogenic species: B. burgdorferi s.s., B. afzelii, B. garinii and B. spielma-
nii ;
– 3 rarely, if at all, pathogenic species: B. bissettii, B. lusitaniae and B. valaisiana;
– 6 species (and 2 genospecies) that have never been isolated in humans.
In the Borrelia Model, Virulence Is Not Associated with Taxonomic Position
In nature, an obvious permanent selective pressure eliminates such avirulent variants
that are not able to colonize their natural host. Loss of some plasmids, such as lp25
and lp28-1, is involved in a decrease in virulence [21] . Similarly the plasmid (lp25)-
encoded PncA gene (nicotinamidase) has been shown to be strongly associated with
virulence in Borrelia [22] .
Nevertheless, virulence is an artifact only observed during in vitro experimental
conditions and has not been studied further. However, theoretically it is possible that
in nature the ticks may be able to diffuse avirulent Borrelia isolates by cofeeding
[23] .
Genes or Products of Potentially Pathogenic Genes
All the genes mentioned in this section, but 2 – P66 and BgP – are plasmid encoded.
Several genes have been suggested to be involved in pathogenesis. Potential adhesins,
able to attach to diverse mammalian cell surface components, promote the bacterial
colonization of the mammalian host.
Adhesins. BgP and P66 are able to bind to platelets and integrins [24] . BbK32 (en-
coded on lp36) is a fibronectin adhesin [25] . DbpA and B (lp49) are decorin-binding
proteins [26] . Decorin-binding proteins and BBK32 (lp36) also bind to glycosamino-
glycans [27] .
Other Candidate Genes for Pathogenicity. VlsE could be involved in escape from
immune response by antigenic variation [28] . Complement regulator-acquiring
surface factors (CRASP) are able to inhibit complement activity by combining with
factor H or other similar substances of the host [29] . CRASP-1 is located on lp54,
CRASP-2 on lp28-3 and CRASP 3–5 are Erp proteins encoded by the cp32 gene fam-
ily [29] . CRASP from different Borrelia species, by binding with factor H of a given
host, confer a corresponding serum resistance. This phenomenon could explain the
host spectrum of each Borrelia species [30] .
OspA (lp54), an outer surface lipoprotein, is an adhesin only expressed in vector,
and is responsible for attachment to Ixodes midgut mucosa [31] . However, exception-
ally, in some cases of chronic arthritis due to Borrelia , antibodies to OspA have been
detected. It has been shown that an OspA motif is quite similar to human leukocyte
B. burgdorferi s.l. Diversity and Pathogenicity 5
function-associated antigen-1, which suggests it could be responsible for resistance to
treatment Lyme arthritis [32] . OspA has also been involved in plasmin fixation [33] .
OspC, another outer surface lipoprotein, is only expressed after the blood meal in
vectors and mainly in vertebrate hosts. The ospC gene is on cp26, a very st abl e pl asmi d
comprising metabolic genes [34] . In pathogenicity, ospC
is a highly variable gene and
plays an important role. Its expression is necessary to initiate the host colonization
[35] . It has been noticed that only a limited number of ospC
alleles could allow Bor-
relia to reach deep organs in humans after blood dissemination [36] . It has also been
shown that distinct alleles of OspC bind with different affinity to plasminogen [37] .
This suggests that only particular ospC alleles allow corresponding Borrelia to cross
the capillary membrane of a given host species to invade its deep organs using host
plasminogen. Such isolates, whose ospC allelic type is able to bind human plasmino-
gen, are called ‘invasive’. OspC has also another indirect role. It has been discovered
that salp 15, a tick saliva component, was overexpressed during the blood meal. OspC
is able to bind to this and block CD4 T cell activation, leading to an increase in the
Spirochaete load due to immunosuppression [38] .
OspA and OspC are immunodominant outer-membrane proteins and both elicit
bactericidal antibodies in hosts that are quite challenging for the strictly parasitical
behavior of Borrelia . However, OspA is expressed in ticks only, and OspC local diver-
sity represents a ‘repertoire’ that allows recontamination of a given host by a new and
unrecognized ospC variant [39] .
In conclusion, most of the genes that up to now have been identified as involved in
pathogenicity are plasmid encoded and upregulated within the host, except the ospA
gene.
Moreover, autoimmunity and the general interaction of B. burgdorferi s.l. with the
immune system has also been proposed as a mechanism of pathogenicity in human
Lyme borreliosis [40, 41] .
B. burgdorferi s.l. Diversity
Borrelia Species Pathogenic for Humans
B. burgdorferi s.s.
B. burgdorferi s.s. is a highly generalist species: several vectors, such as I. scapularis ,
I. pacificus and I. ricinus, are able to transmit it, as are minor ones, such as I. triangu-
liceps and I. hexagonus [42] . Both vector cycles and seasonal fluctuations shape the
transmission potential of Borrelia . As a result, the prevalence of the disease may be
drastically different between places close to each other [43] . Similarly, the expansion
zone of B. burgdorferi s.s. is quite large in the northern hemisphere. In North Amer-
ica, B. burgdorferi s.s. has spread over the West Coast and the eastern half of the USA
(mainly in the northeast), but also some southern areas such as Florida and Texas. In
6 Baranton ⴢ De Martino
the Mid-West, some contaminated spots have been recorded. In Canada, the threat
exists in the southeast of the country. In Europe, B. burgdorferi s.s. is present, but its
density is lower than those of the 2 other main pathogenic species: B. garinii and B.
afzelii . In Africa, ticks harboring B. burgdorferi s.s. have been reported in Morocco
[44] . Currently, it may be abundant, as is the case in the western part of France. To-
wards the east, B. burgdorferi s.s. is considered to be absent from Asia. Indeed, in the
borderline area between Asia and Europe, where both I. ricinus and I. persulcatus co-
exist, B. burgdorferi s.s. was identified only in I. ricinus [45] . B. burgdorferi s.s. has
been isolated in South Central China, but restricted to a hare, Caprolagus sinensis,
whose associated tick is Haemaphysalis bispinosa [46] . B. burgdorferi s.s. is also pres-
ent in Taiwan, but both ospC and ospA genes from several sequenced Taiwanese iso-
lates are almost identical. It mirrors a strictly clonal population in spite of the differ-
ent hosts harboring the isolates [47, 48] . Similarly, European B. burgdorferi s.s. also
represent a subset of the North American population of B. burgdorferi s.s., which is
largely more diverse intraspecifically. Such genetic bottlenecks are called a ‘founder’s
event’, and suggest that some North American clones of B. burgdorferi s.s. have been
subsequently imported into Europe and then into Taiwan [4, 19, 49] .
B. burgdorferi s.s. hosts are still characterized by their diversity in the USA: Pero-
myscus leucopus, Tamias striatus, Blarina brevicauda, Sciurus carolinensis and Sci-
urus griseus, and also passerine birds, blackbirds, robins, pheasants and veeries [42,
50]
. Each distinct host harbors different B. burgdorferi s.s. genotypes at different fre-
quencies, shaping the Borrelia population into distinct enzootic niches [43, 50] . How-
ever, in Europe the range of B. burgdorferi s.s. hosts are less well known, and include
red squirrels and hedgehogs [42] .
Concerning its pathogenicity, B. burgdorferi s.s. – like any other pathogenic
B. burgdorferi s.l. species – is able to provoke EM. It has been shown that lesions cor-
respond to the intradermic inflammatory response fighting the centrifugal migration
of bacteria from the inoculation point [51] . The physiology of multiple EM is quite
different: it reflects the ability of some Borrelia to penetrate the blood vessels and mi-
grate via this route into different parts of the body, including the skin. This necessar-
ily supposes these bacteria to be invasive ones.
Further, Lyme borreliosis may be inconstantly characterized by secondary lesions
distant from the inoculation point, sometimes in deep organs. Septicemia is the way
that the Borrelia invade the whole organism at this late stage. Each pathogenic Bor-
relia species exhibits a preferential organotropism [20] . B. burgdorferi s.s. have been
associated with arthritis. For instance in the USA, where B. burgdorferi s.s. is the only
pathogenic B. burgdorferi s.l. species present, arthritis is the most reported late clini-
cal presentation (33%) [52] . However, this organotropism is elective since B. burgdor-
feri s.s., still in the USA, also causes neurological problems (5%) [52] . In western Eu-
rope, too, B. burgdorferi s.s. has been reported as the species prominently isolated
from arthritic forms [53] , but in eastern areas where B. garinii is highly represented,
such as Germany, the etiology of arthritis is more diverse [54] .
B. burgdorferi s.l. Diversity and Pathogenicity 7
Although some European B. burgdorferi s.s. isolates are very close to North A mer-
ican ones, whatever the method used, polymorphism of B. burgdorferi s.s. is much
larger in North America than in Europe, and only few alleles are endemic in Europe
[55, 56] . These features characterize a founder’s event, suggesting a recent importa-
tion of B. burgdorferi s.s. from Nort h America to Europe. This hyp othesi s is strengt h-
ened by the fact that, although in Europe a significant part of the polymorphism
of ospC gene is due to lateral transfer from other B. burgdorferi s.l. species (mainly
B. afzelii and B. garinii ), no sequence of this type has been found in the USA, suggest-
ing that migration from Europe towards the USA is unlikely [49, 56] .
The pathogenic potential of B. burgdorferi s.s. isolates is variable. In the New York
area, 21 groups have been delineated by sequence analysis of the ospC gene. Among
them, only 4 groups exhibited an invasive potential in the USA [36] . On a global scale,
a single 5th ‘invasive’ group specific to Europe was defined later on [57] .
B. garinii
B. garinii is a very complex species. It has spread all over Europe and Asia (from Tur-
key to Siberia, to northern and eastern China and Japan) [58] and even into North
Africa [42, 59] . In Europe and North Africa, it is transmitted by I. ricinus . In Asia, the
main vector is I. persulcatus and, much more rarely, I. trianguliceps.
However, a second cycle involving seabirds and their associated ticks (I. uriae)
maintains B. garinii in many worldwide bird colonies, including those in the southern
hemisphere and boreal part of North America [60, 61] . Although the seabird or I. ur-
iae -associated Borrelia isolates do not differ genetically from other B. garinii (20047
group), this cycle seems to be enzootic and not to play an important role in the dis-
semination of Lyme disease. Within B. garinii , 2 subspecies (both pathogenic for hu-
mans) are genetically delineated [45, 58] :
– The 20047 group that is spread in both Asia, where it is transmitted by I. persulca-
tus, and Europe, where I. ricinus is the main vector. The usual hosts of the 20047
group are birds in Europe [62] , but rodents and birds in Asia [58] .
– The NT29 (or Ip89) group [45, 58] , which is restricted to Asia (vector I. persulca-
tus ). Rodents and not birds are reservoirs for NT29 group which has never been
found in I. ricinus .
A high diversity within these 2 subspecies, genetically delineated, has been ob-
served by monoclonal antibody typing. This allows us to define 6 serotypes [63] ,
whereas for other pathogenic Borrelia , a serotype corresponds to 1 species only. The
B. garinii diversit y i s se en in th e CSF o f pa tient s pr esent ing w ith neurobor reliosis [64] .
In addition, rodents instead of birds are the reservoir host for serotype 4 isolates [65] .
Serotype 4 also corresponds to both ospA and ospC genotypes [39, 64] .
Concerning organotropism of B. garinii , the neural apparatus is the main target
organ: symptoms reflect meningitis and inflammatory lesions of the peripheral ner-
vous system [3, 20, 64, 66] . Less frequently, B. garinii has been detected in joints [48] ,
and in exceptional cases it causes ACA [67] .
8 Baranton ⴢ De Martino
B. afzelii
B. afzelii [68] is present in both Europe and Asia (from Turkey to Siberia, to northern
and eastern China and Japan) [58] . It is particularly frequent in eastern and northern
Europe. The only known vectors of B. afzelii are I. ricinus in Europe and I. persulcatus
in Asia. I. ricinus is the most permissive Ixodes vector for Borrelia since it is able
to transmit B. burgdorferi s.s., B. garinii, B. afzelii, B. valaisiana, B. lusitaniae and
B. spielmanii , while I. persulcatus only transmits B. garinii and B. afzelii .
In humans, B. afzelii seems to have an organotropism for the skin, since it prefer-
entially causes lymphadenosis benigna cutis [69] and is the etiological agent of ACA
[3, 20] . However, B. afzelii have sometimes been isolated from either joints or CSF
[54] . ACA has never been observed in American citizens who have never left the USA,
confirming the suspicion that endemic B. burgdorferi s.s. are not able to induce this
cutaneous lesion. By contrast, in Europe B. burgdorferi s.s. isolates have occasionally
been isolated from ACA biopsies [70] .
B. spielmanii
B. spielmanii is the last pathogenic Borrelia species to have been discovered [13, 71] .
It is very rarely isolated, although strains have been observed in different European
countries: The Netherlands, the Czech Republic, France, Poland and Russia, among
others (but neither in Asia, nor in North America). It is transmitted by I. ricinus , but
the reason for the scarcity of isolates is due to its unique reservoir: dormice (Eliomys
quercinus) . It is unambiguously a pathogenic species since about one half of the avail-
able isolates have been isolated from human skin biopsies. Up to now, only EM has
been associated with B. spielmanii, and it is not known whether or not this species
comprises potentially invasive isolates.
Borrelia Species Rarely if At All Pathogenic for Humans
B. bissettii
B. bissettii is a large and diverse species. It is mainly isolated in California, where 4
ticks usually harbor B. bissettii: I. spinipalpis, I. neotomae, I. jellisonii and I. pacificus.
B. bissettii has been observed in other US states, like Colorado and Florida, and rare-
ly in Wisconsin and New York (in both areas 1 strain from I. scapularis has been
isolated). Known hosts are Neotoma fuscipes, Dipodomys californiensis and Odocoi-
leus hemionus in California , Peromyscus difficilis, P. maniculatus and N. mexicana
and Microtus ochrogaster in Colorado, and P. gossy pinus and Sigmodon hispidus in
Florida [4, 72] .
In the USA, B. bissettii has never been isolated from humans, and therefore is not
co nside red a s a p at hog enic species. In Europe, B. bissettii has never been isolated from
ticks nor hosts, except in Slovenia from 9 patients with EM [73] . However, these iso-
lations are very controversial since they were characterized in the USA and are no
B. burgdorferi s.l. Diversity and Pathogenicity 9
longer available in Slovenia. Moreover, none of them have been made available to the
scientific community, suggesting a technical mistake.
B. valaisiana
B. valaisiana [74] has spread all over Eurasia. Its vectors are I. ricinus in Europe and
I. granulatus in Asia (China, Japan and Korea). It is associated with birds, Tur du s spp.,
passerines and pheasants, as a B. garinii European subgroup (20047). Additionally, in
cases of mixed infection in ticks, B. valaisiana and B. garinii are frequently associated,
underlining their bird relationships [45] . On some occasions, B. valaisiana has been
identified by PCR in human skin [75] and once in the CSF [76] , but has never been
isolated from patients. One hypothesis for this rarely observed pathogenic potential
is the lateral transfer of a gene involved in pathogenesis from a pathogenic species to
B. valaisiana . The ospC gene, whose lateral transfer has been documented, is such a
candidate gene [56, 77] .
B. lusitaniae
B. lusitaniae [78] is present in both Europe and North Africa, but this distribution is
heterogeneous; it is quite frequent and highly polymorphic in Portugal, and also fre-
quent in North Africa, but this time it is monomorphic [59, 79] . In other places in
Europe, B. lusitaniae is very scarce. This heterogeneity in distribution and diversity
could be due to the original reservoir of B. lusitaniae : lizards [80] .
Although usually isolated only from I. ricinus ticks, B. lusitaniae has been isolated
recently from skin lesions of a Portuguese patient [81] .
Nonpathogenic Borrelia
B. japonica
B. japonica [82] is restricted to Japan [58] , and has only been isolated from I. ovatus .
It has never been associated with human infection.
B. tanukii
B. tanukii [83] has only been isolated from I. tanuki
(raccoon tick in Asia) in both Ja-
pan and Nepal [58] . No human infection has been reported.
B. turdi
B. turdi [83] is associated with I. turdus , a Japanese tick found on Turdidae birds. This
species is restricted to Japan, and no human infection due to this species has been
observed.
B. sinica
B. sinica has recently been delineated [84] , and has been found in I. ovatus in both
China and Nepal [58] . It has never been observed in humans.
10 Baranton ⴢ De Martino
B. andersonii
B. andersonii [5] is characterized by both a specific vector (I. dentatus) and a specific
host (cottontail rabbit; Oryctolagus cuniculus ). Restricted to the eastern part of the
USA, this species has never been associated with disease in humans.
B. californiensis
B. californiensis [4] is a rather homogeneous species, up to now restricted to Califor-
nia. It is associated with a major host, the kangaroo rat D. californicus, which was
previously identified as a reservoir for B. burgdorferi s.l. [85] , and more rarely associ-
ated with O. hemionus (commonly referred to as the mule deer). Identified vectors are
I. jellisonii , I. spinipalpis and I. pacificus .
Genospecies 1 and 2
At the moment, each of these genospecies comprise only 2 strains, which all have been
isolated from I. pacificus . They have been found only in California [4] .
Considerations about Diversity, Taxonomy and Pathogenicity of B. burgdorferi s.l.
Geographic Distribution of Borrelia Species
The B. b urgdorferi s.l. complex is mainly spread across the northern hemisphere. Fur-
thermore, we have noticed that 12 out of the 15 known species have been reported in
1 of 2 areas located at the same latitude (30–40° N) on each side of the Pacific Ocean:
California on one side ( B. burgdorferi s.s., B. bissettii, B. californiensis , genospecies 1
and 2) and Japan, Korea and western China on the other side ( B. afzelii, B. garinii, B.
valaisiana, B. tanukii, B. japonica, B. turdi, B. sinica and even B. burgdorferi s.s.). In-
deed, each of these 2 sets of species usually constitutes a monophyletic clade in phy-
logenetic trees drawn with highly conserved genes or by multilocus sequencing anal-
ysis: the ‘Californian’ clade including European B. burgdorferi s.s. isolates [4] . Con-
versely, B. garinii and B. afzelii associated with both I. ricinus and I. persulcatus and
with an open range of reservoirs – birds and rodents, respectively – have a large ex-
pansion area. Concerning B. burgdorferi s.s., it is noteworthy that the maximum in-
traspecies diversity is observed in California [55, 72] , just as if it had evolved locally
long enough in I. pacificus before some clones adapted to I. scapularis and progressed
towards the east coast and finally got transported overseas to Europe [4, 49, 55] , where
they could adapt to I. ricinus, and then move onwards to Taiwan.
The 3 Borrelia species absent from both California and north-western Asia are
characterized by their narrow and unusual reservoirs (lizards for B. lusitaniae , cot-
tontail rabbit for B. andersonii and dormice for B. spielmanii ). The 2 first ones usu-
ally constitute their own deep and peripheral branch in phylogenetic trees, although
B. spielmanii is close to B. afzelii .
B. burgdorferi s.l. Diversity and Pathogenicity 11
Genome, Host and Vector – Spectrum and Speciation
Schematically, there are 2 kinds of Borrelia species:
– Those associated with a vector characterized by both a broad spectrum of hosts
(I. ricinus, I. persulcatus or I. scapularis) and by a huge expansion area. These spe-
cies have large populations of individuals and a variety of different vertebrate hosts
which do not fully characterize the concerned Borrelia species. These species are
genetically quite diverse and usually pathogenic or potentially pathogenic (B. burg-
dorferi s.s., B. garinii, B. afzelii, B. valaisiana, B. lusitaniae, etc. ) . The best example
of such a species is B. garinii : highly diverse genetically with distinct groups differ-
ing both genetically and ecologically, but still in the species frame (see ‘B. garinii’ ).
– In contrast, there is a second kind of species associated with either a unique reser-
voir and a unique specialized vector (B. andersonii, B.turdi, B. tanukii) , or an un-
specialized vector but still a unique reservoir (B. spielmanii) .
The genome of B. b urgdorferi s.l. is quite unusual for a bacterium since it compris-
es many (15–22) replicons, both linear and circular [86] . The plasmids represent al-
most 40% of the genome. The linear chromosome is quite stable and clonally evolving
by genetic drift (no genetic lateral transfer reported) [15] . In contrast, most of the
plasmid replicons are submitted to duplications and lateral transfers (either complete
plasmid transfers or more often simple transfers of plasmid segments or genes) lead-
ing to redundancy and pseudogenes [86] .
Most of the genes involved in fitness of Borrelia with either tick or host reservoirs
are plasmid encoded. Those which play a role in host invasion or persistence are prob-
ably also involved in pathogenicity in humans. The numerous rearrangements among
plasmid and plasmidic genes allow the reassortment of genes to define new combina-
tions optimal for a particular subset of hosts or vectors. The successful combinations
are positively selected, leading to particular fitness between a clone on the one hand
and a given spectrum of hosts or vectors on the other hand. Although many plas-
midic genes vary, most of the genome (mainly the chromosome) remains unchanged.
Heterogeneity in the frequency of a given clone according to the host species has
indeed been recorded [50] within a Borrelia species. It seems that the main species
are B. burgdorferi s.s., B. garinii and B. afzelii in this case. The best example is
B. garinii (high genetic and phenotypic diversity): European (20047) and Asian
(NT29) groups have different hosts, similarly for serotype 4 of the European group,
even the seabird-associated cycle coexists with the main one within B. garinii .
It is well known that speciation occurs when a small population becomes isolated
either spatially or by a particular behavior. Once built by fast plasmidic f luidity, a suc-
cessful new genetic combination, reflecting the fitness between clones and hosts,
leads to intraspecific diversity. If a unique clone with a unique host relationship is
maintained long enough and stabilized, for instance in a place where the considered
host is highly predominant, a situation of isolation is created which would allow a
slow genetic drift of both the chromosome and the newly specialized plasmids. These
12 Baranton ⴢ De Martino
local conditions allow the development of a new Borrelia species. B. spielmanii, spe-
cifically adapted to a single rare rodent species (dormice), could have been individu-
alized this way from another I. ricinus -transmitted Borrelia (probably B. afzelii, the
closest species to B. spielmanii and whose reservoirs also are rodents species). This
mechanism of rapid plasmidic changes may also lead a clone to adapt to a new vector.
If the new vector has a unique host, the clone would easily become a new species
(B. andersonii?) . However, when the vector has a broad spectrum of hosts it could only
increase the intraspecific diversity ( B. b urgdorferi s.s. in Europe).
Taxonomic Lateral Transfer and Pathogenicity
Pathogenic Potential of B. valaisiana and B. lusitaniae
Pathogenicity of Borrelia for humans appears to be linked to taxonomy with very few
exceptions. Up to now, these exceptions only concerned Europe, where both B. valai-
siana (associat ed w ith bi rds) and B. lusitaniae (associated with lizards) have occasion-
ally been detected in human tissues [76, 81] . In Europe, 4 pathogenic Borrelia species
coexist; moreover, the 4 pathogenic and the 2 nonpathogenic species are transmitted
by a single vector, I. ricinus, which implies frequent mixed infection of the vector [45] .
This promiscuous presence of 2 or more Borrelia populations in the midgut of ticks
provides an opportunity for plasmid or plasmidic gene exchanges. Among the ex-
changeable loci, some of them allow the colonization of a given host species. They
could be either a specific adhesin or CRASP, which confer resistance to the comple-
ment of a given species (the affinity of different CRASP alleles for the Factor H of
distinct potential hosts has been shown to be variable [30] ). However, concerning
CRASP, it has been recently shown that the mechanism of host selection is probably
more complex [87] .
Invasiveness
Several authors have shown that within a pathogenic species, the population is het-
erogeneous at the pathogenicity level [36, 88] . When MLST studies are performed to
define the population structure, the leading role of the ospC gene is usually highlight-
ed [16, 18] . Indeed, Seinost et al. [36] first showed that a restricted number of ospC
groups were responsible for most of the late symptoms of Lyme disease. This suggests
that only isolates belonging to these ospC groups are able to invade blood vessels and
to migrate into deep organs or distant from the inoculation point [36, 39, 57] . A pos-
sible mechanism could be the ability of OspC protein from the so-called invasive
groups to bind with high affinity to human plasminogen which, once activated in
plasmin, allows the concerned isolates to cross the vascular endothelium and other
tissue membranes [37] .
Another striking feature of the ospC gene is the high level of recombination it ex-
hibits: OspC protein sequences look like mosaics of fragments from different origins
B. burgdorferi s.l. Diversity and Pathogenicity 13
and species [15, 49] . On other occasions, the whole gene or a very large fragment is
laterally transferred within or between species. Such large transfers have been ob-
served, even with a pathogenic species as donor and a nonpathogenic one as receiver.
Such recombinations could explain how B. valaisiana isolates have been involved in
neuroborreliosis [76] . Indeed, a B. valaisiana isolate (M7) bearing an OspC protein
quite similar to typically B. afzelii invasive genotypes isolated from ACA (ACA1) has
been found in nature [56] .
Taxonomy, Organotropism and Lateral Transfer
All the pathogenic species, when infecting humans, are able to provoke EM at the in-
oculation point. Some isolates of pathogenic species can provoke multiple EM after
blood dissemination. Later on, when the infection persists, each species exhibits a par-
ticular organotropism (unclear for the rare species B. spielmanii , which up to now has
only been isolated from EM). Schematically, B. burgdorferi s.s. is responsible for ar-
thritis, B. garinii for neuroborreliosis and B. afzelii for ACA and lymphadenosis be-
nigna cutis [3, 20] . However, there is usually no strict association: B. burgdorferi s.s. is
also involved in neuroborreliosis [3] and B. garinii
is sometimes isolated from syno-
vial tissues [53] . In contrast, there are very few exceptions to the unique B. afzelii etiol-
ogy of ACA [75] . For instance, in the USA the rare ACA recordings were always found
in patients who had travelled abroad; no locally acquired ACA have been reported [89] .
This would mean that B. burgdorferi s.s. per se is unable to provoke ACA. By contrast,
in Europe on a few occasions Borrelia other than B. afzelii have been identified (PCR
with chromosomal stable loci) in ACA skin lesions [67, 75] . However, a Danish B. burg-
dorferi s.s. isolate, DK7 (invasive isolate), was once isolated from ACA skin [90] . The
absence of indigenous ACA patients in the USA is obviously due to the absence of B.
afzelii . The reason why B. burgdorferi s.s. may be involved in ACA in Europe and not
in the USA is less clear. Again, a lateral transfer of certain plasmidic loci from B. afzelii ,
the usual agent of this pathology, is a convincing hypothesis.
References
1 Johnson RC, Schm id GP, Hyde FW, Steigerwalt AG,
Brenner DJ: Borrelia burgdorferi sp. nov.: etiologic
agent of Lyme disease. Int J Syst Bacteriol 1984;
34:
496–497.
2 Baranton G, Postic D, Saint Girons I, Boerlin P,
Piffaretti JC, Assous M, Grimont PA: Delineation
of Borrelia burgdorferi sensu stricto, Borrelia gari-
nii sp. nov., and group VS461 associated with Lyme
borreliosis. Int J Syst Bacteriol 1992;
42: 378–383.
3 Wang G, van Dam AP, Schwartz I, Dankert J: Mo-
lecula r typing of Borreli burgdorferi sensu lato: tax-
onomic, epidem iological, and cl inical implic ations.
Clin Microbiol Rev 1999;
12: 633–653.
4 Postic D, Garnier M, Baranton G: Multilocus se-
quence analysis of atypical Borrelia burgdorferi
sensu lato isolates – description of Borrelia califor-
niensis sp. nov. and genomospecies 1 and 2. Int J
Med Microbiol 2007;
297: 253–271.
5 Ma rconi RT, Liveris D, Schwar tz I: Identific ation of
novel insertion elements, restriction fragment
length polymorphism patterns, and discontinuous
23S rRNA in Ly me disease spiro chetes: phylogenet-
ic analy ses of rRNA genes and t heir intergenic sp ac-
ers in Borrelia japonica sp. nov. and genomic group
21038 ( Borrelia andersonii sp. nov.) isolates. J Clin
Microbiol 1995;
33: 2427–2434.
14 Baranton ⴢ De Martino
6 James AM, Liveris D, Wormser GP, Schwartz I,
Montecalvo MA, Johnson BJ: Borrelia lonestari in-
fection after a bite by an Amblyomma americanum
tick. J Infect Dis 2001;
183: 1810–1814.
7 Armstrong PM, Rich SM, Smith RD, Hartl DL,
Spielman A, Telford SR 3rd: A new Borrelia infect-
ing Lone Star ticks. Lancet 1996;
347: 67–68.
8 Barbour AG, Maupin GO, Teltow GJ, Carter CJ,
Piesman J: Identification of an uncultivable Borrel-
ia species in the hard tick Amblyomma america-
num : possible agent of a Lyme disease-like illness. J
Infect Dis 1996;
173: 403–409.
9 Taft SC, Miller MK, Wright SM: Distribution of
borreli ae among ticks col lected from east ern states.
Vector Borne Zoonotic Dis 2005;
5: 383–389.
10 Philipp MT, Masters E, Wormser GP, Hogrefe W,
Martin D: Serologic evaluation of patients from
Missouri with erythema migrans-like skin lesions
with t he C6 Lyme test. Cl in Vaccine Immunol 20 06;
13: 1170 –1171.
11 Wormser GP, Masters E, Liveris D, Nowakowski J,
Nadelman RB, Holmgren D, Bittker S, Cooper D,
Wang G, Schwartz I: Microbiologic evaluation of
patients from Missouri with erythema migrans.
Clin Infect Dis 2005;
40: 423–428.
12 Wayne LG : International C ommittee on Systemat ic
Bacteriology: announcement of the report of the ad
hoc Commit tee on Reconcili ation of Approaches to
Bacterial Systematics. Zentralbl Bakteriol Mikro-
biol 1988;
268: 433–434.
13 Richter D, Postic D, Sertour N, Livey I, Matuschka
FR, Bar anton G: Delineat ion of Borrelia burgdorferi
sensu lato species by multilocus sequence analysis
and confirmation of the delineation of Borrelia
spielmanii sp. nov. Int J Syst Evol Microbiol 2006;
56: 873–881.
14 Post ic D, Assous MV, Grimont PA, Baranton G: Di-
versity of Borrelia burgdorferi sensu lato evidenced
by restric tion fragment leng th polymorphis m of rrf
(5S) - rrl (23S) intergen ic spacer amplicons. I nt J Syst
Bacteriol 1994;
44: 743–752.
15 Dykhui zen DE, Polin DS , Dunn JJ, Wil ske B, Preac-
Mursic V, Dattwyler RJ, Luft BJ: Borrelia burgdor-
feri is clonal: implications for taxonomy and vac-
cine developme nt. Proc Natl Acad Sci USA 1993 ;
90:
10163–10167.
16 Bunikis J, Garpmo U, Tsao J, Berglund J, Fish D,
Barbour AG: Sequence typing reveals extensive
strain diversity of the Lyme borreliosis agents Bor-
relia burgdorferi in North America and Borrelia af-
zelii in Europe. Microbiology 2004;
150: 1741–1755.
17 Qiu WG, Schutzer SE, Bruno JF, Attie O, Xu Y,
Dunn JJ, Fraser CM, Casjens SR, Luft BJ: Genetic
exchange and plasmid transfers in Borrelia burg-
dorferi sensu stricto revealed by three-way genome
comparisons and multilocus sequence ty ping. Proc
Natl Acad Sci USA 2004;
101: 14150–14155.
18 Attie O, Bruno JF, Xu Y, Qiu D, Luft BJ, Qiu WG:
Co-evolution of the outer surface protein C gene
( ospC ) and intraspecific lineages of Borrelia burg-
dorferi sensu stricto in the northeastern United
States. Infect Genet Evol 2007;
7: 1–12.
19 Wang IN, Dykhuizen DE, Qiu W, Dunn JJ, Bosler
EM, Luft BJ: Genetic diversity of ospC in a local
population of Borrelia burgdorferi sensu stricto.
Genetics 1999;
151: 15–30.
20 Assous MV, Postic D, Paul G, Nevot P, Baranton G:
Western blot analysis of sera from Lyme borreliosis
patients according to the genomic species of the
Borrelia strains used as antigens. Eur J Clin Micro-
biol Infect Dis 1993;
12: 261–268.
21 Labandeira-Rey M, Seshu J, Skare JT: The absence
of linear plasmid 25 or 28–1 of Borrelia burgdorferi
dramatically alters the kinetics of experi mental in-
fection via distinct mechanisms. Infect Immun
2003;
71: 4608–4613.
22 Purser JE, Lawrenz MB, Caimano MJ, Howell JK,
Radolf JD, Norris SJ: A plasmid-encoded nicotin-
amidase (PncA) is essential for infectivity of Bor-
relia burgdorferi in a mammalian host. Mol Micro-
biol 2003;
48: 753–764.
23 Ra ndolph SE, Gern L, Nutt all PA: Co-feeding t icks:
epidemiological significance for tick-borne patho-
gen transmission. Parasitol Today 1996;
112: 472–
479.
24 Parveen N, Cornell KA, Bono JL, Chamberland C,
Rosa P, Leong JM: Bgp, a secreted glycosaminogly-
can-binding protein of Borrelia burgdorferi strain
N4 0, di s pl ay s nu cl eo si da se ac t iv it y a nd is no t e ss en -
tial for infection of immunodeficient mice. Infect
Immun 2006;
74: 3016–3020.
25 Seshu J, Esteve-Gassent MD, Labandeira-Rey M,
Kim JH, Trzeciakowski JP, Höök M, Ska re JT: Inac-
tivation of the fibronectin-binding adhesin gene
bbk32 significantly attenuates the infectivity po-
tential of Borrelia burgdorferi . Mol Microbiol 2006;
59: 1591–1601.
26 Guo BP, Brown EL, Dorward DW, Rosenberg LC,
Höök M: Decorin-binding adhesins from Borrelia
burgdorferi . Mol Microbiol 1998;
30: 711–723.
27 Fischer JR, LeBlanc KT, Leong JM: Fibronectin
binding protein BBK32 of the Lyme disease spiro-
chete promotes bacterial attachment to glycosami-
noglycans. Infect Immun 2006;
74: 435–441.
28 Zhang JR, Hardham JM, Barbour AG, Norris SJ:
Antigenic variation in Lyme disease borreliae by
promiscuous recombination of VMP-li ke sequence
cassettes. Cell 1997;
89: 275–285.
29 von Lackum K, Miller JC, Bykowski T, Riley SP,
Woodman ME, Brade V, Kraiczy P, Stevenson B,
Wallich R: Borrelia burgdorferi regulates expres-
sion of complement regulator-acquiring surface
protein 1 during the mammal-tick infection cycle.
Infect Immun 2005;
73: 7398–7405.
B. burgdorferi s.l. Diversity and Pathogenicity 15
3 0 Stevenson B, El-Ha ge N, Hines MA, Mi ller JC, Babb
K: Differential binding of host complement inhibi-
tor factor H by Borrelia burgdorferi Erp sur face pro-
teins: a possible mechanism underlying the expan-
sive host range of Lyme disease spirochetes. Infect
Immun 2002;
70: 491–497.
31 Pal U, de Silva AM, Montgomery RR, et al: Attach-
ment of Borrelia burgdorferi within Ixodes scapu-
laris mediated by outer surface protein A. J Clin In-
vest 2000;
106: 561–569.
32 Gross DM, Forsthuber T, Tary-Lehmann M, Etling
C, Ito K, Nagy ZA, Field JA, Steere AC, Huber BT:
Identification of LFA-1 as a candidate autoantigen
in treat ment-resista nt Lyme ar thritis. S cience 1998;
281: 703–706.
33 Fuchs H, Wallich R, Simon MM, Kramer MD: The
outer surface protein A of the spirochete Borrelia
burgdorferi is a plasmin(ogen) receptor. Proc Natl
Acad Sci USA 1994;
91: 12594–12598.
34 Byram R, Stewart PE, Rosa P: The essential nature
of the ubiquitous 26-kilobase circular replicon of
Borrelia burgdorferi . J Bacteriol 2004;
186: 3561–
3569.
35 Grimm D, Tilly K, Byram R, et al: Outer-surface
protein C of the Lyme disease spirochete: a protein
induced in ticks for infection of mammals. Proc
Natl Acad Sci USA 2004;
101: 3142–3147.
36 Seinost G, Dykhuizen DE, Dattwyler RJ, Golde
WT, Dunn JJ, Wang IN, Wormser GP, Schriefer
ME, Luft BJ: Four clones of Borrelia burgdorferi
sensu stricto cause invasive infection in humans.
Infect Immun 1999;
67: 3518–3524.
37 Lagal V, Portnoi D, Faure G, Postic D, Baranton G:
Borrelia burgdorferi sensu stricto invasiveness is
correlated with OspC-plasminogen affinity. Mi-
crobes Infect 2006;
8: 645–652.
3 8 Ram amo ort hi N, Nar asim ha n S, P al U, B ao F, Ya ng
XF, Fish D, Angu ita J, Norgard MV, Kantor FS, An-
derson JF, Koski RA, Fikrig E: The Lyme disease
agent exploits a tick protein to infect the mamma-
lian host. Nature 2005;
436: 573–577.
39 Baranton G, Seinost G, Theodore G, Postic D,
Dykhuizen D: Distinct levels of genetic diversity of
Borrelia burgdorferi are associated with different
aspects of pathogenicity. Res Microbiol 2001;
152:
149–156.
40 Steere AC, Klitz W, Drouin EE, Falk BA, Kwok
WW, Nepom GT, Baxter-Lowe LA: Antibiotic-re-
fractory Lyme arthritis is associated with HLA-DR
molecules that bind a Borrelia burgdorferi peptide.
J Exp Med 2006;
203: 961–971.
41 Soulas P, Woods A, Jaulhac B, et al: Autoantigen,
innate immunity, and T cells cooperate to break B
cell tolerance during bacterial infection. J Clin In-
vest 2005;
115: 2257–2267.
42 Humair P, Gern L: The wild hidden face of Lyme
borreliosis in Europe. Microbes Infect 2000;
2: 915–
922.
43 Kurtenbach K, Hanincova K, Tsao JI, Margos G,
Fish D, Ogden NH: Fundamental processes in the
evolutionary ecology of Lyme borreliosis. Nat Rev
Microbiol 2006;
4: 660–669.
44 Sarih M, Jouda F, Gern L, Postic D: First isolation
of Borrelia burgdorferi sensu lato from Ixodes rici-
nus ticks in Morocco. Vector Borne Zoonotic Dis
2003;
3: 133–139.
45 Postic D, Korenb erg E, Gorelo va N, Kov alevski Y V,
Bellenge r E, Baranton G: Borrelia burgdorferi sensu
lato in Russia and neighbouri ng countries: high in-
cidence of mixed isolates. Res Microbiol 1997;
148:
691–702.
46 Zhang Z, Xiu L: Personal communication 1996.
47 Shih CM, Chao LL: An OspA -based genospecies
identif ication of Lyme disea se spirochetes ( Borrelia
burgdorferi ) isolated in Taiwan. Am J Trop Med
Hyg 2002;
66: 611–615.
48 Shih CM, Chao LL: Genetic analysis of the outer
surfa ce protein C gene of Lyme dis ease Spirocha etes
(Borrelia burgdorferi sensu lato) isolated from ro-
dents in Taiwan. J Med Microbiol 2002;
51: 318–
325.
49 Marti Ras N, Postic D, Foretz M, Baranton G: Bor-
relia burgdorferi sensu stricto, a bacterial species
‘made in the USA’? Int J Syst Bacteriol 1997;
47:
1112–1117.
50 Brisson D, Dykhuizen DE: ospC diversity in Bor-
relia burgdorferi : different hosts are different nich-
es. Genetics 2004;
168: 713–722.
51 Berger BW, Johnson RC, Kodner C, Coleman L:
Cultivation of Borrelia burgdorferi from erythema
migra ns lesions and peri lesional ski n. J Clin Micro -
biol 1992;
30: 359–361.
52 http://www.cdc.gov/ncidod/dvbid/lyme/Id_
humandisease_symptoms.htm.
53 Jaulhac B, Heller R, Limbach FX, et al: Direct mo-
lecular typing of Borrelia burgdorferi sensu lato
species in synovial samples from patients with
Lyme arthritis. J Clin Microbiol 2000;
38: 1895–
1900.
54 Vasiliu V, Herzer P, Rossler D, Lehner t G, Wilske B:
Heterogeneity of Borrelia burgdorferi sensu lato
demonstrated by an ospA-type-specific PCR in sy-
novial fluid from patients with Lyme arthritis. Med
Microbiol Immunol 1998;
187: 97–102.
55 Foretz M, Postic D, Baranton G: Phylogenetic anal-
ysis of Borrelia burgdorferi sensu stricto by arbi-
trarily primed PCR and pulsed-field gel electro-
phoresis. Int J Syst Bacteriol 1997;
47: 11–18.
56 Dykhuizen DE, Baranton G: The implications of a
low rate of horizontal transfer in Borrelia . Trends
Microbiol 2001;
9: 344–350.
16 Baranton ⴢ De Martino
57 Lagal V, Postic D, Ruzic-Sabljic E, Baranton G: Ge-
netic diversity among Borrelia strains determined
by single-strand conformation polymorphism
analysis of the ospC gene and its association with
invasiveness. J Clin Microbiol 2003;
41: 5059–5065.
58 Masuzawa T: Terrestrial distribution of the Lyme
borreliosis agent Borrelia burgdorferi sensu lato in
East Asia. Jpn J Infect Dis 2004;
57: 229–235.
59 Younsi H, Post ic D, Baranton G, Bouat tour A: High
prevalence of Borrelia lusitaniae in Ixodes ricinus
ticks in Tunisia. Eur J Epidemiol 2001;
17: 53–56.
60 Olsen B, Duffy DC, Jaenson TG, Gylfe A, Bonne-
dahl J, Bergstrom S: Transhemispheric exchange
of Lyme disease spirochetes by seabirds. J Clin Mi-
crobiol 1995;
33: 3270–3274.
61 Smith RP Jr, Muzaffar SB, Lavers J, Lacombe EH,
Cahill BK, Lubelczyk CB, Kinsler A, Mathers AJ,
Rand PW: Borrelia garinii in seabird ticks (Ixodes
uriae), Atlantic Coast, North America. Emerg In-
fect Dis 2006;
12: 1909–1912.
62 Comstedt P, Bergstrom S, Olsen B, Garpmo U,
Marjavaara L, Mejlon H, Barbour AG, Bunikis J:
Migratory passerine birds as reservoirs of Lyme
borreliosis in Europe. Emerg Infect Dis 2006;
12:
1087–1095.
63 Wi lske B, Jau ris-Heipke S, Lob entanzer R, Pr adel I,
Preac-Mursic V, Rössler D, Soutschek E, Johnson
RC: Phenotypic analysis of outer surface protein C
(Osp C) of Borrelia burgdorferi sensu lato by mono-
clonal antibodies: relationship to genospecies and
OspA serotype. J Clin Microbiol 1995;
33: 103–109.
64 Wilske B, Busch U, Eiffert H, et al: Diversity of
OspA and OspC a mong cerebrospinal f luid isolates
of Borrelia burgdorferi sensu lato from patients
with neuroborreliosis in Germany. Med Microbiol
Immunol 1996;
184: 195–201.
65 Huegli D, Hu CM, Humair PF, Wilske B, Gern L:
Apodemus species mice are reservoir hosts of Bor-
relia garinii OspA serotype 4 in Switzerland. J Clin
Microbiol 2002;
40: 4735–4737.
66 Jaul hac B, Nicolini P, Piemont Y, Monteil H: Detec-
tion of Borrelia burgdorferi i n cerebrospinal f luid of
patients with Lyme borreliosis. N Engl J Med 1991;
324: 1440.
67 Picken RN, Strle F, Picken MM, Ruzic-Sabljic E,
Maraspin V, Lotric-Furlan S, Cimperman J: Identi-
ficat ion of three species of Borrelia burgdorferi sen-
su lato ( B. burgdorferi sensu stricto, B. garinii , and
B. afzelii ) among isolates from acrodermatitis
chronica atrophicans lesions. J Invest Dermatol
1998;
110: 211–214.
68 Canica MM, Nato F, du Merle L, Mazie JC, Baran-
ton G, Postic D: Monoclonal antibodies for identi-
fication of Borrelia afzelii sp. nov. associated with
late cutaneous manifestations of Lyme borreliosis.
Scand J Infect Dis 1993;
25: 441–448.
69 Gra nge F, Wechsl er J, G uil laum e JC, Tor tel J , Torte l
MC, Audhuy B, Jau lhac B, Cerron i L: Borrelia burg-
dorferi -associated lymphocytoma cutis simulating
a primary cutaneous large B-cell lymphoma. J Am
Acad Dermatol 2002;
47: 530–534.
70 R ijpkema SG, Tazelaar DJ, Molk enboer MJ, Noord-
hoek GT, Plantinga G, Schouls LM, Schellekens JF:
Detection of Borrelia afzelii , Borrelia burgdorferi
sensu stricto, Borrelia garinii and group VS116 by
PCR in skin biopsies of patients with erythema mi-
grans and acrodermatitis chronica atrophicans.
Clin Microbiol Infect 1997;
3: 109–116.
71 Richter D, Schlee DB, Allgower R, Matuschka FR:
Relationships of a novel Lyme disease spirochete,
Borrelia spielmani sp. nov., with its hosts in Centr al
Europe. Appl Environ Microbiol 2004;
70: 6414–
6419.
72 Postic D, Ras NM, Lane RS, Hendson M, Baranton
G: Expanded diversity among Californian Borrelia
isolates and description of Borrelia bissettii sp. nov.
(formerly Borrelia group DN127). J Clin Microbiol
1998;
36: 3497–3504.
73 Strle F, Picken RN, Cheng Y, Cimperman J,
Maraspin V, Lotric-Furlan S, Ruzic-Sabljic E, Pick-
en MM: Clinical findings for patients with Lyme
borreliosis caused by Borrelia burgdorferi sensu
lato with genotypic and phenotypic similarities to
strain 25015. Clin Infect Dis 1997;
25: 273–280.
74 Wang G, van Dam AP, Le Fleche A, Postic D, Peter
O, Baranton G, de Boer R, Spanjaard L, Dankert J:
Genetic and phenotypic analysis of Borrelia valai-
siana sp. nov. ( Borrelia genomic groups VS116 and
M19). Int J Syst Bacteriol 1997;
47: 926–932.
75 Rijpkema SG, Molkenboer MJ, Schouls LM, Jonge-
jan F, Schellekens JF: Simultaneous detection and
genotyping of three genomic groups of Borrelia
burgdorferi sensu lato in Dutch Ixodes ricinus ticks
by characterization of the amplified intergenic
spacer region between 5S and 23S rRNA genes. J
Clin Microbiol 1995;
33: 3091–3095.
76 D iza E, Papa A , Vezy ri E, Tsounis S, Milo nas I, A n-
toniadis A: Borrelia valaisiana in cerebrospinal flu-
id. Emerg Infect Dis 2004;
10: 1692–1693.
77 Wang G, van Dam AP, Dankert J: Evidence for fre-
quent OspC gene transfer between Borrelia valaisi-
ana sp. nov. and other Lyme disease spirochetes.
FEMS Microbiol Lett 1999;
177: 289–296.
78 Le Fleche A, Postic D, Girardet K, Peter O, Baran-
ton G: Characterization of Borrelia lusitaniae sp.
nov. by 16S ribosomal DNA sequence analysis . Int J
Syst Bacteriol 1997;
47: 921–925.
79 Younsi H, Sarih M, Jouda F, Godfroid E, Gern L,
Bouattour A, Baranton G, Postic D: Characteriza-
tion of Borrelia lusitaniae isolates collected in Tu-
nisia and Morocco. J Clin Microbiol 2005;
43: 1587–
1593.
B. burgdorferi s.l. Diversity and Pathogenicity 17
Sylvie De Martino
Laboratoire de Bactériologie, CNR Borrelia Laboratoire associé, CHU de Strasbourg
3, rue Koeberlé
FR–67000 Strasbourg (France)
Tel. +33 3 90 24 38 05 , Fax +33 3 90 24 38 08 , E-Mail sylvie.demartino@medecine.u-strasbg.fr
80 Dsouli N, Younsi-Kabachii H, Postic D, Nouira S,
Gern L , Bouattour A: Rese rvoir role of liza rd Psam-
modromus algirus in transmission cycle of Borrelia
burgdorferi sensu lato (Spirochaetaceae) in Tunisia.
J Med Entomol 2006;
43: 737–742.
81 Collares-Pereira M, Couceiro S, Franca I, Kurten-
bach K, Schäfer SM, Vitorino L, Gonçalves L, Bap-
tista S, Vieira ML, Cunha C: First isolation of Bor-
relia lusitaniae from a human patient. J Clin
Microbiol 2004;
42: 1316–1318.
82 Kawabata H, Masuzawa T, Yanagihara Y: Genomic
analysis of Borrelia japonica sp. nov. isolated from
Ixodes ovatus in Japan. Microbiol Immunol 1993;
37: 843–848.
83 Fukunaga M, Hamase A, Okada K, Nakao M: Bor-
relia tanukii sp. nov. and Borrelia turdae sp. nov.
found from Ixodid ticks in Japan: rapid species
identification by 16S rRNA gene-targeted PCR
analysis. Microbiol Immunol 1996;
40: 877–881.
8 4 M asuz awa T, Ta kada N, Kud eken M , Fuk ui T, Yano
Y, Ishiguro F, Kawamura Y, Imai Y, Ezaki T: Bor-
relia sinica sp. nov., a Lyme disease-related Borrelia
species isolated in China. Int J Syst Evol Microbiol
2001;
51: 1817–1824.
85 Brown RN, Lane RS: Reservoir competence of four
chapar ral-dwelli ng rodents for Bor relia burgdorferi
in California. Am J Trop Med Hyg 1996;
54: 84–91.
86 Casjens S, Palmer N, van Vugt R, Huang WM, Ste-
venson B, Rosa P, Lathigra R, Sutton G, Peterson J,
Dodson RJ, Haft D, Hickey E, Gwinn M, White O,
Fraser CM: A bacterial genome in flux: the twelve
linear and nine circular extrachromosomal DNAs
in an infectious isolate of the Lyme disease spiro-
chete Borrelia burgdorferi . Mol Microbiol 2000;
35:
490–516.
87 Woodman ME, Cooley AE, Miller J: Borrelia burg-
dorferi binding of host complement regulator fac-
tor H is not requir ed for efficient ma mmalia n infec-
tion. Infect Immun 2007;
75: 3131–3139.
88 Wang G, Ojaimi C, Wu H, Saksenberg V, Iyer R,
Liveris D, McClain SA, Wormser GP, Schwartz I:
Disease severity in a murine model of Lyme bor-
reliosis is associated with the genotype of the in-
fecting Borrelia burgdorferi sensu stricto strain. J
Infect Dis 2002;
186: 782–791.
89 DiCaudo DJ, Su WP, Marshall WF, Malawista SE,
Barthold S, Persing DH: Acrodermatitis chronica
atrophica ns in the United States: c linical and h isto-
pathologic features of six cases. Cutis 1994;
54: 81–
84.
90 Theisen M, Borre M, Mathiesen MJ, Mikkelsen B,
Lebech AM, Hansen K: Evolution of the Borrelia
burgdorferi outer surface protein OspC. J Bacteriol
1995;
177: 3036–3044.
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 18–30
A b s t r a c t
Lyme borreli osis is a zoonosis: its causative agent, Borrelia burgdorferi sensu lato, circulates between
Ixodes ricinus ticks and a large variety of vertebrates. I . ricinus has a wide geographical distribution
throughout Europe within the latitude s of 65° and 39° and from Portugal into Russia . Enzootic cycles
in Europe involve at least 7 Borrelia species. Apparently, associations exist in nature between Bor-
relia species and hosts. B. afzelii and B. burgdorferi sensu stricto are associated with rodents, and
B. garinii and B. valaisiana with birds. B. lusitaniae may be transmitted to ticks by some lizard species
and birds. B. spielmanii appears to be associated with dormice and hedgehogs. Less strict associa-
tions also exist. Transmission of Borrelia infection by I. ricinus to their hosts, including humans, does
not occur immediately when ticks attach to host skin. A delay is observed, which may depend on
the Borrelia species infecting the tick. B. afzelii can be transmitted during the first 24 h, whereas
B. burgdorferi needs 48 h of tick att achment before its transmission begins. Nothing is known about
the other Borrelia species; however, success of transmission always increases with tick attachment
duration. Therefore, care ful visual examinations of the body for at least 2 successive days are recom -
mended after visiting an endemic area. Copy right © 2009 S. Karger AG , Basel
Among diseases due to vector-borne pathogens in Europe, Lyme borreliosis, which is
transmitted by the tick Ixodes ricinus , is the most widespread and has a big impact on
human health. Lyme borreliosis is a zoonosis: its causative agent, Borrelia burgdorferi
sensu lato (s.l.), circulates between ticks and a large variety of vertebrates that act as
hosts for ticks. By acquiring the infection through infected tick bites and by develop-
ing clinical manifestations of Lyme borreliosis, humans reveal the presence of the
microorganism in various geographical areas. Humans are not involved in the trans-
mission cycle of B. burgdorferi s.l. in nature. They act as dead-end hosts.
Life Cycle of Borrelia burgdorferi sensu lato
and Transmission to Humans
Lise Gern
Institute of Biology, University of Neuchâtel, Neuchâtel , Switzerland
Life Cycle and Transmission of B. burgdorferi 19
Biology of I. ricinus
I . ricinus has a very wide geographical distribution throughout Europe. It has been
found within the latitudes of 65° and 39° and from Portugal into Russia, and also in
North Africa (Tunisia, Algeria and Morocco) [1] . In continental Europe, I . ricinus is
mainly present in deciduous woodlands and mixed forests. Ticks colonize biotopes
offering a high relative humidity. In fact, I. ricinus only survives where the relative
humidity in its microhabitat does not fall under 80%. The duration of its life cycle can
vary regionally and from one habitat to another, and can be affected by climatic fac-
tors and host density. The large geographical distribution of I . ricinus implies that this
tick has to survive under various environmental conditions, i.e. throughout this large
geographical area, temperatures vary considerably. Since temperature is known to
have an effect on tick questing activity and on tick development rates, it is an impor-
tant parameter in the dynamic of seasonal activity. Several papers described that the
seasonal activity of questing I. ricinus presents different patterns under different cli-
matic conditions. This seasonal activity pattern may be unimodal with a major peak
of tick activity in spring or in winter, or may be bimodal with 2 peaks of tick activity,
one in spring and another one in autumn [2] . This is important information because
seasonal questing activity of I. ricinus i nfluences the risk of being bitten by ticks, geo-
graphically and temporally.
The vertical distribution limit of I. ricinus differs throughout Europe according to
geographical position. However, recently many studies reported a shift in this limit
to higher altitudes , mo st prob ably du e to the increa se i n temperature obs erved dur ing
these last decades [2] . Interestingly, due to the vertical distribution limit observed in
tick distribution, it is frequently believed that the higher the altitude, the less ticks.
This should not be considered as a rule; various reports have recently shown that in
some habitats the opposite has been observed: the higher the altitude, the more ticks.
However, it is important to note that the tick densities described at the highest alti-
tudes were usually rather low.
In many aspects, ticks differ from insects. One way is that each of their develop-
mental stages (larvae, nymphs and adult females) feeds once on a host, and this lasts
for several consecutive days ( fig. 1 ). Each blood meal is followed by a developmental
phase, except for the females that will lay eggs after their blood meal and then die.
Male ticks may take up a very small quantity of blood, but they never take large blood
meals. The total duration of blood meals of I. ricinus is short, and does not last more
than 12–20 days. Larvae feed for 2 to 4 days, nymphs for 4 to 6 days and females for
6 to 10 days. Ticks can survive for years in their biotopes; however, they spend only a
small part of their life in a parasitic phase. Most of the I. ricinus lifetime is spent out-
side of the hosts, either on the ground or in vegetation. To find a host, I. ricinus climbs
onto low vegetation and waits at the tip where they quest for a host for time-limited
periods. During these periods of questing, I. ricinus tick s stay mainly immobi le at the
tip of the vegetation. When ticks are questing, they respond to mechanical and chem-
20 Gern
ical stimuli produced by hosts, including humans. When hosts pass close enough,
questing ticks grab their hosts. This behaviour of I. ricinus is important since it im-
plies that hosts, including humans, take some active part in the tick-host encounter.
During questing periods, I. ricinus often experiences desiccating conditions. As
already mentioned, I. ricinus ticks are susceptible to desiccation when questing for
hosts on vegetation, and high humidity is a prerequisite for tick survival. The atmo-
sphere is often unsaturated, and this represents a net water loss for the ticks. There-
fore, questing ticks have to rehydrate, and to do so they regularly leave their questing
place and move to the litter zone. There, to maintain their water balance, ticks ac-
tively absorb water from the subsaturated atmosphere. High humidity is found at the
base of vegetation, where ticks uptake atmospheric water. One aspect of the life cycle
of ticks is that they do not have unlimited time to find their hosts. Indeed, their sur-
vival is limited by the amount of energy they gain with blood meals and by their abil-
ity to maintain their water content in a desiccating atmosphere. For example, if high-
ly desiccating conditions develop, ticks reduce their questing duration and move
more often to the soil to rehydrate; eventually, their energy reserves will run out be-
fore they find a host and they will die. In nature, abrupt declines in questing tick
populations have been reported to coincide w ith abrupt inc rea ses in sat uration def icit
Nymph
Blood meal (4–6 days)
Molt (several weeks)
Adults
Eggs
Larva
Female
Blood meal (6–10 days)
Copulation
Egg laying
Death
Hatching
(several weeks)
Blood meal (2–4 days)
Molt (several weeks)
Male
Copulations
Death
Ixodes ricinus life cycle
Fig. 1. Complete life cycle of the I. ricinus tick.
Life Cycle and Transmission of B. burgdorferi 21
(measurement of the drying power of the air that includes relative humidity and tem-
perature) [3–5] . Long-lasting high saturation deficit may influence the evolution of
seasonal questing tick density, and also impair tick population maintenance in some
areas [2, 6] . If highly desiccating conditions are lasting and they coincide with tick
questing activity period, tick populations may greatly suffer from this moisture stress
and may be dramatically reduced. It was observed that under warmer episodes in
spring and summer, when synchrony of weather conditions with the tick life cycle
occurred – e.g. in spring, when many ticks quest and long-lasting highly desiccating
conditions are present – questing duration was reduced and tick mortality was in-
creased, leading to a lower questing tick population [4, 5] .
Life Cycle of B. burgdorferi s.l.
At the time of its discovery in the beginning of the 1980s, the causative agent of Lyme
borreliosis, B. burgdorferi, was thought to be a uniform organism. Currently, 12 Bor-
relia species are included in the complex B. burgdorferi s.l., and 7 of them have been
reported in I. ricinus in Europe: B . burgdorferi sensu stricto (s.s.), B . garinii , B . afzelii ,
B . valaisiana , B . lusitaniae, B . bissettii and B. spielmanii [7, 8] . B . bissettii
has been re-
ported only once in I. ricinus ticks in Europe. This was in a report from Slovakia,
where 1 tick was found to be reactive with probes specific for B . bissettii [9] ; this tick
was also reactive with probes for 2 other species of B . burgdorferi, which complicated
the specific identification of the spirochetes present in this tick, and, as a result, the
presence of B . bissettii in I. ricinus has to be confirmed by additional reports.
In Europe, B. burgdorferi s.l. has been reported from Italy to Iceland and from Por-
tugal to Russia [7] . The reported mean rates of B . burgdorferi in I. ricinus are 1.9% for
larvae, 10.8% for nymphs and 17.4% for adults [10] . Occasionally, higher infection
rates have been reported, mainly using PCR, as for example in Portugal where B . burg-
dorferi DNA in I . ricinus ticks reached 75% [7] . Local and temporal variations in the
infection prevalences of Borrelia in ticks have been recorded.
B . garinii and B . afzelii are the most frequent and most widely distributed species,
whereas B . burgdorferi s.s. and B. valaisiana are less common [7] . B . lusitaniae pres-
ents an interesting geographical distribution. In fact, B. lusitaniae , first isolated from
I . ricinus ticks in Portugal, has been reported in various European countries, for ex-
ample Bulgaria, Portugal, Slovakia, Switzerland, the Czech Republic, Moldavia,
Ukraine, Poland and Spain [1, 7] . Its presence has also been described in North Af-
rica [11] . Interestingly, B . lusitaniae is very common and greatly exceeds the other
species in I . ricinus ticks in Portugal and North Africa, whereas this Borrelia species
is only sporadically reported in ticks from the other areas. Rauter and Hartung [7] in
their meta-analysis give a detailed distribution of the main Borrelia species in differ-
ent parts of Europe. However, it is important to repeat here that the distribution of
the various species of B. burgdorferi s.l. and their frequency vary in endemic areas
22 Gern
over time. For example, B. afzelii may alternatively dominate in an area with B. gari-
nii . The recently described species, B. spielmanii, has been reported in I. ricinus from
The Netherlands, Denmark, Hungary, Slovenia, Germany and France [8] . The re-
ported geographical distribution of the different Borrelia species and their frequency,
and especially of those which are less frequently reported, may greatly change in the
future due to the implementation of more molecular analysis techniques.
Since, in some endemic areas in Europe, at least 6 Borrelia species may circulate,
mixed infection with more than 1 species in ticks can be observed. Infections by mul-
tiple B . burgdorferi s.l. species have been observed in ticks in many parts of Europe
[7] . Different combinations of mixed infections with 2 or 3 species have been detected
in I . ricinus . B. garinii and B . valaisiana constitute the majority of mixed infections,
followed by mixed infections with B . garinii and B . afzelii. Such mixed infections are
reported less frequently than single infections, and are often detected by PCR meth-
ods. Rauter and Hartung [7] , in their analysis of data collected throughout Europe,
reported 13% mixed infections in I. ricinus ticks. These multiple infections may result
from the feeding of ticks on a host infected by more than 1 Borrelia species or from
infected ticks feeding simultaneously with uninfected ticks on a host and exchanging
the Borrelia species through co-feeding transmission from infected to uninfected
ticks ( fig. 2 ) [12] . Moreover, ticks may acquire various Borrelia species through their
successive blood meals on various hosts, and maintain the infection to the subsequent
stage via transstadial transmission. Transovarial transmission of Borrelia from in-
***
Nymph
Larvae
Larvae
Nymph
Co-feeding transmission
Photo: Y. Kneubühler
Fig. 2. Co-feeding transmission.
Life Cycle and Transmission of B. burgdorferi 23
fected I. ricinus females to their progeny is also possible, but it represents a rare phe-
nomenon [1] . Nevertheless, transovarially transmitted spirochetes may also contrib-
ute to mixed infections in ticks.
The efficient persistence of the borreliae in endemic areas requires the involve-
ment of reservoir hosts. Potential hosts for ticks are numerous, and more than 300
vertebrate species have been identified as hosts for I. ricinus, including small mam-
mals, birds, larger mammals and reptiles. Among these hosts, some act as blood meal
sources and as reservoir hosts for pathogens, others as blood meal sources only. Nat-
ural hosts do not seem to develop clinical manifestations of the disease, although it is
difficult to evaluate the impact of Borrelia infection on their health, and minor clin-
ical manifestations may escape our attention.
Only a few dozen of the hosts for ticks have been currently identified as reservoir
hosts for B . burgdorferi s.l. in Europe. Globally, little information is available on the
real significance of most animal hosts as sources for infecting ticks with B . burgdor-
feri s.l. At present, several species of mice, voles, rats and shrews are recognized as
reservoirs of B . burgdorferi s.l. in Europe [1] . In particular, it was evidenced that the
mice Apodemus flavicollis , A . sylvaticus , A . agrarius and the vole, Clethrionomys
glareolus , play key roles in the ecology of Lyme borreliosis as reservoirs for B . burg-
dorferi s. l. in ma ny E uro pea n c ountr ies. Onc e infec ted by a n i nfe ct iou s tick bit e, s ome
reservoir hosts, like Apodemus mice, have been shown to persistently remain infec-
tious for ticks. Small rodents are frequently parasitized by larval and nymphal I . rici-
nus, and this also contributes to their importance as reservoirs. Less information has
been obtained on the roles of other small mammal species in the maintenance cycles
of Borrelia in nature. Nevertheless, another species of vole (Microtus agrestis) in Swe-
den, and black rats (Rattus rattus) and Norway rats (R . norvegicus) in urbanized en-
vironments in Germany and in Madeira, may serve as sources of infection for I . rici-
nus ticks. Similarly, only few data have been collected on B . burgdorferi s.l. in shrews
(Sorex minutus and S . araneus and Neomys fodiens) or in ticks attached on them. Ob-
servations in endemic areas of Germany and France showed that edible dormice (Glis
glis) and garden dormice (Eliomys quercinus) are reservoir hosts for Borrelia . Other
rodent species, like grey squirrels (Sciurus carolinensis) in the UK and red squirrels
(S . vulgaris) in Switzerland, also contribute to the amplification of Borrelia in the tick
population. Red and grey squirrels are usually very heavily infested with ticks, and 1
study reported a high prevalence of infection (69%) in ticks feeding on red squirrels.
In other investigations in Ireland, Germany and Switzerland, it was reported that the
European hedgehog (Erinaceus europaeus) also perpetuates B . burgdorferi s.l. [7] . In
Switzerland, an enzootic transmission cycle of B . burgdorferi s.l. involving hedgehogs
and another tick vector, I . hexagonus , has been observed in an urban environment.
This shows that gardens can also represent zones at risk of Lyme borreliosis as further
discussed below. Examination of the role of lagomorphs (Lepus europaeus, L. timidus,
and Oryctolagus cuniculus) in the support of the enzootic cycle of B . burgdorferi s.l.
has also elucidated their roles as reservoirs [1] .
24 Gern
When attention was first directed at the role of birds in the ecology of Lyme bor-
reliosis, their role was minimized. However, at the beginning of the 1990s, the reser-
voir role of birds was clarified in Europe, and now it is unanimously accepted that
some bird species are reservoirs for B. burgdorferi s.l. In 1998, 2 studies clearly defined
the reservoir role of birds, one on a passerine bird, the blackbird (Turdus merula) , the
other one on a gallinaceous bird species, the pheasant (Phasianus colchicus) [1] . Both
studies examined the reservoir role of these bird species using xenodiagnosis. Tick
xenodiagnosis consists of infecting uninfected ticks – usually larvae – during feeding
on the animal suspected to be reservoir host. These results and others have evidenced
the contribution of birds to the circulation of Borrelia in endemic areas. Interestingly,
a transmission cycle of B . burgdorferi s.l. was discovered in environmental settings
other than the biotopes where I. ricinus usually live. In fact, it was demonstrated, on
a Swedish island, that B. burgdorferi spirochetes could be maintained in seabird colo-
nies among razorbills (Alca torda) by an associated tick species, I . uriae . Of course,
interest in birds was also focused on the potential role of migrating birds in transport-
ing infected ticks. This approach turned out to be justified, and spirochetes were re-
ported in ticks collected from migratory birds in various studies. The involvement of
seabirds and I . uriae (in the marine environment) in the transport of infected Bor-
relia between the northern and the southern hemispheres was described. In this con-
text, it is interesting to mention that in a laboratory study, reactivation of latent Bor-
relia infection could be induced in passerines experimentally submitted to stressful
conditions simulating migration. This implies that during their migration, birds can
infect ticks all along their migration route. Bird migration also allows the transfer and
establishment of particular Borrelia species, as described for B. lusitaniae. In fact,
birds migrating between south-west Europe/North Africa to north-western Europe
have been suggested to be responsible for the transfer of B. lusitaniae from North Af-
rica and south-west Europe, where this Borrelia species clearly dominates, to north-
west Europe where it is much less frequent
[13] .
Assessment of the reservoir competency of large mammals is clearly a difficult
task. It necessitates, if xenodiagnosis is applied, capture of the animals and mainte-
nance in a laboratory structure. The consequence of this is that the role of medium-
sized and large mammalian species has been studied less and is not yet clearly under-
stood. Red foxes seem to be implicated in the maintenance of Borrelia in nature, as
described in Germany. However, these animals do not appear to be very potent res-
ervoirs, since spirochetes were poorly transmitted to ticks feeding on them. Accord-
ing to various reports, ruminants appear to act primarily as sources of blood for ticks.
Controversy long surrounded the exact role of large animals, particularly cervids, in
the maintenance cycle of Borrelia in endemic areas. Currently, most studies seem to
indicate that they do not play a role as reservoirs. In fact, studies undertaken in Swe-
den and in the UK on roe deer (Capreolus capreolus) , moose (Alces alces) , red deer
(Cervu s elaphus) and fallow deer (Dama dama) suggested that these species do not
infect feeding ticks with B . burgdorferi s.l. However, according to some recent devel-
Life Cycle and Transmission of B. burgdorferi 25
opments, the possibility exists that they may act as supports for co-feeding transmis-
sion of Borrelia between infected and uninfected ticks, and therefore may represent
amplifying hosts.
As previously mentioned, in Europe, at least 6 Borrelia species may circulate be-
tween vertebrate hosts and ticks. This raises a fundamental question: how do the dif-
ferent Borrelia species interact with the different host species in endemic areas? The
first findings showing an association between a Borrelia species and some host spe-
cies date back to the middle of the 1990s. At that time, it was shown that Borrelia spe-
cies isolated from Apodemus spp. captured in 2 sites in Switzerland all belonged to B .
afzelii , whereas Borrelia species diversity in ticks collected by flagging vegetation in
these sites displayed heterogeneity. Later, it was shown that small rodents of the genus
Apodemus and of the genus Clethrionomys as well as red (Sciurus vulgaris) and grey
squirrels (S . carolinensis) were usually infected by B . afzelii and less frequently by
B . burgdorferi s.s. and that they transmitted these 2 Borrelia species to ticks feed-
ing on them. On the other hand, at the same time, B . garinii was shown to be associat-
ed with migratory birds, and B . garinii and B . valaisiana with blackbirds and phea-
sants. B . garinii was also described as the Borrelia species involved in marine environ-
ments – in seabird colonies and in the tick I. uriae – located in both the northern and
southern hemispheres.
As far as less common Borrelia species are concerned, like B. lusitaniae and B.
spiel manii , recent works identified associations with some vertebrate hosts as well.
Thus, Dsouli et al. [11] demonstrated the reservoir role of the lizard Psammodromus
algirus for B. lusitaniae in North Africa (Tunisia), Richter and Matuschka [14] the
roles of the common wall lizard Podarcis muralis and sand lizard Lacerta agilis in
Germany, and, finally, Amore et al. [15] reported that P. muralis was a reservoir for
this Borrelia species in Italy. Poupon et al. [13] observed B. lusitaniae in I. ricinus
larvae collected from birds that were migrating between southwest Europe/North
Africa and northwestern Europe. These authors strongly suspected the role of mi-
gratory birds in the dispersal of B. lusitaniae. Concerning B. spielmanii , the garden
dormouse, E. quercinus [16] ,
and the hedgehog E. europaeus [17] have been described
as contributing the majority of B. spielmanii -infected ticks in areas endemic for this
Borrelia species.
At this point, one might justifiably ask: What element is behind this host-specific-
ity of B . burgdorferi s.l.? Explanation for this observation came from studies showing
that determinants for the described phenomenon were linked to the host comple-
ment system [18] . It was demonstrated in vitro that B. burgdorferi s.s., B. garinii, B.
valaisiana and B. afzelii showed different patterns of resistance or sensitivity to se-
rum according to host species, corresponding to the host specificity observed in na-
ture [18] . The main disadvantage of this in vitro system is that a great heterogeneity
is present among Borrelia strains in nature, and therefore a very large number of
various Borrelia strains have to be tested in relation to a very large number of host
sera to be able to mimic situations encountered in nature. An illustration of this is
26 Gern
B. lusitaniae. Kurtenbach et al. [18] reported that B. lusitaniae is sensitive to the
complement of some bird and lizard species, and hence is destroyed by these host
sera. However, as reported before, B. lusitaniae has been found to be associated with
some lizard and bird species in nature. Further research in this field is required to
better understand all subtleties governing these interactions. This is particularly im-
portant because besides these strict associations between Borrelia and vertebrate
hosts, loose associations between Borrelia and hosts have also been described in the
natural environment. B . garinii has occasionally been described as associated with
rodents, and B. afzelii has been detected in xenodiagnostic ticks that fed on birds.
The existence of such loose associations between hosts and Borrelia was confirmed
recently in studies using less classical methods to identify host reservoirs. In fact, the
use of molecular tools upon field-collected ticks – that allow the identification of
host DNA remaining in the tick midgut from the previous blood meal, along with
the detection of Borre lia – tended to show that in parallel to the strict associations
between Borrelia species and hosts, less strict associations also exist [19] . All this goes
to show that in nature strict and loose associations probably occur between Borrelia
species and host species. Additional studies are required to really understand the
relationships between the various Borrelia species and strains and their hosts in na-
ture.
It is striking that among the 300 vertebrate species serving as hosts for ticks, only
a few have been identified as reservoir hosts. We have already touched on the difficul-
ties in assessing the reservoir competency of vertebrates, particularly large mammals.
This can be mainly attributed to the fact that, as a gold standard, reservoir identifica-
tion implies tick xenodiagnosis. This necessitates animal trappings and temporary
maintenance of these animals in captivity. It is obvious that most tick hosts are dif-
ficult to capture and to maintain in a laboratory. That is one of the reasons why re-
searchers have recently developed molecular tools allowing identification of hosts
that have fed the field-collected ticks in their previous developmental stages. This
method coupled with the simultaneous detection of pathogens in ticks, mainly in
nymphs, has been developed and applied in the field. Two main host genes have been
targeted in these studies, the nuclear 18S rRNA gene [20] and the 12S rDNA mito-
chondrial gene [21] . The method based on the nuclear 18S rRNA gene appears to be
less sensitive, in the sense that it allows the discrimination of only major groups of
vertebrate hosts [20] . The other method, based on the 12S rDNA mitochondrial gene,
has the advantage of allowing identification of host DNA to the species level, narrow-
ing down host identification [21] . The use of these molecular tools may help to eluci-
date the maintenance and the circulation of B. burgdorferi s.l. among their different
hosts throughout the large geographical distribution of I. ricinus ticks in Europe and
North Africa.
Life Cycle and Transmission of B. burgdorferi 27
Transmission of B. burgdorferi to Humans
Let us first remember here that the encounter between ticks and their hosts, includ-
ing humans, comprises a tick that is immobile on vegetation waiting for a host that is
moving; this means that the encounter between these 2 elements of the eco-epide-
miological chain is based mainly on the active part of the host. Once the encounter
has taken place, the tick will move on its host to look for an adequate place to intro-
duce its mouthparts into the skin of its host. In humans, it may take a few minutes to
hours before the tick attaches to the skin. The duration of attachment of the tick I.
ricinus to its hosts, as we mentioned before, can vary between 3 and 10 days depend-
ing on the developmental stage. B . burgdorferi s.l. spirochetes are transmitted to their
hosts orally while ticks are taking their blood meal. It took a few years after the dis-
covery of B. burgdorferi in ticks in North America in the 1980s for the mechanism of
how the spirochetes were transmitted to the host to be elucidated. This was mainly
due to the fact that before blood meal, in unfed ticks, spirochetes are located in the
tick midgut. Thus, for some years, regurgitation of midgut content was considered as
the mode of transmission of B. burgdorferi s.l., before the transmission route was elu-
cidated. Currently, it is well established that B . burgdorferi s.l. is transmitted to the
host via infected saliva during the blood meal. Very few studies have investigated the
transmission dynamic of B . burgdorferi s.l. by I . ricinus ; however, these studies showed
that, in the majority of infected I . ricinus ticks, spirochetes (that are present in the
midgut of ticks before blood meal begins) migrate during blood feeding to the sali-
vary glands, from which they are transmitted to the host via saliva. Furthermore,
microscopic examination of unfed nymphal and adult I . ricinus ticks collected in en-
demic areas demonstrated that spirochetes may also be present in the salivary glands
of ticks even before any blood uptake [22] .
When unfed I . ricinus attaches to a vertebrate host, Borrelia transmission does not
occur at the beginning of the blood uptake but later on, and transmission efficiency
increases with the duration of the blood meal [23, 24] . The uptake of blood seems to
trigger spirochetes to migrate from tick midgut to the salivary glands. The delay in
transmission observed during the first hours of the blood meal might be due to this
phenomenon, the migration of the spirochetes. In a laboratory study, an early trans-
mission of borreliae with high efficiency was described for I . ricinus . In fact, Kahl et
al. [23] reported that 50% of laboratory animals were infected by B . burgdorferi s.l.
after only 16.7 h of tick attachment. The observations of high infection rates in sali-
vary glands of unfed I . ricinus suggest that systemically infected ticks may transmit
Borrelia early after attachment to hosts [22] , and this might be a factor that might
reduce the delay in transmission after attachment of the ticks to the hosts. Crippa
et al. [24] , comparing transmission dynamic of spirochetes by B. burgdorferi s.s.- and
B. afzelii -infected ticks, reported that this delay might also be influenced by the Bor-
relia species infecting the ticks. In fact, earlier transmission by I . ricinus occurred
when ticks were infected by B . afzelii rather than by B . burgdorferi s.s. These authors
28 Gern
reported that during the first 48 h of attachment to the host, B . burgdorferi s.s.-in-
fected ticks did not infect the 18 exposed mice, whereas B . afzelii- infected ticks trans-
mitted infection to 33% of the mice [24] . This study not only showed that I . ricinus
transmits B . afzelii earlier than B . burgdorferi s.s., but also that I . ricinus is a more ef-
ficient vector for B . afzelii than for B . burgdorferi s.s. Unfortunately, nothing is known
on the transmission delay for other pathogenic Borrelia species infecting I. ricinus ,
such as B. garinii , B. valaisiana and the recently described species B. spielmanii . All
this indicates that ticks should be removed as soon as they are found attached to the
skin.
The migration of Borrelia from the midgut to the salivary glands during tick feed-
ing is associated with variable protein expression. From studies mainly on the North
American tick vector, I . scapularis , but also on I. ricinus , it is known that in unfed
ticks, before the beginning of blood uptake, spirochetes located in the midgut express
outer surface protein A (OspA). On its surface, OspA possesses a receptor for plas-
minogen of the host organism. After tick feeding starts on the host, plasminogen
changes into plasmin, which facilitates migration through the midgut wall to the
salivary glands. During blood feeding, OspA synthesis is repressed and OspC synthe-
sis is induced. In I . ricinus , very few studies addressed this point. Leuba-Garcia et al.
[22] observed that B . afzelii spirochetes expressing OspA and OspC were present in
the midgut of unfed ticks, and that spirochetes expressing OspA were not detected in
ticks attached to the host for more than 24 h. In salivary glands of engorged ticks,
B . afzelii spirochetes expressed OspC. This study also reported that in the skin of mice
infected by B . afzelii- infected nymphs, spirochetes expressed OspC. Later, Fingerle et
al. [25] , using different B . afzelii and B . garinii strains, demonstrated that in capil-
lary-infected I . ricinus ticks, OspA was expressed in the tick midgut and that the pro-
portion of OspC-positive borreliae was usually greater when the borreliae reached the
salivary glands. In this study, a B . afzelii strain unable to produce OspC was unable
to disseminate and to induce infection in salivary glands, showing the role of OspC
in Borrelia dissemination in I . ricinus . The degree of strain specificity on the dynam-
ics of Osp expression and the dissemination of spirochetes in the vector is an interest-
ing topic. The interactions of the various Borrelia species and strains with I . ricinus
are clearly extremely complex and insufficiently studied.
We cannot end this chapter without adding some words on another tick species,
the hedgehog tick (I. hexagonus), that may transmit Borrelia infection to humans. Its
vector competence has been demonstrated under laboratory conditions, and con-
firmed under field conditions. This tick species is one of the most widespread tick
species in Europe. I. hexagonus is a nidicolous species, which means that this tick lives
in the nest, burrow or cave of its hosts. Hosts for this tick species are mainly recorded
among carnivores. In view of its habitats, I . hexagonus rarely comes in contact with
humans. However, hedgehogs are also frequent hosts for I. hexagonus, and since
hedgehogs are frequent hosts in our gardens, humans can come into contact with this
tick (particularly when they handle nests of hedgehogs, which have surface nests,
Life Cycle and Transmission of B. burgdorferi 29
References
1 Ge rn L , Hu ma ir P F: Ec olo gy of Borrelia burgdorferi
sensu lato in Europe; in Gray JS, Kahl O, Lane RS,
Stanek G (eds): Lyme Borreliosis: Biology, Epidemi-
ology and Control. Wallingford, CAB Internation-
al, 2002, pp 149–174.
2 Morán Cadenas F, Rais O, Jouda F, Douet V, Hu-
mair PF, Moret J, Gern L: Phenology of Ixodes rici-
nus and infection with Borrelia burgdorferi sensu
lato along a north- and south-facing altitudinal
gradient on Chaumont Mountain, Switzerland. J
Med Entomol 2007;
44: 683–693.
3 Randolph SE, Storey K: Impact of microclimate on
immature tick-rodent host interactions (Acari: Ix-
odidae): implications for parasite transmission. J
Med Entomol 1999;
36: 741–748.
4 Perret JL, Guigoz E, Rais O, Gern L: Inf luence of
saturation deficit and temperature on Ixodes rici-
nus tick questing activity in a Lyme borreliosis en-
demic area (Switzerland). Parasitol Res 2000;
86:
554–557.
5 Perret JL, Rais O, Gern L: Influence of climate on
the proportion of Ixodes ricinus nymphs a nd adults
questing in a tick populat ion. J Med Entomol 2004;
41: 361–365.
6 Burri C, Morán Cadenas F, Douet V, Moret J, Gern
L: Ixodes ricinus density and i nfection preva lence of
Borrelia burgdorferi sensu lato along a nort h facing
altitudinal gradient in the Rhône Valley (Switzer-
land). Vector Borne Zoonotic Dis 2007;
7: 50–58.
7 Rauter C, Hartung T: Prevalence of Borrelia burg-
dorferi sensu lato species in Ixodes ricinus ticks in
Europe: a metaanalysis. Appl Environ Microbiol
2005;
71: 7203–7216.
8 Richter D, Postic D, Sertour N, Livey I, Matuschka
FR, Bar anton G: Delineat ion of Borrelia burgdorferi
sensu lato species by multilocus sequence analysis
and confirmation of the delineation of Borrelia
spielmanii sp. nov. Int J Syst Evol Microbiol 2006;
56: 873–881.
9 Hanincová K, Taragelová V, Koci J, Schäfer SM,
Hails R, Ullmann AJ, Piesman J, Labuda M, Kur-
tenbach K: A ssociation of Borrelia garinii and B. va-
laisiana with songbirds in Slovakia. Appl Environ
Microbiol 2003;
69: 2825–2830.
10 Hubálek Z, Halouzka J: Prevalence rates of Bor-
relia burgdorferi sensu lato in host-seeking Ixodes
ricinus ticks in Europe. Parasit Res 1998;
84: 167–
172.
11 Dsouli N, Younsi-Kabachii H, Postic D, Nouira S,
Gern L, Bouattour A: Reservoir role of the lizard,
Psammodromus algirus , in the transmission cycle
of Borrelia burgdorferi sensu lato (Spirochaetacea)
in Tunisia. J Med Entomol 2006;
43: 737–742.
12 Gern L, Rais O: Efficient transmission of Borrelia
burgdorferi between cofeeding Ixodes ricinus ticks
(Acari: Ixodidae). J Med Entomol 1996;
33: 189–
192.
13 Poupon MA, Lommano E, Humair PF, Douet V,
Rais O, Schaad M, Jenni L, Gern L: Prevalence of
Borrelia burgdorferi sensu lato in ticks collected
from migratory birds in Switzerland. Appl Env iron
Microbiol 2006;
72: 976–979.
14 Richter D, Matuschka FR: Perpetuation of the
Lyme disease spirochete Borrelia lusitaniae by liz-
ards. Appl Environm Microbiol 2006;
72: 4627–
4632.
when gardening) . I. hexagonus bites humans, although less frequently than I. ricinus,
and may transmit Borrelia infection to them. In addition to I. ricinus and I. hexago-
nus , other tick species and even insect species have been found to be infected by B.
burgdorferi s.l., but without evidence of vector competence. A list of these insect and
tick species can be found in a report by Gern and Humair [1] .
We have seen that once on their host, I. ricinus ticks do not attach immediately to
the skin, but look for a suitable place. We have also reported that the risk of transmis-
sion of Borrelia by feeding ticks increases with attachment duration. Both these ele-
ments are important in the prevention of Lyme borreliosis. It means that careful vi-
sual examinations of body may prevent tick bites as well as Borrelia infection. Body
examination is recommended not only during and immediately after stays in tick
biotopes, but also during the following days.
30 Gern
15 Amore G, Tomassone L , Grego E, Ragag li C, Berto-
lotti L, Nebbia P, Rosati S, Mannelli A: Borrelia lu-
sitaniae in immature Ixodes ricinus (Acari: Ixodi-
dae) feeding on common wall lizards in Tuscany,
central Italy. J Med Entomol 2007;
44: 303–307.
16 Richter D, Schlee DB, Allgöver R, Matuschka FR:
Relationships of a novel Lyme disease spirochete,
Borrelia spielmani sp. nov., with its hosts in central
Europe. Appl Environ Microbiol 2004;
70: 6414–
6419.
17 Sku bal la J , Oeh me R , Har tel t K, P etn ey T, Bü che r T,
Kimmig P, Taraschewski H: European hedgehogs
as hosts for Borrelia spp., Germany. J Emerg Dis
2007;
13: 952–953.
18 Kurtenbach K, Schäfer SM, de Michelis S, Etti S,
Sewell HS: Borrelia burgdorferi sensu lato in the
vertebrat e host; in Gray JS, Ka hl O, Lane RS, Sta nek
G (eds): Lyme Borreliosis: Biology, Epidemiology
and Control. Wallingford, CAB International,
2002, pp 117–150.
19 Morán Cadenas F, Rais O, Humair PF, Douet V,
Moret J, Gern L: Identification of host bloodmeal
source and Borrelia burgdorferi sensu lato in field-
collected Ixodes ricinus ticks in Chaumont (Swit-
zerland). J Med Entomol 2007;
44: 1109–1117.
2 0 Pichon B, Egan D, Rogers M, Gray J S: Detection an d
identification of pathogens and host DNA in unfed
host-seeking Ixodes ricinus L. (Acari: Ixodidae). J
Med Entomol 2003;
40: 723–731.
21 Humair PF, Douet V, Morán Cadenas F, Schouls L,
Van De Pol I, Gern L: Molecular identification of
blood meal source in Ixodes ricinus ticks using 12S
rDNA as a genetic marker. J Med Entomol 2007; 44:
869–880.
22 Leuba-Garcia S, Martinez R, Gern L: Expression of
outer surface proteins A and C of Borrelia afzelii in
Ixodes ricinus ticks a nd in the skin of mice. Zentlbl
Bakt Hyg 1998;
287: 475–484.
23 Kahl O, Janetzki-Mittmann C, Gray JS, Jonas R,
Stein J, de Boer R: Risk of infection with Borrelia
burgdorferi sensu lato for a host in relation to the
duration of ny mphal Ixodes ricinus feeding and the
method of t ick removal. Zent lbl Bakt Hyg 1998;
287:
41–52.
24 Crippa M, Rais O, Gern L: Investigations on the
mode and dy namics of tra nsmission and i nfectivit y
of Bor relia burgdorferi sensu s tricto and Borrelia af-
zelii in Ixodes ricinus ticks. Vector Borne Zoonotic
Dis 2002;
2: 3–9.
25 Fingerle V, Goettner G, Gern L, Wilske B, Schulte-
Spechtel U: Complementation of a Borrelia afzelii
OspC mutant highlights the crucial role of OspC
for dissemination of Borrelia afzelii in Ixodes rici-
nus. Int J Med Microb 2007;
297: 97–107.
Lise Gern
Institute of Biology
Emile Argand 11, Case postale 158
CH–2009 Neuchâtel (Switzerland)
Tel. +41 32 718 3000, Fax +41 32 718 3001, E-Mail lise.gern@unine.ch
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 31–50
A b s t r a c t
Lyme borreliosis (LB) is the most frequent ixodid tick-borne human disease in the world, with an
estimated 85,500 patients annually (underlying data presented in this review: Europe 65,500, North
America 16,500, Asia 3,500, North Africa 10; approximate figures). This chapter summarizes the up-
to-date knowledge about facts and factors important in the epidemiology of LB all over the world.
Individual sections briefly describe geographic (latitudinal and altitudinal) distribution and inci-
dence rates of LB in individual countries; seasonal distribution of the disease; effects of patients’
age, sex, and profession; comparison of urban versus rural settings; weather-related ef fects on LB
incidence; risk factors for LB acquisition by humans; and risk assessment. This chapter finishes by
recommending a more thorough epidemiological surveillance for LB, including morbidity notifica-
tion in some additional countries where it has not yet been fully implemented.
Copy right © 2009 S. Karger AG , Basel
Introduction
Lyme borreliosis (LB), usually called Lyme disease (LD) in North America, is the most
abundant ixodid-borne disease of humans in the world, though it only occurs in the
northern hemisphere. It is in fact an old disease that was surprisingly only fully rec-
ognized at the end of the 20th century.
Several excellent reviews on LB epidemiology have been published previously
[1–7] . The purpose of this review is to summarize the up-to-date knowledge on, and dis-
cuss briefly all facts and factors important in, the epidemiology of LB over the world.
Geographic Distribution and Incidence Rate
LB occurs in North America (from the Mexican border in the south to the southern
Canadian provinces in the north), the whole of Europe, parts of North Africa
(Maghreb), and northern Asia (Russian Siberia and the Far East, Sakhalin, Japan,
Epidemiology of Lyme Borreliosis
Zdenek Hubálek
Institute of Vertebrate Biology, Academy of Sciences of the Czech Republic, Brno , Czech Republic
32 Hubálek
China, and Korea). In North America, only a few US states do not report LB or even
record it (Alaska, Arizona, Montana, Nebraska, New Mexico, and Wyoming). Occa-
siona l reports of t he occu rrence of L B in the southern he misphere (C entral and South
America, sub-Saharan Africa, South Asia, Australia) have never been reliably con-
firmed. The geographic distribution of LB correlates closely with the range of the
principal vector, ticks of the Ixodes ricinus complex.
Incidence Rates
Incidence rates of LB in different countries are summarized in table 1 . However, LB
is not a mandatorily notifiable disease in a number of European and North American
countries, e.g. Austria, Sweden, Switzerland (in the last decade), France, Belgium, The
Netherlands, Ireland, England and Wales, and Canada. Therefore, the incidence data
from these countries presented here are qualified estimates, based on several prospec-
tive epidemiological studies, usually limited to certain areas (very often those with a
high incidence of LB), and incidence rates of comparable neighboring countries. The
mean annual numbers of LB cases, as summarized from notified cases and qualified
estimates in countries without an obligatory notification system for LB, are 65,467 in
Europe; 3,450 in Asia; 16,340 in North America; and 7 in North Africa (Maghreb);
the annual world total is 85,264 LB cases. In a previous review, about 85,000 LB cases
were estimated in Europe only, with an additional 15,000–20,000 annual cases in the
USA [7] . Our estimates are more conservative.
Many experts admit that there is a significant underreporting of LB, and some of
them estimate that the real LB incidence rate may be 2–3 times higher than reported.
For instance, Campbell et al. [8] calculated an about 2.8-fold real incidence of LB in
Westchester county, N.Y., than that notified by the current passive reporting system.
A very similar figure was found in north-central Wisconsin, where only 34% of LB
cases were reported to the state, i.e. the real incidence was 2.9-fold higher [9] . Over-
reporting that follows overdiagnosis can also pose problems under certain circum-
stances (e.g. state of California in the first years of notification implementation). Nev-
ertheless, the reported figures that are presented here form a relatively good basis for
the comparison of LB incidence among countries, especially when the more recent
periods (1995–2006) are taken into consideration. If the coefficient of 3 is accepted
for underreporting, the mean total annual number of LB cases in the world might be
as many as 255,000.
Additional problems in LB notification are caused by different definitions of LB
cases, and diagnostic pitfalls with LB.
A recent review [10] summarizes well most of
the problems associated with the clinical diagnosis of erythema migrans (EM) and
with various case definitions of LB in both North America and Europe [11, 12] . More-
over, the method used for the serological diagnosis of LB is not unimportant in that
different laboratories use various serological kits and tests, and the proportion of
Epidemiology 33
Country
(region)
Incidence
(per
100,000)
Range Years Annual
cases, n
Remarks Reference number
Europe (65,467)
Albania n.a. (5) no data about LB
Austria (130) (50–350) (4,500) not notifiable –
a rough estimate
2, 3, 13
Belarus n.a. (1,200) not notifiable 65
Belgium 12.58 8.2–16.3 1999–2006 1,297 Ducoffre, G.,
pers. commun., 2007
Bulgaria 5.44 1.9–13.0 1993–2005 433 Christova, I.,
pers. commun., 2007
Croatia 5.91 5.2–7.5 1993–2000 264 compulsory LB reporting
started in 1991
40
Czechland 31.73 14.0–61.2 1989–2006 3,263 LB reporting since 1990 108
Denmark 1.68 0.3–2.7 1994–2006 89 109
Estonia 31.01 14.3–43.8 1994–2006 424 notifiable 109 and Vasilenko, V.,
pers. commun., 2007
Finland 18.46 7.8–23.5 1999–2006 962 109
France 8.2 1999–2000 (4,900) 24
Germany (25) (18,000) not notifiable – except for
6 eastern states
13, 49
Eastern 6 states 26.05 17.8–36.5 2002–2006 4,440 notifiable in: Berlin,
Brandenburg, Mecklenburg-
Vorpommern, Sachsen,
Sachsen-Anhalt, Thüringen
47–49, 111
Great Britain
England
and Wales
0.59 0.3–1.1 1997–2005 311 not notifiable; only 0.2%
seroprevalence in farmers
110
Scotland 1.72 1.6–1.9 2002–2005 87 notifiable 111
Greece n.a. (10) very low seroprevalence in
Navy recruits (ELISA 3.3%,
Western blot 0.3%)
112
Hungary 12.79 12.2–14.3 2001–2005 1,288 reportable 58
Iceland 0.56 0.0–1.1 1999–2003 2 seroprevalence 1–2%;
B. garinii detected in
I. uriae in seabird colonies
13, 109
Ireland 0.6 1995 25 no reliable data on incidence;
not notifiable disease
13 (estimate of Gray, J.)
Italy 0.02 0.001–0.5 2001–2005 11 notifiable since 1991 111
Latvia 21.64 11.7–30.6 1998–2006 507 notifiable 109
Lithuania 42.93 21.7–106.5 1995–2006 1,502 notifiable 109 (data of Asokliene, L.)
Luxembourg n.a. (60)
Moldova 0.73 0.7–0.8 2003–2005 31 Gheorghitsa, S.,
thesis, 2006
The Netherlands 2.01 1.4–2.7 2001–2005 327 not notifiable;
estimates of EM hospital
admissions
113
Norway 4.5 2.6–9.8 1992–2006 199 notifiable from 1989 to 1995 109, 111, 114
Poland 9.29 4.8–17.5 2000–2006 3,549 115
Tab le 1. Geographic distribution of mean annual incidence of LB (expressed mean annual LB cases per 100,000 of the
population)
34 Hubálek
Country
(region)
Incidence
(per
100,000)
Range Years Annual
cases, n
Remarks Reference number
Portugal 0.48 0.2–0.8 1993–2004 49 serologic data on LB cases 116
0.04 0.01–0.15 1999–2004 4 notified cases; notifiable since
1999
116
Romania n.a. (1,500) LB occurs; seroprevalence:
4.3% (blood donors),
9.3% (forestry workers)
Russia
(European okrug)
4.6 4.0–5.7 1999–2006 4,789 recorded since 1992 Korenberg, E.I., pers.
commun., 2007 (all okrug)
North-west 9.24 5.6–15.8 1999–2006 1,314
Central 3.39 2.1–4.7 1999–2006 1,263
Volga 6.8 5.8–8.5 1999–2006 2,192
Southern 0.09 0.04–0.17 1999–2006 20
Serbia and
Montenegro
2.44 1.4–3.3 1988–1994 239 50
Slovakia 12.12 6.3–18.4 1991–2006 650 51 and Bazovska, S., pers.
commun.
Slovenia 136.86 72–206 1991–2005 2,724 reported since 1988 20, 21, 111
Spain 9.8 (26) 7
Sweden 55–110 (8,000) http://www.socialstyrelsen.se Bennet, L., pers. commun.
Southern
Sweden
69 26–160 1992 24% of the population, and
11% of the area of Sweden
28
Northern
Sweden
very
low
seroprevalence only 1–2%; infec-
tion rate of I. ricinus only 0–5%
13
Switzerland 25.09 18.9–32.4 1988–1998 1,743 not reportable in the last 10
years
117
Turkey
(European part)
0.01 1990–2002 1 <20 cases 1990–2002 118
Ukraine n.a. (2,500) LB occurs Korenberg, E.I., pers.
commun.
North America (16,340)
USA15.78 3.2–8.4 1991–2005 15,840 22 (including states)
California 0.3 0.2–0.5 1993–2005 102
Connecticut 72.48 37.7–133.8 1991–2005 2,433
Delaware 24.4 7.8–76.6 1991–2005 189
Maryland 11.19 3.7–22.0 1991–2005 586
Massachusetts 11.98 2.5–36.5 1991–2005 847
Minnesota 8.81 3.1–20.1 1992–2005 429
New Hampshire 7.81 1.3–20.5 1991–2005 98
New Jersey 23.51 9.0–38.6 1991–2005 1,951
New York
(incl. NYC)
24.12 15.5–29.2 1991–2005 4,502
Pennsylvania 22.99 8.9–46.3 1992–2005 2,782
Rhode Island 47.49 15.6–79.7 1991–2004 459
Wisconsin 12.35 7.2–26.3 1991–2005 654
Canada low (500) not notifiable Ogden, N., pers. commun.
Ontario 0.25 0.2–0.4 1999–2004 29 Public Health Canada
Table 1 (continued)
Epidemiology 35
Country
(region)
Incidence
(per
100,000)
Range Years Annual
cases, n
Remarks Reference number
Asia (3,450)
Russia (Asian part)
with the Urals
8.26 7.0–10.7 1999–2006 3,200 Korenberg, E.I.,
pers. commun., 2007
(including okrug)
The Urals
Federal okrug
9.81 7.3–13.9 1999–2006 1,226
Siberian Federal
okrug
8.15 6.1–10.4 1999–2006 1,671
Far Eastern
Federal okrug
4.33 3.1–5.8 1999–2006 303
Sverdlovsk/
Jekaterinbg.
14.7 1994 13
Novosibirsk area (10) 9–11.5 119
Tomsk region 28 1993–1994 29, 30
Turkey
(Asian part)
very
low
<1 B. burgdorferi s.l. isolated from
ixodid ticks
118
Kyrgyzstan low (20) B. burgdorferi s.l. isolated from
ixodid ticks
Korenberg, E.I.,
pers. commun., 1993
Kazakhstan very
low
(10) LB likely to occur Korenberg, E.I.,
pers. commun., 1994
Mongolia n.a. (5) no data about LB
China low (200) no incidence data available;
B. garinii and B. afzelii isolates
from I. persulcatus and rodents
120, 121
Taiwan <0.01 0.1 1 case of LB; also isolations of
B. burgdorferi s.l. from rodents
122
Korea very
low
(5) no incidence data available;
B. garinii and B. afzelii isolated
from I. persulcatus and rodents
120, 121
Japan <0.01 1987–1994 11 notifiable since 1999: 84 LB
cases since 1987 (mainly from
Hokkaido and Honshu);
many B. burgdorferi s.l. isolates
have been obtained from
patients and ixodid ticks
120
Africa 7
Morocco <0.01 <1 124
Algeria <0.01 <1 125
Tunisia 0.06 1992–1996 5 B. lusitaniae often isolated
from local I. ricinus
126, 127
Madeira Island <0.01 <1 2 cases in 1999–2004;
seroprevalence in inhabitants
8.7%; at least 1.3% of nymphal
I. ricinus ticks infected with
B. burgdorferi s.l.
116, 123
Incidence data (cases) in parentheses are qualified estimates, based on restricted prospective studies, extrapolation, incidence data
from neighboring countries, and population size. The figures without parentheses show the number of notif ied cases.
n.a. = No data (not available).
1 The listed states have the highest LB morbidity, except California.
Table 1 (continued)
36 Hubálek
false-positive or false-negative serum samples might be relatively high in particular
circumstances [13, 14] . Probably the best serological assays at present are immunoas-
says (ELISA) for IgM and IgG antibodies, combined with immunoblotting.
Incidence Trends
In many countries, both in Europe and North America, no marked trends in the inci-
dence rate of LB have been recorded (just irregular fluctuations in the morbidity; for
references, see table 1 ), e.g. in Belgium, Switzerland, Czechland (syn. Czech Republic;
fig. 1 ), Slovakia, Hungary, Latvia, Estonia, Lithuania, Croatia, European and Asian Rus-
sia, and the US states of Connecticut, Rhode Island and New York, whereas other coun-
tries have reported a growing incidence of this disease in the last decade, e.g. The Neth-
erlands, Germany (eastern states), Norway, Finland, Denmark, England, Wales, Poland
and Bulgaria, and the US states of Pennsylvania, Wisconsin, Minnesota and Delaware.
However, some of these ‘increasing’ trends might be biased and caused, in fact, by an
improved notification system, greater awareness/vigilance, and better diagnostics for
LB over the last years in particular countries. For instance, it is of interest that in most
US states where LB is followed with great care for years (e.g. New England), no signifi-
cantly increasing trends of LB incidence have been recorded in the last decade.
LB reveals a distinctly focal pattern of distribution, even within small countries
and regions, that is determined by the heterogeneous spatial distribution of vector
ticks [15, 16] . The amount and composition of forest habitats (woodland) play a great
role, of course. Within the whole geographic range of LB, there are some hyperen-
demic high-risk areas (‘hot spots’), with annual incidences of 1 100 LB cases per
100,000 of the population. Such districts have been reported in southern Sweden,
e.g. Blekinge County on the coastline along the Baltic Sea (mean incidence rate of 465
per 100,000 between 1997 and 2003, and a maximum of 664 in 2000 [17] ), the Esto-
nian-owned island Saaremaa [385/100,000; Kutsar, K., pers. commun.], the Åland
islands of Finland (approx. 200/100,000 [18] ), several Brandenburg counties in Ger-
many (Brieskow-Finkenheerd and Scharmützelsee, with 311 and 298 cases per
100,000, respectively, in 2003 [19] ), the whole of Slovenia ( 1
200 per 100,000 in some
parts of the country [20, 21] ), certain parts of Austria, Connecticut (Old Lyme: up to
1,000 per 100,000), and Massachusetts (Nantucket County, with a morbidity rate be-
tween 449 and 1,247 per 100,000 from 1992 to 1999 [22] ).
Influence of Latitude
LB occurs between approximately 35 and 60°N in Europe, and between 30 and 55°N
in North America. In countries at the southern limits of the LB range, its incidence
decreases rapidly along the north-to-south gradient. For instance in Italy, LB is quite
Epidemiology 37
frequent in northern Italy, whereas it is much less common in central and southern
Italy [23] . The situation is similar in France [24] , Spain [25] , the Balkans (including
Bulgaria) [26, 27] , and the southern states of the USA [22] . Conversely, at the northern
limits of its occurrence, the LB incidence decreases sharply with increasing latitude,
i.e. along the south-to-north gradient, e.g. in Scandinavia and European Russia [7, 13,
17, 28–30] or North America [12, 31] . This pattern closely reflects the distribution of
ixodid vectors of LB, which is determined by types of climate (mainly temperature
and humidity) permissive for the I. ricinus tick.
Influence of Altitude
A very low incidence of LB was observed at elevations 1 1,000 m above sea level (a.s.l.)
in Austria [32] , although I. ricinus ticks infected with borreliae were recently detected
in Austrian mountains at 1,350 m a.s.l. [33] . In Czechland, I. ricinus has started to oc-
cur at higher altitudes, up to 1,100 m a.s.l., compared to elevations of up to only ap-
prox. 800 m a.s.l. two decades ago [3 4, 35] . It has nevertheless been demonstrated that
the prevalence rate of Borrelia burgdorferi s.l. in I. ricinus decreases with altitude, as
shown for example in Switzerland along an altitudinal gradient of 750–1,020 m a.s.l.
[36] . Already, Aeschlimann et al. [37] have reported individual ticks infected with
borreliae in Switzerland found at 1,250 m a.s.l. (Kiental), and their infection rate de-
creased with the elevation.
0
12
TBE
TBE cases (per 100,000)
1992
2
4
6
8
10
0
120
LB cases (per 100,000)
20
40
60
80
100
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
LB
Fig. 1. Incidence rates of LB and tick-borne encephalitis (TBE; transmitted by the same vector spe-
cies) in Czechland, 1992–2006 [108]. Pearson correlation between the incidence rates is highly sig-
nificant: r = 0.718 (p ! 0.01).
38 Hubálek
Seasonal Distribution of LB
The annual distribution pattern of LB is strongly affected by the seasonal pattern of
host-seeking (questing) tick activity, lagged by the incubation period of LB which is
usually 1–4 weeks (but up to 2 months in a few cases; median is about 7–12 days) for
EM, 3–9 weeks (median 4–6) for early neuroborreliosis, 1.5–8 months (median 2) for
arthritis, 6–12 months for late neuroborreliosis, and several to many years for acro-
dermatitis chronica atrophicans (ACA) [13, 21, 24, 38, 39] . Therefore, LB as a disease
in all its forms occurs in all months of the year, although its incidence is (very) low in
late autumn, winter, and early spring – usually only chronic manifestations of LB (ar-
thritis, late neuroborreliosis, ACA) are reported in those periods. The peak of annual
LB incidence, the curve of which is usually unimodal, occurs from June to July in
Austria [32] , Belgium [Ducoffre, G., pers. commun.], Bulgaria [27] , Croatia [40] ,
Czechland [41, 42] , France [43, 4 4] , Germany [38, 45–49] , Russia [39] , Serbia [50] , Slo-
vakia [51] , Slovenia [21] , southeastern Sweden [17] , and the USA [5, 15, 22] , indicating
that most infections are acquired during late May to late June. In northern countries
(Estonia, Sweden), the peak of LB incidence could include August [Kutsar, K., pers.
commun; 28 ], while in Alsace (France), May was reported as the peak [52] . In south-
ern Europe, sometimes a smaller secondary peak in the annual incidence rate of LB
occurs in autumn (October to November), when the local weather is warm and per-
missive for tick and human outdoor activity, e.g. in Slovenia [21] .
In most cou ntries, t he timing of LB differs accord ing to cli nical manifestation. For
instance in Austria, the peak occurrence of EM is in July, whereas the peak for neu-
roborreliosis is in August and September [53] . Similarly, in southern Sweden, most of
the EM forms started in August, while the other clinical manifestations of LB peaked
in September [28] . This is caused by the different incubation periods for particular
clinical forms.
An additional factor affecting the seasonality of LB is human behavior and out-
door activity, i.e. the coincidence of maximum vector tick activity with summer-re-
lated leisure behavior of people [49] . For instance, vacation times overlapping with
enhanced exposure to vector ticks during hiking and berry/mushroom picking in
forests are usually June, July, and August in Europe [1] .
P a t i e n t C h a r a c t e r i s t i c s
Lyme borreliosis could affect persons of all age categories, but the age distribution of
the disease is usually bimodal in most countries, with the first (lower) maximum oc-
curring in children 5–9 (14) years old, and the second (higher) maximum in adults
aged (45) 50–64 (69) years. A marked depression in LB morbidity appears among
young people between (15) 20 and 24 years of age. Such a pattern has been reported in
Belgium [Ducoffre, G., pers. commun.], Bulgaria [54] , Croatia [40] , Czechland [41, 42,
Epidemiology 39
55] , England and Wales [56] , Germany [38, 45–49] , Hungary [57, 58] , Serbia [50] , Slo-
vakia [51] , Slovenia [21] , southeastern Sweden [17, 59] , and the USA [5, 15, 22] . Interest-
ingly, a serological survey in Sweden also showed the bimodal pattern according to the
age groups: the antibodies against B. burgdorferi s.l. were most prevalent in children
and young persons below 20 years of age and in persons older than 50 years, while they
were much less frequent in persons aged 21–50 years, with an absolute minimum at
the 21- to 30-year-old group [60] . Explanation of the striking differences between age
groups could be related to the different outdoor activity and leisure-time behavior pat-
terns among these population strata [49] . However, some of these figures might be
biased in that most of them are not recalculated as specific incidence rates, i.e. cases
per number of inhabitants of a particular age category in the corresponding area.
Lymphocytoma manifestation occurs much more often or almost exclusively in
children under 16 years, whereas ACA is predominant in elderly persons [2, 11, 28,
38, 45, 57] . Also, neuroborreliosis and arthritis cases can be more frequent in children
than in adults [45] . Berglund et al. [28] reported the neuroborreliosis form of LB in
28% of children, but only 14% of adult patients in southern Sweden.
Bites of vector ticks vary in their localization on the human body between age
groups: in children they predominate on ears, head, and neck region (49% of bites vs.
2% in adults in Sweden, 23 vs. 1% in adults in Germany, 23 vs. 2% in adults in Bul-
garia), while in adults the predilection sites for ticks are the lower limbs: 62, 60, and
63.5% of bites in Sweden, Germany, and Bulgaria, respectively [28, 45, 54] .
S ex
Results of gender-related analyses differ among countries. In the USA, males (51.9%)
slightly outnumbered females in 1992–1998, especially among children and adoles-
cents aged 5–19 years, but also in the category of adults aged 6 60 years [5, 15] . On
the other hand, a slight female preponderance (usual range of 54–60% females among
recorded LB patients) is reported in most European countries, e.g. Austria [53] , Czech-
land [41, 61] , Germany [45, 49] , Slovakia [51] , Slovenia [21] , and Switzerland [37] . In
southeastern Sweden, among 3,443 EM cases reported in 1997–2003, 54.5% were fe-
males, and the predominance of females was especially marked in the age group 50–
74 years (60.1%) [59] . In Italy, females are infected more often than males [23] , while
only 49.9% of the 1,175 LB patients in Hungary were female [57] . However, some of
these figures might be biased in that most of them are not recalculated as specific in-
cidence rates, i.e. per number of inhabitants of particular gender category in the cor-
responding area.
Females are affected more often than males by ACA, the late chronic cutaneous
manifestation of LB [2, 37, 38] . Reinfection with borreliae was reported 6 times more
frequently for females than for males in southern Sweden, and nearly all reinfected
women were older than 40 years and postmenopausal. Interestingly, Swedish females
40 Hubálek
also attract more tick bites than males, though they spend approximately 30% less
time outdoors than men [59] .
Bites of vector ticks vary in their localization on the human body between gender:
the predilection sites for ticks are the lower limbs and breast region in females, and
the lower limbs and genital region in males [28] .
O cc u p a t i o n
Examples of population groups at risk are forestry workers, military field personnel,
farmers, deer handlers, gamekeepers, hunters, rangers, and outdoor workers in gen-
eral. For instance, LB seropositivity is high among forestry workers in most countries
tested: France 22% (while only 4% in normal population [62] ), Austria 14–18% [2] ,
Bulgaria 18% [26] and Italy up to 27% [23] . Farmers also often have a higher seropos-
itivity rate, e.g. 15% in Bulgaria [26] .
However, in most European countries, occupational exposure generally consti-
tutes only 2% of LB cases [63] ; it is typically a recreation time disease, contracted dur-
ing holidays and leisure time exposure [24, 58, 63] , including sport in forested areas.
In Switzerland, 8.1% of 558 orienteers seroconverted over 1 season, but only 0.8% of
them revealed cli nical symptoms of LB – the r atio of appa rent to inapparent infec tion
was therefore 1:
9 [64] .
Urban versus Rural Inhabitants
There is a low or no significant difference in LB incidence rates between urban and
rural populations [24] , or the LB incidence among urban inhabitants is even higher,
e.g. in Finland where the mean morbidity (per 100,000 population) is 13 in Helsinki
but only 6.6 in rural areas [18] , or in Russia where 84% of LB cases are among urban
residents [30, 65] , and Bulgaria [54] . In addition, infected ticks also occur in urban
parks [66] .
Weather-Related Effects on LB Incidence
In southeast Sweden and Scotland, LB incidence increased following mild winters (i.e.
number of days in preceding winter with mean temperature 1 0 ° C) and during warm
humid summers (i.e. the mean monthly summer temperatures combined with the
number of summer days with relative air humidity 1 86%), but higher mean monthly
precipitation (excess summer rainfall) had a depressing effect on LB morbidity [17, 67] .
The authors have concluded that the main mechanism of these weather factors is either
increasing/decreasing precipitation, which also has an impact upon human outdoor
Epidemiology 41
activity (and subsequently the rate of human exposure to ticks) that is the leading
cause of LB morbidity. However, the tick activity should also be taken into consider-
ation. In 7 northeastern US states, the June moisture index (Palmer Hydrological
Drought Index) 2 years previously correlated well with the current LB incidence, most
probably by enhancing the nymphal I. scapularis survival during the more humid con-
ditions; further, a warmer winter, lagged 1.5 years, increased LB incidence, probably
due to the higher survival and activity of the white-footed mouse, the principal local
vertebrate amplifying host of borreliae [68] . Precipitation during May and June, not
temperature, stimulated LB incidence in the northeastern USA in the period 1992–
2002 [69] . Ashley and Meentemeyer [70] found that LB incidence is affected by meteo-
rological variables prevalent during April to June, and more by moisture (total soil
moisture surplus, total precipitation) than by mean air temperature, which could be
used for LB risk assessment. In general, summer temperature and rainfall affect tick
populations [71] . The effects of weather (and climate) on vector ticks are quite compli-
cated and simple solutions of the interrelationships are usually not the best ones.
Risk Factors for LB Acquisition by Humans and Risk Assessment
LB risk is clearly a product of 2 principal factors: the abundance (density) of infectious
vector ticks and the intensity of human exposure to the vector (degree of human-tick
contact).
Vector Tick Stage
The only competent vectors of pathogenic borreliae to humans are ticks of the I. rici-
nus complex: I. ricinus, I. persulcatus, I. scapularis, and I. pacificus. Most of the LB
patients are infected by nymphal rather than female Ixodes ticks, both in North
America and Europe [1, 63, 72–78] . Nymphs are more numerous in the field and, be-
cause of their smaller size, more difficult to be detected (at that moment and later) on
the human body than adult female ticks. In Connecticut 1989–1996, Westchester
county (New York state) 1991–1996 and South Moravia (Czechland) 1991–2001, 3 in-
dependent teams found that the local annual incidence of human LB correlated sig-
nificantly (R
2 = 58–69%) with the abundance of nymphal, but not female, vector ticks
[74, 75, 79] .
T r a n s m i s s i o n R i s k
The risk of developing LB symptoms after a vector tick bite is estimated to be 2–4%
[63] , or sometimes even ^
1% i n E urope [4] . However, in a LB-endemic area of Poland,
42 Hubálek
4.7% of 426 forestry workers bitten by a tick contracted clinical disease [80] , and sim-
ilarly in Russia, LB transmission was reported in 4–5% persons with attached ticks
[30] . Nahimana et al. [78] followed 376 persons after a tick bite in Switzerland: EM
developed in 2.1% of the probands. In Germany, 2.6% of 730 persons with tick bites
developed LB [81] . In Sweden, 4.6% of persons with attached ticks seroconverted, but
not all of them revealed clinical symptoms of LB [82] . A seroconversion without LB
symptoms is quite common in Europe and results in a high seropositivity rate in the
European population [78] . In New England, the risk of LB after tick bites has been
reported to be 1.2% [83] , 3.7% [84] , and 3.2% [85] .
Duration of Tick Attachment (Transmission Timing)
There is a difference between North America and Europe in the duration of tick at-
tachment required for transmission of borreliae into the human host. The US (Cen-
ters for Disease Control and Prevention) paradigm is that borreliae are only present
in the midgut of infected unfed (host-seeking) ticks, and during the blood feeding on
a host they migrate through the tick’s hemocele to salivary glands after 24–48 h, and
only then can the tick infect the host with saliva. In accordance with that, most North
American epidemiological studies state that transmission of borreliae to humans can
occur only 48 h after attachment [86] . This is obviously not correct for Europe, where
significant transmission of borreliae to the human host may occur within the first
24 h of attachment [63] . For instance, G. Stanek [pers. commun.] observed several
LB patients in Vienna who contracted LB following a tick attachment of no longer
than 8 h.
Importantly, generalized infection with borreliae (including the salivary glands)
ha s repeatedly been obser ved in some host-seeking unfed I. ricinus tick s, e.g. in Swit-
zerland [87–89] . These cases of systemic infection are probably most common with
the ticks containing large numbers of borreliae in their midguts – in some individ-
ual ticks thousands of borreliae have been observed. The proportion of unfed ticks
with 1 100 borreliae were found to be 5.0% in 2,380 female and 1.7% in 3,546 nymph-
al I. ricinus examined in Czechland [90] ; it is noteworthy that the prevalence rate of
the B. burgdorferi s.l. highly loaded nymphs (and females) closely matches the pro-
portion of tick bites giving rise to LB in humans (1–5%, see ‘Transmission Risk’).
Ticks with such a high spirochetal load can transfer them to the host much faster
than ticks with a low burden of borreliae [90, 91] . This difference between the Amer-
ican and European experiences could probably be explained by the quicker trans-
mission rate of B. afzelii and/or B. garinii than that of B. burgdorferi s.s. [92] . Kahl et
al. [93] found that half of experimental Mongolian gerbils (Meriones unguiculatus)
were already infected by spirochete-carrying I. ricinus nymphs 17 h after attach-
ment.
Epidemiology 43
Risk Assessment
Piesman et al. [72] proposed as a standard risk measure the number of infected ticks
per unit sampling effort (area, time). Ginsberg [94] formulated a simple transmission
risk index, the number of tick bites per person. Hubálek et al. [95] quantified the LB
risk exposure as the mean time necessary to encounter the first (heavily) infected tick,
measured by flagging. For risk assessment, Nicholson and Mather [31] suggested us-
ing the abundance of nymphal ticks and prevalence of borrelial infection in ticks, and
combine these with geographic information system analysis. An ecological risk index
[96] has been proposed to identify risk areas for LB transmission; it is composed of 5
components: habitat suitability, habitat amount, habitat accessibility, tick abundance,
and the tick infection rate (all classified on a scale of 1–5). However, this is not a very
useful predictor of LB incidence without taking into account the data on human be-
havior [97] .
Risk ecosystems and habitats are deciduous or mixed forest ecosystems or wood-
lands matching the distribution of the principal vector (ticks of the I. ricinus com-
plex), along with city parks and urban gardens [45–48, 66] , especially gardens within
200 m of forests [98] . In the Würzburg region in Germany, many cases of LB were
reported in the northwestern wooded area, but few cases in the southern, predomi-
nantly agricultural area [45] . Similarly in Brandenburg State, Germany, the majority
of LB cases were acquired in localities close to humid forests, while very low morbid-
ity has been reported in areas with extended agroecosystems [48] . Brandenburg,
steadily reporting about half of all LB cases from 6 eastern German states, is very rich
in forests and water habitats compared to the 5 other states [48] .
There is a higher risk of contracting LB in the ecotones between forests and fields/
meadows, although higher densities of infected vector ticks are within forests; this is
an effect of frequent human presence along the edges of these habitats [99] . Also, for-
est fragmentation in suburban areas (Connecticut, USA) theoretically poses a greater
risk (higher entomological risk) due to an enhanced proportion of ecotones [10 0, 101] .
However, in 1 study, the LB incidence was surprisingly lower in fragmented habitats,
and human behavior played a more significant role in the LB risk [102] . Prusinski et
al. [103] studied the effect of forest habitat structure on LB risk, and found that un-
derstory vegetation structure and coverage dictates vector density. On the other hand,
Nicholson and Mather [31] did not find plant communities as predictive in LB risk
assessment in a geographic information system-based analysis.
Ecological risk factors involve a number of variables. For instance, reforestation
usually causes an increased population not only of forest rodents, but also of deer, the
principal host of adult vector ticks. Growing deer populations (principal hosts of
adult vector ticks in woodland, but not competent hosts for borreliae) increase LB
morbidity [10 4] . In central Bohemia, Zeman and Januška [105] f oun d that LB risk cor-
related with overall population density of game (red deer, roe deer, mouflon, wild
boar) regardless of mouse abundance. Nevertheless, in general, increased populations
44 Hubálek
of competent hosts (forest rodents) usually stimulate the LB incidence. Increased
acorn production favors populations of forest rodents and deer, and results in an in-
crease in vector ticks [10 6] .
Age and Sex
As shown previously, children and elderly people are at higher risk than middle-aged
persons. Bennet et al. [59] found that in southeast Sweden women 6 40 years old had a
48% higher risk of attracting tick bites than men of this age group, a 42% higher risk than
women younger than 40 years, and a 96% higher risk than men younger than 40 years.
O c c u p a t i o n
Outdoor employment and work (forestry workers, military personnel in the field,
farmers, gardeners, gamekeepers, hunters, rangers) are at risk.
Permanent residence in endemic areas with a high density of infectious ticks (e.g.
forested suburban localities in the US states of Connecticut, New Jersey, and New
York) is a serious risk factor for LB.
R i s k B e h a v i o r
All activities that increase human contact with ticks present risks, especially: recre-
ational (leisure time) activities in forested areas, such as camping (including chil-
dren’s holiday camps), picnicking, walking and hiking, sitting on logs or on leaves,
jogging, orienteering, and berry/mushroom picking [107] ; seasonal or occasional liv-
ing by urban residents in country cottages (‘dachas’) in endemic areas with a high
density of infectious ticks [26] ; mowing and clearing of brush around the home in
forested areas and gardening, especially when the garden is within 200 m from a for-
est [98] , even in urban gardens [16, 45] . In Scotland, the 2001 foot-and-mouth disease
outbreak led to countryside access restrictions, decreasing the visitor numbers during
summer months, which resulted in reductions in tick exposure and LB incidence [67] .
Ownership of pet dogs and cats could also present a relative risk in cases where the
pets are frequently parasitized by ticks and the owner removes the ticks [98] .
Epidemiological Surveillance
Epidemiological surveillance for LB is a paramount task for Europe, and this effort
should be coordinated by the European Centre for Disease Prevention and Control,
Epidemiology 45
based in Sweden. It should include such things as improved awareness and recogni-
tion of the disease at national and continental levels, but first of all mandatory report-
ing of LB in all European countries where the disease occurs (and it occurs virtually
in all of them). Under certain circumstances, serosurveys among people, domestic
animals (dogs), and wild vertebrates might also bring useful results. Better surveil-
lance systems for LB should also be installed in some Asian, North African (Maghreb)
and North American (Canada) countries.
Acknowledgments
I am very much obliged to a number of experts who supplied the LB incidence data for particular
countries , or significa ntly assisted in obta ining these dat a (listed alphabet ically): Loreta Asok liene
(Centre for Communicable Diseases Prevention and Control, Lithuania); Sylvia Bazovská (Ko-
menský University, Faculty of Medicine, Department of Epidemiology, Slovakia); Louise Bennet
(University Hospital of Malmö, Sweden); Iva Christova (National Centre of Infectious and Para-
sitic Diseases, National Reference Laboratory for LB and Leptospirosis, Sofia, Bulgaria); Gene-
viève Ducof fre (National Instit ute of Public Health, LB Reference L aboratory, Belgium); Lise Gern
(University of Neuchâtel, Switzerland); Johan Giesecke (ECDC Stock holm, Sweden); Jeremy Gray
(School of Biology and Environmental Science, University College, Dublin, Ireland); Agnetha
Hofhuis (RIVM – Epidemiology a nd Surveillance, Bilt hoven, The Netherlands); Eduard I. Koren-
berg (Gamaleya Institute of Epidemiology and Microbiology, LB Reference Laboratory, Moscow,
Russia); Andras Lakos (Centre for Tick-Borne Diseases, Budapest, Hungary); Laurent Letrilliart
(University of Lyon, Department of General Practice, France); Catherine Linard (University of
Louvaine, Belgium); Elisabet Lindgren (CTM, Stockholm University, Sweden); Nicholas Ogden
(University of Montreal, Canada); Agostino Pugliese (University of Torino, Italy); and Veera Vasi-
lenko (National Institute of Health Development, Tallinn, Estonia).
This review was partially funded by the EU grant GOCE-2003-010284 EDEN; it is catalogued
by the EDEN Steering Committee as EDEN0063 (http://www.eden-fp6project.net). The contents
of this publication are the responsibility of the author and do not necessarily reflect the views of
the European Commission.
References
1 Jaenson TGT: The epidemiology of Lyme borrelio-
sis. Parasitol Today 1991;
7: 39–45.
2 St anek G, Satz N, Strle F, Wilske B: Epidemiology of
Lyme borreliosis; in Weber K, Burgdorfer W (eds):
Aspect s of Lyme Borrel iosis. Berlin, Spr in ger, 1993,
pp 358–370.
3 O’Connel l S, Granström M, Gray JS, Stanek G: Epi-
de miol ogy of Eu rop ean Lym e bor rel iosi s. Z ent ral bl
Bakteriol 1998;
287: 229–240.
4 Ger n L, Falco RC: Lyme disease. Rev Sci Tech 200 0;
19: 121–135.
5 Dennis DT, Hayes EB: Epidemiology of Lyme dis-
ease; in Gray J, Kahl O, Lane RS, Stanek G (eds):
Lyme Borreliosis: Biology, Epidemiology and Con-
trol. Wallingford, CABI, 2002, pp 251–280.
6 Piesman J, Gern L: Lyme borreliosis in Europe and
North America. Parasitology 2004;
129(suppl):191–
220.
7 Lindgren E, Jaenson TGT: Lyme borreliosis in Eu-
rope: inf luences of climate and climate change, ep-
idemiology and adaptation measures; in Menne B,
Ebi KL (eds): Climate Change and Adaptation
Strategies for Human Health. Darmstadt, Stein-
kopff, 2006, pp 157–188.
46 Hubálek
8 Campbell GL, Fritz CL, Fish D, Nowakowski J,
Nadelman RB, Wormser GP: Estimation of the in-
cidence of Lyme disease. Am J Epidemiol 1998;
148:
1018–1026.
9 Naleway AL, Belongia EA, Kazmierczak JJ, Green-
lee RT, Davis JP: Lyme d isease incid ence in Wiscon-
sin: a comparison of state-reported rates and rates
from a population-based cohort. Am J Epidemiol
2002;
155: 1120–1127.
10 Tibbles CD, Edlow JA: Does this patient have ery-
thema migrans? JAMA 2007;
297: 2617–2627.
11 Stanek G, O’Connell S, Cimmino M, Aberer E,
Kri stoferitsch W, Granström M, Guy E, Gray J: Eu-
ropean Union Concerted Action on Risk Assess-
ment in Lyme borreliosis: clinical case definitions
for Lyme borreliosis. Wien Klin Wochenschr 1996;
108: 741–747.
12 Centers for Disease Control and Prevention: Case
definitions for infectious conditions under public
healt h surveill ance. MMW R Recomm Rep 1997;
46:
1–55.
13 World Healt h Organiza tion: Report of WHO work-
shop on Lyme borreliosis diagnosis and surveil-
lance (who/cds/vph/95141-1). Warsaw, 20–22 June
1995, pp 1–220.
14 Hunfeld KP, Stanek G, Straube E, Hagedorn HJ,
Schörner C, Mühlschlegel F, Brade V: Quality of
Lyme disease serology. Wien Klin Wochenschr
2002;
114: 591–600.
15 Orloski KA, Hayes EB, Campbell GL, Dennis DT:
Surveillance for Lyme disease – United States,
1992–1998. MMWR CDC Surveill Summ 2000;
49:
1–11.
16 Robert Koch-Institut: Risikofaktoren für Lyme-
Borreliose: Ergebnisse einer Studie in einem Bran-
denburger Landkreis. Epidemiol Bull 2001;
21: 147–
149.
17 Bennet L, Halling A, Berglund J: Increased inci-
dence of Lyme borreliosis in southern Sweden fol-
lowing m ild winters a nd during war m, humid sum-
mers. Eur J Clin Microbiol Infect Dis 2006;
25:
426–432.
18 Junttila J, Peltoma a M, Soini H, Marjamäki M, Vil-
janen MK: Prevalence of Borrelia burgdorferi in Ix-
odes ricinus ticks in u rban recreation al areas of Hel-
sinki. J Clin Microbiol 1999;
37: 1361–1365.
19 Robert Koch-Institut: Zur Lyme-Borreliose im
Land Brandenburg. Epidemiol Bull 2005;
20: 173–
178.
20 St rle F: Lyme borrel iosis in Slovenia. Z entralbl Bak-
teriol 1999;
289: 643–652.
2 1 S tr le F , Vi de čn ik J, Z or ma n P, C im pe rm an J, L ot ri č-
Fu rla n S, Mar as pin V: C lin ic al a nd e pide mio log ica l
find ings for patients w ith eryt hema migra ns – com-
parison of cohorts from the years 1993 and 2000.
Wien Klin Wochenschr 2002;
31: 493–497.
22 Centers for Disease Control and Prevention: Re-
ports with statistics on Lyme disease cases. Morb
Mort Week Rep, continuously up to August 2007.
23 Ciceroni L, Ciarrocchi S: Lyme disease in Italy,
1983–1996. New Microbiol 1998;
21: 407–418.
24 Letrilliart L, Ragon B, Hanslik T, Flahault A: Lyme
disease in France: a primary care-based study.
Epidemiol Infect 2005;
133: 935–942.
25 Estrada-Peña A, Oteo JA, Estrada-Peña R, Gortázar
C, Osácar JJ, Moreno JA, Castellá J: Borrelia burg-
dorferi sensu lato in ticks (Acari: Ixodidae) from
two different foci in Spain. Exp Appl Acarol 1995;
19: 173–180.
26 Angelov L, Aeschlimann A, Korenberg E, Gern L,
Shchereva C, Marinova R, Kalinin M: Data on the
epidemiology of Lyme disease in Bulgaria (in Rus-
sian). Med Parazitol Parazit Bol 1990;
4: 13–14.
27 Angelov L, Arnaudov D, Rakadjieva T, Lipchev G,
Kostova E: Lyme borreliosis in Bulgaria. Report
WHO Workshop Lyme Borreliosis Diagn Surveill,
Warsaw, 20–22 June 1995, pp 41–52.
28 Berglund J, Eitrem R, Ornstein K, Lindberg A,
Ringner A, Elmrud H, Carlsson M, Runehagen A,
Svanborg C , Norrby R: An epidemiolo gical study of
Lyme disease in southern Sweden. N Engl J Med
1995;
333: 1319–1324.
29 Korenberg EI: Ixodid tick-borne borrelioses
(ITBBs), infections of the Lyme borreliosis group,
in Russia. Report WHO Workshop Lyme Borrelio-
sis Diagn Surveill, Warsaw, 20–22 June 1995, pp
128–136.
30 Korenberg EI: Infections of the Lyme borreliosis
group – ixodid tick-borne borrelioses in Russia (in
Russian). Med Parazitol Parazit Bolez 1996;
3: 14–
18.
31 Nicholson MC, Mathe r TN: Methods for eva luating
Lyme disease risk using geographic information
systems and geospatial analysis. J Med Entomol
1996;
33: 711–720.
32 Stanek G, Flamm H, Groh V, Hirschl A, Kristofer-
itsch W, Neumann R, Schmutzhard E, Wewalka G:
Epidemiology of Borrelia infections in Austria.
Zentralbl Bakteriol Mikrobiol Hyg [A] 1986;
263:
442–449.
33 Stünzner D, Hubálek Z, Halouzka J, Wendelin I,
Six l W, Mar th E: Pr evalence of Borrelia burgdorferi
sensu lato in the tick Ixodes ricinus in the Styrian
mountains of Austria. Wien Klin Wochenschr
2006;
118: 682–685.
34 Daniel M, Danielová V, Kříž B, Jirsa A, Nožička J:
Shift of the tick Ixodes ricinus and tick-borne
encephalitis to higher altitudes in Central Europe.
Eur J Clin Microbiol Infect Dis 2003;
22: 327–328.
35 Zeman P, Beneš Č: A tick-bor ne encephaliti s ceiling
in Central Europe has moved upwards during the
last 30 years: possible impact of global warming?
Int J Med Microbiol 2004;
293(suppl 37):48–54.
Epidemiology 47
36 Burri C, Cadenas FM, Douet V, Moret J, Gern L:
Ixodes ricinus density and infection prevalence of
Borrelia burgdorferi sensu lato along a nor th-facing
altitudinal gradient in the Rhône Valley (Switzer-
land). Vector Borne Zoon Dis 2007;
7: 50–58.
37 Aeschlimann A, Chamot E, Gigon F, Jeanneret JP,
Kesseler D, Walther C: Borrelia burgdorferi in Swit-
zerland. Zentralbl Bakteriol Mikrobiol Hyg [A]
1986;
263: 450–458.
38 Wilske B, Steinhuber R, Bergmeister H, Fingerle V,
Schierz G, Preac-Mursic V, Vanek E, Lorbeer B:
Lyme borrel iosis in South Germa ny. Epidemiologic
data on the i ncidence of cases a nd on the epidemiol-
ogy of ti cks (Ixodes rici nus) carryi ng Borrelia burg-
dorferi (in German). Dtsch Med Wochenschr 1987;
112: 1730–1736.
39 Korenber g EI, Kuznetsova R I, Kovalevskij J V, Vasi-
lenko ZE, Mebel BD: Basic epidemiological pat-
terns of Lyme borreliosis in the north-west of the
USSR (in Russian). Med Parazitol Parazit Bolez
1991;
3: 14–17.
40 Borčić B, Kaić B, Kralj V: Some epidemiological
data on TBE and Lyme borreliosis in Croatia.
Zentralbl Bakteriol 1999;
289: 540–547.
41 Janovská D, Hálková B, Ranná M: Surveillance of
Lyme borreliosis in the Czech Republic. Abstracts
3rd Czech Day s on Lyme Borrel iosis, Prague, 27–29
Aug 1997.
42 Kříž B, Beneš Č: Lyme Borreliosis (in Czech).
Prague, National Institute of Public Health, 2007.
http://www.szu.cz/cem.
43 Dournon E, Villeminot S, Hubert B: Le maladie de
Lyme en France: enquête réalisée auprès d’un ré-
seau sentinelle de médecins généralistes. Bull Épi-
dém Hebd 1989;
45: 185–186.
44 Degeilh B, Pichot J, Gilot B, Allen S, Doche B,
Guiguen C: Dynamique annuelle des cas de pri-
moinfestation humaine de borreliose de Lyme
(eryt hème chronique migra nt) en France et phenol-
ogie des popu lations de tiques vect rices ( Ixodes ric-
inus Linné, 1758): essai de correlation. Acarologia
1996;
37: 7–17.
45 Huppertz HI, Böhme M, Standaert SM, Karch H,
Plotkin SA: Incidence of Lyme borreliosis in the
Würzburg reg ion of Germany. Eur J Cli n Microbiol
Infect Dis 1999;
18: 697–703.
46 Robert Koch-Institut: Zur Lyme-Borreliose in aus-
gewäh lten Bundeslände rn. Epidemiol Bul l 2000;
50:
395–398.
47 Robert Koch-Institut: Erkrankungen an Lyme-
Borreliose in den sechs östlichen Bundesländern in
den Jahren 2 002 und 2003. Epidem iol Bull 2004;
28:
219–222.
48 Robert Koch-Institut: Neuerkrankungen an Lyme-
Borreliose im Jahr 2004. Epidemiol Bull 2005;
32:
285–288.
49 Mehner t WH, Krause G: Sur veillance of Ly me bor-
reliosis in Germany, 2002 and 2003. Euro Surveill
2005;
10: 83–85. http://www.eurosurveillance.org/
ViewArticle.aspx?ArticleId=531.
50 Dmitrovic R: Lyme borreliosis in Yugoslavia 1987–
1994. Report WHO Workshop Lyme Borreliosis Di-
agn Sur veill, Warsaw, 20–22 June 1995, pp 182–191.
51 Bazovska S, Machacova E , Spalekova M, Kontroso-
va S: Reported incidence of Lyme disease in Slova-
kia and antibodies to B. burgdorferi antigens de-
tected i n healthy populat ion. Bratisl Lek L isty 2005;
106: 270–273.
52 Schmitt M, Encrenaz N, Chubilleau C, Verrier A:
Données épidémiologiques sur la maladie de Lyme
en Alsace, Limousin et Rhône-Alpes. Bull Épidém
Hebd 2006;
27–28: 202–203.
53 Stanek G, Kristoferitsch W, Hirschl A, Wewa lka G:
Borrelia -Infektionen in Österreich 1984. Mitt Ös-
terr Ges Tropenmed Parasitol 1985;
7: 55–62.
5 4 Christova I, Komitova R : Clinica l and epidemiolog-
ical features of Lyme borreliosis in Bulgaria. Wien
Klin Wochenschr 2004;
116: 42–46.
55 Hulínská D, Janovská D, Bašta J: Lyme borrelio -
sis – epidemiological survey in the Czech Republic
in 1994. Report WHO Workshop Lyme Borreliosis
Diagn Surveill, Warsaw, 20–22 June 1995, pp 53–
75.
56 Smith R, O’Connell S, Palmer S: Lyme disease sur-
veilla nce in England and Wales, 1986–1998. Emerg
Infect Dis 2000;
6: 404–407.
57 Lakos A: Lyme borreliosis in Hungary. Report
WHO Workshop Lyme Borreliosis Diagn Surveill.
Warsaw, 20–22 June 1995, pp 84–102.
58 Epinfo (Epidemiológiai Informácios Hetilap):
Magyarország 2005. Évi Járványügyi Helyzete
2007;
14: 46.
59 Bennet L, Sternberg L, Berglund J: Effect of gender
on clin ical and epidemiolog ic features of Lyme bor-
reliosis. Vector Borne Zoon Dis 2007;
7: 34–41.
60 Gustafson R, Svennungson B, Gardulf A, Stiern-
stedt G, Forsgren M: Prevalence of tick-borne en-
cephalitis and Lyme borreliosis in a defined Swed-
ish population. Scand J Infect Dis 1990;
22:
297–306.
61 Pazdiora P, Benešová J, Böhm K, Brejcha O, Kubá-
tová A, Machovská E, Mareš J, Morávková I,
Spáčilová M, Turková D, Vodrážková Z: Incidence
of Lyme borreliosis in the West Bohemian Region,
1988–1992 (in Czech). Epidem iol Mikrobiol Immu-
nol 1994;
43: 71–74.
62 Doby JM, Couatarmanac’h A, Fages J, Chevrier S:
Les spiro chétoses à tiques che z les professionnels de
la forêt. Arch Mal Profess 1989;
50: 751–757.
63 Gray J: Risk assessment in Lyme borreliosis. Wien
Klin Wochenschr 1999;
111: 990–993.
48 Hubálek
64 Fahrer H, van der Linden SM, Sauvain MJ, Gern L,
Zhioua E, Aeschlimann A: The prevalence and in-
cidence of cli nical and as ymptomatic Lyme borreli-
osis in a population at risk. J Infect Dis 1991;
163:
305–310.
65 Korenberg EI: Comparative ecology and epidemi-
ology of Lyme disease and tick-borne encephalitis
in the former Soviet Union. Parasitol Today 1994;
10: 157–160.
66 Hubálek Z, Halouzka J, Juřicová Z: Prevalence of
borreliae in Ixodes ricinus ticks from urban parks.
Folia Parasitol 1993;
40: 236.
67 Joss AWL, Mavin S, Ho-Yen DO: Increased inci-
dence of Lyme borreliosis following mild winters
and during warm, humid summers. Eur J Clin Mi-
crobiol Infect Dis 2007;
26: 79.
68 Subak S: Effects of climate on variability in Lyme
disea se incidence in t he northeaste rn United States.
Am J Epidemiol 2003;
157: 531–538.
69 McCabe GJ, Bunnell JE: Precipitation and the oc-
currence of Lyme disease in the northeastern Unit-
ed States. Vector Borne Zoon Dis 2004;
4: 143–148.
70 Ashley ST, Meentemeyer V: Climatic analysis of
Lyme disease in the United States. Clim Res 2004;
27: 177–187.
71 Estrada-Peña A, Venzal JM: Changes in habitat
suitability for the tick Ixodes ricinus (Acari: Ixodi-
dae) in Europe (1900–1999). Ecohealth 2006;
3: 154–
162.
72 Piesman J, Mather TN, Dammin GJ, Telford SR,
Lastavica CC, Spielman A: Seasonal variation of
transmission risk of Lyme disease and human ba-
besiosis. Am J Epidemiol 1987;
126: 1187–1189.
73 Hubálek Z, Halouzka J, Juřicová Z: A comparison
of the occ urrence of borrel iae in nymphal a nd adult
Ixodes ricinus ticks. Zentralbl Bakteriol 1991;
276:
133–137.
74 Hubálek Z, Halouzka J Juřicová Z: Longitudinal
surveillance of the tick Ixodes ricinus for borreliae.
Med Vet Entomol 2003;
17: 46–51.
75 Hub álek Z, Halouz ka J, Juřicová Z: Bor reliae in Ixo-
des ric inus tick s feeding on huma ns. Med Vet Ento-
mol 2004;
18: 228–231.
76 Falco RC, McKenna DF, Daniels TJ, Nadelman RB,
Nowakowski J, Fish D, Wormser GP: Temporal re-
lation between Ixodes scapularis abundance and
risk for Lyme disease associated with erythema mi-
grans. Am J Epidemiol 1999;
149: 771–776.
77 Dorn W, Flügel C, Grübner I: Data on human-bit-
ing Ixodes ricinus ticks in a region of Thuringia
(Germany). Int J Med Microbiol 2002;
291(suppl
33):219.
78 Nahimana I, Gern L, Blanc DS, Praz G, Francioli P,
Péter O: Risk of Borrelia burgdorferi infection in
western Sw itzerland follow ing a tick bite. Eu r J Clin
Microbiol Infect Dis 2004;
23: 603–608.
79 Stafford KC, Cartter ML, Magnarelli LA, Ertel SH,
Mshar PA: Temporal correlations between tick
abundance and prevalence of ticks infected with
Borrelia burgdorferi and increasing incidence of
Lyme disease. J Clin Microbiol 1998;
36: 1240–
1244.
80 Bialowas K, Jablonowski Z: Frequency of contact
with t icks and patho genic effects of s uch contacts in
forestr y workers of north-ea stern Poland. Int J Med
Microbiol 2002;
291(suppl 33):214.
81 Maiwald M, Oehme R, March O, Petney TN, Kim-
mig P, Naser K, Zappe HA, Hassler D, von Knebel
Doeberitz M: Transmission risk of Borrelia burg-
dorferi sensu lato from Ixodes ricinus ticks to hu-
mans in southwest Germany. Epidemiol Infect
1998;
121: 103–108 .
82 Gustafson R, Svennungson B, Forsgren M, Gardulf
A, Granstrom M: Two-year survey of t he incidence
of Lyme borrel iosis and tick-borne encepha litis in a
high-risk population in Sweden. Eur J Clin Micro-
biol Infect Dis 1992;
11: 894–900.
83 Shapiro ED, Gerber MA, Holabird NB, Berg AT,
Feder HM, Bell GL, Rys PN, Persing DH: A con-
trolled trial of antimicrobial prophylaxis for Lyme
disea se after deer-t ick bites. N Engl J Med 1992 ;
327:
1769–1773.
84 Sood SK, Salzman MB, Johnson BJB, Happ CM,
Feig K, Car mody L, Rubin LG, Hi lton E, Piesman J:
Duration of tick attachment as a predictor of the
risk of Lyme disease in an area in which Lyme dis-
ease is endemic. J Infect Dis 1997;
175: 996–999.
85 Nadelman RB, Nowakowski J, Fish D, Falco RC,
Freeman K, McKe nna D, Welch P, Marcus R, Agü e-
ro-Rosenfeld ME, Dennis DT, Wormser GP: Pro-
phylaxis with single-dose doxycycline for the pre-
vention of Lyme disease after an Ixodes scapularis
tick bite. N Eng J Med 2001;
345: 79–84.
86 Piesman J, Mather TN, Sinsky RJ, Spielman A: Du-
ration of tick attachment and Borrelia burgdorferi
transmission. J Clin Microbiol 1987;
25: 557–558.
87 Lebet N, Gern L: Histological examination of Bor-
relia burgdorferi infection in unfed Ixodes ricinus
nymphs. Exp Appl Acarol 1994;
18: 177–183.
88 Leuba-Garcia S, Kramer MD, Wallich R, Gern L:
Characterization of Borrelia burgdorferi isolated
from di fferent organs of Ixodes ricinus ticks collect-
ed in nature. Zentralbl Bakteriol 1994;
280: 468–
475.
89 Zhu Z: Histological observations on Borrelia burg-
dorferi growth in naturally infected female Ixodes
ricinus . Acarologia 1998;
39: 11–22 .
90 Hubálek Z , Halouzka J, Juřicov á Z: Investigation of
haematophagous arthropods for borreliae – sum-
marized data, 1988–1996. Folia Parasitol 1998;
45:
67–72.
Epidemiology 49
91 Korenberg EI, Gorban LY, Kovalevskii YV, Frizen
VI, Karavanov AS: Risk for human tick-borne en-
cephalitis, borrelioses, and double infection in the
pre-Ural region of Russia. Emerg Infect Dis 2001;
7: 459–462.
92 Crippa M, Reis O, Gern L: Investigations on the
mode and dynamics of transmission and infectiv-
ity of Borrelia burgdorferi sensu stricto and B. af-
zelii in Ixodes ricinus tic ks. Vector Bor ne Zoon Dis
2002;
2: 3–9.
93 Kahl O, Janetzki-Mittmann C, Gray JS, Jonas R,
Stein J, de Boer R: Risk of infection with Borrelia
burgdorferi sensu lato for a host in relation to the
duration of nymphal Ixodes ricinus feeding and
the method of tick removal. Zentralbl Bakteriol
1998;
287: 41–52.
94 Ginsberg HS: Transmission risk of Lyme disease
and implications for tick management. Am J Epi-
demiol 1993;
138: 65–73.
95 Hubá lek Z, Halouzk a J, Juřicová Z: A simple meth-
od of t ran sm iss ion ris k as se ssm ent i n en zo oti c fo ci
of Lyme borreliosis. Eur J Epidemiol 1996;
12: 331–
333.
96 Schulze TL, Taylor RC, Taylor GC, Bosler EM:
Lyme disease: a proposed ecological index to as-
sess are as of risk in the nor theastern Unite d States.
Am J Publ Health 1991;
81: 714–718.
97 Connally NP, Ginsbergh HS, Mather TN: Assess-
ing peridomestic entomological factors as predic-
tors for Lyme disease. J Vector Ecol 2006;
31: 364–
370.
98 Fit zner J, Ammon A, Bau mann I, Talask a T, Schön-
berg A, Stöbel K, Fingerle V, Wilske B, Petersen L:
Risk factors in Lyme borreliosis: a German case-
control study. Int J Med Microbiol 2002;
291(suppl
33):220.
99 Horobik V, Keesing F, Ostfeld RS: Abundance
and Borrelia burgdorferi -infection prevalence of
nymphal Ixodes scapularis ticks along forest-field
edges. Ecohealth 2007;
3: 262–268.
100 Stafford KC, Magnarelli LA: Spatial and temporal
patterns of Ixodes scapularis (Acari: Ixodidae) in
southeastern Connecticut. J Med Entomol 1993;
30: 762–771.
101 Fish D: Environmental risk and prevention of
Lyme disease. Am J Med 1995;
98(suppl 4A):2–9.
102 Brownstein JS, Skelly DK, Holford TR, Fish D:
Forest fragmentation predicts local scale hetero-
geneity of Lyme disease risk. Oecologia 2005;
146 :
469–475.
103 Prusinski MA, Chen H, Drobnack JM, Kogut SJ,
Means RG, Howard JJ, Oliver J, Lukacik G, Back-
enson PB, White DJ: Habitat structure associated
with Borrelia burgdorferi prevalence in small
mammals in New York State. Environ Entomol
2006;
35: 308–319.
104 Steere AC: Lyme disease. N Eng J Med 1989;
321:
586–596.
105 Zeman P, Januška J: Epizootiologic background of
dissimilar distribution of human cases of Lyme
borreliosis and tick-borne encephalitis in a join
endemic area. Comp Immunol Microbiol Infect
Dis 1999;
22: 247–260.
106 Ostfeld RS: The ecology of Lyme disease risk. Am
Sci 1997;
85: 338–346.
107 Lane RS, Steinlein DB, Mun J: Human behaviors
elevating exposure to Ixodes pacificus (Acari:
Ixodidae) nymphs and their associated bacterial
zoonotic agents in a hardwood forest. J Med Ento-
mol 2004;
41: 239–248.
108 Epidat: Notification of Infectious Diseases in the
Czech Republic National Public Health Institute.
Prague, Centre of Epidemiology and Microbiolo-
gy, 2007. http://www.szu.cz/cema/hpcema.htm.
109 EpiNorth: Data on Lyme borreliosis. 2007. http://
www.epinorth.org.
110 Health Protection Agency: UK Data on Lyme bor-
reliosis. 2007. http://www.hpa.org.uk/infections.
111 Smith R, Takkinen J: Lyme borreliosis: Eu-
rope-wide coordinated surveillance and action
needed?
Euro Surveill 2006; 11:E0606221.1. http://
www.euro
surveillance.org/ViewArticle.aspx?
ArticleId=2977.
112 Stamouli M, Totos G, Braun HB, Michel G, Giz-
a ri s V: Ver y l ow s er op re va le nc e o f Ly me bo rr el io si s
in young Greek males. Eur J Epidemiol 2000;
16:
495–496.
113 Hofhuis A, van der Giessen JWB, Borgsteede
FHM, Wielinga PR, Notermans DW, van Pelt W:
Lyme borreliosis in the Netherlands: strong in-
crease in GP consultations and hospital admis-
sions in past 10 years. Euro Surveill 2006;
11:E060622.2. http://www.eurosurveillance.org/
ViewArticle.aspx?ArticleId=2978.
114 Hasseltvedt V: Cases of Lyme borreliosis notified
in Norway, 2000. Euro Surveill 2001;
5: 010809.2.
http://www.eurosurveillance.org/ViewArticle.
aspx?ArticleId=1706.
115 Epimeld: Infectious Diseases and Poisonings in
Poland. Warsaw, National Research Centre of
Public Health, 2007. http://www.pzh.gov.pl.
116 Lopes de Car valho I, Nũnc io MS: Laboratory d iag-
nosis of Lyme borreliosis at the Portuguese Na-
tional Institute of Health (1990–2004). Euro Sur-
veill 2006;
11: 257–260.
117 Gern L: Lyme borreliosis in Switzerland. Report
WHO Workshop Lyme Borreliosis Diagn Surveill.
Warsaw, 20–22 June 1995, pp 152–156.
118 Güner ES, Hashimoto N, Takada N, Kaneda K,
Imai Y, Masuz awa T: First isolat ion and character-
ization of Borrelia burgdorferi sensu lato strains
from Ixodes ricinus ticks in Turkey. J Med Micro-
biol 2003;
52: 807–813.
50 Hubálek
Dr. Z. Hubálek
Medical Zoology Laboratory, Institute of Vertebrate Biology, Academy of Sciences
Klasterni 2
CZ–69142 Valtice (Czech Republic)
Tel. +420 519 352 961, Fax +420 519 352 387, E-Mail zhubalek@ivb.cz
119 Romanova EV, Buchinskaya EA: Peculiarities of
clinical manifestations of tick-borne borrelioses
based on the data from 1st Novosibirsk City Infec-
tious Diseases Hospital (in Russian); in Matush-
enko AA (ed): Current Aspects of Diseases with
Natural Focality. Omsk, 2001, pp 123–124.
120 Miyamoto K, Masuzawa T: Ecology of Borrelia
burgdorferi sensu lato in Japan and East Asia; in
Gra y J, Ka hl O, L ane R S, Sta nek G: Lyme Borrelio -
sis – Biology, Epidemiolog y and Control. Walling-
ford, CABI, 2002, pp 201–222.
121 Masuzawa T: Terrestrial distribution of the Lyme
borreliosis agent Borrelia burgdorferi sensu lato in
East Asia. Jap J Infect Dis 2004;
57: 229–235.
122 Shih CM, Wang JC, Chao LL, Wu TN: Lyme dis-
ease in Taiwan: first human patient with charac-
teristic erythema chronicum migrans skin lesion.
J Clin Microbiol 1998;
36: 807–808.
123 Matuschka FR, Eiffert H, Ohlenbusch A, Richter
D, Schein E, Spielman A: Transmission of the
agent of Lyme dis ease on a subtropica l island. Trop
Med Parasitol 1994;
45: 39–44.
124 Ouhabi H, Slassi I, El Aloui-Frais M: Paralysie fa-
ciale et maladie de Lyme. Arch Inst Pasteur Ma roc
1994;
9: 51–55.
1 25 R ous sel le C , Flo ret D , Co chat P, Rei gni er F, Wrig ht
C: Encépha lite aige à Bor relia burgdorferi (ma ladie
de Lyme) chez un enfant algérien. Pédiatrie 1989;
44: 265–269.
126 Aoun K, Kechrid A, Lagha N, Zarrouk A, Bouz-
ouaia N: La maladie de Lyme en Tunisie, résultats
d’une étude clinico-sérologique (1992–1996). Cah
Santé 1998;
8: 98–100.
127 Younsi H, Postic D, Baranton G, Bouattour A:
High prevalence of Borrelia lusitaniae in Ixodes
ricinus ticks in Tunisia. Eur J Epidem 2001;
17: 53–
56.
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 51–110
A b s t r a c t
Lyme borrelosis is a multi-systemic disease caused by Borrelia burgdorferi sensu lato. A complete
presentation of the disease is an extremely unusual oberservation, in which a skin lesion follows a
tick bite, the lesion itself is followed by heart and nervous system involvement, and later on by ar-
thritis; late involvement of the eye, nervous system, joints and skin may also occur. Information on
the relative frequency of individual clinical manifestations of Lyme borreliosis is limited; however,
the skin is most frequently involved and skin manifestations frequently represent clues for the di-
agnosis. The only sign that enables a reliable clinical diagnoisis of Lyme borreliosis is a typical ery-
thema migrans. Laboratory confirmation of a borrelial infection is needed for all manifestations of
Lyme borreliosis, with the exception of typical skin lesions. Copy right © 2009 S. Karger AG , Basel
General Remarks
Lyme borreliosis, caused by Borrelia burgdorferi sensu lato (s.l.), presents with a vari-
ety of clinical signs and symptoms and with several variations in the course of the
disease. This may frequently result in an uncritical interpretation of manifestations
mistakenly attributed to Lyme borreliosis [1] . Most often the diagnosis of Lyme bor-
reliosis is based on erroneous interpretations of serologic or PCR test results and an
equation of infection with disease [2, 3] . On the other hand, some patients with typi-
cal clinical signs still remain undiagnosed and untreated. In spite of possible varia-
tions in the clinical course, certain rules could be useful for identification of patients
and confirmation of borrelial infection. Lyme borreliosis should not become a do-
main in which everyone interprets findings according to their own feelings and in-
tentions. This temptation exists not only with Lyme borreliosis, but also with several
other illnesses presenting with numerous clinical features and limited laboratory
confirmation. Such behavior regarding Lyme borreliosis is coupled not only with in-
Clinical Manifestations and Diagnosis of
Lyme Borreliosis
Franc Strle a ⭈ Gerold Stanek b
a Depar tment of Infectious Diseases, University Medical Center Ljubljana, Ljubljana , Slovenia;
b Medical University of Vienna, Clinical Institute of Hygiene and Medical Microbiology, Vienna , Austria
52 Strle ⴢ Stanek
complete information about the disease, but most often with inadequate familarity
with the existing knowledge. This may lead to more restricted recognition of the dis-
ease by some (predominantly academic) physicians, and others to the fantasy that
substantial numbers of patients with chronic symptoms such as arthralgia, myalgia,
headache, fatigue and so on – symptoms quite frequently present in the general pop-
ulation – are suffering from chronic Lyme borreliosis, and thus require long-term
treatment with antibiotics. The latter approach appears to be much more frequent
than the former, and has been expanding fairly rapidly, not only in the USA but also
in several countries in Europe. It is mostly a consequence of the pronounced expecta-
tions of patients with nonspecific and/or devastating signs and symptoms and their
desire to get a ‘decent’ diagnosis offering efficacious and relatively simple treatment.
Therapy in these cases is often coupled with limited proficiency of the care providers
and unfortunately in some cases also with malevolent activities of some individuals
who are not able to avoid the temptations of financial opportunities in the manage-
ment of ‘chronic Lyme disease’.
Not knowing what to do is frustrating, not doing what is known is tragic, inten-
tionally doing things that are not efficient and can even be harmful is ethically intol-
erable.
Diagnosing Lyme Borreliosis
The terms Lyme borreliosis and Lyme disease are generally used synonymously.
However, t he term Lyme disease w as coined to n ame an enlarging spectrum of symp-
toms that were obviously linked to each other by an etiology that was unknown until
the early 1980s; the first observations of Lyme arthritis and Lyme carditis were made
in the USA [4, 5] . After the discovery of the borrelial origin of these disorders, the
more specific term Lyme borreliosis was introduced, and now appears to be the more
appropriate term to describe a disorder that exists in moderate climates all over the
northern hemisphere.
When diagnosing Lyme borreliosis it is important to acknowledge some simple
facts that are often neglected or not properly recognized [1–3] . One such fact is that
Lyme borreliosis is a disease. Disease is defined as ‘any deviation from or interruption
of the normal structure or function of any body part, organ, or system that is mani-
fested by a characteristic set of symptoms and signs and whose etiology, pathology,
and prognosis may be known or unknown’ [6] . Therefore, there is no disease without
signs and/or symptoms, and consequently there is no diagnosis of Lyme borreliosis
in the absence of clinical manifestations. The mere proof of an infection with bor-
reliae is not sufficient, because the infection may not always result in illness. It ap-
pears that the proportion of symptomatic infections is much higher in the USA, at
about 90% [7] , than in Europe, where fewer than 50% of infections result in clinical
illness [8–10] . In addition, demonstration of antibodies to B. burgdorferi s.l. does not
Clinical Manifestations and Diagnosis of Lyme Borreliosis 53
discriminate between active infection and an immunologic imprint of previous
(symptomatic or asymptomatic) infection. Because signs and symptoms form the ba-
sis for recognition of the disease, good knowledge of clinical features is important in
diagnosing Lyme borreliosis [2] . Case definitions for Lyme borreliosis are beneficial
in everyday clinical practice, and especially for comparing the findings of different
researchers. Unfortunately, clinically useful definitions are rare. Those of the Centers
for Disease Control and Prevention (CDC) in the USA [11] were made primarily for
epidemiologic purposes and are, wit h the exception of the definition of ery thema m i-
grans (EM), not applicable in clinical practice, whereas European definitions [12, 13]
are somewhat complicated for a busy clinician. Guidelines for diagnosis and treat-
ment (management) are also useful. They are available as the Infectious Diseases So-
ciety of America (IDSA) guidelines for the USA [14] , were termed clinica l case defini-
tions by the European Union Concerted Action on Lyme Borreliosis (EUCALB), and
as laboratory guidelines by a working group of the European Society for Clinical Mi-
crobiology and Infectious Diseases (ESCMID) [12, 13] .
Another often neglected fact is that the clinical presentations of Lyme borreliosis
in America and Europe differ in some respects, making it inappropriate to uncriti-
cally apply the findings from one side of the Atlantic to the other side [15] . Another
important aspect is that, because of the much higher publication frequency of USA
researchers and physicians in the field of Lyme borreliosis, it is quite possible that the
diagnosis of Lyme borreliosis in Europe is predominantly assessed through ‘Ameri-
can eyes’. The opinions offered in the present report are based primarily on European
data and experience, and most probably fit better to the situation in Europe.
The only sign that enables a reliable clinical diagnosis of Lyme borreliosis is a typ-
ical EM [1–3, 12–14, 16–19] . However, according to current knowledge, even this is
valid only for Europe and is less straightforward in the USA where skin lesions of
STARI (Southern tick-associated rash illness; Masters’ disease) are very similar to EM
[20, 21] . Ear lobe lymphocytoma, meningoradiculoneuritis (Garin-Bujadoux-Bann-
warth syndrome) and acrodermatitis chronica atrophicans (ACA) are also highly
supportive of the diagnosis [2, 3, 13] . The large majority of numerous other symptoms
and signs, especially when expressed individually, have only minimal or even sym-
bolic diagnostic value. Laboratory confirmation of a borrelial infection is needed for
all manifestations of Lyme borreliosis, with the exception of typical skin lesions [1– 3,
12–14, 16–19] . An apparently favorable effect of treatment with antibiotics is of small
diagnostic value, because the natural course of Lyme borreliosis in an individual pa-
tient is difficult to predict (is variable) and, moreover, the majority of clinical mani-
festations will resolve spontaneously [2, 3] . Individual case reports of unusual clinical
manifestations may serve as a trigger for scientific evaluation, but it is incorrect to
conclude that these are ‘new’ signs of Lyme borreliosis or new (newly discovered)
clinical manifestations of the disease. Moreover, coincidence should be ruled out by
controlled prospective clinical studies, since the presence of borrelial antibodies in
serum and/or the presence of specific nucleic acid sequences of B. burgdorferi s.l. in a
54 Strle ⴢ Stanek
patient’s specimen, and in some circumstances even the isolation of borreliae from
involved tissue or organ, do not alone prove the etiology [1–3] .
Little information exists on the frequency of coinfections of tick-borne pathogens
and their effects on the clinical manifestations, diagnosis, treatment and outcome of
Lyme borreliosis. Dual infection with Babesia microti and B. burgdorferi sensu stric-
to (s.s.) can result in more serious disease than infection with either agent alone [22] .
A combination of Lyme borreliosis with tick-borne encephalitis could cause diagnos-
tic dilemmas, and consequently a delay in antibiotic treatment [23] . Coinfection with
the agent of human granulocytic anaplasmosis, Anaplasma phagocytophilum , affects
the choice of antibiotic for treatment of early Lyme borreliosis [24] .
Only the main clinical ma nifestations of Lyme borreliosis wi ll be de alt wit h in this
chapter.
C l i n i c a l M a n i f e s t a t i o n s
A complete presentation of the disease is an extremely unusual observation, in which
a skin lesion follows a tick bite, the lesion is then followed by heart and nervous sys-
tem involvement, and later on by arthritis; late involvement of eye, nervous system,
joints and skin may also occur. Information on the relative frequency of individual
clinical manifestations of Lyme borreliosis is limited. The disease has traditionally
been divided into stages; howe ver, althoug h this may be va luable for didactic reasons,
it is somewhat theoretical and often not in agreement with clinical findings.
Skin Involvement
Skin is the most frequently involved tissue in Lyme borreliosis, and skin manifesta-
tions frequently represent clues for the diagnosis. EM, borrelial lymphocytoma (for-
merly lymphadenosis benigna cutis) and ACA are today rated as classic manifestations
of Lyme borreliosis. These manifestations were well known as distinct skin disorders
long before the discovery of the causative agent [17, 25 –2 7] . In addition, Lyme bor-
reliosis may be associated with several other skin manifestations, such as scleroderma
circumscripta, lichen sclerosus et atrophicus and cutaneous B cell lymphoma.
Erythema Migrans
Short Definition
Severa l definitions of EM have been proposed for different purposes. Best known a mong
these are the definitions of the CDC [11] , EUCALB [12] and the ESCMID study group
[13] . In Slovenia, a modified CDC definition has been used since 1988. EM is defined as
Clinical Manifestations and Diagnosis of Lyme Borreliosis 55
an erythematous skin lesion that develops days to weeks after infection at t he site where
borreliae were inoculated into the skin. It typically begins as a red macula or papule and
expands over a period of days to weeks to usually an oval or round lesion, with or with-
out central clearing. For a reliable diagnosis, a single primary lesion must reach 6 5 cm
in size. A lesion ! 5 cm qualifies for the diagnosis of EM only if: (1) it develops at the site
of a tick bite, (2) a time interval between the bite and the onset of the lesion is reported,
and (3) the lesion is enlarging (fulfillment of all 3 requirements is needed). Secondary
lesions may also occur. Multiple EM is defined as the presence of 2 or more skin lesions,
at least 1 of which must fulfil the size criteria for solitary EM given above.
Frequency
EM is by far the most frequent manifestation of Lyme borreliosis. In the USA, more
than 70% of patients registered with Lyme borreliosis had EM [28] . Among 1,471 pa-
tients shown to have Lyme borreliosis in an epidemiologic study in southern Sweden,
EM was seen in 77% of all cases, and was accompanied by other signs of the disease
such as nervous system involvement, ar thritis, lymphocytoma and/or cardit is in only
6.5% [29] . Mandatory notification in Europe has been instituted in only a limited
number of countries. In Slovenia, where notification of Lyme borreliosis has been
mandatory for more than 20 years and where during the past 10 years the incidence
of the disease has been more than 100 per 100,000 inhabitants, rising to 224 per
100,000 in 2006, EM represents about 90% of registered cases [30, 31] . The relative
freque ncy of ind ividual clin ica l ma nifestations in pat ients registered at t he Lyme bor-
reliosis outpatient clinic at the Department of Infectious Diseases, University Medical
Center Ljubljana, Slovenia, are shown in table 1 .
Etiology
In North America, EM is caused by B. burgdorferi s.s., this species apparently being
the sole cause of human Lyme borreliosis there. Reports from Europe, based on the
Tab le 1. Frequency of the main clinical manifestations of Lyme borreliosis in patients registered at
the Lyme borreliosis outpatient clinic in Ljubljana, Slovenia, in 2000
Manifestation Adults Children Total
Erythema migrans 621 (83.4) 218 (79.3) 839 (82.3)
Borrelial lymphocytoma 4 (0.5) 4 (1.5) 8 (0.8)
Lyme neuroborreliosis 48 (6.4) 40 (14.5) 88 (8.6)
Lyme carditis 2 (0.3) 0 2 (0.2)
Lyme arthritis 21 (2.8) 13 (4.7) 34 (3.3)
ACA 49 (6.6) 0 49 (4.8)
Total 745 275 1,020
Figures in parentheses are percentages.
56 Strle ⴢ Stanek
characterization of borreliae isolated from skin, revealed that EM is most often caused
by B. afzelii (up to 96%, most often 70–90%), less frequently by B. garinii (up to 33%,
most often 10–20%), rarely by B. burgdorferi s.s. and only exceptionally by other spe-
ci es such as B. bissettii , B. spielmanii and as yet unidentifiable species [32–4 4] . Among
488 skin isolates from Slovenian patients with EM, 433 (89%) were typed as B. afzelii ,
53 (11%) as B. garinii and only 2 as B. burgdorferi s.s. [38] . However, in a Finnish series
of 82 patients with EM, 21.5% were skin culture positive (a rather low isolation rate),
and all the isolates were typed as B. garinii [45] . It seems that the predominance of B.
afzelii is valid for western and central Europe, but may not be for eastern Scandinavia,
eastern Europe and Asia. It is of interest that the proportions of the main Borrelia
species isolated from EM skin lesions do not completely match with the proportions
found in ticks. Studies in Slovenia and Germany found that B. garinii and B. burgdor-
feri s .s. were relativel y more frequently i solated from tic ks t han B. afzelii , and that this
differed from the Borrelia species isolated from the skin of patients with EM in the
same region [39, 46] .
Information obtained predominantly from PCR [34, 47, 48] but also from culture
results [49, 50] indicates that an individual patient with Lyme borreliosis may simul-
taneously harbor more than 1 Borrelia strain of the same species and even more than
1 Borrelia species.
Borreliae enter the skin during the blood meal of an infected Ixodid tick. Most
probably, the bacteria initially accommodate to the new environment and then spread
into the skin and other tissue. Results of experimental infection suggest that borre-
liae may disseminate in the skin over a long period of time without causing disease,
unless the host’s defenses are imbalanced [3] .
T ic k B i t e
In the USA, only about 1 in 4 patients (14–32%) with EM recall a previous tick bite at
the site of the skin lesion [15, 28, 51, 52] . In several European studies, the proportion
of patients recalling a tick bite is substantially higher [15, 53 –56] . Among 892 adult
patients diagnosed with typical EM at the Ljubljana Lyme borreliosis clinic in 1993,
73% reported a tick bite at the site where the EM skin lesion expanded, and in 2000
the corresponding rate was 311 of 535 (58%) [56] . Patients with EM who do not recall
a tick bite were most probably bitten, but were not aware of it. The history of an insect
bite followed by skin lesion and interpreted as EM is often insecure, and cannot ex-
clude an unnoticed tick bite.
Histologic Findings
Commonly mild superficial perivascular infiltration by lymphocytes and some his-
tiocytes is usually present, and is sometimes accompanied by plasma cells, rarely by
neutrophils, in the dermis at the site of the EM lesion and also in the clinically nor-
mal-looking skin bordering the lesion [57] . The epidermis is usually unaffected. The
presence of T cells and increased numbers of Langerhans cells suggest that cell-medi-
Clinical Manifestations and Diagnosis of Lyme Borreliosis 57
ated immune mechanisms are involved in the initial host response to B. burgdorferi
s.l. [3] . High levels of mRNA expression of the T cell-active chemokines CXCL9 and
CXCL10 and low levels of the B cell-active chemokine CXCL13 have been established
in EM. CD3+ T cells and CXCL9 have been visualized using immunohistologic meth-
ods [58] .
Clinical Characteristics
EM affects all ages and both sexes with a slight predomination of females in Europe,
but not in the USA. The lesion usually appears on the skin at the site of a tick bite.
Days to weeks thereafter, a small red macula or papule appears. In 1 study of adult
European patients with B. afzelii isolated from skin, the median time from bite to rash
onset was 17 days, whereas the median time in B. burgdorferi s.s. patients in the USA
was 11 days [15] . Because of the close temporal proximity of tick bites and onset of
EM, this manifestation of Lyme borreliosis has a pronounced seasonal occurrence.
The erythema slowly enlarges and central clearing usually begins – in adult patients
in Europe typically by the end of the first week – resulting in a ring-like lesion that
spreads outward (EM). Untreated lesions persist and expand over days to several
months. EM skin lesions are typically oval or round, but can have an irregular shape.
Their diameter may range from a few centimeters to more than a meter. In adult pa-
tients EM is most often located on the lower extremities; in children the upper part
of the body is relatively more often involved [3, 15–17, 19, 53–56] .
About half of adult European patients report local symptoms at the site of EM,
usually mild itching, burning or pain; a smaller proportion (20–51%) have systemic
symptoms such as fatigue and malaise, headache, myalgia and arthralgia, which are
usually intermittent and often vary in intensity and location. In European patients
with EM, fever is an exception, being present or recalled in fewer than 5% [17, 19,
54–56, 59] , whereas in the USA it is documented in about 16% and recalled by more
than one third of patients [28] . Although the frequencies of local symptoms appear
similar in the USA and Europe [15] , the proportion of patients with systemic symp-
toms is higher in the USA, where as many as 80% of patients evaluated for EM have
simultaneous systemic complaints [28, 60] . In a study on culture-proven EM, 82 of
119 (69%) adult patients in the USA, in whom B. burgdorferi s.s. was causing disease,
reported systemic symptoms, in contrast to 43 of 85 (51%) Slovenian patients with B.
afzelii isolated from their skin lesion. The comparison also revealed several other dif-
ferences, including briefer duration of EM in the USA (median 4 days vs. 14 days in
European patients), greater frequency of abnormal findings on physical examination
(57 vs. 14%) including lymphadenopathy (39 vs. 9%) and fever (15 vs. 1%), and differ-
ences in seroreactivity; central clearing was more likely in European patients (68 vs.
35%). The frequency of multiple EM was greater in the USA than in the Slovenian
patients (13 vs. 7%), but the difference was not significant [15] . Several distinctions
have also been found in European patients when comparing culture-confirmed EM
caused by B. afzelii with EM caused by B. garinii [33, 61, 62] . According to some
58 Strle ⴢ Stanek
authors, the presence of systemic symptoms associated with a solitary EM skin lesion
might indicate dissemination of the etiologic agent; however, this most probably ap-
plies more to patients in North America than in Europe. According to the somewhat
limited information in Europe, the yield from blood cultures of patients with EM is
low and spirochetemia is often clinically silent. The isolation rate from blood was
found to be only about 1% in adult patients and 9% in children with solitary EM [59,
63]
, which is in contrast to reports from the USA where as many as 50% of patients
with EM had a positive blood culture [64] . Possible explanations for these distinctions
are the much larger volume of blood cultured in the USA than in Europe, and differ-
ences in the species causing EM. All blood isolates in the USA belong to B. burgdorferi
s.s., but only a subset of subtypes of this species is prone to disseminate and to cause
spirochetemia. In Europe, B. afzelii predominates, not only among skin isolates but
also among blood isolates ( 6 80%) of patients with EM [38, 59, 63] . In 1 study, only 7
of 35 (20%) adult patients with EM and B. burgdorferi s.l. isolated from blood report-
ed constitutional symptoms [59] . Comparison of 12 blood culture-positive and 122
blood culture-negative children with solitary EM found no differences in pretreat-
ment characteristics, including the frequency of the associated systemic symptoms
[63] . The fact that in Europe only some of the patients with multiple EM report sys-
temic symptoms indicates that the absence of systemic symptoms is not a reliable in-
dication of the lack of dissemination. For example, nearly 50% of adult Slovenian pa-
tients and 70% of children with multiple EM do not report any systemic complaints
[unpublished data, 65 ]. Multiple EM is defined as the presence of 2 or more skin le-
sions in an individual patient and is interpreted as a consequence of hematogeneous
dissemination of borreliae from the primary EM skin lesion. The secondary lesions
are similar in morphology to the initial solitary lesion, but lack the indurated center
usually seen in primary lesions at the site of the tick bite; secondary lesions are also
smaller and are only exceptionally associated with local itching or pain. It seems that
they are more frequent in children than in adults, and are apparently a more common
finding in EM in the USA (up to 50% [60] ) than in Europe (3–8% of adult patients)
[15, 19, 53–5 6] . It is of interest that in children with multiple EM, a mild predomi-
nantly lymphocytic pleocytosis was seen in 18–26% of patients, although none had
clear clinical evidence of central nervous system (CNS) involvement [65, 66] , and
fewer than hal f of these patients reported systemic symptoms [66] . European patients
with EM are mostly seronegative in convalescent-phase serum samples, whereas the
majority of such patients in the USA are seropositive. However, in both groups rou-
tine medical laboratory tests do not reveal signs of inflammation or any other abnor-
malities [4, 15, 51–55, 60] .
D ia g n o s i s
Diagnosis of a typical EM is clinical [1–3, 14, 16] . For atypical lesions, proof is required
by the demonstration of borreliae in skin [2, 3] . However, even ‘typical’ EM may not
be considered pathognomonic for Lyme borreliosis, especially in the southern part of
Clinical Manifestations and Diagnosis of Lyme Borreliosis 59
the USA, where skin lesions consistent with EM but with no microbiologic evidence
for Borrelia infection have been established [20, 21] .
Differential Diagnosis
EM is sometimes misdiagnosed as fungal infection and vice versa, especially when
lesions are present in inguinal or axillary regions. Skin lesions that do not show cen-
tral clearing may resemble erysipelas, although in patients with erysipelas the onset
of the lesion is typically preceded by rigors and high fever and is accompanied by
high fever, malaise and laboratory signs of inflammation, which are – at least in Eu-
rope – not present in patients with EM. When a skin lesion appears immediately or
during the first 24 h after a tick bite, it is usually the result of a hypersensitivity reac-
tion and not a borrelial infection. In Lyme borreliosis there is typically a symptom-
free interval of at least some days from the bite to the onset of a skin lesion. Other
differential diagnoses may include reaction to an insect bite, urticaria, contact ecze-
ma, folliculitis, cellulitis, granuloma annulare, tinea corporis (ring worm), fixed drug
eruption or pseudolymphoma [2, 3, 12, 67] .
Borrelial Lymphocytoma
Basic Description and Histologic Findings
Borrelial lymphocytoma is a solitary swelling with a diameter of up to a few centi-
meters, consisting of a dense lymphocytic infiltration of cutis and subcutis as a result
of borrelial infection [17, 6 8–72] . The infiltration is polyclonal with a predominance
of B lymphocytes and may show germinal centers [17, 57, 68, 69, 72, 73] . In contrast
to the other 2 main skin manifestations of Lyme borreliosis, EM and ACA, where
high levels of the T cell-active chemokines CXCL9 and CXCL10 have been estab-
lished, in borrelial lymphocytoma high levels of the B cell-active chemokine CXCL13
are found [58] . In children, borrelial lymphocytoma is most frequently located on the
ear lobe and in adults in the region of the areola mammae [17, 6 8–72] . When located
on the ear lobe, the involved skin is bluish red; at other locations, the skin color is
usually normal. Borrelial lymphocytoma usually appears later, has slower evolution
and is of longer duration than EM, but also resolves spontaneously although some-
times only after more than a year [17, 6 8–70 , 7 2] . Other signs of Lyme borreliosis may
develop in the course of (untreated long-lasting) borrelial lymphocytoma [17, 68, 69,
71, 72] .
Frequency
Borrelial lymphocytoma is a rare manifestation of European Lyme borreliosis. There
are no reliable reports on autochthonous borrelial lymphocytoma from North Amer-
ica. Data on the exact frequency of this manifestation in Europe are limited. In a well-
designed epidemiologic study in southern Sweden, borrelial lymphocytoma was
60 Strle ⴢ Stanek
found in 16 of 232 (7%) children and in 25 of 1,239 (2%) adults registered with Lyme
borreliosis [29] . In Slovenia, only 18 of 1,582 (1.1%) patients registered with Lyme bor-
reliosis in the years 1986–1988 had borrelial lymphocytoma [74] . The proportion of
patients with borrelial lymphocytoma diagnosed at the Ljubljana Lyme borreliosis
clinic during 1999 is shown in table 1 . Similar ratios were also found for the following
years [unpublished data].
Etiology
Information on the genospecies of borreliae that cause borrelial lymphocytoma is lim-
it ed . T he la rge m ajo ri ty of isol ate s f ro m b orre li al ly mphocy toma t is sue h ave be en fou nd
to be B. afzelii , but in some patients B. garinii and B. burgdorferi s.s. have been isolated,
and in 1 patient the presence of B. bissettii was established [38, 70, 71, 75–77] .
Clinical Characteristics
After the recognition that solitary lymphocytoma (lymphadenosis benigna cutis) is a
manifestation of Lyme borreliosis, only 5 studies [68–71, 73] with large numbers of
patients, including 1 with a predominantly pathologic orientation [73] , and a few re-
ports on a very limited number of patients have been published [78–80] . A review of
36 patients with a solitary borrelial lymphocytoma diagnosed at the Department of
Infectious Diseases of the University Medical Center Ljubljana (the department cares
for both children and adults) over a 5-year period revealed that in most of these pa-
tients the onset of borrelial lymphocytoma was in the second half of the year and that
distribution according to sex was well balanced. The lesion was localized on the ear
lobe in 47% of patients, on the breast in 42%, and on the nose, arm, shoulder or scro-
tum in 11%. Patients with ear lobe borrelial lymphocytoma were younger than those
with the lesion on the breast (median 12 vs. 42 years); of 17 pat ients with ea r-lobe bor-
relial lymphocytoma only 3 were adults and all the others were 10 years or younger;
in breast borrelial lymphocytoma, all patients but 1 were 18 years or older [69] . This
accords with observations of other researchers and with further reports from the
same group [68, 70, 71, 73] . The reasons for such distinctive localizations and for dif-
ferences in location of the lesion according to age are not completely understood. As-
brink and Hovmark [81] hypothesized that borreliae prosper at a temperature below
37
° C, which would explain why the ear lobe and the nipple, the cooler parts of the
body, are most frequently affected. However, there are some additional explanations.
Lymphocytoma on the ear lobe is easy to notice and can be easily recognized from its
characteristic appearance, provided the physician is familiar with the disorder.
Changes in the nipples and nodules in the breast often scare the patient into seeking
medical help, although t he physician has to use various dia gnostic measures to achieve
a possibility of correct diagnosis. Nodules found in other areas of the skin, whether
in the dermis or subcutis, are usually no cause for consulting a physician. Even if the
patient seeks medical attention in such cases, it is difficult to establish a clinical diag-
nosis without other manifestations of a borrelial infection. It is also difficult to inter-
Clinical Manifestations and Diagnosis of Lyme Borreliosis 61
pret the differences in localization of borrelial lymphocytoma in children and adults.
Possibly, one reason may be the different sites of tick bites. It is known that ticks are
usually found on vegetation a few centimeters up to one meter above ground. This
explains why children more often have tick bites on the head and neck than adults
[29] , and consequently why EM is localized much more frequently on t he face of chil-
dren than adults and also why ear lobe borrelial lymphocytoma is found predomi-
nantly in children. Yet, the localization of the tick bite does not explain why borrelial
lymphocytoma on the breast is an exception in children. It seems that there are local
tissue factors which support the development of borrelial lymphocytoma on the breast
in adults [69] . In the same study, a tick bite was reported by 29 of 36 (81%) patients, a
median of 30 days before borrelial lymphocytoma developed. In 24 (83%) of the pa-
tients the tick bite was in close vicinity to the location of the subsequent borrelial
lymphocytoma, indicating that in the great majority of patients the spirochetes may
spread from the site of the bite to the site where the disorder appears. This is well
known in EM, which spreads out from the site of inoculation. In addition, borrelial
lymphocytoma was located within the EM in 24 of 25 patients with concomitant EM.
The onset of EM, the typical early manifestation of Lyme borreliosis, preceded bor-
relial lymphocytoma in 19 out of 25 cases. Only 3 of 17 (18%) patients with ear lobe
borrelial lymphocytoma had mild systemic symptoms, such as moderate headache,
general malaise and fatigue, and 8 (47%) patients reported mild local itching; also in
8 (47%) members of this group, enlarged regional lymph nodes were found on exam-
ination. In contrast, 12 out of 15 (80%) patients with breast borrelial lymphocytoma
reported constitutional symptoms, and all but 1 reported localized discomfort in the
region of the areola mammae – the patients were bothered by clothing and the area
was slightly painful to touch. Mild itching, breast tension, burning and pain of the
thoracic wall on the affected side were complained of by 9 (60%), 8 (53%), 6 (40%) and
4 (27%) patients, respectively. On inspection, the nipples were found to be asymmet-
ric and, with 1 exception, showed no discoloration; they were edematous, painful to
touch, and completely hardened in 8 (53%) patients and partly so in 4 patients. Infil-
tration was regularly found in the area of areola mammae, within a diameter of up to
3 cm. At presentation, 26 of 36 (72%) patients had borrelial antibodies in serum. Rou-
tine laboratory blood tests did not reveal any significant abnormality
[69] .
Among 85 adult patients with solitary borrelial lymphocytoma diagnosed at the
Department of Infectious Diseases, University Medical Center Ljubljana, during a
period of 15 years [71] , there were 36 (42%) females and 49 (58%) males with a me-
dian age of 49 (15–74) years. Borrelial lymphocytoma was located on the breast (nip-
ple/areola mammae region) in 68 (80%) patients, on the ear lobe in 8 (9%) and at
other locations in 9 (11%). A concomitant EM enabling clinical diagnosis of Lyme
borreliosis was registered or reported in 67 (79%) patients. Fifteen (18%) patients had
no accompanying symptoms, 34 (40%) reported local and constitutional symptoms,
23 (27%) recounted local symptoms only and 13 (15%) had solely constitutional symp-
toms. Clinical findings indicating early disseminated borrelial infection were ob-
62 Strle ⴢ Stanek
served at the first visit in 12 (14%) patients: 6 (7%) had multiple EM , 1 had meningi-
tis, 1 meningoradiculitis and arthritis, 1 radiculoneuritis and arthritis, 1 peripheral
facial palsy and concomitant meningitis, and 2 arthritis. In addition, 1 of the patients
with borrelial lymphocytoma on the breast had ACA. A seropositive response to bor-
relial antigens was found in only 30 (35%) patients at the initial examination. In 11 of
46 (24%) patients, infection with B. burgdorferi s.l. was confirmed by isolation of the
agent from lymphocytoma tissue. Eight of 9 (89%) typed borrelial strains were B. af-
zelii , and 1 (11%) was B. bissettii [71] .
D ia g n o s i s
A reasonably consistent diagnosis of ear lobe lymphocytoma is usually possible on
clinical grounds that can often be further supported by the presence or a reliable his-
tory of EM (usually in the region of the ly mphocytoma), the occurrence of other man-
ifestations of Lyme borreliosis, and/or by the demonstration of borrelial infection –
usually by positive serology [17, 69, 70] . The isolation rate of Borrelia from le sion al skin
is difficult to assess because of the limited information; nevertheless, it appears to be
considerably lower than from the skin of EM, but similar to that from the skin of pa-
tients with ACA. According to 2 reports, borreliae were isolated from skin biopsies of
lymphocytoma in 4 of 11 (36%) patients and 11 of 46 (24%) patients [70, 71] .
Differential Diagnosis
Differential diagnosis in ear lobe borrelial lymphocytoma is much more limited than
in patients with breast lymphocytoma or lymphocy toma at other (aty pical) locat ions;
thus, the need for histologic examination is much greater in patients with lymphocy-
toma at locations other than the ear lobe [69] . Diagnostic difficulties in ear lobe bor-
relial lymphocytoma are usually the result of unawareness, whereas the main differ-
ential diagnostic possibility in breast lymphocytoma is a malignancy [17, 69] . It is
sometimes difficult to distinguish the difference between borrelial lymphocytoma, B
cell lymphoma and other pseudolymphomas [17, 69–71, 82, 83] .
Acrodermatitis Chronica Atrophicans
Frequency
ACA is a chronic skin manifestation of Lyme borreliosis seen almost exclusively in
Europe [3, 14, 16] . Reports on this skin condition from the USA are rare, and are pre-
dominantly limited to descriptions of the manifestation in immigrants from Europe
[84, 85] .
ACA is much less frequently observed than EM, but is more common than bor-
relial lymphocytoma [17] . In an epidemiologic study on Lyme borreliosis in southern
Sweden, it was found in only 47 of 1,471 (3%) patients who fulfilled the criteria for
Lyme borreliosis [29] . The proportion of patients with ACA diagnosed at the Ljubljana
Clinical Manifestations and Diagnosis of Lyme Borreliosis 63
Lyme borreliosis clinic in 1999 is shown in table 1 . Similar ratios were also found for
the following years [unpublished data].
E t i o l o g y
According to the results of PCR and isolation of borreliae from skin, the large major-
ity of ACA cases are caused by B. afzelii [76, 86–90] ; however, in some patients B. ga-
rinii and B. burgdorferi s.s. have been isolated from the skin lesion [77, 91] . Analysis
of the genetic profiles of 22 strains of B. burgdorferi s.l. cultivated from skin biopsies
of Slovenian patients with ACA lesions revealed 17 (77%) B. afzelii strains, 4 (18%) B.
garinii and 1 (5%) B. burgdorferi s.s., indicating that B. afzelii is the predominant, but
not the exclusive, etiologic agent of ACA [91] . This was confirmed later in a larger
study. According to Ružić-Sabljić et al., among 74 isolates from the skin of patients
with ACA, 89% were B. afzelii , 7% B. garinii and 4% B. burgdorferi s.s. [38] .
Tick Bite
Because of the long incubation time and the long duration of the skin lesions prior to
diagnosis, it is understandable that no reliable data exist on the frequency and location
of tic k bit es. Most patients re port being repe atedly bitten every year or being, or hav ing
been, outdoor workers in endemic areas, but almost no patient specifically recalls a tick
bite at the affected body site [67] . The only exceptions are patients in whom ACA was
preceded by an EM lesion in the same location several months to many years before.
However, such a history is reported by no more than 10–20% of these patients [67, 92] ,
and only some of them recall a tick bite prior to the onset of their EM skin lesion.
Histologic Findings
Findings depend upon the phase of the illness, which is rather academically divided
into an early edematous (infiltrative) and a late atrophic phase. The disease starts with
a nonspecific perivascular lymphocytic infiltrate. In early lesions, the epidermis is
frequently thinned. The upper and middle portions of the dermis show a band-like
and perivascular infiltrate consisting of lymphocytes and plasma cells, often in com-
bination with more or less pronounced edema [57] . Dilated blood vessels can be found
in the superficial dermis. Periarticular fibroid nodules seen in some patients with
ACA are located in the deeper portions of the reticular cutis extending into the sub-
cutaneous fat. Clinically, they resemble rheumatoid nodules, but have a different his-
tologic structure with a homogeneous eosinophilic center surrounded by irregular
fascicles of collagen typically arranged in an onion-like concentric fashion. Perivas-
cular infiltrates of lymphocytes and plasma cells are present predominantly in the
peripheral parts of the lesion, and fibrosis is present. In the late stage of ACA, cutane-
ous atrophy with more or less pronounced inflammation is present. The epidermis
often has only a few layers of cells. Dilated blood vessels surrounded by lymphocytes
and plasma cells can be found in the superficial cutis [57, 92, 93] . In very long-stand-
ing atrophic lesions, the inflammatory infiltrates are sparse or may even be absent.
64 Strle ⴢ Stanek
The collagen fibers are strongly reduced in numbers and degeneration of elastic fibers
is present [57] . In general, histologically constant findings in active ACA lesions are
telangiectases and a lymphocytic infiltrate with a moderate-to-rich admixture of
plasma cells [93] . The histopathologic pattern is not diagnostic in itself, but charac-
teristic enough to alert the experienced pathologist [94] .
Clinical Characteristics
ACA is a chronic borrelial skin manifestation that in contrast to EM and borrelial
lymphocytoma does not disappear spontaneously [16 , 17] . It is most often located on
acral parts of the body, usually on the extensor part of hands or feet. Initially, the le-
sion is usually unilateral, later on it may become more or less symmetrical. The initial
changes usually manifest themselves several months or years after the introduction
of borreliae into the body. Some patients remember having had other signs of Lyme
borreliosis – such as EM, neurologic involvement, heart involvement or arthritis be-
fore the onset or diagnosis of ACA – but most patients do not. Asbrink et al. [95] re-
ported that in 9 out of 50 patients (18%) spontaneous healing of EM was followed at
the same location by ACA lesions after a latency period of 6 months to 8 years. Thus,
ACA can be the first and the only clinical sign of Lyme borreliosis [17, 95, 96] .
ACA is more often diagnosed in women than in men, and occurs only very excep-
tionally in children. Patients are usually over 40 years old; in several reports the me-
dian value was over 60 years [17, 95, 96] . The onset is insidious, hardly appreciable:
mildly bluish-red discoloration of the skin appears (usually on the foot, knee or dorsal
part of one of the hands, mostly pronounced over metacarpophalangeal joints) and en-
la rge s ve ry slo wly over pe rio ds of mont hs to y ears. The i nvolve d re gion i s us ually edem-
atous; swelling may occasionally dominate the clinical picture. Initially, the erythema
and swelling may vary in intensity. In some patients, the cutaneous manifestations are
confined to a heel that is swollen, sometimes discolored and painful. A common typi-
cal sign is that one of the feet (sometimes both) gradually increases in size, and the need
for larger shoes arises [96] . After the initial months to years, the edema slowly vanishes
and gradually atrophy becomes more and more prominent. The skin becomes increas-
ingly violaceous, t hin and wrinkled, with prominently visible underlying vessels. When
exposed to a cold environment, the skin becomes pronouncedly bluish. The violaceous
color also becomes more visible when involved arms or legs are in a dependent position.
Healing of damage to the skin is impaired. In some patients, a concomitant migrating
erythema, similar to EM, can be seen at the periphery of ACA lesions [96] .
Up to one fifth of patients may have fibrous indurations in the involved regions
[67, 95] ; they may be band-like (usually in ulnar or tibial regions) or nodular (most
often prepatellary or in the vicinity of the olecranon). The indurations are more fre-
quent in the initial years of the evolution of ACA than in the late phase with pro-
nouncedly atrophic skin.
In some patients with ACA, sclerotic lesions develop that are clinically and histo-
logically indistinguishable from localized scleroderma (morphea) or lichen sclerosus
Clinical Manifestations and Diagnosis of Lyme Borreliosis 65
et atrophicus. According to Asbrink and Hovmark [81] , about 10% of patients with
typical inflammatory ACA have sclerotic lesions. In one of the studies from that
group, in addition to ACA lesions, lichen sclerosus et atrophicus-like lesions were
found clinically in 5 of 32 (16%) examined patients. Four of these patients displayed
a histopathologic picture compatible with lichen sclerosus et atrophicus, suggesting
a relationship between these 2 skin conditions [93] .
Peripheral nerves and joints are quite often involved in the regions of affected skin
[16, 17, 95] . An association between ACA and peripheral neuropathy was established
in systematic studies in the 1960s and 1970s. In these reports, nearly half the patients
with ACA showed signs of predominately sensory polyneuropathy, often most pro-
nounced in the limbs, with cutaneous involvement [96 , 97] . After the recognition that
ACA is a manifestation of borrelial infection, it became obvious that the majority of
untreated patients with ACA have some kind of mild (mostly) or moderate neuropa-
thy, as indicated by clinical and/or neurophysiologic examination [98, 99] . Peripheral
nervous involvement is more frequent in the late phase of ACA. Sensory and motor
mononeuropathy or polyneuropathy or patchy dysesthesia may develop at the site of
the cutaneous lesions. Patients with ACA quite often complain of hyperesthesia/dys-
esthesia, muscle cramps, weakness in the muscles and/or sensations of heaviness,
mainly in the affected limb(s).
In contrast to peripheral neuropathy, there are far fewer data on CNS involvement
in patients with ACA. According to published information, CNS involvement and
cerebrospinal fluid (CSF) abnormalities are rare [96] .
In an investigation of 50 patients with ACA, radiographic examination revealed
subluxation and/or luxations of small joints of the hands or feet in 11 (22%) patients; 4
(8%) patients showed periosteal thickening of bones (similar to dactylitis syphilitica in
the late phase of syphilis) [95, 96] . The affected joints and bones were usually located
underneath the skin lesions. The patients with skeletal involvement had had their dis-
ease for a longer period than the patients with skin lesions a lone [81, 95, 96] . In 17 of 86
(20%) patients, episodic attacks of joint effusions of a knee were found to have preced-
ed or have occured simultaneously with the ACA lesions [81] . Periarticular manifesta-
tions – such as kne e or olecranon bursitis, epicondylitis, retro- or subca lcane al bursit is,
and Achilles tendinitis on the same extremity as the cutaneous involvement – have
been reported; they usually precede, but sometimes also accompany ACA [81, 100] .
According to some reports, enlarged regional lymph nodes are a common finding
in patients with ACA [101] . Some patients report headaches, myalgia and/or arthral-
gia [92] .
D i a g n o s i s
For proper diagnosis, appropriate clinical findings should be corroborated with the
establishment of borrelial infection. Patients with ACA usually have high serum con-
centrations of borrelial IgG antibody; the absence of borrelial antibody in a patient
with clinically suspicious ACA should be the reason for rechecking the diagnosis and
66 Strle ⴢ Stanek
searching for an alternative explanation, because ‘seronegative’ ACA patients are al-
most nonexistent [16, 17, 95, 96] . Histologic examination of the involved skin is also
needed in suspected ACA, for exclusion of other possibilities and for consolidating
the diagnosis of ACA. The histologic findings depend on the duration and severity of
the skin involvement; more or less pronounced lymphocytic and plasma cell infiltra-
tion of dermis (and sometimes subcutis) is frequently seen, with or without atrophy
[17, 95, 96] . Thus, the diagnosis of ACA is based on clinical, serologic and histologic
criteria. Routine laboratory tests may find mild-to-moderately elevated erythrocyte
sedimentation rates, and raised ␥ -globulin and C-reactive protein concentrations,
but these are usually in normal range and are not of substantial diagnostic help [17,
96]
. Diagnosis of ACA can be further supported by the isolation of borreliae from the
involved skin; isolation is successful in about one third of patients who have not pre-
viously received antibiotics [91] .
Differential Diagnosis
ACA is a relatively frequent borrelial skin manifestation that usually causes many di-
agnostic problems [17, 95, 96] . It can be the first and only sign of Lyme borreliosis,
although a detailed history may reveal antecedent signs of the disease. Previous EM
on the extremity on which months to years later a skin lesion compatible with ACA
develops has been reported by about 10–20% of patients. In some patients, the his-
tory reveals preceding nervous system or joint involvement [17, 95, 96] .
ACA is often overlooked or misinterpreted, not only by patients, but also by their
physicians. Frequent visits to the doctor without establishing a proper diagnosis are
more often the rule than the exception. Difficulties in recognition are usually the re-
sult of limited acquaintance with the disease, but can also be a consequence of atypi-
cal clinical features. ACA has many differential diagnoses, which partly depend on
the stage of the disease. ACA skin lesions on lower extremities are often falsely inter-
preted to be a result of vascular insufficiency (chronic venous insufficiency, superfi-
cial thrombophlebitis, hypostatic eczema, arterial obliterative disease, acrocyanosis,
livedo reticularis, lymphedema, etc.), a consequence of old age (‘old skin’) or chil-
blains. Fibrous nodules are often misinterpreted as rheumatoid nodules and some-
times as skin involvement in the course of gout (tophi) or e ven a s er yt hema nodosum.
It is not unusual for patients with ACA to visit their doctor because of difficulties with
shoes associated with deformations of joints, or because of dysesthesias, hyperesthe-
sias or paresthesias. General physicians and the specialists to whom these patients are
quite frequently referred often fail to appreciate ACA skin lesions, do not take them
seriously or are not able to associate the skin lesions with the involvement of joints
and/or peripheral nervous system [17, 95, 96] .
ACA should be considered as a possible diagnosis in a patient with bluish-red dis-
coloration of a limb with or without swelling and/or atrophy [67] .
Clinical Manifestations and Diagnosis of Lyme Borreliosis 67
Fig. 1. Adult tick on a human host (kindly supplied by Prof.
D. Lipsker).
Fig. 2. Cutaneous biopsy of a tick bite. Mouth piece of the tick
(yellow) is within the human dermis (kindly supplied by Prof.
D. Lipsker).
68 Strle ⴢ Stanek
ab
cd
e
Fig. 3. Examples of erythema migrans with or without central clearing. Erythema migrans is a slowly
expanding red macule or plaque. Usually, but not always, the periphery of the lesion is more visible
and can be slightly raised. Many variants exist, including lesions with more inflammation as well as
small lesions. In other patients, the erythema is hardly visible ( e ) (kindly supplied by Prof. D. Lipsker).
Clinical Manifestations and Diagnosis of Lyme Borreliosis 69
ab
ab
Fig. 5. A redish-blue nodule on the ear lobe is a
typical finding in borrelial lymphoc ytoma (kind-
ly supplied by Prof. D. Lipsker).
Fig. 6. Biopsy specimen of borrelial lymphocytoma. A dense perivascular and perisudoral lympho-
cytic inf iltrate is present and perinervous involvement, as well as the p resence of some plasma cells,
should raise suspicion of borrelial lymphocytoma (kindly supplied by Prof. D. Lipsker).
Fig. 4. Biopsy specimen of erythema migrans. A perivascular and perisudoral lymphocytic infiltrate
is common, and some findings will help lead experienced dermatopathologists to the diagnosis.
Clues are interstitial spreading, the presence of plasma cells and perineural involvement (kindly
supplied by Prof. D. Lipsker).
70 Strle ⴢ Stanek
a
bc
Fig. 7. Acrodermatitis chronica atrophicans
manifests first as a red violaceous inflammatory
patch ( a ), mainly localized on an extremity.
Within months to years it atrophies, and thus
the skin becomes wrinkly, and superficial ves-
sels become visible through a transparent epi-
dermis and dermis ( b , c ) (kindly supplied by
Prof. D. Lipsker).
ab
8
Clinical Manifestations and Diagnosis of Lyme Borreliosis 71
Other Skin Manifestations of Potential Borrelial Etiology
Scleroderma circumscripta and Lichen sclerosus et atrophicus
Soon after the recognition that Lyme disease is a multisystem disorder, several der-
matologic entities were proposed as candidate manifestations of the disease. EM was
accepted very early as being the essential part of the disease, and has been recognized
as a clinical hallmark of Lyme borreliosis; somewhat later, ACA and solitary lympho-
cytoma (lymphadenosis benigna cutis) were clearly demonstrated to be representa-
tions of skin manifestations of Lyme borreliosis. Discussions on the potential bor-
relial etiology of scleroderma circumscripta and lichen sclerosus et atrophicus (scle-
rotic skin lesions of unknown etiology) have been continuing.
Borrelial etiology of these 2 entities has been implicated on the basis of humoral
and cellular immune responses to B. burgdorferi s.l., immunohistologic findings or
silver staining, as well as demonstration of borrelial DNA in and isolation of bor-
reliae from lesional tissue. However, findings reported in the literature are markedly
discordant. The highest prevalence of antibodies to B. burgdorferi s.l. was found
among scleroderma circumscripta patients in Austria (33–54%) and Switzerland (up
to 38%), whereas no differences were found in the frequency or level of borrelial an-
tibodies compared with controls in most other European countries [67] , the USA
[102] and Japan [103] . Lymphoproliferative responses to B. burgdorferi s.l., reflecting
the cellular immune response of patients, were elevated in about one third of 39 Aus-
trian patients with scleroderma circumscripta [10 4] , whereas analyses of 52 Swiss pa-
tients gave inconclusive results [105] . Because of pronounced limitations in specific-
ity and sensitivity of lymphocyte proliferation assays, these findings cannot be reli-
ably interpreted; therefore, the use of this diagnostic approach for the diagnosis of
borrelial infection has been discouraged [14] . There have been several attempts to
demonstrate borreliae in the skin lesions. As reviewed by Mullegger [67] in 2004, spi-
rochetes were found by immunohistology or silver staining of lesional tissue from
about 20 patients with scleroderma circumscripta and a similar number with lichen
sclerosus et atrophicans. Those methods, however, are susceptible to artifacts and in-
terpretation faults, and the findings could not be reproduced by other investigators.
In the same review, Mullegger [67] reported that PCR studies of lesional skin gave
positive results in 21 of 140 scleroderma circumscripta patients and 15 of 40 lichen
sclerosus et atrophicans patients in Europe (particularly Germany and Italy) and Ja-
Fig. 8. Even at lat e and atrophic stages ( a ), diagnosis of acrodermatitis chronica atrophicans should
be suspected histologically as plasma cells remain abundant ( b ). There are numerous clinical and
pathological variants, mimicking granuloma annulare or interstitial granulomatous dermatitis, but
the presence of plasma cells and a perineural involvement are rarely missing (kindly supplied by
Prof. D. Lipsker).
72 Strle ⴢ Stanek
pan [106] , whereas B. burgdorferi s.l.-specific DNA could not be amplified in any of
98 scleroderma circumscripta and 48 lichen sclerosus et atrophicans patients in the
USA [106, 10 7] . With the exception of positive PCR findings in some additional pa-
tients, nothing substantially new has happened during the past 4 years (2004–2008).
Various types of primer have been used in the PCR studies, for example, primers spe-
cific for flagellin, ospA, or rRNA genes of B. burgdorferi s.l. The negative studies ap-
pear to be more comprehensive in that usually more than 1 primer set was applied to
a larger collection of cases [67] . Some of the PCR-positive cases were seronegative;
however, a positive PCR in a seronegative patient with a manifestation lasting for sev-
eral months or even years should be regarded with skepticism [14 , 108] . The attempt
to isolate B. burgdorferi s.l. from lesional skin [67] was successful in 5 scleroderma
circumscripta patients from Austria and southern Germany [109 –111] , but failed in
most other studies [112, 113] . For lichen sclerosus et atrophicans, the demonstration
of B. burgdorferi s.l. by cultivation has succeeded in probably only 1 patient so far
[114] . The isolation of the causative agent (borreliae) from the lesion is the most reli-
able demonstration of the etiology of the process, and indicates that culture-positive
scleroderma circumscripta and lichen sclerosus et atrophicans lesions were really
caused by B. burgdorferi s.l. Although such findings might indicate that a subset of
scleroderma circumscripta and lichen sclerosus et atrophicus is of borrelial origin, it
may well be that this subset of patients in fact have ACA with sclerotic lesions. Scle-
rotic lesions, which are clinically and histologically indistinguishable from localized
scleroderma (morphea) or lichen sclerosus et atrophicus, develop in about 10% of pa-
tients with typical inflammatory ACA [93, 96] .
Cutaneous Lymphoma
A possible association between primary cutaneous B cell lymphomas and B. burg-
dorferi s.l. infection was first suspected because of raised serum borrelial antibody
titers in several small series of patients with primary cutaneous B cell lymphoma.
This was later supported by more definite evidence, including demonstration of bor-
relial DNA by PCR in 18–35% of European patients with various types of primary
cutaneous B cell lymphoma [67, 115] , and by isolation of B. burgdorferi s.l. from skin
lesions in 2 further patients [116] . In addition, the results of a recent case-control
study in Denmark and Sweden suggest an association between B. burgdorferi s.l. in-
fection and risk of mantle cell lymphoma [117] . These European results are in con-
trast to findings in the USA and Asia, where neither molecular [118] nor epidemio-
logic [119] studies could demonstrate an etiopathogenetic role for B. burgdorferi s.l.
in cutaneous B cell lymphoma. This discrepancy was interpreted as possibly due to
differences between B. burgdorferi s.l. strains on the different continents. As shown
in ACA, B. burgdorferi s.l. can persist in the skin for many years, despite the presence
of an active host immune system, possibly by modulation of surface antigens by the
spirochete [17] . In analogy to Helicobacter pylori -associated MALT (mucosa-associ-
ated lymphoid tissue) lymphomas, it is conceivable that the chronic stimulation of
Clinical Manifestations and Diagnosis of Lyme Borreliosis 73
skin-associated lymphoid tissues in response to B. burgdorferi s.l. infection may be
operative in the pathogenesis of a subset of primary cutaneous B cell lymphoma [67,
120] .
The association of borrelial infection and cutaneous B cell lymphomas might have
substantial practical consequences concerning management of these lymphomas. Al-
though from a scientific point of view the magnitude and even the existence of this
association are still uncertain, everyday clinical practice has been influenced. The
European Organization for Research and Treatment of Cancer and the International
Society for Cutaneous Lymphoma recently published consensus recommendations
on management of cutaneous B cell lymphomas in which the authors stated that ‘be-
cause an association between B. burgdorferi infection has been reported in a signifi-
cant minority of European cases of primary cutaneous marginal zone lymphoma, but
not in Asian cases or cases from the United States [115, 118, 120, 121] , in European
areas with endemic B. burgdorferi infection, the presence of B. burgdorferi should be
investigated by serology and polymerase chain reaction techniques on skin biopsy
specimens’ [122] . In the article, treatment with antibiotics is proposed for patients
with primary cutaneous marginal zone lymphoma and evidence of B. burgdorferi s.l.
infection [122] . The proposal is based on analogy with antibiotic treatment of gastric
mucosa-associated lymphoid tissue lymphomas to eradicate Helicobacter pylori [123–
125] and on several recent reviews suggesting that primary cutaneous marginal-zone
lymphoma associated with B. burgdorferi s.l. infection should first be treated with
antibiotics before more aggressive therapies are used [67, 126] . However, the efficacy
of antibiotic treatment in borrelia-associated primary cutaneous marginal-zone lym-
phoma is poorly documented [116, 122, 127–131] . Six of 14 (43%) reported patients
achieved clinical response after various antibiotic regimens; data on 8 patients sug-
gest that systemic treatment with cephalosporins is superior to oral treatment with
high-dose tetracyclines [122] .
We may hope that in the next few years more information will be available on the
association of Borrelia infection and cutaneous B cell lymphoma, which at the moment
seems to be operative in a subset of European patients with this type of lymphoma.
Nervous System Involvement
Lyme Neuroborreliosis
Lyme neuroborreliosis is the involvement of the central and/or peripheral nervous
systems in an infection with B. burgdorferi s.l.
Etiology
In America, all manifestations of Lyme borreliosis, including Lyme neuroborreliosis,
are caused by B. burgdorferi s.s.
74 Strle ⴢ Stanek
In Europe, Lyme neuroborreliosis is most often caused by B. garinii , less frequent-
ly by B. afzelii , rarely by B. burgdorferi s.s. and only exceptionally by other Borrelia
species such as B. valaisiana [132] , B. bissettii [39–41] or as yet unidentifiable species
[133] . The information is based on results of typing borreliae isolated from CSF of
patients with Lyme neuroborreliosis [32, 38, 39, 133–136] , demonstration of distinct
nucleic acid sequences of Borrelia species in the CSF [137, 138] and on species-spe-
cific serologic responses [132, 133] . In all the approaches, the principal species found
in patients with Lyme neuroborreliosis was B. garinii , followed by B. afzelii ( table 2 ).
However, the design of some of the cited studies does not allow one to draw very pre-
cise conclusions on the proportion of the etiologic agents, because of several potential
biases in the collection of isolates and in their selection for typing.
A comparison of patients with B. garinii or B. afzelii isolated from CSF found that
patients with B. garinii infection have a clinical presentation distinct from that of pa-
tients with B. afzelii [136] . In contrast to the B. garinii group, the large majority of the
B. afzelii group did not fulfil the European criteria for Lyme neuroborreliosis [12, 13] .
The findings of the study might indicate that although B. afzelii is able to pass through
the blood-brain barrier, it has restricted ability to initiate substantial inflammation
Tab le 2. Genospecies of B. burgdorferi s.l. as agents of Lyme neuroborreliosis in European patients
[modified from 136]
Mode of detection Reference
No.
Genospecies All
B. garinii B. afzelii B. burgdorferi s.s. others
Isolation from CSF 134 21 10 4 1136
133 3 3
135 25 14 1 40
32 5 1 6
38 26 8 1 35
136 23 10 3 36
39 38 15 18 1272
Total 141 58 27 2 228 (75)
PCR (CSF) 137 11 1 1113
138 4 1 2 7
Total 15 2 2 1 20 (7)
Serology 133 18 2 3 5328
132 16 7 2 3428
Total 34 9 5 8 56 (18)
Total 190 (63) 69 (23) 34 ( 11) 11 (4) 304 (100)
Figures in parentheses are percentages.
1 B. garinii and B. afzelii. 2 B. bissettii. 3 Inconclusive. 4 B. valaisiana.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 75
of the CNS [136] . The significance of this genospecies and of B. valaisiana and B. bis-
settii in Lyme neuroborreliosis remains to be elucidated.
Frequency
Although in the 1980s early neurologic Lyme disease was reported to occur in ap-
proximately 10–15% of untreated patients with Lyme disease in the USA [139, 14 0] ,
the frequency of this manifestation has become less in more recent reports [14, 16 ,
141] , possibly because of bias of ascertainment in the early studies and/or improved
recognition and treatment of patients with EM [14] . In the USA, cranial neuropathy
is the most common manifestation of early neurologic Lyme disease [142] . Peripheral
facial palsy is the most common of the cranial neuropathies, and bilateral involve-
ment of nerve VII may occur [14 3, 14 4] . In areas where Lyme disease is endemic, about
1 in 4 patients who present with nerve VII palsy in nonwinter months can be shown
to have Lyme disease [145] . By far the most common borrelial CNS disorder in the
USA is lymphocytic meningitis [146] ; Lyme encephalitis seems to be extremely rare.
Although there are no firm incidence numbers, estimates are that no more than 1
patient per 1 million population at risk will develop this disorder in any year [14 6] .
Whereas there are several (minor) differences between American and European
Lyme borreliosis, the general trends in the frequency of clinical manifestations in Eu-
rope are most probably similar. Among 1,471 patients with Lyme borreliosis in an
epidemiologic study in southern Sweden, the most frequent clinical manifestation
was EM (77%), followed by Lyme neuroborreliosis (16%) and arthritis (7%) [29] . Ac-
cording to data from the National Institute of Public Health in Slovenia, Lyme neu-
roborreliosis represented 24% of all cases of Lyme borreliosis in 1988 [30] , whereas
during the past 10 years about 90% of patients were registered with EM and only 4–7%
with Lyme neuroborreliosis [31] . Data from the Ljubljana Lyme borreliosis clinic are
shown in table 1 . In Slovenia, about 20% of adult patients and 25% of children with
peripheral facial palsy are associated with Lyme borreliosis [ 147 , unpublished data].
Tick Bites
In meningopolyneuritis (Garin-Bujadoux-Bannwarth syndrome), the most promi-
nent clinical manifestation of Lyme neuroborreliosis in adult European patients, be-
tween one and two thirds of patients remember arthropod bites preceding the onset
of the neurologic involvement [148] . According to the study of Kristoferitsch [149] , a
median of 3 weeks (range 1–18 weeks) elapses from the bite to the onset of neurolog-
ic symptoms. However, the causal relationship between an individual tick bite and
Lyme neuroborreliosis is rather uncertain; it is most reliable when a bite is followed
by an EM. This skin lesion has been reported to precede or sometimes accompany
meningopolyneuritis in 34–64% of patients [148–151] , and has been found in 18 of 33
(55%) patients with B. garinii or B. afzelii isolated from CSF [13 6] . Close topical asso-
ciation between the cutaneous region involved by the EM (and thus by the tick bite)
and the initial radicular lesion has been established in European patients [148 , 151–
76 Strle ⴢ Stanek
156] , in contrast to American patients in whom no such association was found
[146 , 157] .
Histology
Knowledge of histopathologic findings in t he CNS is li mited. In patients w ith menin-
goradiculoneuritis, lymphocytic involvement of leptomeninges, ganglia, and afferent
and efferent rootlets is present. The CNS may show focal microgliosis [57, 158, 159] .
In peripheral neuropathy accompanied by ACA, lymphocytes and plasma cells are
present around blood vessels in the perineurium, with occasional sparse lymphocytes
in the vessel wall. Vessel walls show no signs of necrosis, but may become thickened
and obliterated; thrombosis may develop [57] . Fibers within the nerve eventually lose
myelin. The most striking finding is axonal degeneration [57, 98] .
Neuropathologic and neurophysiologic evidence in patients with peripheral ner-
vous system involvement resulting from borrelial infection [14 6] , and in experimen-
tally i nfected rhesus macaque monkeys [160] , indicates that this infection causes chang-
es in multiple peripheral nerves that are affected individually (mononeuropathia mul-
tiplex type of involvement) as a consequence of local damage to vessels (but without
evidence of vessel wall necrosis, the usual requirement to be termed vasculitis) [146] .
Clinical Characteristics
Early Lyme Neuroborreliosis
Lyme neuroborreliosis may appear early, during the first few weeks or months, or
late in the course of Lyme borreliosis. The initial clinical report of early Lyme neu-
roborreliosis was in 1922 [161] , although it was not classified as such until more than
65 years later. Early Lyme neuroborreliosis typically comprises lymphocytic menin-
gitis and involvement of cranial and peripheral nerves [3, 156, 157, 162] . Usually the
most pronounced clinical symptom is pain as a result of radiculoneuritis. The pain
is usually severe and most pronounced during the night; patients may be deprived
of sleep for several weeks. When located in the thoracic or abdominal region, the
pain is often belt-l ike. Radicular pain is seen more often in European t han in Amer-
ican patients, and is usually more frequent and more pronounced in adults than
children [16 , 157, 162] . Although painful radiculoneuritis is clinically the most typ-
ical and pronounced manifestation of peripheral nervous system involvement in
adults with early European Lyme neuroborreliosis, other types of peripheral nerve
involvement may be present. Involvement of motoric nerves may lead to paresis,
usually asymmetric [162, 163] and, in contrast to general opinion, not always clini-
cally prominent [164] .
Patients with borrelial meningitis usually suffer from mild intermittent headache,
but in some patients the headache may be excruciating. In adult European patients,
there is often no fever, nausea is usually mild or absent, and vomiting is frequently
absent. Meningeal signs are usually only mildly expressed or may be absent [16 2, 163] .
Physicians not used to patients with borrelial meningitis are often surprised by ab-
Clinical Manifestations and Diagnosis of Lyme Borreliosis 77
normal CSF findings. These comprise lymphocytic pleocytosis up to several hundred
! 10 6 cel ls/l, normal or slight-to-moderately elevated protein concentration, and nor-
mal or mildly depleted glucose concentration. Overall, the course of borrelial menin-
gitis resembles relatively mild but unusually protracted viral meningitis with inter-
mittent improvements and deterioration [3] .
Any cranial nerve may be affected in early Lyme neuroborreliosis, but facial nerves
are by far the most frequently involved (about 80%), resulting in unilateral or bilat-
eral peripheral facial palsy [3, 143, 145–147, 157] . Patients with borrelial peripheral
facial palsy often show lymphocytic pleocy tosis, even those without any sign or symp-
tom of meningitis [3, 16, 146, 147] . According to general opinion, prognosis of bor-
relial peripheral facial palsy is good not only in antibiotic-treated patients, but also in
those who are not treated [16, 157, 163] . According to data from the USA, more than
90% of patients show improvement leading to, or close to, normal [143, 14 5, 146] .
However, in clinical and neurophysiologic examinations, mild sequelae were found
in as ma ny a s ha lf of Swed ish ch ildren w ho had per ipheral facial palsy associat ed w ith
Lyme neuroborreliosis 3–5 years earlier [165] . Results from another Swedish study
revealed that one fifth of children with acute facial palsy have permanent mild-to-
moderate dysfunction of the facial nerve, but that other neurologic symptoms or
health problems do not accompany the sequelae of the facial palsy, and that treatment
of Lyme neuroborreliosis seems to have no correlation with clinical outcome of pe-
ripheral facial palsy [166] . Shortly after onset of symptoms, intrathecal antibodies
may not be detectable and CSF pleocytosis may be absent in patients (predominantly
children) with isolated facial palsy [3] . Patients who present with peripheral facial
palsy as the sole neurologic manifestation of Lyme borreliosis only very rarely have (a
history of recent) EM. Involvement of most other cranial nerves has been described,
but particularly III (oculomotor), VI (abducens) and VIII (vestibulo-auditory). Criti-
cal appraisal of the literature suggests that the involvement of some cranial nerves (for
example, optic nerve) occurs extremely rarely, if ever [146 , 167] .
In adult European patients, early Lyme neuroborreliosis usually begins gradually
with increasing pain, later on accompanied by palsies and other neurologic signs and
symptoms that will, if untreated, not diminish for many weeks [3] . In children, pain-
ful radiculoneuritis is rare, but isolated meningitis and peripheral facial palsy are
more common than in adults. In Slovenia, about 20% of adult patients and 25% of
children with peripheral facial palsy have associated Lyme borreliosis [ 147 , unpub-
lished data]. Pseudotumor cerebri is an unusual manifestation of Lyme neurobor-
reliosis seen primarily in children [168, 169] .
L a t e L y m e N e u r o b o r r e l i o s i s
With the exception of peripheral neuritis in association with ACA, late Lyme neu-
roborreliosis is most probably very rare. Peripheral neuritis occurs in more than half
of patients with long-lasting (advanced) ACA skin lesions [162, 170] . Critical apprais-
al of the literature suggests that peripheral neuritis without ACA is an extremely rare
78 Strle ⴢ Stanek
condition; that is, among patients with peripheral neuropathy, the proportion of those
with Lyme neuroborreliosis is negligible.
Up to 10% of European patients with untreated meningopolyneuritis (Garin-Bu-
jadoux-Bannwarth syndrome) develop features of disseminated encephalomyelitis
that may in some respects resemble those seen in multiple sclerosis [162] .
Subtle encephalopathy has been reported predominantly by American authors [16,
157, 171] .
D i a g n o s i s
Lyme neuroborreliosis may appear during the first few weeks or months after infec-
tion or not until late in the course of Lyme borreliosis. Early Lyme neuroborreliosis,
which is better defined and much more frequent than late Lyme neuroborreliosis [1,
3, 12, 13, 18] , typically comprises lymphocytic meningitis and involvement of cranial
and peripheral nerves [157] . Clinical diagnosis is straightforward when the triad is
complete or when 1 or more manifestations of the triad are associated with the pres-
ence of or a reliable history of EM [1, 3, 12, 13, 18, 157] .
The diagnosis of early Lyme neuroborreliosis is normally based on clinical char-
acteristics, the presence of lymphocytic pleocytosis and demonstration of CNS bor-
relial infection, as evidenced by seroconversion, intrathecal borrelial antibody pro-
duction, isolation of borreliae from CSF samples or demonstration of borrelial DNA
in CSF samples [12, 13, 108, 136] . In practice, seroconversion is rarely found to be a
useful criterion because by the time that neurologic signs appear, the majority of pa-
tients are seropositive. In addition, seroconversion confirms recent borrelial infec-
tion, but it does not confirm CNS involvement. The main limitations of PCR for dem-
onstration of borrelial DNA in CSF samples are low sensitivity, the possibility of false-
positive findings and the lack of procedure standardization [13, 108] . Isolation of the
etiologic agent from patient samples is the most reliable method for diagnosis of bor-
relial infection, and isolation of the etiologic agent from CSF is the most reliable
method for diagnosis of Lyme neuroborreliosis. Isolation also provides live micro-
organisms that can be further characterized; however, isolation from CSF samples
is a markedly low-yield procedure, and results are obtainable only after several weeks
[1, 3, 108, 136 , 172] . Demonstration of intrathecally synthesized borrelial antibodies
has generally been used for establishment of a diagnosis of Lyme neuroborreliosis in
everyday European clinical practice. The problem with this diagnostic approach is
insensitivity during the first few weeks of CNS involvement and long persistence of
the antibodies; intrathecal borrelial antibody production can be detected for several
months or years, even after appropriate antibiotic treatment [12, 13, 108, 136] .
A diagnosis of Lyme neuroborreliosis involving the peripheral nervous system is
even more difficult because of the limited possibilities of demonstrating borrelial in-
fection of peripheral nerves. For a reliable diagnosis, (an objective) proof of the in-
volvement of the nervous system is necessary (clinical, neurophysiologic and neuro-
pathologic approaches are generally available for demonstration of peripheral nervous
Clinical Manifestations and Diagnosis of Lyme Borreliosis 79
system involvement), together with demonstration of (active) borrelial infection (usu-
ally the only available approach in this group of patients is demonstration of borrelial
antibodies in serum; however, serology has many limitations) and proof that the bor-
relial infection really is the cause of the peripheral nervous system involvement. Be-
cause of the many obstacles with all 3 requirements (the second and especially the
third are even harder to fulfil than the first), it is obvious that reliable diagnosis of pe-
ripheral nervous system involvement as a consequence of borrelial infection pro-
foundly depends upon the concomitant presence of CNS Lyme neuroborreliosis (in
which borrelial CNS involvement can be demonstrated by corresponding findings in
CSF examination) and/or the presence of some other manifestations of Lyme borreli-
osis such as EM (for example, in patients with cranial nerve involvement) or ACA.
Differential Diagnosis
Differential diagnosis comprises a list of differential diagnoses for each main mani-
festation of Lyme neuroborreliosis [meningitis, radiculo(neuritis), cranial nerve in-
volvement and so on]. However, an exact history and meticulous clinical examination
often substantially narrow the differential possibilities.
Cardiac Involvement
Lyme Carditis
Lyme carditis is heart involvement related to a Borrelia infection that usually presents
with the acute onset of varying degrees of intermittent atrioventricular (A-V) heart
block, sometimes in association with clinical evidence of myopericarditis.
Frequency
Information on the relative frequency of Lyme carditis is incomplete. Lyme carditis had
ea rl ier been reporte d to occu r i n 0. 3– 4% of u nt rea ted Europea n patients wi th Lyme bor -
reliosis and in 4–10% of corresponding patients in the USA [14, 173–175] . However, the
frequency of this manifestation is reported to be much lower in more recent series [1 76 ,
177]
. No evidence of carditis was found among 233 cases with definite Lyme disease in
2 prospective studies on the evaluation of a recombinant OspA vaccine in the USA [17 8,
179] ; in a Swedish epidemiologic study, only 7 of 1,471 (0.5%) patients diagnosed with
Lyme borreliosis had Lyme carditis [29] , and at the Ljubljana Lyme borreliosis clinic,
where between 600 and 900 patients with different manifestations of Lyme borreliosis
are diagnosed each year, Lyme carditis represents up to 0.5% of cases [unpublished
data]. This diminution in the frequency of Lyme carditis, like the one observed for acute
neurologic manifestations, could be the result of a bias of ascertainment in early studies
and/or improved recognition and treatment of patients with EM [14] .
80 Strle ⴢ Stanek
Etiology
There are no direct data on the Borrelia species causing Lyme carditis. In the USA,
Lyme carditis should be caused by B. burgdorferi s.s., the only species causing Lyme
borreliosis in humans there; in Europe, the main candidates are B. afzelii , B. garinii
and B. burgdorferi s.s. A heart isolate of 1990 [180] was later identified as B. burgdor-
feri s.s., but this has not been published.
Tick Bites
In a series of 20 patients with Lyme carditis presented by Steere et al. [174] , 2 reported
a tick bite, and in a series of 66 European patients with Lyme carditis collected by van
der Linde [175] , tick bite prior to the onset of Lyme carditis was recalled by 31 (47%)
patients.
Histology
Information on histologic findings is limited, and is based on rare cases of heart tissue
examination obtained at autopsy and on material acquired by endomyocardial biopsy.
Histopathologic findings include an interstitial infiltrate of lymphocytes and plasma
cells involving the myocardium, pericardium and endocardium. Aggregates of lym-
phocytes may be seen in the myocardium. Muscle fibers are usually intact, but indi-
vidual myocardial fibers show sporadic infiltration with lymphocytes. The endocar-
dium shows band-like infiltrates of lymphocytes and plasma cells [174, 175, 181, 182] .
Examination of the heart conducting system in 1 patient revealed localized edema and
slight lymphocytic infiltration of sinoatrial and A-V nodes, fibers with contraction
band necrosis in an edematous area of the sinoatrial node, focal edema in the bundle of
Hiss, and a fibrotic lesion in the left bundle branch [57] . Vasculitis involving the small
and large intramyocardial vessels can be present [173] . The small vessels frequently
show endothelial cell edema, whereas large vessels show adventitial infiltrates with
loose reticulin and increased collagen deposition [158, 183] . Spirochetal forms located
inside and near cellular infiltrates, between muscle fibers, and in the myocardium [15 8 ,
184, 185] have been found i n endomyoca rdial biopsy [184] and autopsy specimens [181] .
They have also been cultured from biopsy specimens [180] . Whether the presence of
live borreliae is required for continued disease or whether the disease results (predom-
inantly) from immune-mediated mechanisms remains to be determined [173] .
Clinical Characteristics
Lyme carditis typically occurs between June and December, usually within 2 months
(range 4 days–7 months) after the onset of infection, and more often affects men than
women [14, 174, 176, 186] . The cardiac manifestations are often coincident or in close
temporal proximity with other features of Lyme borreliosis such as EM [174, 186, 187] ,
Lyme neuroborreliosis [174 , 187] or arthritis [174, 185] . In a large European series of
patients who had Lyme carditis, EM was found in 67%, joint complaints in 51% and
Lyme neuroborreliosis in 27% [185] . However, there are patients who present with
Clinical Manifestations and Diagnosis of Lyme Borreliosis 81
Lyme carditis (usually with complete heart block) as the sole manifestation of Lyme
borreliosis.
Cardiac involvement may be asymptomatic. When symptomatic, the most com-
mon complaints include light-headedness, syncope, dyspnea, palpitations and/or
chest pain [173] . Patients with symptomatic cardiac involvement associated with
Lyme borreliosis usually present with the acute onset of varying degrees of intermit-
tent A-V heart block, sometimes in association with clinical evidence of myopericar-
ditis [174, 176, 183, 185–187] . Electrophysiologic studies have usually demonstrated
block occurring above the bundle of Hiss, often involving the A-V node, but heart
block may occur at multiple levels [174, 176, 185] . Cases of pericarditis, endocarditis,
myocardial infarction, coronary artery aneurism, QT-interval prolongation and con-
gestive heart failure have also been associated with Lyme borreliosis [173] , but for
some of these the causal association remains uncertain.
Lyme carditis is characterized by changing A-V blocks as a result of conduction
disturbances [18, 174, 176, 185] . The course is usually favorable. In both antibioti-
cally treated and untreated patients, complete heart block usually disappears within
a week, whereas symptoms of heart involvement and ECG abnormalities usually van-
ish within 3–6 weeks [14, 174, 176, 185] . Hospitalization and permanent ECG surveil-
lance are needed in patients who have first-degree A-V block with P-Q interval longer
than 0.30 s, second- or third-degree A-V blocks, quickly changing A-V blocks or he-
modynamica lly important arrhythmias [3, 176, 18 5] . In a case of complete heart block,
insertion of temporary heart pacemaker may be life-saving. Complications are rare
and include partial improvement of conduction disturbances with a consequent per-
sistent (first-degree A-V) block, and possible induction of chronic cardiomyopathy
[180] . Complete heart block would be the only reason for a lethal outcome in patients
with Lyme borreliosis, and fortunately it is an extremely rare event [3, 16, 188] .
Diffuse ST segment and T wave changes on surface electrocardiograms were not-
ed in 65% of patients in the series of patients with Lyme carditis of Steere [174] ; al-
though nonspecific, these findings may indicate diffuse myocardial involvement
[173] . Myocardial involvement may lead to cardiomegaly, left-ventricular dysfunction
or clinical congestive heart failure and is thought to be present in 10–15% of patients
with Lyme carditis [185, 186] . In most cases, myocardial dysfunction is mild and self-
limited [174, 189] .
It has been suggested that borreliae may play a causative role in chronic heart fail-
ure. This hypothesis originated from a 1990 Austrian case report on a 54-year-old
man with a 4-year history of dilated cardiomyopathy, high levels of B. burgdorferi s.l.
IgG antibodies in serum, and isolation of B. burgdorferi s.l. from an endomyocardial
biopsy specimen [180] . The hypothesis was supported in some later reports on a lim-
ited number of p ati ent s [19 0, 191] , whereas in other reports, apparently more convinc-
ing ones, it was not backed up [19 2] . Further studies are warranted to clarify the po-
tential role of B. burgdorferi s.l. in acute and chronic congestive heart failure [173] .
According to the recent IDSA guidelines [14] , severe or fulminant congestive heart
82 Strle ⴢ Stanek
failure or development of valvular heart disease are not associated with Lyme disease
[176] and, at least in the USA, there is no convincing evidence that Lyme disease is a
cause of chronic cardiomyopathy [192 , 193] .
D i a g n o s i s
Lyme carditis usually presents with the acute onset of varying degrees of intermittent
A-V heart block, sometimes in association with clinical evidence of myopericarditis
[174, 176, 183, 185–187] .
Diagnosis of Lyme carditis should be based on demonstration of heart involve-
ment manifested by either conduction disturbances (established by electrocardio-
graphic and/or electrophysiologic findings) and/or myo(peri)carditis (demonstrated
pathohistologically in endomyocardial biopsy specimens, or suggested by electrocar-
diographic, echocardiographic and/or MRI findings), and corroborated with the
demonstration of borrelial infection by 1 or more of the following: (1) isolation of bor-
reliae from an endomyocardial biopsy specimen and/or demonstration of borrelial
DNA in the specimen; (2) by seroconversion to borrelial antigens; (3) by the presence
of Borrelia antibodies in serum; (4) by the presence of EM and/or Lyme neurobor-
reliosis together with or in close temporal proximity to Lyme carditis. In practice,
there are several obstacles to the proposed diagnostic approaches. Endomyocardial
biopsy is not a routine diagnostic procedure in patients with suspected Lyme carditis
because the potential yield is suboptimal, due to the focality of myocarditis, and the
procedure carries an inherent risk [173] . In addition, seroconversion is rarely found
to be a useful criterion, because at the time of the appearance of Lyme carditis the
majority of patients are seropositive [175, 176] . Moreover, seroconversion confirms
recent borrelial infection, but does not confirm heart involvement and, in addition,
seropositivity cannot distinguish between recent and delayed infection or between
active and past infection. In practice, therefore, the most reliable method of demon-
strating borrelial infection to enable the interpretation of heart involvement to be
Lyme carditis is the presence of another typical manifestation(s) of Lyme borreliosis.
Because Lyme carditis usually occurs within 2 months after onset of infection, EM
[174, 186, 187] or Lyme neuroborreliosis [174 , 187] quite often occur concomitantly or
in close proximity to the carditis. In fact, concurrent EM, which enables a reliable di-
agnosis of early Lyme borreliosis, is present in up to 85% of cases [186] .
The diagnosis of Lyme carditis should be further substantiated by the absence or
exclusion of other (obvious) explanations for cardiac abnormalities.
Differential Diagnosis
The differential diagnosis of Lyme carditis is extremely broad and includes diseases
that can cause conduction disturbances, endomyocarditis and pericarditis that may be
due to infectious agents (viral, bacterial, mycotic and parasitic), as well as noninfec-
tious causes. Because of a large number of potential other causes, the attribution of
rhythm disturbances to the infection is highly problematic [175] , and is usually sup-
Clinical Manifestations and Diagnosis of Lyme Borreliosis 83
ported with only indirect demonstration of infection (often limited to demonstration
of specific antibodies in serum). The clinical manifestations of other diseases, specific
laboratory tests, epidemiologic data and general information, such as age and state of
health at the onset of the illness, can help in differentiating from Lyme carditis [175] .
Joint Involvement
Lyme Arthritis
Lyme arthritis, the main joint manifestation in the course of Lyme borreliosis, is an
inflammatory arthritis associated with B. burgdorferi s.l. infection. It is predominant-
ly a monoarticular or oligoarticular form of arthritis, and typically involves the knee.
Frequency
Although Lyme arthritis was reported to occur in 60% of untreated patients with Lyme
disease in the USA about 20 years ago [194] , the frequency of this manifestation has
been ^ 10% in recent series [141, 178, 179, 195] , probably because of improved recogni-
tion and earlier treatment of patients with early Lyme disease [14] . However, this is in
contrast to the much higher frequency of arthritis among Lyme disease cases reported
to the CDC [142] . For example, during 2003–2005, the CDC received reports of 64,382
Lyme disease cases. Records for 32,095 (50%) of these patients met the criteria for
evaluation of symptoms. A history of EM was reported for 70%, arthritis for 30%, fa-
cial palsy for 8%, radiculopathy for 3%, meningitis or encephalitis for 2%, and heart
block for ! 1% [142] . Possible explanations for the higher proportion of arthritis cases
in national reporting include reporting bias favoring the tabulation of seropositive
Lyme disease cases, confusion between arthritis and arthralgia by the treating health
care provider, and inaccuracy of Lyme disease diagnosis. In addition, surveillance re-
port forms differ by state, and reported seropositivity in support of a diagnosis of Lyme
arthritis is not necessarily based on recommended two-tier testing [14, 14 2] .
The existence of Lyme arthritis in Europe was recognized only after the reports
from the USA. Although joint abnormalities in patients with ACA had been repeat-
edly described in the European dermatologic literature since 1922 [100] , and even the
term ‘akrodermatitis atrophicans arthropathica’ had been proposed [196] , a causal
relation of joint and bone abnormalities with ACA had been questioned [101] . Joint
symptoms had been mentioned in case reports of patients in Europe with erythema
chronicum migrans [100, 19 7] and lymphocytic meningitis [100, 198, 199] , yet the as-
sociation of arthritis with EM and neurologic disease was not recognized until Lyme
arthritis was described in the USA [5] .
From the very beginning of understanding that arthritis is a manifestation of
Lyme borreliosis, there has been a firm conviction that this is less common in Europe
than in the USA [100] . However, information on the (relative) frequency of Lyme ar-
84 Strle ⴢ Stanek
thritis in Europe is limited. In an epidemiologic study in southern Sweden, 98 of 1,491
(7%) patients diagnosed with Lyme borreliosis had Lyme arthritis [29] , and among
Lyme borreliosis cases at the Ljubljana Lyme borreliosis clinic arthritis is present in
2–5% of adult patients [unpublished data]. However, in a nationwide survey in Ger-
many where 3,935 patients were reported to be diagnosed with Lyme borreliosis in a
1-year period (March 1998 to February 1999), the most frequent clinical manifesta-
tion was EM in 50.9% of the patients, 24.5% had Lyme arthritis (14.7% mono- or oli-
goarthritis, 9.8% polyarthritis) and 18.4% had neuroborreliosis [200] . Possible expla-
nations for the relatively high proportion of Lyme arthritis in that survey, especially
in comparison with the frequency of neuroborreliosis, could be at least partly similar
to those for the national reporting system in the USA.
E t i o l o g y
Since the isolation rate of borreliae from joint fluid and synovia is notoriously low
[108] , data on the etiology of Lyme arthritis are based predominantly on detection
and typing of borrelial DNA in synovial fluid or synovial tissue by PCR. Information
on the etiology in Europe is limited. Because of the apparently (much) higher preva-
lence of Lyme arthritis in the USA than in Europe, there was a conviction that in Eu-
rope the arthritis was due to infection with B. burgdorferi s.s., the strain causing Lyme
borreliosis in North America. However, the association of European Lyme arthritis
and B. burgdorferi s.s. does not appear to be firm. PCR-based analyses of samples
from European patients with Lyme arthritis gave inconsistent results, indicating that
B. burgdorferi s.s. appears to be either the sole, the major or just one of the pathogens
involved. In the Netherlands, borrelial DNA was detected in synovial tissue and sy-
novial f luid in 3 of 4 patients with Lyme arthritis; in all 3, B. burgdorferi s.s. was iden-
tified by reverse line blot [201] . However, among 10 consecutive PCR-positive patients
with Lyme arthritis from northeastern France, 2 species were identified in synovial
samples: B. burgdorferi s.s. in 9 cases and B. garinii in 1 case [202] . The conclusion
that B. burgdorferi s.s. is the principal but not the only Borrelia species involved in
Lyme arthritis was further substantiated by another report of 2 cases of treatment-
resistant Lyme arthritis, in which DNA amplification of the flagellin gene followed
by dot-blot hybridization in the synovial fluid identified B. garinii as the causative
agent [203] . A study from Munich, using ospA type-specific PCRs, found B. burgdor-
feri s.l. DNA in synovial fluid in 13 of 20 patients with the diagnosis of Lyme arthritis
(positive serologic findings and fulfilled clinical criteria): B. burgdorferi s.s. was es-
tablished in 27%, B. afzelii in 33% and B. garinii in 40%. The conclusion of the authors
was that in Europe B. burgdorferi s.l. strains causing Lyme arthritis are considerably
heterogeneous, and that there is no prevalence of particular genospecies or OspA
types among these strains [204] . Similar results have been reported by Eiffert et al.
[205] , where PCR was used to identify a part of the ospA gene in 7 of 11 synovial
fluid samples of patients with Lyme arthritis: sequencing the amplified DNA found
B. burgdorferi s.s. in 3 patients, B. garinii in 3 patients and B. afzelii in 1 patient.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 85
Pathogenesis
In spite of abundant research, several issues in the pathogenesis of Lyme arthritis re-
main obscure. As in other manifestations of Lyme borreliosis, the presence of the
causative agent (most information on Lyme arthritis is for B. burgdorferi s.s.) and im-
mune mechanisms are involved; in Lyme arthritis, the immune mechanisms are
probably e ven mo re i mpo rtant t han i n mo st o ther mani fes tations of Lyme borreliosis.
After transmission in the bite of an infected tick, the borreliae change expression of
several immunostimulatory outer-surface lipoproteins thought to play a role in dis-
semination to synovial tissue and in the pathogenesis of inflammation in the joint
itself [206] . B. burgdorferi s.l. does not produce proteases, and therefore does not cause
the rapid joint destruction seen in classic septic arthritis [207] . The acute arthritis
results from borrelia-induced infiltration of mononuclear cells into the synovial tis-
sue and the accumulation of neutrophils, immune complexes, complement and cyto-
kines in the synovial fluid. In untreated Lyme arthritis, host factors involved may
include TLR2 and MyD88 [208] . Other arthritogenic factors may comprise adhesion
molecules such as P66 that bind the extracellular matrix, decorin-binding proteins A
and B, Bgp and BKK [209] . Matrix metalloproteinases may be involved in the patho-
genesis of erosive features in the joint in long-standing infection, and possibly also in
antibiotic-refractory arthritis [210, 211] .
A small subset of patients who have already received standard antibiotic treatment
may have persistent Lyme arthritis. In general, 3 main models for the immunopatho-
genesis of antibiotic-refractory Lyme arthritis have been proposed [207] : persistent
infection, T cell epitope mimicry and bystander activation. None of them has enabled
a reliable and complete explanation for all patients: the etiology is most probably mul-
tifactorial and may vary from patient to patient [207] .
Histologic Findings
The pathologic alternatives in Lyme arthritis correspond to a nonspecific synovitis.
The inf lammatory infiltrate shows predominately lymphocytes, often in follicular
structures with incomplete germinal centers, and plasma cells. Mast cells can easily
be found in the areas of increased vascularization [57, 158, 212] .
Chronically inflamed hypertrophic synovial villi with deposition of fibrinaceous
eosinophilic material in the synovia are seen in specimens of synovectomized pa-
tients. Unlike other nonspecific inflammation of joints, in Lyme arthritis the synovi-
um is rarely scarred. Obstruction of small blood vessels with synovial fibrin deposi-
tion is quite often seen [57, 100, 212, 213] .
Clinical Characteristics
The spectrum of articular manifestations in Lyme arthritis can be, rather academi-
cally, classified into 3 categories: (1) arthralgias (musculoskeletal pain) without objec-
tive findings; (2) arthritis (intermittent or chronic) with objective clinical findings; (3)
chronic joint and bone involvement under the affected skin in ACA [10 0] . The main
86 Strle ⴢ Stanek
and the most important rheumatic manifestation of Lyme borreliosis is arthritis, and
the most elusive presentation is arthralgia that may precede, accompany or follow ar-
thritis, but may sometimes be the only rheumatic manifestation of Lyme borreliosis.
The most complete description of the clinical evolution of Lyme arthritis is in the
report by Steere et al. [194] on 55 untreated patients who had EM during the years 1976–
1979, that is, before antibiotic treatment of Lyme disease was established in the USA. Of
these 55 patients, 11 (20%) had no musculoskeletal symptoms after the resolution of
EM, arthritis developed in 34 (62%; in about half, the arthritis was preceded by arthral-
gias), and arthralgias alone were seen in 10 (18%) patients. Those with arthralgias had
brief episodes of pain in joints, tendons, enthesis, bones or muscles without objective
signs of inflammation. The symptoms tended to be migratory, with onset from 1 day
to 8 weeks (mean, 2 weeks) after the onset of EM. Symptoms lasting from 1 month to
as long as 6 years (mean, 3.1 years) had a relapsing/remitting pattern, and were often
accompanied by fatigue [194] ; however, patients with arthralgias associated with Lyme
borreliosis (who may or may not have Lyme arthritis) generally did not experience
widespread chronic pain [207] . No corresponding European report on the natural his-
tory of a large number of untreated EM patients exists, most probably as a consequence
of antibiotic treatment of EM which has been widely practiced in Europe since 1951
[214] , long before the complete clinical picture of Lyme borreliosis (including arthritis)
and the etiology of the disease were established. It has been reported that only 1 of 16
Swedish patients developed arthritis after spontaneous healing of EM [215] .
The succession or coexistence of intermittent attacks of musculoskeletal pain and
arthritis have also been reported in Europe, and have been interpreted as particu-
larly indicative of Lyme arthritis [10 0] . In 25 of 65 patients with Lyme arthritis in
Germany [216] , episodes of severe pain in joint and periarticular sites had either pre-
ceded arthritis for several weeks or months (8 patients), had preceded and continued
after arthritis (5 patients), or had developed as late as arthritis (12 patients). Particular
episodes lasted from some hours to several days, and were separated by days to months
of remission. Episodes of arthralgias sometimes alternated with attacks of arthritis.
Predominantly large but also small joints were affected in an often migratory pattern,
but commonly only 1 or 2 sites were affected at any one time [100] .
Arthralgias are a relatively frequent complaint early in the course of Lyme bor-
reliosis, in patients with EM before therapy and in some patients even after antibi-
otic treatment, and more commonly accompany EM in the USA than in Europe. In
the early studies, arthralgias were reported in as many as 48% of patients with EM in
North America [60] , but in only 22% at the most in European patients [53] . In a group
of culture-positive adult patients in New York state with EM caused by B. burgdorferi
s.s., arthralgias were reported in 48 of 119 (40%) prior to treatment, whereas in Slo-
venian patients with B. afzelii isolated from the skin lesion, the frequency was only 23
of 85 (27%) [15] . In a study in 1994 on 231 European patients with culture-confirmed
EM at the Ljubljana Lyme borreliosis clinic, 27 (12%) patients reported arthralgias
that a s a r ule wer e m ild-t o-mod er ate ly se ver e [55] . Arthralgias may be present in some
Clinical Manifestations and Diagnosis of Lyme Borreliosis 87
patients after standard antibiotic treatment of EM, usually during the first few weeks
after treatment, but normally vanish within 6 months after treatment. Whether they
had arthralgias or not, patients treated for solitary EM with standard courses of an-
tibiotics only very exceptionally develop later objective manifestations of Lyme bor-
reliosis, including arthritis [14] .
Lyme arthritis affects both children and adults. Several patients remember tick
bite(s); however, temporal association between an individual tick bite and the onset
of Lyme arthritis is often difficult to assess and is most reliable in patients who de-
velop EM at the site of the bite. In patients from North America who had EM but did
not receive antibiotic treatment and were followed up for a mean duration of 6 years
(range 3–8 years), arthritis occurred from 4 days to 2 years after disease onset (mean
6 months) [194] . In a European series of patients [216] , the period from tick bites or
EM to the onset of arthritis ranged from 10 days to 16 months (median, 3 months).
However, there are case reports of patients in whom tick bite and EM had preceded
arthritis for much longer periods of time [100] . Since the latent period between in-
fection and onset of Lyme arthritis is highly variable and mostly runs for several
months, there is no seasonal peak in the occurrence of Lyme arthritis [100] .
Lyme arthritis can be preceded or accompanied by other manifestations of Lyme
borreliosis. In the initial description of Lyme disease in the USA, 13 of 51 (25%) pa-
tients reported having had EM before they developed arthritis [5] . Of 65 German pa-
tients with Lyme arthritis, 40 were without history of well-defined Lyme borreliosis
or concurrent extra-articular disease manifestations, whereas 25 (38%) had at least 1
additional manifestation including EM (21 patients, 32%), Lyme neuroborreliosis (14
patients, 22%), ACA (5 patients, 8%) and carditis (1 patient) [10 0] . In a 1-year nation-
wid e sur vey i n Ger many, 32% of p atients w ith Ly me ar th riti s reme mbered havi ng had
an EM [200] . An epidemiologic study of Lyme borreliosis in southern Sweden found
that among 98 patients diagnosed with Lyme arthritis, the arthritis was the sole main
manifestation in 65 (66%) patients, whereas in the others it was associated with ad-
ditiona l ma nifes tat ion(s) suc h as EM (10 patient s), Lyme ne urobor reliosis (8 patients),
ACA (8 patients) and borrelial lymphocytoma (1 patient); 6 patients with arthritis had
at least 2 additional main manifestations of the disease [29] .
Several European authors have emphasized that Lyme arthritis often begins in the
extremity that was affected by a tick bite or EM [216–218] ; for example, this correla-
tion was observed in 15 of 18 patients in whom EM had preceded arthritis [216] . Such
an observation has not been reported from the USA.
Lyme arthritis usually consists of intermittent attacks of inflammation of one or a
few joints and is often preceded by intermittent migratory joint pain. Joint involve-
ment is usually asymmetric, onset of arthritis is acute and with effusion, and skin
over the affected joint is warm but of normal color [16] . The arthritis is frequently
mono- or oligoarticular, only rarely polyarticular. In a European series of 65 patients
with Lyme arthritis [100] , the course was intermittent in 55 (85%), initially intermit-
tent and later chronic in 4 (6%) and unremitting (chronic) in 6 (9%); the pattern of
88 Strle ⴢ Stanek
joint involvement was monoarticular in 39 (60%; onset of arthritis was monoarticular
in as many as 55 patients), oligoarticular in 21 (32%) and polyarticular in 4 (6%) pa-
tients. One patient had isolated heel swelling [10 0] .
Large joints are predominantly involved, most often the knee. In 28 patients with
a relapsing/remitting course of Lyme arthritis presented in a classic series by Steere
et al. [194] , the knee was involved in all but 1 patient; shoulder, ankle, elbow, temporo-
mandibular joint, wrist and hip were affected in the range of 28–43%, and metacar-
pophalangeal, proximal interphalangeal, distal interphalangeal and metatarsopha-
langeal joints were involved in 3 (11%) patients. One patient had sternoclavicular in-
volvement. Similarly, in the European series of 65 patients with Lyme arthritis
reported by Herzer [10 0, 216] , involvement of the knee was by far the most common
(outnumbering the frequency of any other joint involvement by 6 2.5 times), followed
by ankle, wrist, finger, toe and elbow (seen in 10–30% of patients); involvement of
midtarsal joints, sternoclavicular joint and hip occurred only exceptionally. Heel
swelling was found in 6 (9%) patients (1 had heel swelling only) and sausage digits
(dacty litis) i n as many as 15 (23%). In a subgrou p of 24 p atients with knee invol vem ent
investigated by ultrasound, Baker cysts were found in as many as 12 (50%).
Joints are painful; however, some patients with pronounced joint (knee) effusions
may have disproportionately mild pains [19 4] . Joint inflammation usually lasts a few
days to weeks, sometimes several months [194] . The course of Lyme arthritis is very
variable, usually recurring and may continue for several years. In the beginning, the
attacks of arthritis are more frequent and short, later they may be more prolonged.
Every year about 10–20% of patients have complete resolution of the attacks. About
10% of patients develop chronic arthritis with duration of a year or longer; in some of
them erosions may develop [19 4, 219] .
Although constitutional symptoms mostly occur early in Lyme borreliosis [60] ,
they occasionally outlast the initial period and may accompany arthritis [194] . In the
study by Herzer [100, 216] , 9 of 65 patients with Lyme arthritis also had fatigue, mal-
aise, low fever or night sweats.
Clinical characteristics of joint involvement in association with ACA are outlined
in the section ‘Skin Involvement’.
Lyme arthritis is one of the rare inflammatory joint diseases in which routine lab-
oratory parameters are often completely normal. Only about half the patients with
Lyme arthritis have moderately elevated erythrocyte sedimentation rate ( 1 20 mm/h)
with median values of approximately 20–30 mm/h [194, 216] . Concentration of C-re-
active protein is usually in the normal range or slightly elevated. Findings of an eryth-
rocyte sedimentation rate 1 80 mm/h or demonstration of pronounced elevation of
other laboratory indicators of inflammation in a patient with arthritis points strongly
against Lyme arthritis. Some patients have white cel l blood counts slightly above 10 !
10
9 cells/l, some have elevated serum IgM. Cryoglobulins and circulating immune
complexes may be present. Rheumatoid factors and antinuclear antibodies are usually
negative, but in some patients may be positive in low titer [4, 16, 194, 216, 220] .
Clinical Manifestations and Diagnosis of Lyme Borreliosis 89
Elevated white cell counts in synovial fluid, usually 10–35 ! 10 9 cells/l (range
0.5–110 ! 10 9 cells/l) with predominance of polymorphonuclear leu kocy tes (average
70–80%), are found [5, 100, 194, 216, 219] . Total protein concentration commonly
ranges from 3.5 to 5.6 g/l [5, 100, 194, 216] . Cryoglobulins and abnormal C1q binding
consistent with antigen-antibody complexes are commonly present in synovial fluid
[220, 221] .
There are no specific radiographic findings for Lyme arthritis. Soft tissue changes,
particularly effusions, are commonly present. Erosions are rare and generally seen
only in some long-lasting (persistent) cases. Osseous changes, including subarticular
cysts and osteophytes are uncommon [100, 222] .
In patients with Lyme arthritis, borrelial IgG antibodies in serum are almost al-
ways strongly positive; negative IgG serology essentially rules out Lyme arthritis [10 8 ,
207] . Investigation of paired sera with the aim of identifying seroconversion to Bor-
relia antigens is usually unsuccessful because almost all patients with Lyme arthritis
are seropositive at presentation. Serologic investigation of paired samples of serum
and synovial fluid for determination of intra-articular antibody production (parallel
to determination of intrathecal antibody synthesis in Lyme neuroborreliosis) is of no
value because of the lack of a blood/synovial barrier that would efficiently prevent
diffusion of immunoglobulins from blood into synovial fluid and vice versa. In pa-
tients with arthritis and borrelial IgG antibodies in serum, the diagnosis of Lyme ar-
thritis is substantially supported by demonstration of borrelial DNA in synovial flu-
id or in synovial tissue.
D i a g n o s i s
Diagnosis of Lyme arthritis is based on the medical history and clinical features, labo-
ratory findings, exclusion of other causes of arthritis and demonstration of serum IgG
antibodies to Borrelia [1–3, 16, 18] . Unfortunately, serology has many methodologic
limitations and several pitfalls in interpretation of the results. Demonstration of bor-
relial (IgG) antibodies in serum does not enable distinction between symptomatic and
asymptomatic infection, between active and past infection, or between acute and chron-
ic (short- and long-lasting) infection; it also does not enable location of the disease pro-
cess. Thus, demonstration of borrelial antibodies in the serum of a patient with arthri-
tis does not guarantee that the infection is active or that it is located in the joints – it
does not indicate Lyme arthritis. Isolation of Borrelia from synovial fluid is rarely suc-
cessful. Detection of borrelial DNA in synovial tissue or synovial fluid by PCR is much
more sensitive (up to 85%) [14, 108, 201, 202, 204, 205, 223, 224] . However, a positive
PCR finding in a seronegative patient is most probably of low diagnostic value, and
should be regarded with skepticism [14, 10 8] . Cultures of synovial fluid and synovial
tissue for the presence of Borrelia have been generally unsuccessful [108 , 207] .
The presence or a reliable history of other manifestations of Lyme borreliosis such
as EM, Lyme neuroborreliosis or ACA is of substantial help for relatively straightfor-
ward diagnosis.
90 Strle ⴢ Stanek
Differential Diagnosis
The differential diagnosis of Lyme arthritis is broad and generally includes inflam-
matory rheumatic diseases, bacterial (septic) arthritis, viral arthritis and crystal-in-
duced arthritis [3, 18, 100, 219] .
The acute presentation of (monoarticular) Lyme arthritis can be mistaken for bac-
terial (septic) or crystal-induced arthritis (gout, pseudogout) and sometimes also for
sarcoid arthritis in Borrelia -seropositive persons. In Europe, adult patients with Lyme
arthritis only very exceptionally have fever ( 1 38 ° C), do not have signs of sepsis,
and usually have normal or slightly elevated laboratory indicators of inflammation,
which – in addition to synovial fluid smears for the presence of bacteria and syno-
vial fluid culture – permits a fairly reliable distinction of Lyme arthritis from septic
arthritis. The presence of hyperuricemia and Borrelia IgG antibodies in serum may
be conflicting diagnostic criteria in a patient with acute monoarticular arthritis un-
less crystals are demonstrated in synovial fluid. Acute sarcoid arthritis, which com-
monly affects the ankles, may be wrongly diagnosed as Lyme arthritis, especially in
cases of sarcoidosis without erythema nodosum.
Migratory arthritis in Lyme borreliosis is similar to that of rheumatic fever, dis-
seminated gonococcal infection and viral infections. Diffuse hand swelling, which
may occur in some patients with early Lyme arthritis, may also occur in viral infec-
tions such as those with parvovirus B19 [100] .
With regard to the intermittent course, Lyme arthritis may be mistakenly diag-
nosed as intermittent hydarthrosis or palindromic rheumatism in persons with bor-
relial antibodies in serum. Recurrent episodes of arthritis may precede (more) indic-
ative signs of Whipple’s disease [100] .
In general, Lyme arthritis is most like pauciarticular juvenile arthritis in children
and reactive arthritis in adults [3] . Thus, there may be difficulties in differentiation
between Lyme arthritis and reactive arthritis, as well as between Lyme arthritis (in
children) and HLA B27-positive juvenile oligoarthritis or antinuclear antibody-posi-
tive pauciarticular juvenile arthritis. The pattern of joint involvement in Lyme arthri-
tis resembles that in seronegative spondyloarthropathies; in addition, heel involve-
ment and sausage digits are not limited to seronegative spondyloarthropathies, but
are also seen in some patients with Lyme arthritis [10 0] . Other differential diagnoses
include psoriatic arthritis, early rheumatoid arthritis and systemic lupus erythema-
tosus in patients who have borrelial antibodies in serum.
Musculoskeletal pain in Lyme borreliosis may be mistaken for psychogenic rheu-
matism or fibromyalgia. However, more often fibromyalgia in Borrelia -seropositive
persons is wrongly diagnosed as Lyme borreliosis. In contrast to the rather distinctive
intermittent and migratory pattern of musculoskeletal pain in Lyme borreliosis, fi-
bromyalgia is characterized by more generalized chronic pain and by symmetric ten-
der points [100] .
Clinical Manifestations and Diagnosis of Lyme Borreliosis 91
Eye Involvement
Information on eye involvement in the course of Lyme borreliosis is limited. It ap-
pears to occur very rarely, and is often associated with other signs of Lyme bor-
reliosis [16, 225, 226] such as EM, Lyme neuroborreliosis or Lyme arthritis, but can
also be the sole manifestation of the disease. Ocular Lyme borreliosis may be un-
derdiagnosed because of difficulties in the (serologic) diagnosis and because the
clinical ocular features are often not recognized [227–229] . Some ophthalmologists
are not acquainted with the possibility of ocular manifestations of this disease, nor
are most other specialists and general practitioners. Intraocular material is usually
not available from humans, therefore serology is the main aid in diagnosis. False
seropositivity and asymptomatic seropositivity can lead to substantial overdiagno-
sis, particularly in highly endemic regions. Frequent association of eye involvement
with other manifestations of Lyme borreliosis may be the consequence of diagnos-
tic bias.
The interval from EM to the onset of eye involvement is variable and may be from
a few days to years, conjunctivitis being representative of an early ocular lesion,
whereas keratitis appears late in the course of Lyme borreliosis [16, 230] .
Eyes can be affected primarily as the result of inflammation, such as conjuncti-
vitis, keratitis, iridocyclitis, retinal vasculitis, chorioiditis, optic neuropathy, episcle-
ritis, panuveitis, panophthalmitis (some of these manifestations appear to be ex-
tremely rare and not all are reliably proven to be the consequence of borrelial infec-
tion), or secondarily as a result of extra-ocular manifestations of Lyme borreliosis,
including pareses of cranial nerves (VII, III, IV or VI cranial nerve), pseudotumor
cerebri and orbital myositis [227, 229, 231, 232] . Inflammation, particularly when
long-lasting, may lead to severe impairment or even complete loss of vision [16 , 226,
228–230] .
According to the reports on EM that were published soon after Lyme borreliosis
was recognized, conjunctivitis was found in as many as 35 of 314 (11%) patients in the
USA [230] , whereas in Europe the proportion of patients with EM and conjunctivitis
was lower: of 104 patients with EM in southern Germany only 1 had conjunctivitis
[53] , and it was found in 23 of 425 (5%) Slovenian patients diagnosed with EM before
1990 [230] and in 10 of 231 (4%) skin culture-confirmed patients diagnosed in 1994
[136] . In the majority of later series on EM, conjunctivitis was reported only rarely or
not mentioned at all. Among 19 European patients with intraocular involvement in-
terpreted as due to borrelial infection, 12 had chorioiditis (bilateral 8, unilateral 4;
diffuse or disseminated 8, focal 4), 3 had neuroretinitis, 2 bilateral retinal vasculitis,
1 bilateral iridocyclitis and 1 keratitis [230] . Borrelial infection was demonstrated in
all the patients by the presence of borrelial antibodies in serum, and in 9 it was also
indicated by the presence of other objective manifestation(s) of Lyme borreliosis
(3 patients had lymphocytic meningitis, 1 had meningoradiculitis with second-de-
gree A-V block, 2 had peripheral facial palsy – 1 also had lymphocytic pleocytosis,
92 Strle ⴢ Stanek
and 3 had oligoarthritis). None of these 9 patients had EM, but 3 of the 10 remaining
patients had a reliable history of EM. Patients were treated with antibiotics, and were
followed for a median of 12 months (range 3–49 months). Visual acuity, which was
initially found impaired in 18 patients (1 patient was not assessed), improved or nor-
malized in the large majority of patients [230] . Huppertz et al. [233] reported that 3
of 84 (4%) children and adolescents with Lyme arthritis had ocular inflammation,
including keratitis, anterior uveitis and uveitis intermedia. All 3 had symptoms of
decreased visual acuity. Whereas anterior uveitis disappeared without sequelae, cor-
neal scarring and permanent loss of visual acuity remained in the patients with kera-
titis and intermediate uveitis. The authors stressed that loss of vision appears to be
symptomatic, making regular ocular screening of such patients unnecessary.
Several case reports and some series of patients with (presumed) ocular Lyme bor-
reliosis have been published [226–229] , indicating that uveitis (which may be associ-
ated with photophobia, macular edema, retinal vasculitis and decreased vision), neu-
roretinitis and choroiditis with retinal detachment may develop, and that interstitial
keratitis, episcleritis and follicular conjunctivitis are possible anterior-segment man-
ifestations. Transient worsening of symptoms as a result of a Jarisch-Herxheimer re-
action after the intravenous administration of ceftriaxone has also been described
[226] .
Diagnosis of borrelial ocular involvement is difficult. It should be based on medi-
cal history (epidemiologic data and information on other antecedent or concurrent
manifestations of Lyme borreliosis are of particular importance, but often fail to be
noticed), complete physical not only ophthalmologic examination and demonstra-
tion of borrelial infection. In clinical practice, demonstration of serum antibodies is
the most often used test. In addition to several problems of borrelial serology that are
discussed elsewhere, concerns have been expressed that in some patients with iso-
lated borrelial eye involvement the antibody response to this localized Borrelia infec-
tion might be inadequate [226–228] . Antibodies in ocular fluid could also be deter-
mined, and demonstration of intraocular production of borrelial antibodies could be
of substantial diagnostic help [234] . However, eye puncture is not a procedure includ-
ed in routine clinical practice, and the volume of obtainable ocular fluid is small. In
the literature, there are many reports of eye involvement attributed to Lyme borrelio-
sis, in which borrelial infection was indicated only by the presence of serum antibod-
ies. It is very difficult if not impossible to prove that an individual ocular clinical sign
(particularly without the presence of or a reliable history of other manifestations of
Lyme borreliosis) is really a result of infection with B. burgdorferi s.l. without direct
demonstration of the causative agent in the involved eye [225, 226, 228, 230] . Isolation
of Borrelia from eye tissue has been reported only once [235] , but there are several
publications on the demonstration of borrelial DNA in eye structures and ocular
fluid [226, 228, 236] . However, several patients with positive PCR findings were re-
ported to be seronegative to borrelial antigens, a finding that needs critical interpre-
tation [14, 10 8] .
Clinical Manifestations and Diagnosis of Lyme Borreliosis 93
The ocular manifestations described resemble those seen in ocular syphilis in
some ways, and are not pathognomonic for Lyme borreliosis. Differential diagnosis
is rather broad [226, 230] . Granulomatous iridocyclitis or chorioiditis are seen in sev-
eral diseases caused by bacteria (such as syphilis, tuberculosis and leprosy) and pro-
tozoa (Toxoplasma gondii) , and can be associated with fungal infections and immu-
nologic processes of unclear etiology such as sarcoidosis and Vogt-Koyanagi-Harada
syndrome, as well as with rheumatic disorders [230] , particularly in children and
adolescents with pauciarticular juvenile rheumatoid arthritis (typical ocular mani-
festation is chronic anterior uveitis) and juvenile spondyloarthropathy (acute anterior
uveitis) [233] . Generally, the association of arthritis and uveitis is suggestive of HLA
B27-positive spondyloarthropathies, and uveitis is a typical feature of antinuclear an-
tibody-positive pauciarticular juvenile arthritis [100] .
Other Rare (Potential) Manifestations of Lyme Borreliosis
Some case reports have implicated B. burgdorferi s.l. infection as a possible cause of 2
subty pes of scleroderma circumscripta, progressive facia l hemiatrophia (suggested by
silver staining) and eosinophilic fasciitis (Shulman syndrome, indicated by silver
staining, immunohistology, PCR) [67, 237–239] .
There are case reports on patients with myositis [240–242] , the existence of which
has also been demonstrated in an animal model in nonhuman primates [243] , der-
matomyositis [244, 245] , nodular fasciitis [246] , panniculitis [247–249] and osteomy-
elitis [250] . Most authors are of the opinion that borrelial infection is not causally
associated with the syndrome of fibromyalgia [3, 16] . There are also reports on the
effect on individual organs or organ systems, such as the liver, lymphatic system, re-
spiratory tract, urinary tract and genitalia [16] , but proof of the existence of such in-
volvement in humans is weak.
Short Comment on Chronic Lyme Borreliosis and ‘Chronic Lyme Borreliosis’
The designation chronic Lyme borreliosis should be reserved for patients with objec-
tive manifestations of late Lyme borreliosis (in Europe typically represented by ACA,
chronic arthritis and rare cases of chronic Lyme neuroborreliosis without ACA) and
not misused for: (1) symptoms of unknown cause with no (objective or valid) evidence
of B. burgdorferi s.l. infection, (2) well-defined illness unrelated to borrelial infection
(even with the presence of borrelial antibodies in serum), (3) symptoms of unknown
cause, with antibodies against B. burgdorferi s.l. but no history of objective clinical
findings that are consistent with Lyme borreliosis, or (4) post-Lyme borreliosis (post-
Lyme disease) syndrome [251, 252] . A definition of post-Lyme disease syndrome was
proposed in the recent IDSA clinical practice guidelines [14] . The problems associ-
94 Strle ⴢ Stanek
at ed wi th diag nosis a nd m an ageme nt of p at ien ts wi th ‘ch ronic Ly me di sease’ (pati ent s
in categories 1, 2, 3 and especially 4) have been discussed in several articles, including
a critical appraisal in the New England Journal of Medicine [251] and a recent review
in Infectious Disease Clinics of North America [252] . The information in these reports
is valid not only for North America, but also for Europe.
Lyme Borreliosis in Special Groups of Patients
Although Lyme borreliosis has been recognized for more than 30 years, knowledge
of the course and outcome of the illness is limited in certain groups, including preg-
nant women and immunocompromised patients. Lyme borreliosis during pregnancy
is discussed elsewhere in this book; here, we present some basic data on Lyme bor-
reliosis in immunocompromised patients.
Lyme Borreliosis in an Immunocompromised Host
In general, it is well known that bacteria can induce infections of varying severity,
and that the preinfection immune status is often crucial for the clinical course of a
disease. Information on the course and outcome of B. burgdorferi s.l. infection in
immunocompromised patients is very limited; as a consequence, neither the natural
course nor the efficacy of treatment of Lyme borreliosis has been accurately assessed
in this diverse group comprising several distinct types and severities of immuno-
suppression. Data in the literature are scant and predominantly restricted to indi-
vidual case reports, such as a report on a B. burgdorferi infection in a patient with
dermatomyositis [253] , a description of a morphea-like skin condition apparently
caused by B. burgdorferi in an immunocompromised patient [254] , a case of Lyme
borreliosis in a transplant recipient [255] and several cases of Lyme borreliosis in
conjunction with human immune deficiency virus infection [256–258] . We were
able to find only 3 reports on a series of cases of Lyme borreliosis in immunocom-
promised patients.
In the first report, several distinctions were revealed in a comparison of the course
and outcome of borrelial infection in 67 adult patients with typical EM and an un-
derlying immunocompromised condition with 67 previously healthy age- and sex-
matched individuals with EM, who were examined and diagnosed in the period
1990–1996 at a single center. The duration of EM after starting antibiotic treatment
was similar in the 2 groups, but the occurrence of early disseminated borrelial infec-
tion before treatment and the frequency of treatment failure were found more often
in immunocompromised patients than in the control group (16/67 vs. 6/67, respec-
tively). Treatment failure was defined as the occurrence of severe minor or major
manifestations of Lyme borreliosis, persistence of B. burgdorferi s .l. in the sk in and/or
Clinical Manifestations and Diagnosis of Lyme Borreliosis 95
persistence of EM after treatment; the mode and duration of antibiotic treatment was
the same in both groups of patients. Re-treatment was required in 13 (19%) immuno-
compromised
patients, but in only 5 (7%) patients in the control group. However, in
spite of the more severe course and the more frequent need for retreatment among
patients whose immune system was impaired, both groups had a favorable outcome
of borrelial infection after 1 year [259] . Persistence of B. burgdorferi s.l. in normal-
looking skin at the site of previous EM 2 months after treatment was found in 1 of 20
immunocompromised patients and in none of 21 immunocompetent patients who
had positive Borrelia culture from an EM lesion before treatment and were rebiopsed
2–3 months later at the same site. As stressed by the authors of the study, these results
should be interpreted with caution because the causes of immune deficiency were
somewhat heterogeneous. The findings in the small numbers of patients with indi-
vidual underlying diseases could give only a hint of potential differences between
distinct immunocompromised settings, but could not permit reliable statistical anal-
ysis; 1 of 7 patients (14%) with cirrhosis of the liver, 4 of 22 (18%) patients treated for
diabetes, 2 of 8 (25%) with autoimmune disease, and 4 of 14 patients with underlying
malignant disease presented with signs of disseminated Lyme borreliosis or devel-
oped treatment failure during the observational period of 1 year. The various types
and levels of altered immunity in patients within individual immunocompromised
subgroups might also have considerably influenced the results. Nevertheless, accord-
ing to the results of the study, it appears that in patients with underlying malignant
disease the likelihood of developing disseminated infection or treatment failure may
be higher among those with hematologic malignancies: signs of disseminated bor-
relial infection or development of treatment failure were present in 3 of 7 patients (2/3
with chronic lymphatic leukemia, 1/2 with lymphoma and 0/2 with myeloprolifera-
tive disorders), in contrast to 1 of 7 patients with nonhematologic malignancies. The
authors concluded that although in the majority of immunocompromised patients
with EM the management can be the same as in immunocompetent patients with
early Lyme borreliosis, more aggressive initial antibiotic treatment might be appro-
priate for some subgroups of patients with altered immunity; for example, in patients
with hematologic malignancy
[259] .
A second study [260] investigated the impact of immunosuppression on EM in 33
patients with malignant or autoimmune disease, chronic infection or immunosup-
pressive therapy for organ transplantation by comparing findings in the immunosup-
pressed patients with those in 75 otherwise healthy patients with EM. The 2 groups
were matched for sex, age and antibiotic therapy. Comparison did not reveal any sig-
nificant difference between the 2 groups in pretreatment clinical parameters, such as
presentation of the skin lesion and presence of extracutaneous signs and symptoms,
in the disease course during a median follow-up of 9 months after treatment, or in
serum borrelial antibodies before treatment and at the end of follow-up. Further, it
appeared that immunosuppression did not influence clinical presentation, response
to therapy or production of B. burgdorferi antibodies in patients with EM. The au-
96 Strle ⴢ Stanek
thors concluded that it is not necessary to treat immunosuppressed patients with EM
differently from immunocompetent patients [260] . Again, one of the several draw-
backs of this retrospective study was the pronounced heterogeneity in types and lev-
els of altered immunity.
The third report comprised 6 adult recipients of solid-organ transplants who had
chronic drug-induced immunosuppression and presented with solitary EM. These
patients appeared to have only localized infection of the skin, even though they were
immunosuppressed; all had a mild and smooth course of illness, as well as a favorable
outcome of the illness after treatment with antibiotics administered at the same dos-
age and for the same duration as used in treatment of early localized Lyme borreliosis
in immunocompetent patients. However, the number of patients in the study was too
small to enable valid generalization of the findings. Potential application of the ob-
servations might be appropriate for European patients with solitary EM caused by
B. afzelii (in this study 3 of 4 Borrelia isolates from lesional skin were typed as B. af-
zelii and 1 as B. garinii ; a skin sample from 1 patient was culture negative) , but the
observations may not apply to patients with B. burgdorferi infection in the USA (lo-
calized infection of the skin is more commonly associated with B. afzelii infection in
Europe than with B. burgdorferi infection in the USA [15] ) or to patients with dis-
seminated Borrelia infection [261] .
Laboratory Diagnosis of Lyme Borreliosis
An important observation in Lyme borreliosis is that there is usually no clinical lab-
oratory parameter in the peripheral blood that is indicative of this infectious disease.
Almost all patients have normal CRP values and usually normal white blood cell
counts [1–3, 16, 18] .
The marked impression of EM on the skin could be expected to represent a typical
histologic reaction, but the histologic picture in EM is generally nonspecific with
some perivascular infiltration, mainly of lymphocytes and sometimes plasma cells.
In borrelial lymphocytoma, the respective skin area, in contrast to EM, frequently
shows lymphocytic infiltration in the dermis with plasma cells, macrophages and eo-
sinophils. The histopathologic picture of ACA is also characterized by a lymphocytic
infiltration, and also by telangiectases. The cellular infiltration is again mixed with
plasma cells and is present not only in the dermis, but also not infrequently in the
subcutis. Histology in ACA may be supportive of the diagnosis, but it is not typical
enough to be exclusive, and in borrelial lymphocytoma the histologic picture is not
unique and may be difficult to differentiate from malignant lymphomas.
In Lyme neuroborreliosis, the CSF usually shows moderate-to-intense lympho-
cytic pleocytosis, but some patients have only elevated CSF protein. Lymphocytic
pleocytosis is absent in several patients with peripheral facial palsy and in patients
with isolated peripheral neuropathy, and may be absent very early in CNS involve-
Clinical Manifestations and Diagnosis of Lyme Borreliosis 97
ment particularly in children [262] . Intrathecal IgM and IgG production and oligo-
clonal IgG bands are common findings in patients with CNS involvement of a few
weeks or longer and are supportive of the diagnosis. Concentration of CSF glucose is
usually normal. Patients with ‘chronic’ peripheral polyneuropathy, usually a feature
of ACA, have normal CSF findings.
Thus, without a specific marker, full proof of the borrelial etiology of any of the
given disorders in Lyme borreliosis is missing. The specific etiology of any infectious
disease is usually best documented by direct detection of the agent, but this is not
straightforward in suspected Lyme borreliosis.
Direct Detection of the Agent
Culture
Culture of B. burgdorferi s.l. strains is possible in complex media [263, 264] , with suc-
cess depending on the type of specimen. For example, cultivation of B. burgdorferi s.l.
from skin biopsies of EM is usually very successful, at 60–80% [38, 77, 108] . However,
the clinical conditions EM and ACA will mostly be identified by inspection, to some
extent with the help of histology in the latter case, and cultivation is only rarely re-
quested. In CSF the success of culture is usually around 10% or less, possibly increas-
ing to 30% in children in the very early phase of neurologic disorders [262] . Borreliae
have also been isolated from the blood of patients with EM, most successfully in the
USA by using high-volume blood cultures [64] , from cardiac tissue of patients with
dilated cardiomyopathy [180] , and from synov ial f luid of pat ient s with Lyme art hritis
[265] . Although some results suggest that even early Lyme borreliosis such as EM is
very frequently a disseminated infectious disease, most medical laboratories would
not be able to manage the relatively sophisticated demands of Borrelia culture. Thus,
blood, cardiac tissue and synovial fluid are less suitable sources for culture of B. burg-
dorferi s.l.
Nucleic Acid Amplification Techniques
Genus- and species-specific PCR methods can be used to detect low copy numbers of
B. burgdorferi s.l. Unlike culture, PCR detects borrelial DNA of both viable and non-
viable organisms, which means that a positive PCR cannot explicitly establish wheth-
er an infection is active or not. PCR appears to be a valuable tool, particularly in the
diagnosis of patients with arthritis, since it can detect borrelial DNA in 85% of syno-
vial fluid samples and even more if the synovial membrane is examined [224] .
Urine has been investigated by several groups [266] ; however, results are contradic-
tory and studies indicate that more attention to methods of DNA extraction may help
improve this situation [267] . A further problem is illustrated by a study in which a
proportion of urine samples of healthy individuals whose serum contained Borrelia -
specific antibodies also reacted positive in a Borrelia -specific PCR. Thus, as with se-
98 Strle ⴢ Stanek
rologic findings, PCR results should always be interpreted with caution and the clin-
ical significance of a PCR-positive finding in urine remains to be established.
Lastly, reference should be made to the fact that a negative result for culture and/or
PCR does not exclude active infection.
Indirect Detection of Borrelial Infection: Serology
Currently, there are almost uncountable numbers of commercial test kits on the mar-
ket for detection of IgG and IgM antibodies against B. burgdorferi s .l. The tes t systems
comprise immunofluorescence assay (IFA), enzyme-linked immunosorbent assay
(ELISA) and immunoblot.
IFA were the first serodiagnostic tests used for detection of antibodies against
B. burgdorferi s.l., and are still used in many countries. Nevertheless, although IFA
can be automated today, ELISA are the most frequently used tests. Since the two-tier
testing principle was introduced, ELISA has become the most commonly used sero-
diagnostic screening method for Lyme borreliosis. Sonicate and recombinant ELISA
are in use. Most assays are either enriched with VlsE (variable-like sequence ex-
pressed) antigen or use VlsE or C6 as a single antigen for detection of specific IgG
antibodies. OspC antigen as a single ELISA antigen is used for detection of specific
IgM antibodies in serum. VlsE and C6 were originally considered markers for active
infection; however, the strong immune reaction to these antigens is also present in
convalescent and healthy persons and thus does not differentiate between active and
past infection.
Immunoblot, or Western blot, is important in characterization of immune re-
sponses to specific B. burgdorferi s.l. proteins, and is generally used in the two-tier
testing procedure. The interpretation criteria for immunoblot results are based on
diagnostic antigens. Standardization of criteria for interpretation of immunoblot re-
sults in Europe was the subject of a study by EUCALB
[268] . This multicenter study,
involving 6 European laboratories using different immunoblot protocols, identified
8 bands that were discriminatory in all the laboratories, though with variations in
significance. From these bands, 5 closely related European rules were formulated giv-
ing acceptable sensitivity and specificity, though there was no single rule that could
be applied in all laboratories. This panel of European rules provides a framework for
immunoblot interpretation that may be adapted in relation to the characteristics of
Lyme borreliosis in local areas. Another source for the selection of diagnostic anti-
gens is the work of Wilske and colleagues [269, 270] . Since complete standardization
of immunoblotting protocols in Europe cannot be achieved, there was hope that new
recombinant immunoblots would help to solve this problem [271] . However, even this
hope was not fulfilled, particularly with recombinant IgM blots, which proved to be
more sensitive than recombinant IgM ELISA.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 99
With the introduction of VlsE and C6 peptides in the serology of Lyme borreliosis
and the similar success in detecting Borrelia -specific IgG and IgM antibodies by us-
ing VlsE and OspC as single antigens in ELISA systems, it appears logical to replace
the two-tier test principle, as indicated by results of recent studies [272] . However,
even if the two-tier principle is abandoned, there is still no method or technique for
identification of active infection. In addition, the high seroprevalence of specific an-
tibodies in the general population in highly endemic areas will cause the problem of
relevance to clinical disease. Moreover, persons such as hunters continuously exposed
to ticks show an age-related seroprevalence as high as 83% in those over 70 years old
[273] . Thus, physicians must take local seroprevalence into account when interpreting
the clinical relevance of positive serology in patients. After more than 20 years of
Tab le 3. L ab or ato ry sup po rt in t he dia gn osi s o f Ly me b or re lio sis ; m odi fi ed acc or din g t o th e EU CA LB
clinical case definitions in Lyme borreliosis [12]
Initial clinical
diagnosis
Essential laboratory evidence Supporting laboratory evidence
EM none if typical culture from skin biopsy;
significant change in levels of specific
antibodies or presence of specific IgM1
Borrelial
lymphocytoma
specific IgG antibodies histology; culture from skin biopsy
ACA high level of specific serum IgG
antibodies
histology; culture from skin biopsy
Early Lyme
neuroborreliosis
lymphocytic pleocytosis in CSF;
intrathecally produced specific
antibodies2
intrathecal total IgM and IgG;
specific oligoclonal bands in CSF;
significant change in levels of
specific antibodies1; culture from CSF
Chronic Lyme
neuroborreliosis
lymphocytic pleocytosis in CSF;
intrathecally produced specific
antibodies2; specific serum IgG
specific oligoclonal bands in CSF
Lyme arthritis high level of specific serum
antibodies
detection of borrelial DNA in synovial
fluid and/or tissue (culture from synovial
fluid and/or tissue)
Lyme carditis significant change in levels of
specific IgG antibodies1
culture from endomyocardial biopsy
1 Specific antibody levels in serum may increase in response to progression of infection or treat-
ment, or may decrease due to abrogation of the infection process. Samples collected a minimum
of 3 months apart may be required in order to detect a decrease in IgG levels.
2 Intrathecall y produced specific antibodies are determined by investigating simultaneously drawn
samples of CSF and serum.
100 Strle ⴢ Stanek
‘Lyme serology’ it appears that for diagnostic purposes serology has created more
problems than it has solved. It is possible that the immune response to Borrelia infec-
tion still requires further elucidation. The results of a recent study appear to offer
reasons for optimism with respect to diagnostic support [274] .
Nevertheless, serologic tests for detection of intrathecal production of specific an-
tibodies are very beneficial in the diagnosis of Lyme neuroborreliosis. Differing con-
centrations of immune globulins and specific antibodies in serum and CSF must be
taken into account in detection of intrathecally produced specific antibodies; this is
expressed as the CSF/serum index as follows:
ELISA units in CSF total IgG in serum
CSF/serum index ELISA units in serum total IgG in CSF
q
q
Thus, the index expresses the proportion of pathogen-specific IgG antibodies in
the total IgG content in the CSF compared with the serum. An index 1 1.0 would,
strictly mathematically, prove the intrathecal production of specific antibodies. With
respect to small volume variations when diluting samples, an index 6 1.5 is consid-
ered significantly elevated.
Table 3 refers to EUCALB recommendations listing the suspected clinical condi-
tions and the weight of laboratory results required to confirm the clinical suspicion
[12] .
References
1 Nadelman RB, Wormser GP: Lyme borreliosis.
Lancet 1998;
352: 557–565.
2 Strle F: Principles of the diagnosis and antibiotic
treatment of Lyme borreliosis. Wien Klin Wochen-
schr 1999;
111: 911–915.
3 Stanek G, Strle F: Lyme borreliosis. Lancet 2003;
362: 1639–1647.
4 Steere AC, Malawista SE, Hardin JA, Ruddy S,
Askenase W, Andiman WA: Erythema chronicum
migrans and Lyme arthritis: the enlarging clinical
spectrum. Ann Intern Med 1977;
86: 685–698.
5 Steere AC, Malawista SE, Snydman DR, Shope RE,
Andim an WA, Ross MR, Stee le FM: Lyme arthr itis:
an epidemic of oligoarticular arthritis in children
and adults in three Connecticut communities. Ar-
thritis Rheum 1977;
20: 7–17.
6 The Free Dictionary: Medical dictionary. www.
thefreedictionary.com.
7 Steere AC, Sikand VK, Schoen RT, Nowakowski J:
Asymptomatic infection with Borrelia burgdorferi .
Clin Infect Dis 2003;
37: 528–532.
8 Gu stafson R, Svenu ngsson B, Gardul f A, Stiern stedt
G, Forsgren M: P revalence of t ick-borne encephal itis
and Lyme borreliosis in a defined Swedish popula-
tion. Scand J Infect Dis 1990;
22: 297–306.
9 Fahrer H, van der Linden SM, Sauvain MJ, Gern L,
Zhioua E, Aeschlimann A: The prevalence and in-
cidence of cli nical and as ymptomatic Lyme borrel i-
osis in a population at risk. J Infect Dis 1991;
163:
305–310.
10 Z hioua E, Gern L , Aeschli mann A, Sauva in MJ, van
de r L in den S, Fa hr er H : L on git ud i na l st ud y o f Ly me
borrelio sis in a high risk p opulation in Switz erland.
Parasite 1998;
5: 383–386.
11 Anonymous: Case definitions for infectious condi-
tions under public health surveillance: Lyme dis-
ease (revisited 9/96). MMWR Morb Mortal Wkly
Rep 1997;
46(suppl RR-10):20–21.
12 Stanek G, O’Connell S, Cimmino M, Aberer E,
Kri stoferitsch W, Granstrom M, Guy E, Gray J: Eu-
ropean Union Concerted Action on Risk Assess-
ment in Lyme borreliosis: clinical case definitions
for Lyme borreliosis. Wien Klin Wochenschr 1996;
108: 741–747.
13 Brouqui P, Bacellar F, Baranton G, Birtles RJ, Bjo-
ersdor ff A, Blanco JR, Car uso G, Cinco M, Fourni-
er PE, Fra ncavilla E , Jensenius M, Kaz ar J, Laferl H,
Lakos A, Lotric Furlan S, Maurin M, Oteo JA, Pa-
rola P, Perez-Eid C, Peter O, Postic D, Raoult D,
Tellez A, Tselentis Y, Wilske B: Guidelines for the
Clinical Manifestations and Diagnosis of Lyme Borreliosis 101
diagnosis of tick-borne bacterial diseases in Eu-
rope. Clin Microbiol Infect 2004;
10: 110 8–1132.
14 Wormser GP, Dattwyler RJ, Shapiro ED, Halperin
JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS,
Strle F, Stanek G, Bockenstedt L, Fish D, Dumler S,
Nadelman R: The clinical assessment, treatment,
and prevention of Lyme disease, human granulo-
cyt ic anaplasmosis , and babesiosis : clinical pr actice
guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2006;
43: 1089–1134.
15 Strle F, Nadelman RB, Cimperman J, Nowakowski
J, Picken RN, Schwartz I, Maraspin V, Aguero-
Rosenfeld ME, Varde S, Lotric-Furlan S, Wormser
GP: Comparison of culture-confirmed erythema
migra ns caused by Borrelia burgdorferi sensu stric-
to in New York state and Borrelia afzelii in Slovenia.
Ann Intern Med 1999;
130: 32–36.
16 Steere AC: Lyme disease. N Engl J Med 1989;
321:
586–596.
17 Asbrink E, Hovmark A: Early and late cutaneous
manife stations in Ixodes -borne borreliosis (eryt he-
ma migra ns borreliosis, Ly me borreliosis). Ann NY
Acad Sci 1988;
539: 4–15.
18 Steere AC: Lyme disease. N Engl J Med 2001;
345:
115–125.
19 Weber K, Neubert U, Buchner SA: Erythema mi-
grans and early signs and symptoms; in Weber K,
Burgdorfer W (eds): Aspects of Lyme Borreliosis.
Heidelberg, Springer, 1993, pp 105–121.
2 0 M asters E, Gra nter S, Duray P, Cordes P: Physicia n-
diagnosed erythema migrans and erythema mi-
grans-like rashes following Lone Star tick bites.
Arch Dermatol 1998;
134: 955–960.
21 Masters EJ, Grigery CN, Masters BE: STARI, or
Masters Disease: Lone sta r tick-vectored Lyme-like
illness. Infect Dis Clin North Am 2008;
22: 361–
376.
22 Krause PJ, Telford SR 3rd, Spielman A, Sikand V,
Ryan R, Christianson D, Burke G, Brassard P, Pol-
lack R, Peck J, Persing DH: Concurrent Lyme dis-
ease and babesiosis: evidence for increased severity
and duration of illness. JAMA 1996;
275: 1657–
166 0.
23 Cimperman J, Maraspin V, Lotric-Furlan S, Avsic-
Zupanc T, Picken RN, Strle F: Concomitant infec-
tion wit h tick-borne encephal itis viru s and Borrelia
burgdorferi sensu lato in pat ients with acute men in-
gitis or meningoencephalitis. Infection 1998;
26:
160–164.
24 Nadelman RB, Horowitz HW, Hsieh TC, Wu JM,
Aguero-Rosenfeld ME, Schwartz I, Nowakowski J,
Varde S, Wormser GP: Simultaneous human gran-
ulocy tic ehrlichiosis a nd Lyme borreliosis. N Eng l J
Med 1997;
337: 27–30.
25 Herxheimer K, Hartmann K: Über Acrodermatitis
chronica atrophicans. Arch Dermatol Syph 1902;
61: 57–76.
26 Afzelius A: Verhandlungen der Dermatologischen
Gesellschaft z u Stockholm, 28 Oct 1909. Arch Der-
matol Syph 1910;
101: 404.
27 Lipschütz B: Über eine seltene Erythemform (Ery-
thema chronicum migrans). Arch Dermatol Syph
1913;
118: 349–356.
2 8 Da ndac he P, Na del man RB: Er yth ema mig ran s. I n-
fect Dis Clin North Am 2008;
22: 235–260.
29 Berglund J, Eitrem R, Ornstein K, Lindberg A,
Ringer A, Elmrud H, Carlsson M, Runehagen A,
Svanborg C, Norrby R: An epidemiologic study of
Lyme disease in southern Sweden. N Engl J Med
1995;
333: 1319–1327.
30 Anonymous: Epidemiologic Surveillance of Infec-
tious Diseases in Slovenia (in Slovene). Ljubljana,
Institute of Public Health of the Republic of Slove-
nia, Slovenia, 2000.
31 Anonymous: Epidemiologic Surveillance of Infec-
tious Diseases in Slovenia (in Slovene). Ljubljana,
Institute of Public Health of the Republic of Slove-
nia, 2008.
32 Ornstein K, Berglund J, Nilsson I, Norrby R, Berg-
strom S: Characterization of Lyme borreliosis iso-
lates from patients with erythema migrans and
neuroborre liosis in southern Sweden . J Clin Micro-
biol 2001;
39: 1294–1298.
33 Carlsson SA, Granlund H, Jansson C, Nyman D,
Wahlberg P: Characteristics of erythema migrans
in Borrelia afzelii and Borrelia garinii infections.
Scand J Infect Dis 2003;
35: 31–33.
34 Cerar T, Ružić-Sabljić E , Glinsek U, Zore A, Strle F:
Comparison of PCR methods and culture for the
detection of Borrelia spp. in patients with er ythema
migrans. Clin Microbiol Infect 2008;
14: 653–658.
35 Zore A , Ružić-Sabljić E, Maraspi n V, Ci mperman J,
Lotrič-Furlan S, Pikelj A, Jurca T, Logar M, Strle F:
Sensitivity of culture and polymerase chain reac-
tion for the etiologic diagnosis of erythema mi-
grans. Wien Klin Wochenschr 2002;
114: 606–609.
36 Kuiper H, Cairo I, van Dam A, de Jongh B, Ramse-
laar T, Spanjaard L, Dankert J: Solitary erythema
migrans: a clinica l, laboratory and epidemiological
study of 77 Dutch patients. Br J Dermatol 1994;
130:
466–472.
37 Ciceroni L, Ciarrochi S, Ciervo A, Mondarini V,
Guzzo F, Caruso G, Murgia R, Cinco M: Isolation
and characterization of Borrelia burgdorferi sensu
lat o stra ins i n an area of I taly w here Ly me bor relio -
sis is endemic. J Clin Microbiol 2001;
39: 2254–
2260.
38 Ružić-Sabljić E, Maraspin V, Lotrič-Furlan S, Jurca
T, Logar M, Pikelj-Pečnik A, Strle F: Characteriza-
tion of Borrelia burgdorferi sensu lato strains iso-
lated from human material in Slovenia. Wien Klin
Wochenschr 2002;
114: 544–550.
102 Strle ⴢ Stanek
39 Fingerle V, Schulte-Spechtel UC, Ružić-Sabljić E,
Leonha rd S, Hofmannd H, Weber K , Pfister K, St rle
F, Wilske B: Epidemiolo gical aspec ts and molecula r
characterization of Borrelia burgdorferi s.l. from
southern Germany with special respect to the new
species Borrelia spielmanii s p. nov. Int J Med Micro -
biol 2008;
298: 279–290.
40 Picken RN, Cheng Y, Strle F, Picken MM: Patient
isolates of Borrelia burgdorferi sensu lato with ge-
notypic a nd phenotypic simi larities of st rain 25015.
J Infect Dis 1996;
174: 1112 –1115.
41 Strle F, Picken RN, Cheng Y, Cimperman J,
Maraspin V, Lotrič-Furlan S, Ružić-Sabljić E, Pick-
en MM: Clinical findings for patients with Lyme
borreliosis caused by Borrelia burgdorferi sensu
lato with genotypic and phenotypic similarities to
strain 25015. Clin Infect Dis 1997;
25: 273–280.
42 Foldvari G, Farkas R, Lakos A: Borrelia spielmanii
erythema migrans, Hungary. Emerg Infect Dis
2005;
11: 179 4–1795.
4 3 Ma ra spi n V, R už ić- Sab lji ć E , St rle F: Ly me bor rel io -
sis and Borrelia spielmanii . Emerg Infect Dis 2006;
12: 1177.
44 Ružić-Sabljić E, Zore A, Strle F: Characterization of
Borrelia burgdorferi sensu lato isolates by pulsed-
field gel electrophoresis after MluI restriction of ge-
nomic DNA. Research Microbiol 2008;
159: 441–448.
45 Oksi J, Marttila H, Soini H, Aho H, Uksila J, Vil-
janen MK : Early dissem ination of Bor relia burgdor-
feri w ithout generalized symptoms in patients with
erythema migrans. APMIS 2001;
109: 581–588.
46 Picken RN, Cheng Y, Strle F, Cimperman J,
Maraspin V, Lotrič-Furlan S, Ružić-Sabljić E, Han
D, Nelson JA, Picken M M, Trenholme GT: Molecu-
lar characterization of Borrelia burgdorferi sensu
lato from Slovenia revealing significant differences
between tick and human is olates. Eur J Clin Micro-
biol Infect Dis 1996;
15: 313–323.
47 Picken MM, Picken RN, Han D, Cheng Y, Strle F:
Single-t ube nested polymer ase chain reac tion assay
based on f lagellin gene sequences for detection of
Borrelia burgdorferi sensu lato. Eur J Clin Micro-
biol Infect Dis 1996;
6: 489–498.
48 Seinost G, Golde WT, Berger BW, Dunn JJ, Qiu D,
Dunkin DS, Dykhuizen DE, Luft BJ, Dattwyler RJ:
Infect ion with multiple str ains of Borrelia burgdor-
feri sensu stricto in patients with Lyme disease.
Arch Dermatol 1999;
135: 1329–1333.
49 Ru žić-Sabljić E , Arnez M , Lotrič-F urlan S , Maraspi n
V, Cimperman J, Strle F: G enotypic and phenoty pic
characterisation of Borrelia burgdorferi sensu lato
strains isolated from human blood. J Med Micro-
biol 2001;
50: 896–901.
50 Ružić-Sabljić E, Arnez M, Logar M, Maraspin V,
Lotr ič-Furlan S, Cimp erman J, Strle F: Compa rison
of Borrelia burgdorferi sensu lato strains isolated
from specimens obtained simultaneously from two
different sites of infection in individual patients. J
Clin Microbiol 2005;
43: 2194–2200.
51 Nadelman RB, Nowakowski J, Forseter G, Gold-
berg NS, Bitt ker S, Cooper D, Aguero -Rosenfeld M,
Wormser GP: The clinical spectrum of early Lyme
borreliosis in patients with culture-confirmed ery-
thema migrans. Am J Med 1996;
100: 502–508.
52 Smith RP, Schoen RT, Rah n DW, Sikand VK , Nowa-
kowski J, Parenti DL, Holman MS, Persing DH,
Steere AC: Clinical characteristics and treatment
outcome of early Lyme disease in patients with mi-
crobiologica lly confirmed erythema migrans. Ann
Intern Med 2002;
136: 421–428.
53 Weber K, Neubert U: Clinical features of early
erythema migrans disease and related disorders.
Zentralbl Bakteriol Mikrobiol Hyg [A] 1986;
263:
209–228.
54 Asbri nk E, Olsson I, Hovmark A: Erythema chron-
icum migrans Afzelius in Sweden: a study on 231
patients. Zentralbl Bakteriol Mikrobiol Hyg [A]
1986;
263: 229–236.
55 Strle F, Nelson JA, Ružić-Sabljić E, Nowakowski J,
P ic ke n RN , S c hw a r tz I, M ar a sp i n V, Ag u er o -R os e n-
feld ME, Varde S, Lotrič-Furlan S, Wormser GP:
European Lyme borreliosis: 231 culture-confirmed
cases involving patients with erythema migrans.
Clin Infect Dis 1996;
23: 61–65.
5 6 S tr le F, Vi de cni k J , Z or ma n P, C im per ma n J , L otr ič -
Fu rla n S, Mar as pin V: C lin ic al a nd e pide mio log ica l
findings for patients with erythema migrans: com-
parison of cohorts from the years 1993 and 2000.
Wien Klin Wochenschr 2002;
114: 493–497.
57 De Koning J, Duray PH: Histopathology of human
Lyme borreliosis; in Weber K, Burgdorfer W (eds):
Aspects of Lyme Borreliosis. Heidelberg, Springer,
1993, pp 70–92.
58 Mul legger RR, Mea ns TK, Shin JJ, L ee M, Jones KL,
Glickstein LJ, Luster AD, Steere AC: Chemokine
signatu res in the skin disorders of Lyme borreliosis
in Europe: predominance of CXCL9 and CXCL10
in erythema migrans and acrodermatitis and
CXCL13 in lymphocytoma. Infect Immun 2007;
75:
4621–4628.
59 Maraspin V, Ružić-Sabljić E, Cimperman J, Lotrič-
Furlan S, Jurca T, Picken RN, Strle F: Isolation of
Borrelia burgdorferi sensu lato from blood of pa-
tients with erythema migrans. Infection 2001;
29:
65–70.
60 Steere AC, Bartenhagen NH, Craft JE, Hutchinson
GJ, Newman JH, Rahn DW, Sigal LH, Spieler PN,
Stenn KS , Malawista SE: T he early clin ical mani fes-
tations of Lyme disease. Ann Intern Med 1983;
99:
76–82.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 103
61 Logar M, Ružić-Sabljić E, Maraspin V, Lotrič-Fur-
lan S, Ci mperman J, Jurca T, Strle F: Compa rison of
erythema migrans caused by Borrelia afzelii and
Borrelia garinii. Infection 2003; 31: 404–409.
62 Bennet L, Fraenkel CJ, Garpmo U, Halling A, Ing-
man M, Ornstein K, Stjernberg L, Berglund J: Clini-
cal appearance of erythema migrans caused by Bor-
relia afzelii and Borrelia garinii – effect of t he patient’s
sex. Wien Klin Wochenschr 206;
118: 531–537.
63 Arnez M, Ružić-Sabljić E, Ahcan J, Radsel-Med-
vescek A, Pleterski-Rigler D, Strle F: Isolation of
Borrelia burgdorferi sensu lato from blood of chil-
dren with solitary erythema migrans. Pediatr In-
fect Dis J 2001;
20: 251–255.
64 Wormser GP, McKenna D, Carlin J, Nadelman RB,
Cavaliere LF, Holmgren D, Byrne DW, Nowakows-
ki J: Hematogenous dissemination in early Lyme
disease. Ann Intern Med 2005;
142: 751–755.
65 Ar nez M, Pleterski-R igler D, Ahcan J, Ruž ić-Sabljić
E, Strle F: Demographic features, clinical charac-
teristics and laboratory findings in children with
multiple erythema migrans in Slovenia. Wien Klin
Wochen schr 20 01;
113: 98–101.
66 Arnez M, Pleterski-Rigler D, Luznik-Bufon T,
Ružić-Sabljić E, Strle F: Children with multiple
erythema migrans: are there any pre-treatment
symptoms and/or signs suggestive for central
nervous system involvement? Wien Klin Wochen-
schr 2002;
114: 524–529.
67 Mullegger RR: Dermatological manifestations of
Lyme borreliosis. Eur J Dermatol 2004;
14: 296–
309.
68 Asbrink E, Hovmark A, Olsson I: Lymphadenosis
benigna cutis solitaria – borrelia lymphocytoma in
Sweden. Zentralbl Bakteriol 1989;(suppl 18):156–
163.
69 Strle F, Pleterski-Rigler D, Stanek G, Pejovnik-
Pustinek A, Ruzic E, Cimperman J: Solitary bor-
relial lymphocytoma: report of 36 cases. Infection
1992;
20: 201–206.
70 Strle F, Maraspin V, Pleterski-Rigler D, Lotrič-Fur-
lan S, Ružić-Sabljić E, Jurca T, Cimperman J: Treat-
ment of borrelial lymphocytoma. Infection 1996;
24: 80–84.
71 Maraspin V, Cimperman J, Lotrič-Furlan S, Ružić-
Sabljić E, Jurca T, Picken RN, Strle F: Solitary bor-
relial lymphocytoma in adult patients. Wien Klin
Wochenschr 2002;
114: 515–523.
72 Hovmark A, Asbrink E, Weber K, Kaudewitz P:
Borrelial lymphocytoma; in Weber K, Burgdorfer
W (eds): Aspects of Lyme Borreliosis. Heidelberg,
Springer, 1993, pp 122–130.
73 C olli C, Lei nweber B, Mullegger R , Chott A, Kerl H,
Cerron i L: Borrelia burgdorferi -associated lympho-
cytoma cutis: clinicopathologic, immunopheno-
typic, and molecular study of 106 cases. J Cutan
Pathol 2004;
31: 232–240.
74 St rle F: Lyme borrel iosis in Slovenia. Z entralbl Bak-
teriol 1999;
289: 643–652.
75 Picken RN, Strle F, Ružić-Sabljić E, Maraspin V,
Lotrič-Furlan S, Cimperman J, Cheng Y, Picken
MM: Molecular subtyping of Borrelia burgdorferi
sensu lato isolates from five patients with solitary
lymphcytoma. J Invest Dermatol 1997;
108: 92–97.
76 Busch U, Hizo-Teufel C, Bohmer R, Fingerle V,
Ro ssle r D, W ils ke B, Pre ac-Mu rsi c V: Borrelia burg-
dorferi sensu lato strains isolated from cutaneous
Lyme borreliosis biopsies differentiated by pulsed-
field gel ele ctrophoresis. Sc and J Infect Dis 199 6;
28:
583–589.
77 Ružić-Sabljić E, Strle F, Cimperman J, Maraspin V,
Lotrič-Furlan S, Pleterski-Rigler D: Characterisa-
tion of Borrelia burgdorferi sensu lato strains iso-
lated from patients with skin manifestations of
Lyme borrel iosis residing in Slove nia. J Med Micro-
biol 2000;
49: 47–53.
78 We ber K, Schi erz G , Wil ske B, Prea c-Mur sic V: Da s
Lymphozytom – eine Borrelize? Z Hautkr 1985;
60:
1585–1598.
79 Weber K, Neubert U, Thurmayr R: Antibiotic ther-
apy in early erythema migrans disease and related
disorders. Zentralbl Bakteriol Mikrobiol Hyg [A]
1986;
263: 377–388.
80 Hovmark A, Asbrink E, Olsson I: The spirochetal
etiology of lymphadenosis benigna cutis solitaria.
Acta Derm Venereol 1986;
66: 479–484.
81 Asbrink E, Hovmark A: Cutaneous manifestations
in Ixode s-borne borrelia spirechetosis. Int J Derma-
tol 1987;
26: 215–225.
82 B oye T: W hat ki nd of c lin ical , epid emiol ogic al, a nd
biologica l data is essentia l for the diagno sis of Lyme
borreliosis? Dermatological and ophtalmological
courses of Lyme borreliosis. Med Mal Infect 2007;
37(suppl 3):S175–S188.
83 Lipsker D: Dermatological aspects of Lyme borreli-
osis. Med Mal Infect 2007;
37: 540–547.
84 DiCaudo DJ, Su WP, Marshall WF, Malawista SE,
Barthold S, Persing DH: Acrodermatitis chronica
atrophica ns in the United States: c linical and h isto-
pathologic features of six cases. Cutis 1994;
54: 81–
84.
85 Lavoie PE, Wilson AJ, Tuffanelli DL: Acrodermati-
tis chronica atrophicans with a ntecedent Lyme dis-
ease in a California. Case report. Mol Pathol 1997;
50: 186–193.
8 6 Wie neck e R, Zoc hli ng N , Neu ber t U, S chl upen EM,
Meurer M, Volkenandt M: Molecular subtyping of
in erythema migrans and acrodermatitis chronica
atrophicans. J Invest Dermatol 1994;
103: 19–22.
87 Ohlenbusch A, Matuschka FR, Richter D, Christen
HJ, Thoms sen R, Spielman A , Eif fert H : Etiol ogy of
the acrodermatitis chronica atrophicans lesion in
Lyme disease. J Infect Dis 1996;
174: 421–423.
104 Strle ⴢ Stanek
88 R ijpkema SG, Tazelaar DJ, Molk enboer MJ, Noord-
hoek GT, Plantinga G, Schouls L, Schellekens JF:
Detection of Borrelia afzelii , Borrelia burgdorferi
sensu stricto, Borrelia garinii and group VS116 by
PCR in skin biopsies of patients wit h eryt hema mi-
grans and acrodermatitis chronica atrophicans.
Clin Microbiol Infect 1997;
3: 109–116.
89 Lunemann JD, Zarmas S, Priem S, Franz J,
Zschende rlein R, Aberer E , Klein R, Sc houls L, Bur-
mester GR, Krause A: Rapid typing of Borrelia
burgdorferi sensu lato species in specimens from
patients with different manifestations of Lyme bor-
reliosis. J Clin Microbiol 2001;
39: 1130–1133.
90 Maraspin V, Ružić-Sabljić E, Strle F: Isolation of
Borrelia burgdorferi sensu lato from a fibrous nod-
ule in a patient with acrodermatitis chronica atro-
phicans. Wien Klin Wochenschr 2002;
114: 533 –
534.
91 Picken RN, Strle F, Picken MM, Ružić-Sabljić E,
Maraspin V, Lotric-Fu rlan S, Cimperman J: Identi-
ficat ion of three species of Borrelia burgdorferi sen-
su lato (B. burgdorferi sensu stricto, B. garinii , and
B. afzelii) among isolates from acrodermatitis
chronica atrophicans lesions. J Invest Dermatol
1998;
110: 211–214.
92 Asbrink E: Erythema chronicum migrans Afzelius
and acrodermat itis chronica atrophica ns: early and
late manifestations of Ixodes ricinus -borne Borrelia
spirochetes. Acta Derm Venereol Suppl (Stockh)
1985;
118:1– 63.
93 Asbr ink E, Brehmer Andersson E, Hovma rk A: Ac-
rodermatitis chronica atrophicans – a spirochet-
osis: clinical and histopathological picture based
on 32 patients. Am J Dermatopathol 1986;
8: 209–
219.
94 Breh mer-Andersson E, Hov mark A, Asbri nk E: Ac-
rodermatit is chronica atrophica ns: histopathologic
findings and clinical correlations in 111 cases. Acta
Derm Venereol 1998;
78: 207–213.
95 Asbr ink E, Hovmark A , Olsson I: Clinic al manifes-
tations of acrodermatitis chronica atrophicans in
50 Swedish patients. Zentralbl Bakteriol Mikrobiol
Hyg [A] 1986;
263: 253–261.
96 Asbrink E, Hovmark A, Weber K: Acrodermatitis
chronica atrophicans; in Weber K, Burgdorfer W
(eds): Aspects of Lyme Borreliosis. Heidelberg,
Springer, 1993, pp 193–204.
97 Hopf HC: Periphera l neuropathy in acrodermat i tis
chronica atrophicans (Herxheimer). J Neurol Neu-
rosurg Psychiat 1975;
38: 452–458.
98 Kristoferitsch W, Sluga E, Graf M, Partsch H, Neu-
mann R, Stanek G, Budka H: Neuropathy associ-
ated with acrodermatitis chronica atrophicans:
clinical and morphological features. A nn NY Acad
Sci 1988;
539: 35–45.
99 Kindstrand E, Nilsson BY, Hovmark A, Pirskanen
R, Asbrink E: Peripheral neuropathy in acroder-
matitis chronica atrophicans – effect of treatment.
Acta Neurol Scand 2002;
106: 253–257.
100 Herzer P: Joint manifestations; in Weber K, Burg-
dorfer W (eds): Aspects of Lyme Borreliosis. Hei-
delberg, Springer, 1993, pp 168–184.
101 Hauser W: Zur Kenntnis der Acrodermatitis
chronica atrophicans. Arch Dermatol Syph 1955;
199; 350–393.
102
Hoesly JM, Mertz LE, Winkelmann RK: Localized
scleroderma (morphea) and antibody to Borrelia
burgdorferi . J Am Acad Dermatol 1987;
17: 455–458
.
103 Akimoto S, Ish ikawa O, Miyachi Y: The abs ence of
antibodies against Borrelia burgdorferi in the sera
of Japanese patients with localized scleroderma. J
Rheumatol 1996; 3: 573–574.
104 Breier F, Klade H, Stanek G , Poitschek C , Kirnbau-
er R, Dorda W, Aberer E: Lymphoproliferative re-
sponses to Borrelia burgdorferi in circumscribed
scleroderma. Br J Dermatol 1996;
134: 285–291.
105 Buechner SA, Lautenschlager S, Itin P, Bircher A,
Erb P: Lymphoproliferative responses to Borrelia
burgdorferi in patients with eryt hema migrans, ac-
rodermatitis chronica atrophicans, lymphadeno-
sis benigna cutis, and morphea. Arch Dermatol
1995;
131: 673–677.
106 Fujiwara H, Fujiwara K, Hashimoto K, Mehregan
AH, Schaumburg-Lever G, Lange R, Schempp C,
Gollnick H: Detection of Borrelia burgdorferi
DNA (B. garinii or B. afzelii) in morphea and li-
chen sclerosu s et atrophicus ti ssues of German a nd
Japanese but not of US patients. Arch Dermatol
1997; 133: 41–44.
107 Dillon WI, Saed GM, Fivenson DP: Borrelia burg-
dorferi DNA is undetectable by polymerase chain
reaction i n skin lesions of morphea, scleroderma, or
li ch en s cl er osu s e t at ro ph ic us o f p at ien ts fro m N ort h
America. J Am Acad Dermatol 1995;
33: 617–620.
108 Aguero-Rosenfeld ME, Wang G, Schwartz I,
Wormser GP: Diagnosis of Lyme borreliosis. Clin
Microbiol Rev 2005;
18: 484–509.
10 9 A berer E, S tane k G, Er tl M , Neum ann R : Evi dence
for spirochetal origin of circumscribed scleroder-
ma (morphea). Acta Derm Venereol 1987;
67: 225–
231.
110 Weber K, Preac-Mursic V, Reimers CD: Spiro-
chetes isolated from two patients with morphea.
Infection 1988;
16: 25–26.
111 Breier FH, Aberer E, Stanek G, Khanakaha G,
Schlic k A, Tappeiner G: Isol ation of Borrelia afzelii
from circumscribed scleroderma. Br J Dermatol
1999;
140: 925–930.
112 Ranguin G, Boisnic S, Souteyrand P, Baranton G,
Piette JC, Godeau P, Francès C: No evidence for a
spirochetal origin of localized scleroderma. Br J
Dermatol 1992;
127: 218–220.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 105
113 Alonso-Lla mazares J, Persin g DH, Anda P, Gibson
LE, Rutledge BJ, Iglesias L: No evidence for Bor-
relia burgdorferi infection in lesions of morphea
and lichen sclerosus et atrophicus in Spain: a pro-
spective study and literature review. Acta Derm
Venereol 1997;
77: 299–304.
114 Breier F, Khanakah G, Stanek G, Kunz G, Aberer
E, Schmidt B, Tappeiner G: Isolation and poly-
merase chain reaction typing of Borrelia afzelii
from a skin lesion in a seronegative patient with
generalized ulcerating bullous lichen sclerosus et
atrophicus. Br J Dermatol 2001;
144: 387–392.
115 Cerroni L, Zöchling N, Pütz B, Kerl H: Infection
by Borrelia burgdorferi and cutaneous B-cell lym-
phoma. J Cutan Pathol 1997;
24: 457–461.
116 Kutting B, Bonsmann G, Metze D, Luger TA, Cer-
roni L: Borrelia burgdorferi -associated primary
cutaneous B cell lymphoma: complete clearing of
skin lesions after antibiotic pulse therapy or intra-
lesional injection of interferon alfa-2a. J Am Acad
Dermatol 1997;
36: 311–314.
117 Schöllkopf C, Melbye M, Munksgaard L, Ekström
Smedby K, Rostgaard K, Glimelius B, Chang ET,
Roos G, Hansen M, Adami HO, Hjalgrim H: Bor-
relia infection and risk of non-Hodgkin lympho-
ma. Blood 2008;
111: 5524–5529.
118 Wood GS, Kamath N V, Guitart J, Hea ld P, Kohler S,
Smoller BR, C erroni L: Absence of Borrelia burgdor-
feri DNA in cutaneous B-cell lymphomas from the
United States. J Cutan Pathol 2001; 28: 502–507.
119 Munksgaard L, Frisch M, Melbye M, Hjalgrim H:
Incidence pat terns of Lyme disease and cutaneous
B-cell non-Hodgkin’s lymphoma in the United
States. Dermatology 2000;
201: 351–352.
120 Goodlad JR, Davidson MM, Hollowood K, Ling C,
MacKenzie C, Christie I, Batstone PJ, Ho-Yen DO:
Primary cutaneous B-cell lymphoma and Borrelia
burgdorferi infection in patients from the highlands
of Scotland. Am J Surg Pathol 2000;
24: 1279–1285.
121 Li C, Inaga ki H, Kuo TT, Hu S, Okabe M, Ei moto T:
Primary cutaneous marginal zone B-cell lympho-
ma: a molecular and clinicopathologic study of 24
Asian cases. Am J Surg Pathol 2003;
27: 1061–1069.
122 Senff NJ, Noordijk EM, Youn H, Kim YH, Bagot M,
Bert i E, Cerroni L , Dummer R, D uvic M, Hoppe RT,
Pimpinel li N, Rosen ST, Vermeer MH, W hittaker S ,
Willemze R: European Organization for Research
and Treatment of Cancer and International Society
for Cutaneous Lymphoma consensus recommen-
dations for the management of cutaneous B-cell
lymphomas. Blood 2008;
112: 1600 –1609.
123 Bayerdorffer E, Ne ubauer A, Rudolph B, Thiede C ,
Lehn N, Eidt S, Stolte M: Regression of primary
gastric lymphoma of mucosa-associated lymphoid
tissue type after cure of Helicobacter pylori infec-
tion: MA LT Lymphoma Study G roup. Lancet 1995;
345: 1591–1594.
12 4 Neub auer A, Thiede C, Mor gner A, Alpen B, R itter
M, Neubauer A, Wundisch T, Ehninger G, Stolte
M, Bayerdorffer E: Cure of Helicobacter pylori in-
fection and duration of remission of low-grade
gastric mucosa-associated lymphoid tissue lym-
phoma. J Natl Cancer Inst 1997;
89: 1350–1355.
125 Roggero E, Zucca E, Pinotti G, Pascarella A, Ca-
pella C, Savio A, Pedrinis E, Paterlini A, Venco A,
Cavalli F: Eradication of Helicobacter pylori infec-
tion in primary lowgrade gastric lymphoma of
mucosa-associated lymphoid tissue. Ann Intern
Med 1995;
122: 767–769.
126 Dreno B: Standard and new treatments in cutane-
ous B-cell lymphomas. J Cutan Pathol 2006;
33(suppl 1):S47–S51.
127 Zena hlik P, Fink-Puches R, Kapp KS, Kerl H, Cer-
roni L: Therapy of primary cutaneous B-cell lym-
phomas. Hautarzt 2000;
51: 19–24.
128 Hoefnagel JJ, Vermeer MH, Jansen PM, Heule F,
van Voorst Vader PC, Sanders CJ, Gerritsen MJ,
Geerts ML, Meijer CJ, Noordijk EM, Willemze R:
Primary cutaneous marginal zone B-cell lympho-
ma: clinical and therapeutic features in 50 cases.
Arch Dermatol 2005;
141: 1139–1145.
129 Bogle MA, Riddle CC, Triana EM, Jones D, Duvic
M: Primary cutaneous B-cell lymphoma. J Am
Acad Dermatol 2005;
53: 479–484.
130 Monari P, Farisoglio C , Calzava ra Pinton PG: Bor-
relia burgdorferi -associated primary cutaneous
marginal-zone B-cell lymphoma: a case report.
Dermatology 2007;
215: 229–232.
131 Roggero E, Zucc a E, Mainet ti C, Bertoni F, Valsa n-
giacomo C, Pedrinis E, Borisch B, Piffaretti JC,
Cavalli F, Isaacson PG: Eradication of Borrelia
burgdorferi infection in primary ma rginal zone B-
cell lymphoma of the skin. Hum Pathol 2000;
31:
263–268.
132 Ryffel K, Peter O, Rut ti B, Suard A, Dayer E: S cored
antibody reactivity determined by immunoblot-
ting shows an association between clinical mani-
festations and presence of Borrelia burgdorferi
sensu stricto, B. garinii, B. afzelii, and B. valaisiana
in humans. J Clin Microbiol 1999;
37: 4086–4092.
133 Peter O, Bretz AG, Postic D, Dayer E: Association
of distinct species of Borrelia burgdorferi sensu
la to wi th ne ur ob or re li os is in Sw it ze rl a nd . C li n M i-
crobiol Infect 1997;
3: 423–431.
134 Hizo-Teufel C, Fingerle V, Nitschko H, Wilske B,
Preac-Mursic V: Three s pecies of Bor relia burgdor-
feri sensu lato (B. burgdorferi sensu stricto, B. af-
zelii and B. garinii) identified from cerebrospinal
fluid isolates by pulsed-field gel electrophoresis
and PCR. J Clin Microbiol 1996;
34: 1072–1078.
135 Ružić-S abljić E, Lotri č-Furlan S, Mar aspin V, Cim-
perman J, Pleterski-Rigler D, Strle F: Analysis of
Borrelia burgdorferi sensu lato isolated from cere-
brospinal fluid. APMIS 2001;
109: 707–713.
106 Strle ⴢ Stanek
13 6 Strle F, Ružić-S abljić E, Cimperm an J, Lotricč-Fu r-
lan S, Maraspin V: Comparison of findings for pa-
tients with Bor relia garinii and Borrelia afzelii iso-
lated from cerebrospinal f luid. Clin Infect Dis
2006;
43: 704–710.
137 Lebech AM, Hansen K, Rutledge BJ, Kolbert CP,
Rys PN, Pershing DH: Diagnostic detection and
direct genotyping of Borrelia burgdorferi by poly-
merase chain reaction in cerebrospinal f luid in
Lyme neuroborreliosis. Mol Diagn 1998;
3: 131–
141.
138 Ornstein K, Berglund J, Bergstrom S, Norrby R,
Barbour AG: Three major Lyme Borrelia genospe-
cies (Borrelia burgdorferi sensu stricto, B. afzelii
and B. garinii) identified by PCR in cerebrospinal
fluid from patients with neuroborreliosis in Swe-
den. Scand J Infect Dis 2002;
34: 341–346.
139 Steere AC, Schoen RT, Taylor E: The clin ical evolu-
tion of Lyme arthritis. Ann Intern Med 1987;
107:
725–731.
140 Reik L, Steere AC, Bartenhagen NH, Shope RE,
Malawista SE: Neurologic abnormalities of Lyme
disease. Medicine 1979;
58: 281–294.
141 Gerber MA, Shapiro ED, Burke GS, Parcells VJ,
Bell GL: Lyme disease in children in southeastern
Connec ticut. Pediat ric Lyme Diseas e Study Group.
N Engl J Med 1996;
335: 1270–1274.
142 C enters for Disease Cont rol and Prevention: Lyme
disea se – United States, 2003 –2005. MMWR 20 07;
6: 573–576.
143 Clark JR, Carlson RD, Sasaki CT, Pachies AR,
St ee re AC : Fa ci al par al ys is i n L yme di se ase . L ar yn -
goscope 1985;
95: 1341–1345.
144 Shapiro ED, Gerber MA: Lyme disease and facial
nerve palsy. Arch Pediatr Adolesc Med 1997;
151:
1183–1184.
145 Halperi n JJ, Golightl y M: Lyme borreliosis i n Bell’s
palsy. Long Island Neuroborreliosis Collaborative
Study Group. Neurology 1992;
42: 1268–1270.
146 Halperin JJ: Nervous system Lyme disease. Infect
Dis Clin North Am 2008;
22: 261–274.
147 Lotrič-Fu rlan S, Cimperm an J, Maraspi n V, Ru žić-
Sabljić E, Logar M, Jurca T, Strle F: Lyme borrelio-
si s an d pe rip her al f ac ial pa lsy. Wie n Kl in Woch en-
schr 1999;
111: 970–975.
148 Pfi ster HW, Kristoferit sch W, Meier C: Early neuro-
logical involvement (Bannwarth’s syndrome); in
Weber K, Burgdor fer W (eds): Aspect s of Lyme Bor-
reliosis. Heidelberg, Springer, 1993, pp 152–167.
149 K ristoferitsch W: Neuropat hien bei Lyme-Borrel i-
ose. Wien, Springer, 1989.
150 Stiernstedt GT, Granstrom M, Hederstedt B,
Skoldenberg B: Diagnosis of spirochetal meningi-
tis by enzyme-linked immunosorbent assay and
indirect immunofluorescence assay in serum and
cerebrospinal fluid. J Clin Microbiol 1985;
21: 819–
825.
151 Pfiste r HW, Einhaupl K M, Wilske B, P reac-Mursic
V: Bannwarth’s syndrome and the enlarged neuro-
logical spectrum of arthropod-borne borreliosis.
Zentralbl Bakteriol Mikrobiol Hyg [A] 1987;
263:
343–347.
152 Bammer H, Schenk K: Meningomyeloradikulitis
nach Zeckenbiss mit Erythem. Dtsch Z Nerven-
heilkunde 1965;
187: 25–34.
153 Schaltenbrand G: Durch Arthropoden übertra-
gene Infektionen der Haut und des Nervensys-
tems. Verh Dtsch Ges Inn Med 1967;
72: 975–1005.
154 Erbsloh F, Kohlmeyer K: Über polytope Er-
krankungen des peripheren Nervensystems bei
Lymphozytarer Meningitis. Fortschr Neurol Psy-
chiatr 1968;
36: 321–342.
155 Horstup P, Ackermann R: Durch Zecken über-
tragene Meningopolyneuritis (Garin-Bujadoux-
Bannwarth). Fortschr Neurol Psychiatr 1973;
41:
583–606.
156 Kristoferitsch W, Spiel G, Wessely P: Meningo-
polyneuritis (Garin-Bujadoux-Bannwarth): clini-
cal aspects and laboratory findings. Nervenarzt
1983;
54: 640–646.
157 Pachner AR, Steere AC: The triad of neurologic
manifestations of Lyme disease: meningitis, cra-
nial neuritis, and radiculoneuritis. Neurology
1985;
111: 47–53.
158 Duray PH: Clinical pathologic correlations of
Lyme disease. Rev Infect Dis 1989;
11(suppl 6):
S1487– S1493.
159 Meurers B, Kohlhepp W, Gold R, Rohrbach E,
Mertens HG: Histopathological findings in the
central and peripheral nervous systems in neu-
roborreliosis: a report of three cases. J Neurol
1990 ;
237: 113–116.
160 Roberts ED, Bohm RP Jr, Lowrie RC Jr, Habicht G,
Katona L, Piesman J, Philipp MT: Pathogenesis of
Lyme neuroborreliosis in the rhesus monkey: the
early disseminated and chronic phases of disease
in the pe ripheral nervou s system. J Infec t Dis 1998;
178: 722–732.
161 Garin C, Bujadoux R: Paralisie par les tiques. J
Med Lyon 1922;
71: 765–767.
162 Kristoferitsch W: Neurological manifestations of
Lyme borreliosis: clinical definition and differ-
ential diagnosis. Scand J Infect Dis 1991;
77
(sup pl): 64–7 3.
163
Hansen K: Lyme neuroborreliosis: improvements
of the laboratory diagnosis and a survey of epide-
miologica l and clinica l features in Denmark 1985–
1990. Acta Neurol Scand 1994;
89(suppl 151):7–44
.
164 Pfadenhaue r K, Schonsteiner T, Stohr M: T horaco-
abdominal manifestation of stage II Lyme neu-
roborreliosis. Nervenarzt 1998;
69: 296–299.
165 Bagger-Sjoback D, Remahl S, Ericsson M: Long-
term outcome of facial palsy in neuroborreliosis.
Otol Neurotol 2005;
26: 790–795.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 107
166 Skogman BH, Croner S, Odkvist L: Acute facial
palsy in children – a 2-year follow-up study with
focus on Lyme neu roborreliosis. Int J Pediatr Oto-
rhinolaryngol 2003;
67: 597–602.
167 Sibony P, Halperin J, Coyle PK, Patel K: Reactive
Lyme serology in optic neuritis. J Neuroophthal-
mol 2005;
25: 71–82.
168 Steenhoff AP, Smith MJ, Shah SS, Coffin SE: Neu-
roborreliosis with progression from pseudotumor
cerebri to aseptic meningitis. Pediatr Infect Dis J
2006;
25: 91–92.
169 Feder HM Jr: Lyme disease in children. Infect Dis
Clin North Am 2008;
22: 315–326.
170 Kristoferitsch W. Chronic peripheral neuropathy;
in Weber K, Burgdorfer W (eds): Aspects of Lyme
Borreliosis. Heidelberg, Springer, 1993, pp 219–
227.
171 Logigian EL, Kaplan RF, Steere AC: Chronic neu-
rologic manifestations of Lyme disease. N Engl J
Med 1990;
323: 1438–1444.
172 Cerar T, Ogrinc K, Cimperman J, Lotrič-Furlan S,
Strle F, Ružić-Sabljić E: Validation of cultivation
and PCR methods for diagnosis of Lyme neu-
roborreliosis. J Clin Microbiol 2008;
46: 3375–
3379.
173 Fish AE, Pride YB, Pinto DS: Lyme carditis. Infect
Dis Clin North Am 2008;
22: 275–288.
174 Steere AC, Batsford WP, Weinberg M, Ale xander J,
Berger , Wolfson S, Malawista SE: Lyme carditis:
cardi ac abnormalitie s of Lyme disease. A nn Intern
Med 1980;
93: 8–16.
175 Van der Linde MR: Lyme carditis; in Weber K,
Burgdorfer W (eds): Aspects of Lyme Borreliosis.
Heidelberg, Springer, 1993, pp 131–151.
176 Sigal LH: Early disseminated Lyme disease: car-
diac manifestations. Am J Med 1995;
98(suppl
4A):25–28.
177 Rubin DA, Sorbera C, Nikitin P, McAllister A,
Wormser GP, Nadelman RB: Prospective evalua-
tion of heart block complicating early Lyme dis-
ease. Pacing Clin Electrophysiol 1992;
15: 252–255.
178 Steere AC, Sikand VK, Meurice F, Parenti DL, Fi-
krig E, Schoen RT, Nowakowski J, Schmid CH,
Laukamp S, Buscarino C, Krause DS: Vaccination
against Lyme disease with recombinant Borrelia
burgdorferi outer surface lipoprotein A with adju-
vant. Lyme D isease Vaccine Study Group. N Engl J
Med 1998;
339: 209–215.
179 Sigal LH, Za hradni k JM, Lavin P, Patella SJ, Br yant
G, Haselby R, Hilton E, Kunkel M, Adler-Klein D,
Dohert y T, Evans J, Molloy PJ, Seid ner AL, Sabet ta
JR, Simon HJ, Klempner MS, Mays J, Marks D,
Malawista SE: A vaccine consisting of recombi-
nant Borrelia burgdorferi outer-surface A to pre-
vent Lyme disease. Recombinant Outer-Surface
Protein A Lyme Disease Vaccine Study Consor-
tium. N Engl J Med 1998;
339: 216–222.
180 Stanek G, Klein J, Bittner R, Glogar D: Isolat ion of
Borrelia burgdorferi from the myoca rdium of a pa-
tient with longstanding cardiomyopathy. N Engl J
Med 1990;
322: 249–252.
181 Marcus LC, Steere AC, Duray PH, Anderson AE,
Mahoney EB: Fatal pancarditis in a patient with
coexisting Lyme disease and babesiosis. Ann In-
tern Med 1985;
103: 374–376.
182 Reznick JW, Braunstein DB, Walsh RL, Smith CR ,
Wolfson PM, Gierke LW, Gorelkin L, Chandler
FW: Lyme carditis: electrophysiologic and histo-
pathologic study. Am J Med 1986;
81: 923–927.
183 Cox J, Krajden M: Cardiovascular manifestations
of Lyme disease. Am Heart J 1991;
122: 1449–1455.
184 de Koning J, Hoogkamp-Korstanje JA, van der
Linde MR, Crijns HJ: Demonstration of spiro-
chetes in cardiac biopsies of patients with Lyme
disease. J Infect Dis 1989;
160: 150–153.
185 van der Linde MR: Lyme carditis: clinical charac-
teristics of 105 cases. Scand J Infect Dis 1991;
77(suppl):81–84.
186 McAlister HF, Klementowicz PT, Andrews C,
Fisher JD, Feld M, Furman S: Lyme carditis: an
important course of reversible heart block. Ann
Intern Med 1989;
110: 339–345.
187 Pinto DS: Cardiac manifestat ions of Lyme disease.
Med Clin North Am 2002;
86: 285–296.
188 Cary NR, Fox B , Wright DJ, Cutler SJ, S hapiro LM,
Grace AA: Fatal Lyme carditis and endodermal
heterotopia of the atrioventricular node. Postgrad
Med J 1990;
66: 134–136.
189 Midttun M, Lebech AM, Hansen K, Videbaek J:
Lyme card itis: a clinic al presentation and lon g time
follow-up. Scand J Infect Dis 1997;
29: 153–157.
19 0 L ardieri G, Sa lvi A, Camer ini F, Cinco M, Trevisa n
G: Isolation of Borrelia burgdorferi from myocar-
dium. Lancet 1993;
342: 490.
191 Gasser R, D usleag J, Reisinger E , Stauber E, Feigl B ,
Pongratz S, Klein W, Furian C, Pierer K: Reversal
by ceftriaxone of dilated cardiomyopathy Borrelia
burgdorferi infection. Lancet 1992;
339: 1174–1175.
192 Sonnesyn SW, Diehl SC, Johnson RC, Kubo SH,
Goodman JL: A prospective study of the seroprev-
alence of Borrelia burgdorferi infection in patients
with severe heart failure. Am J Cardiol 1995;
76:
97–100.
193 Sangha O, Phillips CB, Fleischman KE, Wang TJ,
Fossel AH , Lew R, Liang MH, Shadick NA: Lack of
cardi ac manifestat ions among patients wit h previ-
ously treated Lyme disease. Ann Intern Med 1998;
128: 346–353.
194 Steere AC, Schoen RT, Taylor E: The clin ical evolu-
tion of Lyme arthritis. Ann Intern Med 1987;
107:
725–731.
108 Strle ⴢ Stanek
195 Krause PJ, McKay K, Thompson CA, Sikand VK,
Lentz R, Lepore T, Closter L, Christianson D, Tel-
ford SR, Persing D, Radolf JD, Spielman A; Deer-
Associated Infection Study Group: Disease-spe-
cific diagnosis of coinfecting tick-borne zoonoses:
babesiosis, human granulocytic ehrlichiosis, and
Lyme disease. Clin Infect Dis 2002;
34: 1184–1191.
19 6 Ga ns O, Lan des E : Ak roderma tit is at roph ica ns a r-
thropathica. Hautarzt 1952;
3: 151–155.
197 Weber K: Erythema-chronicum migrans-Me-
ningitis – eine bakterielle Infektionskrankheit?
Münch Med Wochenschr 1974;
116: 1993–1998.
198 Bannwarth A: Chronische Lymphocytare Menin-
gitis, entzündliche Polyneu ritis und ‘Rheum athis-
mus’. Ein Beitrag zum Problem ‘Allergie und Ner-
vensystem’ in zwei Teilen. Arch Psychiatr Ner -
venkr 1941; 113: 284–376.
199 Schaltenbr and G: Chronische a septische Men ingi-
tis. Nervenarzt 1949;
20: 433–442.
200 Priem S, Munkelt K, Franz JK, Schneider U, Wer-
ner T, Burmester GR, Krause A: Epidemiolog y and
therapy of Ly me arthritis and other mani festations
of Lyme borrel iosis in Germa ny: results of a nat ion-
wide sur vey. Z Rheumatol 2003;
62: 450–458.
201 van der Heijden IM, Wilbrink B, Rijpkema SG,
Schouls L M, Heyman s PH, van Embden JD, Bree d-
veld FC, Tak PP: Detection of Borrelia burgdorferi
sensu stricto by reverse line blot in the joints of
Dutch patients with Lyme arthritis. Arthritis
Rheum 1999;
42: 1473–1480.
2 02 Jaulh ac B, Heller R, Li mbach FX, Hans mann Y, Lip-
sker D, Monteil H, Sibilia J, Piemont Y: Direct mo-
lecula r typing of Borrelia burgdorferi sensu lato spe-
cies in synovial samples from patients with Lyme
arthritis. J Clin Microbiol 2000;
38: 1895–1900.
203 Limbach FX, Jaulhac B, Puechal X, Monteil H,
Kuntz JL, Piemont Y, Sibilia J: Treatment resistant
Lyme arthritis caused by Borrelia garinii . Ann
Rheum Dis 2001;
60: 284–286.
204 Vasiliu V, Herzer P, Rossler D, Lehnert G, Wilske
B: Heterogeneit y of Borrelia burgdorferi sensu lato
demonstr ated by an ospA-type-s pecific PCR i n sy-
novial fluid from patients with Lyme arthritis.
Med Microbiol Immunol 1998;
187: 97–102.
205 Eiffert H, Karsten A, Thomssen R, Christen HJ:
Characterization of Borrelia burgdorferi strains in
Lyme arthritis. Scand J Infect Dis 1998;
30: 265–
268.
206 Steere AC, Glickstein L: Elucidation of Lyme ar-
thritis. Nat Rev Immunol 2004;
4: 143–152.
207 Puius YA, Kalish RA: Lyme arthritis: pathogene-
sis, clinical presentation, and management. Infect
Dis Clin North Am 2008;
22: 289–300.
208 Guerau-de-Arellano M, Huber BT: Chemokines
and Toll-like receptors in Lyme disease pathogen-
esis. Trends Mol Med 2005;
11: 114–120.
209 Coburn J, Fischer JR, Leong JM: Solving a sticky
problem: new genetic approa ches to host cell adhe-
sion by the Lyme disease spirochete. Mol Micro-
biol 2005;
57: 1182–1195.
210 Hu LT, Eskildsen MA, Masgala C, Steere AC, Arn-
er EC, Pratta MA, Grodzinsky AJ, Loening A,
Perides G: Host metalloproteinases in Lyme ar-
thritis. Arthritis Rheum 2001;
44: 1401–1410 .
211 Behera AK, Hildebrand E, Scagliotti J, Steere AC,
Hu LT: Induction of host matrix metalloprotein-
ases by Borrelia burgdorferi differs in human and
murine Lyme arthritis. Infect Immun 2005;
73:
126–134.
212 Johnston YE , Duray PH, Steere AC, Ka shgarian M ,
Buza J, Malawista SE, Askenase PW: Lyme arthri-
tis: spiro chetes found in sy novial microa ngiopath-
ic lesions. Am J Pathol 1985;
118: 26–34.
213 Duray PH, Steere AC: The spectrum of organ and
systems pathology in human Lyme disease.
Zentralbl Bakteriol Mikrobiol Hyg [A] 1986;
263:
169–178.
214 Hollstrom E: Successful treatment of erythema
chronicum migrans Afzelii. Acta Derm Venereol
1951;
31: 235–243.
215 Asbrink E, Olsson I: Clinical manifestations of er-
ythema chronicum migrans Afzelius in 161 pa-
tients: a comparison with Lyme disease. Acta
Derm Venereol 1985;
65: 43–52.
216
Herzer P: Joint manifestations of Lyme borreliosis
in Europe. Scand J Infect Dis 1991;
77(suppl):55–63
.
217 Kryger P, Hansen K, Vinterberg H, Pedersen FK:
Lyme borreliosis among Danish patients with ar-
thritis. Scand J Rheumatol 1990;
19: 77–81.
218 Valesova M, Trnavsky K: Joint manifestations of
Lyme borreliosis in Czechoslovakian patients. Z
Rheumatol 1990;
49: 192–196.
219 Rees DH, Axford JS: Lyme arthritis. Ann Rheum
Dis 1994;
53: 553–556.
220 Steere AC, Hardin JA, Ruddy S, Mummaw JG, Ma-
lawist a SE: Lyme arthr itis: correlation of se rum and
cryoglobulin IgM with activity, and serum IgG
with remission. Arthritis Rheum 1979;
22: 471–483.
221 Hardin JA, Ste ere AC, Malaw ista SE: Immune com-
plexes and t he evolution of Lyme arth ritis: dissem i-
nation and localization of abnormal C1q binding
activity. N Engl J Med 1979;
301: 1358–1363.
222 Lawson JP, Steere AC: Lyme arthritis: radiologic
findings. Radiology 1985;
154: 37–43.
223 Snydman DR, Schenkein DP, Berardi VP, Lastavi-
ca CC, Pariser KM: Borrelia burgdorferi in joint
fluid in chronic Lyme arthritis. Ann Intern Med
1986;
104: 798–800.
22 4 Nocton J J, Dressler F, Rutledge BJ, Rys PN, Persi ng
DH, Steere AC: Detection of Borrelia burgdorferi
DNA by polymerase chain reaction in synovial
fluid from patients with Lyme arthritis. N Engl J
Med 1994;
330: 229–234.
Clinical Manifestations and Diagnosis of Lyme Borreliosis 109
225 Strle F: Ocular ma nifestations of Lyme borreliosis.
Acta Dermatovenerol Alp Panoncia Adriat 1994;
1–2: 71–76.
226 Mikkila HO, Seppala IJ, Viljanen MK, Peltomaa
MP, Karma A: The e xpanding cl inical spec trum of
ocular Lyme borreliosis. Ophthalmology 2000;
107: 581–587.
227 Karma A, Seppala I, Mikkila H, Kaakkola S, Vil-
janen M, Tarkkanen A: Diagnosis and clinical
characteristics of ocular Lyme borreliosis. Am J
Ophthalmol 1995;
119: 127–135.
228 Mikkila H, Karma A, Viljanen M, Seppala I: The
laboratory diagnosis of ocular Lyme borreliosis.
Graefes A rch Clin Exp Opht halmol 1999;
237: 225–
230.
229 Colucciello M: Ocular Lyme borreliosis. N Engl J
Med 2001;
345: 1350–1351.
2 30 Schonhe rr U, Strle F: Ocula r manifestat ions; in We-
ber K, Burgdorfer W (eds): Aspects of Lyme Bor-
reliosis. Heidelberg, Springer, 1993, pp 131–151.
231 Steere AC, Duray PH, Kauffmann DJ, Wormser
GP: Unilateral blindness caused by infection with
the Lyme disease spirochete, Borrelia burgdorferi.
Ann Intern Med 1985;
103: 382–384.
232 Carvounis PE, Mehta AP, Geist CE: Orbital myo-
sitis associated with Borrelia burgdorferi (Lyme
disease) infection. Ophthalmology 2004;
111:
1023–1028.
2 33 Hupp er tz H I, Mu nch mei er D , Lie b W: O cu lar man -
ifestations in children and adolescents with Lyme
arthritis. Br J Ophthalmol 1999;
83: 1149–1152.
234 de Boer JH, Luyendijk L, Rothova A, Kijlstra A:
Analysis of ocular f luids for local antibody pro-
duction in uveitis. Br J Ophthalmol 1995;
79: 610–
616.
235 Preac-Mursic V, Pfister HW, Spiegel H, Burk R,
Wilske B , Reinhardt S, Boh mer R: First isolat ion of
Borrelia burgdorferi from an iris biopsy. J Clin
Neuroophthalmol 1993;
13: 155 –161.
236 Lohmann CP, Winkler von Moh renfels C, Gabler B,
Reischl U, Kochanowski B: Polymerase chain reac-
tion (PCR) for microbiological diagnosis in refrac-
tory infectious keratitis: a clinical study in 16 pa-
tients. K lin Monatsbl Augenheilkd 2000;
217: 37–42.
237 Stanek G, Konrad K, Jung M, Ehringer H: Shul-
man syndrome, a scleroderma subtype caused by
Borrelia burgdorferi ? Lancet 1987; 1: 1490.
238 Granter SR, Barnhill RL, Hewins ME, Duray PH:
Identification of Borrelia burgdorferi in diffuse
fasciitis with peripheral eosinophilia: borrelial
fasciitis. JAMA 1994; 272: 1283–1285.
239 Hashimoto Y, Takahashi H, Matsuo S, Hirai K,
Takemori N, Nakao M, Miyamoto K, Iizuka H:
Polymerase chain reaction of Borrelia burgdorferi
flagellin gene in Shulman syndrome. Dermatolo-
gy 1996;
192: 136 –139.
240 Muller-Felber W, Reimers CD, de Koning J, Fisch-
er P, Pilz A, Pongratz DE: Myositis in Lyme bor-
reliosis: an immunohistochemical study of seven
patients. J Neurol Sci 1993;
118: 207–212.
241 Reimers CD, de Koning J, Neubert U, Preac-Mur-
sic V, Koster JG, Muller-Felber W, Pongratz DE,
Duray PH: Borrelia burgdorferi myositis: report of
eight patients. J Neurol 1993;
240: 278–283.
242 Holmgren AR, Matteson EL: Lyme myositis. Ar-
thritis Rheum 2006;
54: 2697–2700.
243 Cadavid D, Bai Y, Dail D, Hurd M, Narayan K,
Hodzic E, Barthold SW, Pachner AR: Infection
and inf lammation in skeletal muscle from nonhu-
man primates infected with different genospecies
of the Lyme disease spirochete Borrelia burgdor-
feri . Infect Immun 2003;
71: 7087–7098.
244
Horowitz HW, Sanghera K, Goldberg N, Pechman
D, Kamer R, D uray P, Weinstein A: Der matomyosi-
tis associated with Lyme disease: case report and
review of Lyme myositis. Clin Infect Dis 1994;
18:
166–171.
245 Waton J, Pinault AL, Pouaha J, Truchetet F: Lyme
disease could mimic dermatomyositis. Rev Med
Interne 2007;
28: 343–345.
246 S chna rr S, Wah l A, Ju rgens -Saa thof f B, Men gel M,
Kreipe HH, Z eidler H: Nodula r fasciitis, er ythema
migrans, and oligoarthritis: manifestations of
Lyme borreliosis caused by Borrelia afzelii . Scand
J Rheumatol 2002;
31: 184–186.
247 Kramer N, Rickert RR, Brodkin RH, Rosenstein
ED: Septal panniculitis as a manifestation of Lyme
disease. Am J Med 1986;
81: 149–152.
248 Hassler D, Zorn J, Zoller L, Neuss M, Weyand C,
Goronzy J, Born IA, Preac-Mursic V: Nodular
panniculitis: a manifestation of Lyme borreliosis?
Hautarzt 1992;
43: 134–138.
249 Viljanen MK, Oksi J, Salomaa P, Skurnik M, Pel-
tonen R, Kalimo H: Cultivation of Borrelia burg-
dorferi from the blood a nd a subcutaneous les ion of
a patient with relapsing febrile nodular nonsuppu-
rative panniculitis. J Infect Dis 1992;
165: 596–597.
250 Oksi J, Mertsola J, Reunanen M, Marjamaki M,
Viljanen MK : Subacute multiple-site os teomyelitis
caused by Borrelia burgdorferi . Clin Infect Dis
1994;
19: 891–896.
251
Feder HM Jr, Johnson BJ, O’Connell S, Shapiro ED,
Steere AC, Wormser GP; Ad Hoc I nternational Ly me
Disease Group, Agger WA, Artsob H, Auwaerter P,
Dumler JS, Bakken JS, Bockenstedt LK, Green J,
Dattwyler RJ, Munoz J, Nadelman RB, Schwartz I,
Draper T, McSweegan E , Halperin JJ, Klempner MS,
Kr ause P J, Mea d P, Mors hed M, Porwa nche r R, R ad-
olf JD, Smith RP Jr, Sood S, Weinstein A, Wong SJ,
Zemel L: A critical appraisal of ‘chronic Lyme dis-
ease’. N Engl J Med 2007;
357: 1422–1430.
252 Marques A: Chron ic Lyme dis ease: a review. Infe ct
Dis Clin North Am 2008;
22: 341–360.
110 Strle ⴢ Stanek
253 Fraser DD, Kong LI, Miller FW: Molecular detec-
tion of persistent Borrelia burgdorferi in a man
with dermatomyositis. Clin Exp Rheumatol 1992;
10: 387–390.
254 Sartin JS, Oettel KR: A morphealike skin condi-
tion caus ed by Borrelia burgdorferi in an immuno-
compromised patient. Mayo Clin Proc 2006;
81:
1259–1260.
255 Rodriguez M, Chou S, Fisher DC, De Girolami U,
Amato AA, Marty FM: Lyme meningoradiculitis
and myositis after allogeneic hematopoietic stem
cell tr ansplantation. Cl in Infect Dis 20 05;
41:e112–
e114.
256 Garcia-Monco JC, Frey HM, Villar BF, Golightly
MG, Benach JL: Lyme disease conc urrent with hu-
man im munodeficienc y virus i nfection. Am J Me d
1989;
87: 325–328.
257 Cordoliani F, Vig non-Pennamen MD, Assou s MV,
Vabres P, Dronne P, Rybojad M, Morel P: Atypical
Lyme borreliosis in an HIV-infected man. Br J
Dermatol 1997;
137: 437–439.
2 58 Dudle G, O pravil M, Lut hy R, Weber R: Mening itis
after acute Borrelia burgdorferi infection in HIV
infec tion. Dtsch Med Wochensc hr 1997;
122: 1178–
1180 .
259 Maraspin V, Lotrič-Furlan S, Cimperman J, Ružić-
Sabljić E, Strle F: Erythema migrans in the immu-
nocompromised host. Wien Klin Wochenschr
1999;
111: 923–932.
260 Furst B, Glatz M, Kerl H, Mullegger RR: The im-
pact of im munosuppression on ery thema migra ns:
a retrospective study of clinical presentation, re-
sponse to t reatment and product ion of Borrelia an-
tibodies in 33 patients. Clin Exp Dermatol 2006;
31: 509–514.
261 Maraspin V, Cimperman J, Lotrič-Furlan S, Logar
M, Ružić-Sabljić E, Strle F: Erythema migrans in
solid-organ transplant recipients. Clin Infect Dis
2006;
42: 1751–1754.
262 Millner M, Schimek MG, Spork D, Schnizer M,
Stanek G: Lyme borreliosis in children: a con-
trolled clinical study based on ELISA values. Eur J
Pediatr 1989;
148: 527–530.
2 63 Barbou r AG: Isolation a nd cultivat ion of Lyme dis-
ease spirochetes . Yale J Biol Med 1984;
57: 521–
525.
264 Preac-Mursic V, Wilske B, Reinhardt S: Culture of
Borrelia burgdorferi on six solid media. Eur J Clin
Microbiol Infect Dis 1991;
10: 1076–1079.
Franc Strle
Depar tment of Infectious Diseases, University Medical Center Ljubljana
Japljeva 2
SI–1525 Ljubljana (Slovenia)
Tel. +386 1 522 2110, Fax +386 1 522 2456, E-Mail franc.strle@kclj.si
265 Marlovits S, Khanakah G, Striessnig G, Vécsei V,
Stanek G: Emergence of Lyme arthritis after au-
tologous chondrocyte transplantation. Arthritis
Rheum 2004;
50: 259–264.
266 Aberer E, Bergmann AR, Derler AM, Schmidt B:
Course of Borrelia burgdorferi DNA shedding in
urine after treatment. Acta Derm Venereol 2007;
87: 39–42.
267 Rauter C, Mueller M, Diterich I, Zeller S, Hassler
D, Meergans T, Hartung T: Critical evaluation of
urine-based PCR assay for diagnosis of Lyme bor-
reliosis. Clin Diagn Lab Immunol 2005;
12: 910–
917.
26 8 Robert son J, Guy E, Andrews N, Wi lske B, Anda P,
Granström M, Hauser U, Moosmann Y, Sambri V,
Sc hell eken s J, St anek G, Gr ay J: A E urop ean m ulti-
center study of immunoblotting in serodiagnosis
of Lyme borreliosis. J Clin Microbiol 2000;
38:
2097–2102.
269 Hauser U, Lehnert G, Wilske B: Validity of inter-
pretation criteria for standardized Western blots
(immunoblots) for serodiagnosis of Lyme borreli-
osis based on sera collected throughout Europe. J
Clin Microbiol 1999;
37: 2241–2247.
270 Wilske B, Zöller L, Brade V, Eiffert H, Göbel UB,
Stanek G: MiQ (Quality Standards for the Micro-
biological Diagnosis of Infectious Diseases) 12
2000: Lyme Borreliosis. Munich/Jena, Urban &
Fischer Verlag, 2000.
271 Wilske B, Habermann C, Fingerle V, Hillenbrand
B, Jauris-Heipke S, Lehnert G, Pradel I, Rössler D,
Schulte-Spechtel U: An improved recombinant
IgG immunoblot for serodiagnosis of Lyme bor-
reliosis. Med Microbiol Immunol 1999;
188: 139–
144 .
272 Steere AC, McHugh G, Damle N, Sikand VK: Pro-
spective study of serologic tests for Lyme disease.
Clin Infect Dis 2008;
47: 188–195.
2 73 Ce ti n E, S otou deh M , Auer H, St ane k G: Pa rad igm
Burgenland: risk of Borrelia burgdorferi sensu lato
infection indicated by variable seroprevalence
ra tes i n hunt ers . Wien Kli n Woch ensc hr 20 06 ;
118:
677–681.
274 Barbour AG, Jasinskas A, Kayala MA, Davies DH,
Steere AC, Baldi P, Felgner PL: A genome-wide
proteome array reveals a limited set of immuno-
gens in natural infections of humans and white-
footed mice with Borrelia burgdorferi . Infect Im-
mun 2008;
76: 3374–3389.
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 111–129
A b s t r a c t
Randomized controlled trials have ascertained the efficiency of antibiotics in treating erythema
migrans, the hallmark of early stage Lyme borreliosis. Oral amoxicillin and doxycycline are first-line
treatment options, though phenoxymethylpenicillin, cefuroxime axetil and azithromycin are alter-
native second-line options. Treatments for secondary and tertiary Lyme borreliosis are more poor-
ly documented, and antibiotics are not always effective. This is due to the unique pathophysiology
of late Lyme borreliosis, which involves not only bacterial infection, but also immunological re-
sponse. Since there is no completely reliable method of diagnosis, it is dif ficult to choose the prop-
er treatment and to evaluate treatment efficacy. However, numerous studies have shown that cef-
triaxone and doxycycline are the 2 most efficient antibiotics, particularly in Lyme arthritis and in
neuroborreliosis. In late Lyme borre liosis, these antibiotics are less effici ent, and different treatment
schemes with variations in dosage or duration did not produce convincing results.
Copy right © 2009 S. Karger AG , Basel
The treatment of Lyme disease varies according to the clinical stage. For each stage,
the pathophysiology differs, and therefore the antibiotherapy has to be adapted to the
clinical signs. Recently published guidelines and recommendations follow this strat-
egy, in order to help choose the best antibiotics for each clinical situation [1– 4] .
During the first stage of the infection, the main clinical sign, erythema migrans,
is due to the progression of Borrelia in the skin. At this stage, many antibiotics are ef-
fective. Three families of antibiotics are frequently used:  -lactams (especially amox-
icillin and ceftriaxone) and tetracyclines (especially doxycycline), and, as a second
choice, macrolides, which are probably less efficient. In the next stage, hematogenous
spread occurs and the bacteria can be found in the blood, and subsequently in the
synovial fluid (in cases of arthritis) or in the cerebrospinal fluid (CSF; in cases of men-
ingitis). To be effective, the treatment must not only have bactericidal activity, but
must also diffuse correctly in these 2 fluids. For example, in neuroborreliosis, higher
Treatment and Prevention of Lyme Disease
Yves Hansmann
Service des Maladies Infectieuses et Tropicales, Hôpitaux Universitaires de Strasbourg, et
Faculté de Médecine de Strasbourg, Université Louis Pasteur, Strasbourg , France
112 Hansmann
dosages of  -lactams are needed for sufficient diffusion into the CSF. Finally, the late
stage of the disease is characterized by difficulty in identifying Borrelia in various
tissues, so the main mechanism in this phase could be an immunological reaction to
fragments of the bacteria acting as antigens. These immunologically based mecha-
nisms are one possible explanation for the low efficacy of antibiotic treatment in a lot
of patients with advanced Lyme disease [5] .
Historically, the first time that the presence of Borrelia was correlated with the
clinical symptoms, antibiotics were tested on their ability to cure patients with Lyme
diseases. In the early stage, the antibiotics were effective and the symptoms regressed.
The first reported cases were rapidly followed by larger studies that confirmed these
results. However, there were only a few studies using rigorous scientific methodology.
Many studies were retrospective or without real randomization, and neither con-
trolled, nor comparative. Therefore, a lot of questions remained.
On the other hand, physicians quickly noticed that some patients with Lyme dis-
ease did not respond to the antibiotic treatment. Thus, some doubt remained about
the real efficacy of antibiotics, as well as the responsibility of Borrelia in some mani-
festations of the disease (especially in the later stages); this raised a question about the
validity of the diagnostic criteria of Lyme disease. There is still no treatment that can
guarantee the regression of clinical symptoms after completing an antibiotic treat-
ment in all stages of Lyme disease. So, it seems quite important to highlight preven-
tion, and to inform all subjects living in highly endemic areas for Lyme disease to
avoid tick bites. No repellents prevent all tick bites. However, knowing the pathophys-
iology of the transmission of Borrelia during a tick bite helps to prevent infection.
Borrelia needs several hours for transition from the gut of ticks to their salivary
glands. So, if the ticks are removed rapidly (within some hours), the risk of Borrelia
transmission is low, though this is less certain in Europe than in North America.
In vitro Data
Several antibiotics have good in vitro activity against Borrelia . Among  -lactams, the
best in vitro activity is obtained with parenteral third-generation cephalosporins.
Amoxicillin and oral second- and third-generation cephalosporins also have good
activity [6, 7] . Ureidopenicillins and carbapenems have shown interesting properties,
but penicillin seems less efficient in vitro [7, 8] . Tetracyclines have activity equivalent
to amoxicillin, and sometimes even to ceftriaxone or cefotaxime [6, 7, 9] .
There are many differences within the family of macrolide antibiotics. The new
telithromycin is the only one that has shown better in vitro activity than ceftriaxone
[10] . Clarithromycin has superior activity compared to tetracyclines [11] . Other mac-
rolides have sufficiently good activity to suggest that they could be useful in vivo:
azithromycin, erythromycin, roxithromycin, dirithromycin and quinupristin-dalfo-
pristin [10, 12, 13] . Trimethoprim is more difficult to test in vitro, but seems to have
Treatment and Prevention of Lyme Disease 113
some activity against Borrelia [14] . Most of these results have been confirmed on dif-
ferent strains of Borrelia , B. burgdorferi sensu stricto and B. afzelii , isolated in Europe
and the Far East [9, 15] . Other antibiotics did not show any activity against Borrelia :
amikacin, aztreonam, vancomycin, fusidic acid and fluoroquinolones [6, 8, 12] . The
in vitro test does not predict the risk of acquired resistance to most of the antibiotics,
except for erythromycin under specific conditions, like a heavy inoculum [16, 17] .
Pharmacological data are rarely used for treating borreliosis. However, 2 proper-
ties are important: the diffusion of antibiotics in CSF for neuroborreliosis, and the
intracellular penetration for all forms of borreliosis.
 -Lactams are considered to have rather poor CSF penetration. High dosages of
this family of antibiotics are often used to treat neuromeningeal infections. For tet-
racyclines, there are not much data about diffusion into CSF, and though their use
has been validated in clinical studies, their diffusion into CSF appears to be relative-
ly poor. The mean intrathecal concentrations were 0.6 mg/l in patients treated with
100 mg of doxycycline twice a day and 1.1 mg/l in patients treated with 200 mg twice
a day. The minimal inhibitory concentration of doxycycline for Borrelia ranges be-
tween 0.6 and 0.7 mg/l, so theoretically the higher dosage should be more effective
[18] . This has not been confirmed in clinical studies, however.
On the other hand, the intracellular penetration of doxycycline is superior to that
of the  -lactams. This data could be important from a physiopathological point of
view, because of the possibility of the intracellular presence of Borrelia . However, it
has still not been shown that doxycycline is more effective than  -lactams in bor-
reliosis, whatever the stage of the infection.
Some experimental animal models have confirmed the in vitro results, including
the high activity of  -lactams and doxycycline in borreliosis. These studies have also
confirmed some advantages for using macrolides and everninomycin [7, 11, 19–22] .
The animal models can also help identify the best duration of treatment. For ex-
ample, in B. burgdorferi -infected mice, a 1-day treatment with ceftriaxone showed the
same activity as a 5-day treatment [23] .
Primary (Early Localized) Lyme Borreliosis
During the early stage of the infection, the first objective of treatment is to make ery-
thema migrans disappear. However, in most of the cases, the skin heals spontane-
ously even without antibiotic treatment. So another objective, actually the main one,
is to prevent the dissemination of the disease, which could lead to the involvement of
other organ systems and to the late manifestations of the disease. Obviously, an es-
sential criteria when evaluating drug effectiveness should be the absence of the late
manifestation of the disease.  -Lactams, tetracyclines and macrolides were tested for
effective treatment of erythema migrans in clinical studies, which were sometimes
controlled, randomized or double-blinded. Most of the studies were conducted in
114 Hansmann
North America, though some of them were conducted in Europe, where species di-
versity is more important. The results did not differ significantly according to the
geographic area, suggesting that most of the different species of Borrelia ( B. burgdor-
feri, B. afzelii, B. garinii ) respond in the same manner to antibiotics. This clinical re-
sult was confirmed by in vitro studies [15] .
The antibiotics tested initially were phenoxymethylpenicillin, doxycycline and
erythromycin [24] . Efficacy of these antibiotics was higher for doxycycline (absence
of neurological complications) compared to penicillin. Erythromycin was the least
efficient of the 3 tested antibiotics, with an increased risk of neurological complica-
tions and a slower resolution of erythema migrans.
Among the  -lactams, phenoxymethylpenicillin was initially the antibiotic used
most often to treat erythema migrans [25–29] . Amoxicillin showed equivalent activ-
ity to phenoxymethylpenicillin. The addition of probenecid does not seem to improve
the clinical response [30, 31] . Only 1 study has compared amoxicillin without proben-
ecid (3 ! 500 mg/day) to azithromycin (3 ! 50 0 mg/day). In th is st udy, more az it hro-
mycin recipients (16%) than amoxicillin recipients (4%) had relapses [32] .
The dosage of amoxicillin, in most cases, is 3 ! 500 mg per day for adults and 50
mg/kg/day for children. Not everybody agrees with this, because of concern about
underdosage in adults. Some authors propose increasing the dosage of amoxicillin if
probenecid is not associated with it [3] .
Two other  -lactams have been found to be equivalent to amoxicillin, but they of-
fer no significant advantage: ceftriaxone, which requires parenteral administration,
and cefuroxime axetil, which has a larger spectrum than amoxicillin and is more ex-
pensive [26, 33, 34] .
In the studies, the duration of treatment was 10, 14 or 21 days [24, 25, 34, 35] ,
though no duration was found to be clearly superior. After a 10-day treatment course,
some studies showed more long-term complications [24, 26] . One comparative study
showed equivalence whatever the duration of treatment, though there was 1 failure
in the group of patients treated for 10 days compared to no failures in the group of
patients treated longer, but this difference was not significant [34] .
In all the therapeutic studies, tetracycline has shown similar activity to amoxicillin,
and can thus be considered as another first-line option. The first studies using tetra-
cycline showed equivalence to phenoxymethylpenicillin. Eryt hema migrans wa s cured
more rapidly in patients treated with doxycycline compared to erythromycin [24] .
Further studies compared doxycycline with several other antibiotics: phenoxy-
methylpenicillin, azithromycin, amoxicillin and cefuroxime axetil. In most cases, the
activity of doxycycline was at least as efficient as the other antibiotics [27, 30, 31, 33–
39]
. Minocycline was used in only 1 study, and had the same efficacy as phenoxy-
methylpenicillin [29] . The recommended dosage of doxycycline is 200 mg per day
(once or twice) for 2 weeks.
The first macrolide to be tested was erythromycin; results showed that it was infe-
rior to both phenoxymethylpenicillin and doxycycline [24] . Azithromycin, a long half-
Treatment and Prevention of Lyme Disease 115
life elimination macrolide with excellent intracellular diffusion, showed globally com-
parable results to penicillin and doxycycline in terms of resolution of clinical symp-
toms and complications occurring after erythema migrans [27, 28, 31, 32, 37–39] .
In children, 3 studies showed similar efficacies of phenoxymethylpenicillin
(100,000 U/kg/day, 14 days), cefuroxime axetil (20 or 30 mg/kg/day, 14–20 days),
azithromycin (20 mg/kg/day on the first day, 10 mg/kg/day over the following 4 days)
and amoxicillin (50 mg/kg/day) [40–42] . Treatment recommendations for erythema
migrans are shown in table 1 . For pregnant or breast-feeding women, the treatment
is the same, except for tetracyclines which are not recommended. In cases with an al-
lergy to  -lactams, only macrolides can be used.
Secondary and Tertiary (Early Disseminated and Late) Lyme Borreliosis
Secondary Lyme borreliosis corresponds to the manifestations occurring during and
after dissemination of Borrelia in the blood. Articular and neurological tissues, and
less frequently the heart, the skin and the eye, are the principal targets of Borrelia .
An epidemiological study performed in eastern France from 2001 to 2003 [43]
found that disseminated and late infections (secondary and tertiary) represent 37.3%
of all of the diagnosed cases of Lyme diseases.
During the secondary stage, clinical manifestations are directly related to the pres-
ence of Borrelia . Without treatment, the disease progresses and can cause long-term
complications. If this happens, the disease enters a new stage (called tertiary or late
Lyme disease) where some clinical manifestations might not be due to Borrelia , but
could possibly be explained by immunological modifications [44–47] . The precise
mechanisms are not known, but the release of bacterial antigens, characterized by
Tab le 1. Choice of antibiotic treatment in early localized or primary borreliosis (erythema migrans)
Antibiotic Dosage Duration of
treatment, days
Adults
First-line choice amoxicillin
doxycycline
3 ! 500 or 3 ! 1,000 mg/day
200 mg/day
14–21
14–21
Second-line choice cefuroxime axetil 2 ! 500 mg/day 14–21
Third-line choice azithromycin 500 mg first day, 250 mg
following days
7–10
Children
Less than 8 years amoxicillin 50 mg/kg/day 14–21
More than 8 years adult dosage
Second-line choice cefuroxime axetil 30 mg/kg/day 7–10
116 Hansmann
their similarity to articular or neurological antigens (‘molecular mimicry’), could be
the cause of the clinical manifestations. Thus, we can understand why antibiotics are
less efficient in tertiary Lyme disease, but still remain the only treatment that can be
potentially curative.
Another problem with secondary Lyme disease that remains is the difficulty in di-
agnosing the disease at this stage; this difficulty directly affects evaluation of its treat-
ment. Accurate diagnosis requires several clinical and biological or microbiological
criteria [48] . Direct identification of Borrelia remains exceptional. Culture of the in-
fected tissue requires specific medium; however, its sensitivity is low. Molecular diag-
nosis, like PCR, allows more frequent identification of Borrelia , but it involves tissue
samples. So, in most situations, the diagnosis is based on the clinical manifestations and
on the detection of specific antibodies. If the clinical manifestations are unspecific, the
presence of Borrelia antibodies is insufficient to conf irm diagnosis. So, in clinical prac-
tice, antibiotics are often given to patients even if the diagnosis has not been definitely
confirmed. However, this problem is also frequently encountered in a lot of therapeutic
studies. Unrestrictive criteria allow many patients who are not infected with Borrelia
to be included in studies. The consequence is that the response to treatment becomes
difficult to evaluate. On the other hand, a diagnosis of neuroborreliosis according to
classical diagnostic criteria requires the presence of meningitis, yet most of authors
agree that some cases of neuroborreliosis affect only the peripheral nervous system, so
no CSF effect can be found. Even though this form of peripheral neuropathy is due to
borreliosis, it does not comply with the diagnostic criteria, and therefore cannot be in-
cluded in clinical studies to test the efficacy of antibiotics. For these forms of neurobor-
reliosis, we have no evidence-based guidance to determine the treatment.
In real-life clinical practice, the physician often prescribes antibiotics to a patient
because, even if the diagnosis is not confirmed, it cannot be excluded. A study con-
ducted in the USA in 1994 to evaluate the toxicity of ceftriaxone used to treat Lyme
disease showed that only 2% of the patients responded to the EUCALB (European
Union Concerted Action on Lyme Borreliosis) diagnostic criteria [49] . In another
therapeutic study, the consequences of overdiagnosis and overtreatment were evalu-
ated. Even though only 21% of the patients met the criteria for Lyme disease, these
patients relied heavily on medical assistance and were subjected to high antibiotic
toxicity. This raises questions about the wisdom of prescribing antibiotics to a large
number of patients without any certainty of the diagnosis of borreliosis [50] . On the
other hand, Donta [51] showed in 1997 that the prescription of doxycycline for pa-
tients with articular or neurological manifestations led to significant improvement in
61% of the patients, whatever the results of Borrelia serological testing had been.
Finally, for several reasons the late manifestations of borreliosis are probably the
most difficult to be efficiently treated with antibiotics. Indeed, some clinical mani-
festations are probably not directly due to bacterial proliferation, and the difficulty in
establishing a diagnosis with certainty leads to difficulty in evaluating the response
to antibiotic treatment.
Treatment and Prevention of Lyme Disease 117
Which Antibiotics Should Be Used for Secondary or Tertiary Lyme Arthritis or
Neuroborreliosis?
Since the 1980s, some clinical studies have validated different treatment options.
These studies have shown the superiority of antibiotics compared to a placebo in
eliminating the clinical manifestations in second stage borreliosis. Several clinical
studies have tested  -lactams and tetracyclines during this stage in patients with ar-
ticular manifestations, neurological manifestations or both. These studies have
helped validate the use of these treatments in secondary Lyme disease. In most of
these studies, no significant difference between the different families of antibiotics
was found, whatever the manifestation of borreliosis. However, we have to consider
that:
– A multitude of variables make these studies difficult to interpret and limit our
ability to establish evidence-based recommendations: diagnostic criteria are not
very specific for Lyme arthritis, or can be too restrictive for neuroborreliosis (CSF
results are necessary and not always tested in therapeutic studies); the large num-
ber of treatment modalities (choice of antibiotic, dosage, duration of treatment,
association of several antibiotics, multiple antibiotic schemes); and the difficulty
in defining healing criteria (improvements in clinical signs, absence of microbio-
logical criteria, duration of follow-up).
– The main difference between treating articular or neurological borreliosis is the
necessity of significant antibiotic diffusion into the CSF for neurological manifes-
tations, meaning that for each indication, a specific treatment should be pro-
posed.
Treatment of Lyme Arthritis
For articular manifestations during secondary Lyme borreliosis, several antibiotics
have proven to be efficient: penicillin, ceftriaxone and doxycycline [52–59] . Penicil-
lin was the first antibiotic tested, but it sometimes leads to the persistence of musculo-
skeletal manifestations [52] , especially if administered intramuscularly. Efficacy is
best when it is used intravenously at a high dosage [53] for at least 10 days. Many
studies used 3 weeks of treatment. Amoxicillin associated with probenecid is effec-
tive in treating Lyme arthritis. Since amoxicillin has always been tested in associa-
tion with probenecid during the comparative clinical studies, it is difficult to know
exactly what is the best dosage of this antibiotic for treating secondary borreliosis
when used without probenecid. Third-generation cephalosporins are at least as ef-
ficient as penicillin. Of these, the most frequently used is ceftriaxone because of its
simple once daily administration. The efficacy of ceftriaxone in Lyme arthritis is ei-
ther equivalent to penicillin or better. If oral treatment of Lyme arthritis fails, a sec-
ond-line treatment with ceftriaxone can be efficient [60] . Ceftriaxone can also be
118 Hansmann
used in children [57, 61] . Cefotaxime is rarely used, even though the efficacy is the
same in Lyme arthritis, because administration requires 3 daily injections [62, 63] .
Cefix ime, an oral cephalospor in, sh owed lack of eff icac y in Lyme a rthr itis w ith more
relapses after treatment than ceftriaxone [64] . Doxycycline is also effective in Lyme
arthritis. Two studies suggested that a 2-week treatment with doxycycline, amoxicil-
lin or ceftriaxone in Lyme arthritis leads to a good resolution of symptoms, without
relapse within a 40-week follow-up [65, 66] . Given for 21 days at 200 mg/day, doxy-
cycline has shown equivalent effectiveness to ceftriaxone and to amoxicillin plus
probenecid [60, 67] . Doxycycline cannot be used in children.
In conclusion, doxycycline and ceftriaxone are the most efficient antibiotics for
Lyme arthritis. Since doxycycline is less expensive than ceftriaxone, it can be used as
a first-line treatment for articular borreliosis (table 2).
Treatment of Neuroborreliosis
For neuroborreliosis, most of the clinical trials included different types of manifesta-
tions: radiculitis (with or without meningitis), facial palsy (that has to be considered
as a special form of radiculitis), peripheral neuropathy or central nervous system in-
volvement. High-dosage intravenous penicillin is an effective treatment for neu-
roborreliosis [52] . For amoxicillin, the use of probenecid, which prolongs its half-life,
could hinder the diffusion of amoxicillin into the CSF [68, 69] . Ceftriaxone showed
equivalence or a better efficacy at 2 g/day than penicillin. Increasing the dosage to
4 g/day showed no additional benefit [55, 61] . Ceftriaxone was effective in cases of
neuroborreliosis where penicillin had failed [54–56] , and can also be used in children
with neurological involvement [57, 61] . It is also effective for meningoradiculitis, even
if the central nervous system is involved [70] . Among patients with Lyme encepha-
lopathy, characterized by loss of memory, ceftriaxone is able to improve the clinical
signs in some, but not all, cases [71] . This superiority could be explained by the rela-
tively good diffusion of ceftriaxone into the central nervous system. Cefotaxime has
also been compared to penicillin; however, despite its good activity, this antibiotic has
no real advantage over ceftriaxone which is much easier to administer, especially in
ambulatory patients [62, 63] .
The question of the use of doxycycline for neuroborreliosis has not been totally
solved. Several studies seem to show that its efficacy (200 mg/day, 3 weeks) in neu-
roborreliosis could be equivalent to ceftriaxone and high-dosage intravenous penicil-
lin [72–74] . However, in other studies, neurological complications occurred after
doxycycline treatment [60, 67] , perhaps because doxycycline diffuses poorly into the
CSF. Only when its dosage was increased to 400 mg/day, in order to improve the CSF
diffusion, was it found to be equivalent to ceftriaxone [58] .
Treatment and Prevention of Lyme Disease 119
Facial palsy is one of the most frequent manifestations in neuroborreliosis, for
which some specific recommendations exist. Although it may persist for a long time,
facial palsy generally has a good prognosis [75] . Both ceftriaxone and doxycycline
tre atm ent s have shown goo d ac tivity in treat ing facia l pa lsy, t hough res olution o ccu rs
slowly [74, 75] . The Infectious Disease Society of America recommends the use of
amoxicillin in absence of meningitis [2, 76] . However, there is only a descriptive non-
comparative study supporting this recommendation. So, the use of ceftriaxone or
doxycycline, by analogy with the recommendations for other forms of neuroborreli-
osis (including peripheral neuropathy without meningitis), should be considered un-
til more data can justify the use of oral amoxicillin [1] .
Tab le 2 . Choice of antibiotic treatment in borreliosis (except isolated erythema migrans) according to the clinical stage
of the disease
First-line treatment Alternative treatment Other possibilities1
Disseminated early
forms (multiple
erythema migrans2)
ceftriaxone 2 g/day 14 days or
doxycycline 200 mg/day 14–21 days
Borrelial
lymphocytoma
amoxicillin 1.5–3 g/day (B-III) or
doxycycline 200 mg/day 14–21 days (B-III)
ACA ceftriaxone 2 g/day or doxycycline
200 mg/day 30 days (B-II)
penicillin G or amoxicillin
30 days (B-II)
Neuroborreliosis ceftriaxone 2 g or
50–75 mg/kg/day 14–28 days (B-I)
doxycycline 200 mg/day3
14–21 days (B-II)
intravenous penicillin G
400,000–500,000 U/day (B-II)
Lyme arthritis doxycycline4 200 mg/day
14–21 days (B-I)
ceftriaxone 2 g/day
14–28 days (B-I)
amoxicillin (+ probenecid)
4 ! 500 mg/day 30 days? (B-II)
Lyme carditis ceftriaxone 2 g/day or doxycycline
200 mg/day 14–21 days (B-III)
Ocular borreliosis ceftriaxone 2 g/day 14–21 days (B-III) doxycycline
200 mg/day (B-III)
ACA = Acrodermatitis chronica atrophicans. Strength of recommendation: A = strongly in favor, B = moderately in favor,
C = optional, D = moderately against, E = strongly against. Quality of evidence: I = evidence from ≥1 properly randomized,
controlled trial; II = evidence from ≥1 well-designed clinical trial, without randomization, from cohort or case-controlled
analytic studies (preferably from >1 center), from multiple time series studies, or from dramatic results from uncontrolled
experiments; III = evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or re-
ports of expert committees.
1 Evaluated, but no clinical evidence of equivalent efficacy with first-line treatments, so these options should not be used
first.
2 Only few data are available; in so far as this stage corresponds to a hematogenous dissemination, treatment options have
to address the risk of articular or neurological localization.
3 No clinically proven benefit for increasing the dosage to 400 mg/day.
4 Pharmaco-economical benefit of doxycycline versus ceftriaxone.
120 Hansmann
In conclusion, 2 g/day of ceftriaxone remains the reference treatment for menin-
goradiculitis in neuroborreliosis. As for Lyme arthritis, the optimal duration of treat-
ment is not clearly established, and the response seems better if the treatment is start-
ed rapidly, less than 3 months after the onset of the clinical manifestations [77, 78] .
Doxycycline can be used as an alternative treatment (table 2).
Post-Lyme Disease and Late-Stage Borreliosis
All the therapeutic studies in secondary Lyme borreliosis (neuroborreliosis and Lyme
arthritis) showed that a complete response to treatment is not obtained for all pa-
tients, even if ceftriaxone or doxycycline are used. Some authors have highlighted the
problem of the patients that did not respond to several antibiotic treatments, and/or
studied the second-line treatment after failure of a first-line antibiotic. In all the stud-
ies, a certain number of patients remained symptomatic, whatever treatment they
received. This points out two sorts of problems: first, the risk of a false diagnosis in
patients without criteria for borreliosis, a very frequent situation in clinical practice,
as well as in clinical studies; second, the possibility of developing a late form of bor-
reliosis or even the so-called ‘post-Lyme disease’. The difference between the late form
of borreliosis and post-Lyme disease could be the persistence of Borrelia (or at least
antigens) in the so-called ‘late form’, suggesting that the clinical manifestations are
directly related to the presence of bacteria. From a therapeutic point of view, these 2
stages of the disease are characterized by the often poor response to antibiotherapy.
There are 2 types of clinical studies: (1) studies that concern patients with clinical
manifestations that have evolved over several months, sometimes for more than 1
year, and who have never been treated with effective antibiotics for borreliosis; (2)
studies including patients who have had clinical manifestations for more than 1 year
and who have already been treated.
For the first type of patients, it appears that the older the clinical manifestations,
the more difficult it is to cure borreliosis. Different lines of long-duration treatments
have been tested: first-line treatment with tetracyclines or oral amoxicillin associated
with probenecid, followed by administration of ceftriaxone or benzathine penicillin
[60, 79] , or prolongation of oral antibiotic treatment after initial parenteral treatment
or an increase in the dosage of ceftriaxone [55, 57] . Generally, there was no clinically
evident benefit, but the evaluation of efficacy also depends on the duration of the fol-
low-up: relapses, which occur several months after initial antibiotic treatment, are
usually considered to be failures. Only a 28-day ceftriaxone (2 g/day) treatment gave
better results than a 14-day treatment, but without reaching a significant statistical
difference in a non-randomized study [80] .
For the second type of patients, a descriptive study showed that after a new treat-
ment, clinical signs were resolved in 42% of the patients, 36% of the patients had im-
provement followed by recurrence and 22% had no response at all [50] . However, in
Treatment and Prevention of Lyme Disease 121
this study, many of the treated and evaluated patients did not have all the criteria re-
quired for the diagnosis of Lyme borreliosis. Several randomized studies have evalu-
ated the efficacy of ceftriaxone (3 weeks) versus prolonged therapy with oral antibiot-
ics, and ceftriaxone (30 days) followed by 6 weeks of oral treatment versus placebo,
without any benefit for patients receiving antibiotics [81–83] . The persistence of a
positive serology is not associated with the absence of response to treatment in these
studies.
In clinical practice, the situation where a patient with secondary borreliosis did not
respond to a first-line antibiotic is relatively frequent. If the diagnosis is based on
solid criteria, it seems reasonable to propose an alternative treatment (ceftriaxone if
the first-line treatment was doxycycline, or doxycycline if the first-line treatment was
ceftriaxone). This proposition has to take into account the possibility of delayed im-
provement, occurring only some weeks after the treatment.
What Place for Other Antibiotics?
Other antibiotics have been tested during late Lyme borreliosis, especially macro-
lides. Clarithromycin (500 mg twice a day), azithromycin (250 or 500 mg/day), eryth-
romycin (500 mg, 3 times a day) sometimes associated with hydroxychloroquine
(200 mg, twice a day) have been proposed, especially in long-term chronic borrelio-
sis. In a descriptive study, after 3 months of treatment, 80% of these patients had 50%
improvement in their clinical signs; the results were even better if hydroxychloro-
quine was added. However, these results should be confirmed in randomized studies,
and are not yet sufficient to justify macrolide prescription for treatment of late bor-
reliosis [84] .
Treatment for Other Manifestations of Lyme Disease
Usually, for borrelial lymphocytoma, the same treatment regimens are used as for
erythema migrans. However, complete recovery of borrelial lymphocytoma is slow,
with complete regression occurring in 1–12 weeks.
Only non-randomized studies were conducted in patients with acrodermatitis
chronica atrophicans (ACA). These studies suggested that prolonged therapy (at least
30 days) is more efficient if using penicillin, ceftriaxone or doxycycline. However, in
47% of treated patients, cutaneous manifestations persist [85, 86] in dependence upon
the stage of ACA, with a better prognosis for the early inflammatory stage than the
late atrophic. If clinical signs are associated with neurological involvement, treatment
with penicillin, cefuroxime axetil followed by doxycycline, or doxycycline alone over
3 weeks showed a good efficacy, not only on the cutaneous manifestations, but also
on the neurological manifestations that can be associated with ACA (85% improve-
122 Hansmann
ment 6 months after the beginning of treatment). However, the electromyographic
abnormalities were not influenced by the treatment [87] .
In cardiac or other tissue involvement during borreliosis, no study has shown an
advantage for any kind of treatment. So, it appears that the classically validated treat-
ments in early disseminated forms of borreliosis should also be used: ceftriaxone or
doxycycline.
For symptomatic patients, or patients with second- or third-degree atrioventricu-
lar block, hospitalization and continuous cardiac monitoring is recommended. A
temporary pacemaker can be required. First-line antibiotherapy with ceftriaxone
seems preferable in severe disease, but oral regimens can be proposed for outpatient
treatment. A duration of 14–21 days is required.
For other forms of secondary (early disseminated) borreliosis, the same treatment
regimens as for Lyme arthritis or for neuroborreliosis are usually recommended,
without any study that can support this choice. If the eyes are involved, ceftriaxone
treatment should be proposed in the first-line because of the poor diffusion of doxy-
cycline in the aqueous humor.
Conclusions
Early borreliosis generally has an excellent prognosis, with a good response to anti-
biotherapy and no recurrence after long-term follow-up [88] . Oral amoxicillin or oral
doxycycline are first-line options and are adequate to cure patients with erythema
migrans. In secondary (early disseminated) borreliosis, oral  -lactam treatment may
fail, suggesting that the use of ceftriaxone or tetracyclines is more effective, though
no clinical study has proven this. Pharmacological data encourages the use of ceftri-
axone in patients with neuroborreliosis, whereas pharmaco-economical studies sup-
port the use of doxycycline. In late borreliosis, antibiotics are poorly efficient, except
for some situations, e.g. the inflammatory stage of ACA. At this stage, there is no ob-
vious benefit for prolonged therapy, though further investigations are needed.
Prevention of Borreliosis
Borreliosis is a very frequent infection in areas where its vectors are present. There
are several different strategies to prevent Lyme disease: actions against its reservoir,
actions against its vector or against the presence of Borrelia in the vector, prevention
of tick bites, prevention of the disease by stimulating the immune system in humans
and finally prophylaxis after tick bites.
Among the different strategies that can be implemented to prevent Lyme disease,
the best ones to rely on are preventing human tick bites and vaccination.
Treatment and Prevention of Lyme Disease 123
Prevention of Tick Bites
This strategy remains the cornerstone of the prevention of Lyme disease.
The first stage of this strategy is to prevent the contact between ticks and humans
that occurs when people go into the tick’s biotope. Repellents that prevent mosquito
bites do so by disturbing the arthropods’ ability to locate their targets. Most of these
repellents are tested for their ability to repel mosquitoes, and they might not be as ef-
fective against ticks. Some studies suggest that repellents, especially those containing
DEET (
N , N -diethyl-3-methylbenzamide), could effectively decrease the risk of tick
bites. However, to be effective, a certain number of rules must be followed: repellents
must be regularly applied on the skin, they must be applied on all of the exposed skin
and the contraindications should be respected, especially in young children and preg-
nant women [89] .
Among the numerous repellents, the products containing DEET are most often
used. Their activity, proven against mosquitoes, has also been proven against ticks
[90] . To be efficient they must be at least 30 or 35% DEET, and remain efficient for
4–5 h. They cannot be used at this dosage by children or pregnant women (risk of
neurotoxicity and skin toxicity). At a lower dosage, DEET can be attractive for ticks.
Other repellents (picaridin and
N -butyl, N -acetyl-3ethylaminopropionate or EBAAP)
can also be used. For EBAAP, protection is limited to 4 h. Picaridin is recommended
by the World Health Organization against arthropod bites [91] , but has not been test-
ed against Ixodes . There are also some natural repellents that are effective against
ticks. Citronella and p -menthane-3-8-diol both repel ticks for 2 to 4 h [92, 93] . Soya
oil has a short-duration activity [94] , and other natural products have been tested with
less or more repellent activity [95] . Impregnation of clothes with repellents is a com-
plementary strategy. DEET can also be useful, and its efficacy may then last for 4 to
6 weeks. Permethrin is an insecticide and a repellent. When used on clothes, it is to
be considered more efficient against ticks than DEET, and it is effective for 6 weeks
(up to 6 months if it is applied by immersion). Permethrin on clothes resists removal
by washing or ironing. A recent study suggested that I. ricinus may be more attracted
to light-colored than dark-colored clothing [95] .
After a tick’s initial contact with a human, Borrelia is transferred from the gut of
Ixodes to its salivary glands. This property of Borrelia cycle may help preventing
Lyme disease. Indeed, thanks to this approximately 24-hour delay in the migration
of the bacteria, the rapid withdrawal of ticks after each walk, trek or outdoor activity
can be considered an efficient measure of prevention. However, some reports suggest
that transmission may be faster in Europe.
Tick removal techniques are not clearly defined. It seems preferable that the
whole tick be removed by grasping it as close to the skin as possible, though awk-
ward attempts may leave tick mouth parts in the skin. To minimize the risk of break-
ing the tick, specific instruments are recommended, like fine-tip forceps used with
vertical traction without twisting. Specific hooks are also suitable, but need a twist-
124 Hansmann
ing gesture to remove the tick. The use of these instruments limits the risk of apply-
ing pressure to the tick, and thus the risk of salivary regurgitation. However, if a
mouth part remains in the skin, it should not be removed. The risk of skin damage
is greater than the risk of transmission of Borrelia, which is only initially present in
the gut of ticks. The use of chemical methods (alcohol, oil, etc.) is not recommended
because of their ineffectiveness, the increased delay and because they induce regur-
gitation. Immediate removal of the tick remains an important step against trans-
mission of Borrelia .
Prevention of Lyme Disease by Specific Immunization
There is currently no vaccination available against Lyme disease. A few years ago, a
vaccine was commercialized in the USA, but it was taken out of service because of
commercial reasons and concerns about its toxicity. It was estimated to protect be-
tween 70 and 80% of vaccinated subjects in North America, but it was never recom-
mended in Europe where it was expected to be less effective because of the broader
diversity of Borrelia species. However, this prevention strategy still holds promise and
is being explored by several research centers.
Antibiotic Prophylaxis after Tick Bites [96]
Only 1 randomized controlled study tested the use of a single dose of 200 mg of
doxycycline administered within 72 h after a tick bite as a primary prophylaxis [97] .
This study showed a decrease in the frequency of erythema migrans in the group of
patients treated with doxycycline. However, in this study there was no evaluation of
the long-term complications of borreliosis. Another study, performed in Russia, eval-
uated the risk of transmission of Borrelia in humans bitten by infected ticks, with or
without doxycycline (200 mg/day over 5 days). Infection occurred in 12.3% of non-
treated patients and in 0.8% of treated patients [98] . The strategy of treating patients
after a tick bite is recommended by the IDSA if: (1) the attached tick can be reliably
identified as an adult or nymphal I. scapularis tick that is estimated to have been at-
tached for 36 h on the basis of the degree of engorgement of the tick with blood or of
certainty about the time of exposure to the tick, (2) prophylaxis can be started within
72 h of the time that the tick was removed, (3) ecological information indicates that
the local rate of infection of these ticks with B. burgdorferi is 6 20%, and (4) doxycy-
cline treatment is not contraindicated [2] .
The problem that remains is identifying such risk factors in daily practice for all
physicians. This treatment could be proposed to some patients, especially in highly
endemic areas for Lyme disease.
Treatment and Prevention of Lyme Disease 125
Other works studied the efficacy of antibiotic prophylaxis after tick bites [99–101] .
A meta-analysis of 3 of these studies showed that after a tick bite, there was no ben-
efit from taking oral G penicillin, amoxicillin or doxycycline for 3 or 10 days [102] .
For children and pregnant women, there are no recommendations. Some authors
propose a systematic treatment. They argue that there is a risk of a severe form of the
disease for the fetus and for the children less than 3 years old [103 –105] . Generally,
the treatment used in these circumstances is the same as for curative treatment of
erythema migrans: amoxicillin. No overall study has been done to evaluate the effi-
cacy of this systematic treatment [106 –110] .
In an American study, the risk of developing Lyme disease after a tick bite by an
engorged I. scapularis (estimated to have been attached for 72 h) was 20% [111] .
References
1 Halperin JJ, Shapiro ED, Logigian E, Belman AL,
Dotevall L, Wormser GP, Krupp L, Gronseth G,
Bever CT: Prac tice parame ter: treatment of ner vous
system Lyme disease (an evidence-based review):
report of the Quality Standards Subcommittee of
the American Academy of Neurology. Neurology
2007;
69: 91–102.
2 Wormser GP, Dattwyler RJ, Shapiro ED, Halperin
JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS,
St rle F, Sta nek G , Bo cke nste dt L , Fis h D, D uml er J S,
Nadelman RB: The clinical assessment, treatment
and prevention of Lyme disease, human granulo-
cyt ic anaplasmosis , and babesiosis : clinical pr actice
guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2006;
43: 1089–1134.
3 SPILF: Lyme borreliosis: diagnostic, therapeutic
and preventive approaches. Short text (in French).
Med Mal Infect 2007;
37: 187–193.
4 Hansmann Y: Treatment of Lyme borreliosis sec-
ondar y and tertia ry stages (in French). Med Ma l In-
fect 2007;
37: 479–486.
5 Steere AC: Lyme disease. N Engl J Med 2001;
345:
115–125.
6 Hunfeld KP, Kraiczy P, Wichelhaus TA, Schäfer
V, Brade V: Colorimetric in vitro susceptibility
of penicillins, cephalosporins, macrolides, strep-
togramins, tetracyclines, and aminoglycosides
against Borrelia burgdorferi isolates. Int J Antimi-
crob Agents 2000;
15: 11–17.
7 Johnson RC, Kodner CB, Jurkovich PJ, Collins J:
Comparative in vitro and in vivo susceptibilities of
the Lyme disease spirochete Borrelia burgdorferi to
cefuroxime and other antimicrobial agents. Anti-
microb Agents Chemother 1999;
34: 2133–2136.
8 Hunfeld KP, Weigand J, Wichelhaus TA, Kekouh E,
Kraiczy P, Brade V: In vitro activity of mezlocillin,
meropenem, aztreonam, vancomycin, teicoplanin,
ribost amycin and fu sidic acid again st Borrelia burg-
dorferi . Int J Antimicrob Agents 2001;
17: 203–208.
9 Muqing L, Toshiyuki M, Jianhui W, Masato K, Ya-
sutake Y: In vitro and in vivo susceptibilities of
Lyme disease Borrelia isolated in China. J Infect
Chemother 2000;
6: 65–67.
10 Hunfeld KP, Wichelhaus TA, Rödel R, Acker G,
Brade V, Kraiczy P: Comparison of in vitro activi-
ties of ketolides, macrolides, and an azalide against
the spirochete Borrelia burgdorferi . Antimicrob
Agents Chemother 2004;
48: 344–347.
11 Alder J, Mit ten M, Jarvis K, Gupta P, Clement J: Ef-
ficacy of clarithromycin for treatment of experi-
mental Lyme disease in vivo. Antimicrob Agents
Chemother 1993;
37: 1329–1333.
12 Levin JM, Nelson JA, Segreti J, Harrison B, Benson
CA, Strle F: In vitro susceptibility of Borrelia burg-
dorferi to 11 antimicrobial agents. Antimicrob
Agents Chemother 1993;
37: 1444–1446.
13 Murg ia R, Cinco M: Sensit ivity of Borrelia a nd Lep-
tospira to quinupristin-dalfopristin in vitro. New
Microbiol 2001;
24: 193–196.
14 Reisinger EC, Wendelin I, Gasser R: In vitro activ-
ity of trimethoprim against Borrelia burgdorferi.
Eur J Clin Microbiol Infect Dis 1997;
16: 458–460.
15 Ruzic-Sabljic E, Podreka T, Maraspin V, Strle F:
Susceptibility of Borrelia afzelii strains to antimi-
crobial agents. Int J Antimicrob Agents 2005;
25:
474–478.
16 Terekhova D, Sa rta kova ML , Wormser GP, Schwartz
I, Cabello FC: Erythromycin resistance in Borrelia
burgdorferi . Antimicrob Agents Chemother 2002;
46: 3637–3640.
126 Hansmann
17 Hunfeld KP, Ruzic-Sabljic E, Norris DE, Kraiczy P,
Strle F: In vitro susceptibility testing of Borrelia
burgdorferi sensu lato isolates cultured from pa-
tients with erythema migrans before and after an-
timicrobial chemotherapy. Antimicrob Agents
Chemother 2005;
49: 1294–1301.
18 Dotevall L, Hagberg L: Penetration of doxycycline
into cerebrospinal fluid in patients treated for sus-
pected Lyme neuroborreliosis. Antimicrob Agents
Chemother 1989;
33: 1078 –1080.
19 Kazragis RJ, Dever LL, Jorgensen JH, Barbour AG:
In vivo activities of ceftriaxone and vancomycin
against Borrelia spp. in the mouse brain and other
sites. Antimicrob Agents Chemother 1996;
40:
2632–2636.
20 Moody K D, Adams RL, Barthold SW: Effec tiveness
of antimicrobial treatment against Borrelia burg-
dorferi infection in mice. Antimicrob Agents Che-
mother 1994;
38: 1567–1572.
21 Pavia CS, Wormser GP, Nowakowski J, Cacciapuo-
ti A: Efficacy of evernimicin (SCH27899) in vitro
and in an animal model of Lyme disease. Antimi-
crob Agents Chemother 2001;
45: 936–937.
22 Li M, Masuzawa T, Wang J, Kawabata M, Yanagi-
ha ra Y: In -vi tro an d in -vi vo s us cep tib il it ies of Ly me
disease Borrelia isolated in China. J Infect Che-
mother 2000;
6: 65–67.
23 Pavia C, Inchiosa MA, Wormser GP: Efficacy of
short-cour se therapy for Bor relia burgdorferi infec-
tion in C3H mice. Antimicrob Agents Chemother
2002;
46: 132–134.
24 Steere AC, Hutchinson GJ, Rahn DW, Sigal LH,
Craft JE, DeSanna ET, et al: Treatment of early
manifestation of Lyme disease. Ann Intern Med
1993;
99: 22–26.
25 Aberer E, Kahofer P, Binder B, Kinaciyan P,
Schauperl H, Berghold A: Comparison of a two- or
three-week regimen and a review of treatment of
erythema migrans with phenoxymethylpenicillin.
Dermatology 2006;
212: 160–167.
26 Weber K, Preac-Mursic V, Wilske B, Thurmayr R,
Neubert U, Scherwitz C: A randomized tria l of cef-
triaxone versus oral penicillin for the treatment of
early European Lyme borreliosis. Infection 1990;
18: 91–96.
27 Strle F, Ruzic E, Cimperman J: Erythema migrans:
comparison of treatment with azithromycin,
doxycycline and phenoxymethylpenicillin. J Anti-
microb Chemother 1992;
30: 543–550.
28 Weber K, Wilkse B, Preac-Mursic V, Thurmayr R:
Azithromycin versus penicillin V for the treatment
of early Lyme borreliosis. Infection 1993;
21: 367–
372.
29 Breier F, Kunz G, Klade H, Stanek G, Aberer E: Ery-
thema migrans: three weeks treatment for preven-
tion of late Lyme borreliosis. Infection 1996;
24:
69–72.
30 Dattwyler RJ, Volkman DJ, Conaty SM, Platkin SP,
Luft BJ: Amoxycillin plus probenecid versus doxy-
cycline for treatment of erythema migrans borreli-
osis. Lancet 1990;
336: 14 04–1406.
31 Massarotti EM, Luger SW, Rahn DW, Messner RP,
Wong JB, Johnson JC, et al: Treatment of early
Lyme disease. Am J Med 1992;
92: 396–403.
32 Luft BJ, Dattwyler RJ, Johnson RC, Luger SW, Bos-
ler EM, Rahn DW, et al: Azithromycin compared
with amoxicillin in the treatment of erythema mi-
grans: a randomized, double blinded, controlled
trial. Ann Intern Med 1996;
124: 785–791.
33 Nadelman RB, Luger SW, Frank E, Wisniewski M,
Collins JJ, Wormser GP: Comparison of cefurox-
ime axetil and doxycycline in treatment of early
Lyme disease. Ann Intern Med 1992;
117: 273–280.
34 Wormser GP, Ramanathan R, Nawakowski J, Mc-
Kenna D, Holmgren D, Visintainer P, Dornbush R,
Singh B, Na delman RB: Du ration of antibiot ic ther-
apy for early Lyme disease: a randomized, double
blinded , controlled tr ial. Ann I ntern Med 2003;
138:
697–704.
35 Nawakowski J, Nadelman RB, Forseter G, Mc Kenna
D, Wormser GP: Doxycycline versus tetracycline
therapy for Lyme disease associated with er ythema
migrans. J Am Acad Dermatol 1995;
32: 223–227.
3 6 Luger SW, Paparone P, Wormser GP, Nadelman RB ,
Grunwaldt E, Gomez G: Comparison of cefuro-
xime a xetil and dox ycycline in t he treatment of ea r-
ly Lyme disease with erythema migrans. Antimi-
crob Agents Chemother 1995;
39: 661–667.
37 Strle F, Preac-Mursic V, Cimperman J, Ruzic E,
Maraspin V, Jereb M: Azithromycin versus doxycy-
cline for treatment of erythema migrans: clinical
and microbiological findings. Infection 1993;
21:
83–88.
38 B arsic B, Maretic T, Majerus L , Str ugar J: Comp ari-
son of azithromycin and doxycycline in the treat-
ment of erythema migrans. Infection 2000;
28: 153–
156.
39 Strle F, Maraspin V, Lotric-Furlan S, Ruzic-Sabljic
E, Cimp erman J: Azit hromycin and dox ycycline for
treatme nt of Borrelia cu lture positive er ythema mi-
grans. Infection 1996;
24: 64–68.
40 Arnez M, Radsel-Medvescek A, Pleterski-Rigler D,
Ruzic-Sa bljic E, Strle F: Compar ison of cefurox ime-
axetil and phenoxymethylpenicillin for the treat-
ment of children with solitary erythema migrans.
Wien Klin Wochenschr 1999;
111: 916–922.
41 Arnez M, Pleterski-Rigler D, Luznik-Bufon T, Ru-
zic-Sabljic E, Strle F: Solitary erythema migrans in
children: comparison of treatment with azithro-
mycin and phenoxymethylpenicillin. Wien Klin
Wochen schr 20 02;
114: 498–504.
Treatment and Prevention of Lyme Disease 127
42 Eppes SC, Childs JA: Comparative study of cefu-
roxime axetil versus amoxicillin in children with
early Lyme disease. Pediatrics 2002;
109: 1173–
1177.
43 Institut de veille sanitaire: La maladie de Lyme:
données du réseau de surveillance de la maladie en
Alsace. www.invs.sante.fr.
4 4 St eere AC, Gross D, Meyer AL, Hub er BT: Auto-im-
mune mechanism in antibiotic treatment-resistant
Lyme arthritis. J Autoimmun 2001;
16: 263–268.
45 Singh SK, Girschick HJ: Lyme borreliosis: from in-
fection to autoimmunity. Clin Microbiol Infect
2004;
10: 598–614.
4 6 L engl-Janssen B, St rauss AF, Steere AC, Ka mradt T:
The T helper response in Lyme arthritis: differen-
tial recognition of Borrelia burgdorferi outer sur-
face protein A in patients with treatment-resistant
or treatment responsive Lyme arthritis. J Exp Med
1994;
180: 2069–2078.
47 D rouin EE, Glic kstein LJ, Steere A: Molec ular char-
acteri zation of the OspA
161–175 T cell epitope as soci-
ated with treatment resistant Lyme arthritis: differ-
ences among the three pathogenic species of
Borrelia burgdorferi sensu lato. J Autoimmun 2004;
23: 281–292.
48 European Union Concerted Action on Lyme Bor-
reliosis: Di agnosis of Lyme bor reliosis. w ww. eucalb.
com.
49 Ettestad PJ, Campbell GL, Welbel SF, Genese CA,
Spitalny KC, Marchetti CM, Dennis DT: Biliary
complications in the treatment of unsubstantiated
Lyme disease. J Infect Dis 1995;
171: 356–361.
50 Reid MC, Schoen RT, Evans J, Rosenberg JC, Hor-
witz RI: The consequences of overdiagnosis and
overtreatment of Lyme disease: an observational
study. Ann Intern Med 1998;
128: 354–362.
51 Donta ST: Tetracycline therapy for chronic Lyme
disease. Clin Infect Dis 1997;
25(suppl 1):S52–S56.
52 Steere AC, Pachner AR, Malawista SE: Neurologic
abnormalities of Lyme disease: successful treat-
ment with high-dose intravenous penicillin. Ann
Intern Med 1983;
99: 767–772.
53 Steere AC, Green J, Schoen RT, Taylor E, Hutchin-
son GJ, Rahn DW, Malawista ME: Successful par-
enteral penicillin therapy of established Lyme ar-
thritis. N Engl J Med 1985;
312: 869–874.
5 4 Dat twyler RJ, Ha lperin JJ, Pass H, Lu ft BJ: Ceftr iax-
one as effec tive therapy in refractory Lyme disease.
J Infect Dis 1987;
155: 1322–1324.
55 Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ:
Treatment of late Lyme borreliosis – randomised
comparison of ceftriaxone and penicillin. Lancet
1988;
1: 1191–1194.
56 B org R, Dotev all L , Hagberg L , Mar aspin V, Lot ric-
Furlan S, Cimperman J, Strle F: Intravenous ceftri-
axone compared with oral doxycycline for the
treatment of Lyme neuroborreliosis. Scand J Infect
Dis 2005;
37: 449–454.
57 Eichenfield AH, Goldsmith DP, Benach JL, Ross
AH, Loeb FX, Doughty RA, Athreya BH: Child-
hoo d ar thritis : exp erience i n an en demic are a. J Pe-
diatr 1986;
109: 753–758.
58 Borg R, Dotev all L , Hagberg L , Mar aspin V, Lot ric-
Furlan S, Cimperman J, Strle F: Intravenous ceftri-
axone compared with oral doxycycline for the
treatment of Lyme neuroborreliosis. Scand J Infect
Dis 2005;
37: 449–454.
59 Caperton EM, Heim-Dutoit KM, Matzke GM, Pe-
terson PK, Johnson RC: Ceftriaxone therapy of
chronic in flamm atory arth ritis: a double-blind pla-
cebo controlled trial. Arch Intern Med 1990;
150:
1677–1682.
60 Steere AC, Levin RE, Molloy PJ, Kalish RA, Abra-
ham JH, Liu NY, Schmid CH: Treatment of Lyme
arthritis. Arthritis Rheum 1994;
37: 878–888.
61 Mulleger RR, Millner MM, Stanek G, Spork KD:
Penicillin G sodium and ceftriaxone in the treat-
ment of neuroborreliosis in children a prospective
study. Infection 1991;
19: 279–283.
62 Pfister HW, Preac-Mursic V, Wilske B, Einhaupl
KM: Cefotaxime vs. penicillin G for acute neuro-
logic man ifestations in Ly me borreliosis: a prosp ec-
tiv e randomiz ed stu dy. Arch Neurol 1989;
46: 1190–
1194 .
63 Pfister HW, Preac-Mursic V, Wilske B, Schielke E,
Sorgel F, Einh aupl KM: Randomi zed comparis on of
ceft riaxone and cefot axime in Ly me neuroborrelio-
sis. J Infect Dis 1991;
19: 279–283.
64 Oksi J, Nikoskelainen J, Viljanen MK: Comparison
of oral cefixime and intravenous ceftriaxone fol-
lowed by oral amoxicillin in disseminated Lyme
borreliosis. Eur J Clin M icrobiol Infect Dis 1998;
17:
715–719.
65 Renaud I, Cachin C, Gerster JC: Good outcomes of
Lyme arthritis in 24 patients in an endemic area of
Switzerland. Joint Bone Spine 2004;
71: 39–43.
66 Valesova H, Mailer J, Havlik J, Hulinska D, Herco-
gova J: Long-term results in patients with Lyme ar-
thrit is following treatment with cef triaxone. Infec-
tion 1996;
24: 98–102.
67 Eckman MH, Steere AC, Kalish RA, Pauker SG:
Co st ef fe ct iv ene ss of o ra l a s c omp ar ed wit h i nt ra ve -
nous antibiot ic therapy for patient s with early Lyme
disease or Lyme arthritis. N Engl J Med 1997;
337:
357–363.
68 Wormser GP, Nadelman RB, Dattwyler RJ, Dennis
DT, Shapiro ED, Steere AC, Rush TJ, Rahn DW,
Coyle PK, Persing DH, Fish D, Luft BJ: Practice
guidelines for the treatment of Lyme disease. Clin
Infect Dis 2000;
31(suppl):S1–S14.
128 Hansmann
69 Fishman RA: Blood-br ain and CSF bar riers to pen-
icillin and related organicacids. Arch Neurol 1966;
15: 113–124.
70 Logigia n EL, Kaplan R F, Steere AC: Chronic neuro-
logic manifestations of Lyme d isease. N Engl J Med
1990 ;
323: 1438–1444.
71 Logigian EL, Kaplan RF, Steere AC: Successful
treatment of Lyme encephalopathy with intrave-
nous ceftriaxone. J Infect Dis 1999;
180: 377–383.
72 Karlsson M, Hammers-Berggren S, Lindquist L,
Stiernstedt G, Svenugsson B: Comparison of intra-
venous penicillin G and oral doxycycline for treat-
ment of Lyme neuroborreliosis. Neurology 1994;
44: 1203–1207.
73 Dattwyler RJ, Luft BJ, Kunkel MJ, Finkel MF,
Wormser GP, Rush TJ, Grunwaldt E, Agger WA,
Franklin M, Oswald D, Cockey L, Maladorno D:
Ceftriaxone compared with doxycycline for the
treatment of acute disseminated Lyme borreliosis.
N Engl J Med 1997;
337: 289–294.
74 Dotevall L, Hagberg L: Successful oral doxycycline
treatment of Lyme disease-associated facial palsy
and meningitis. Clin Infect Dis 1999;
28: 569–574.
75 Thorstrand C, Belfrage E, Bennet R, Malmborg P,
Erik sson M: Successf ul treatment of neu roborrelio-
sis with ten day regimens. Pediatr Infect Dis 2002;
21: 1142–1145.
76 Clark JR, Carlson RD, Sasaki CT, Pachner AR,
Steere AC: Facial para lysis in Lyme disease. Laryn-
goscope 1985;
95: 1341–1345.
77 Rohacova H, Hancil J, Hulinska D, Mailer H, Hav-
lik J: Ceftriaxone in the treatment of Lyme neu-
roborreliosis. Infection 1996;
24: 88–90.
78 K aiser R: Cl inical cour ses of acute and chron ic neu-
roborreliosis following treatment with ceftriaxone
(in German). Nervenarzt 2004;
75: 553–557.
79 Cimmino MA, Accardo S: Long term treatment of
chronic Lyme arthritis with benzathine penicillin.
Ann Rheum Dis 1992;
51: 1007–1008.
80 Dattwyler RJ, Wormser GP, Rush TJ, Finkel MF,
Schoen RT, Grunwa ldt E, Frank lin M, Hilton E , Bry-
ant GL, Agger WA, Maladorno D: A comparison of
two treatment regimens of ceftriaxone in late Lyme
disease. Wien Klin Wochenschr 2005;
117: 393–397.
81 Kaplan RF, Trevino RP, Johnson GM, Levy L,
Dornbush R, Hu LT, Evans J, Weinstein A, Schmid
CH, Klempner MS: Cognitive function in post-
treatment Lyme disease: do additional antibiotics
help? Neurology 2003;
60: 1916–1922.
82 Klempner MS, Hu LD, Evans J, Schmid CH, John-
son GM, Trevino RP, Norton D, Lev y L, Wall D,
McC all J, Kos insk i M, Wei nstein A : Two cont rol led
t ri al s of an ti bio ti c t re at me nt i n p at ien ts wi th pe rsi s-
tent symptoms and a history of Lyme disease. N
Engl J Med 2001;
345: 85–92.
83 Krupp LB, Hyman LG, Grimson R, Coyle PK, Mel-
vil le P, Ahnn S, Dat twyler R , Chandler B: Study a nd
Treatment of Post-Lyme Dis ease (STOP-LD): a ran-
domized double masked clinical trial. Neurology
2003;
60: 1923–1930.
84 Donta ST: Macrolide therapy of chronic Lyme dis-
ease. Med Sci Monit 2003;
9: 136–142.
85 Aberer E, Breier F, Stanek G, Schmidt B: Success
and failure in the treatment of acrodermatitis
chronica atrophicans. Infection 1996;
24: 85–87.
86 Weber K, Preac-Mursic V, Neubert U, Thur mayr R,
Herzzr P, Wilske B, Schierz G, Marget W: Antibi-
otic therapy of ea rly European Lyme borreliosi s and
acrodermatitis chronica atrophicans. Ann NY
Acad Sci 1988;
539: 324–345.
87 Kindstrand E, Nilsson BY, Hovmark A, Pirskanen
R, Asbrink E: Peripheral neuropathy in acroderma-
titis chronica atrophicans – effect of treatment.
Acta Neurol Scand 2002;
106: 253–257.
88 Li psker D, Antoni-Bach N, Han smann Y, Jaulhac B:
Long term prognosis of patients treated for er ythe-
ma migrans in France. Br J Dermatol 2002;
146:
872–876.
89 Boulanger N: What primary prevention should be
used to preve nt Lyme disease? Me d Mal Infect 2 007;
37: 456–462.
90 Carroll JF, Klun JA, Debboun M: Repellency of
DEET and SS220 applied to skin involves olfactory
sensing by two species of ticks. Med Vet Entomol
2005;
19: 101–106.
91 WHO Committee to Advise on Tropical Medicine
and Travel (CATMAT): Statement on per sonal pro-
tective measures to prevent arthropod bites. Can
Commun Dis Rep 2005;
31:1–18.
92 T hrosell W, Mikive r A, Tunon H: Repell ing proper-
ties of some plant material on tick Ixodes ricinus.
Phytomedicine 2006;
13: 132–134.
93 Gardu lf A, Wohlfart A, Gustafson R: A prospective
cross-over field trial shows protection of lemon eu-
calyptus extract against tick bites. J Med Entomol
2004;
41: 1064–1067.
94 Fradin MS, Day JF: Comparative efficacy of insect
repellents against mosquito bites. N Engl J Med
2002;
347: 13–18.
95 Sternberg L, Berglund J: Detecting ticks on light
versus dark clothing. Scand J Infect Dis 2005;
37:
361–364.
96 Patey O: Lyme disease: prophylaxis after tick bite.
Med Mal Infect 2007;
37: 446–455.
9 7 Na del ma n R B, N owa kow sk i J, Fis h D, e t a l: P rop hy-
laxis with single dose doxycycline for the preven-
tion of Lyme disease after an Ixodes scapularis tick
bite. N Engl J Med 2001;
345: 79–84.
98 Korenberg EI, Vorobyeva NN, Moskvitina HG,
Gorban LY: Prevention of bor reliosis in person s bit-
ten by infected ticks. Infection 1996;
24: 187–189.
Treatment and Prevention of Lyme Disease 129
Yves Hansmann
Service des Maladies Infec tieuses et Tropicales, Hôpitaux Universitaires de Strasbourg
1, place de l’hôpital
FR–67091 Strasbourg Cedex (France)
Tel. +33 3 88 11 53 51, Fax +33 3 88 11 64 64, E-Mail yves.hansmann@chru-strasbourg.fr
99 Wormser GP: Controversies in the use of antimi-
crobial for the prevention and treatment of Lyme
disease (letter). N Engl J Med 2001;
345: 1349.
100 Magid D, Schwar tz B, Craft J, S chwartz JS: Pre ven-
tion of Lyme disease after tick bites. N Engl J Med
1992;
327: 534–541.
101 Dennis DT, Meltzer MI: A ntibiotic prophylax is af-
ter tick bites. Lancet 1997;
350: 1191–1192.
102 Warshafsky S, Nowakowski J, Nadelman RB, Ka-
mer RS, Peterson SJ, Wormser GP: Efficacy of an-
tibiotic prophylaxis for prevention of Lyme dis-
ease. J Gen Intern Med 196;
11: 329–333.
103 Centers for Disea se Control: Update: Ly me disease
and cases occurring during pregnancy – United
States. M MWR Morbid Mortal W kly Rep 1985;
34:
376–378, 383–384.
104 Markowitz LE, Steere AC, Benach JL, Stade JD,
Broome CV: Lyme disease during pregnancy.
JAMA 1986;
255: 3394–3396.
105 Schlesinger PA, Duray PH, Burke BA, Steere AC,
Stillman MT: Maternal-fetal transmission of the
Lyme disease spirochete, Borrelia burgdorferi .
Ann Intern Med 1985;
103: 67–69.
106 Strobino BA, Williams CL, Abid S, Chalson R,
Spier ling P: Lyme disea se and pregnanc y outcome:
a prospective study of two thousand prenatal pa-
tients. Am J Obstet Gynecol 1993;
169: 367–374.
107 Maraspi n V, Cimperma n J, Lotric-Furla n S, Pleter-
ski-Riegler D, Strle F: Treatment of erythema mi-
grans in pregnancy. Clin Infect Dis 1996;
22: 788–
793.
108 Williams CL , Strobino BA, Weinstein A, Spierling
P, Medici F: Materna l Lyme dis ease and congenit al
ma lf orm at ion s: a c ord blo od s er osu rv ey i n en dem -
ic and control areas. Paediatr Perinat Epidemiol
1995;
9: 320–330.
109 Strobino BA, Abid S, Gewitz M: Maternal Lyme
disease and congenital heart disease: a case-con-
trol study in an endemic area. Am J Obstet Gyne-
col 1999;
180: 711–716.
110 Maraspi n V, Cimperma n J, Lotric-Furla n S, Pleter-
ski-Riegler D, Strle F: Erythema migrans in preg-
nancy. Wien Klin Wochenschr 1999;
111: 933–940.
111 Sood SK, Sal zman MB, John son BJ, Happ CM, Feig
K, Car mody L, Rubin LG, Hi lton E, Piesma n J: Du-
ration of tick attachment as a predictor of the risk
of Lyme disease in an area in which Lyme disease
is endemic. J Infect Dis 1997;
175: 996–999.
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 130–154
A b s t r a c t
Tick s are obligate blood-sucking arthropods that transmit pathogens while feeding, and in Europe,
more vector-borne diseas es are transmitted to humans by ticks than by any other agent. In addition
to neurotoxins, ticks can transmit bac teria (e.g. rickettsiae, spirochetes) viruses and protozoa. Some
tick-borne diseases, such as Lyme disease and ehrlichiosis, can cause severe or fatal illnesses. Here,
we examine tick-borne diseases other than Lyme disease that are found in Europ e; namely: anaplas-
mosis, relapsing fever, tularemia, tick-borne encephalitis, tick-borne babesiosis and tick-borne rick-
ettsiosis. Each disease is broken down into a description, epidemiology, signs and symptoms, diag-
nosis and treatment, providing clear overviews of each disease course and the interventions
required. Furthermore, in the section concerning tick-borne rickettsiosis, a clear summary of the
Rickettsia conorii complex and its role in the disease is provided. Copyright © 2009 S . Karger AG, Basel
In Europe, more vector-borne diseases are transmitted to humans by ticks than by
any other agent [1] . In addition to neurotoxins, ticks can transmit bacteria (e.g. rick-
ettsiae, spirochetes) viruses and protozoa [2] . Some tick-borne diseases, such as Lyme
disease [3, 4] and ehrlichiosis, can cause severe or fatal illnesses [5, 6] . Cardiopulmo-
nary complications associated with tick-borne diseases are particularly serious and
may be life-threatening [5, 7] . Many species of ticks that have been found over a very
wide geographic distribution [8, 9] may transmit diseases to humans ( table 1 ). Ticks
are obligate blood-sucking arthropods that transmit pathogens while feeding [9] .
Large reservoirs of ticks feed on the rodents and small mammals that inhabit wooded
areas, gardens and parklands [10, 11] . Nevertheless, outbreaks of tick-borne diseases
are not confined to rural areas. Successful management of tick-borne diseases de-
pends on a high index of suspicion and an awareness of their geographic epidemiol-
ogy and clinical features [3, 12] . Tick-borne diseases have protean manifestations.
Patients at risk of tick bites may harbor 2 or more concurrent tick-borne infections
[13] . The diagnosis of a tick-borne disease is most often based on a constellation of
clinical signs and a history of outdoor pursuits, skin rashes or tick bites [3, 9, 14] .
Other Tick-Borne Diseases in Europe
Idir Bitam ⭈ Didier Raoult
Unité des Rickettsies CNRS-IRD UMR 6236, Faculté de Médecine, Université de la Méditerranée, Marseille , France
Other Tick-Borne Diseases in Europe 131
Anaplasmosis
Introduction
The genus Anaplasma (Rickettsiales: Anaplasmataceae) includes several pathogens
such as A. marginale and A. phagocytophilum that have an impact on human and
animal health [15] . A. phagocytophilum
belong to the order Rickettsiales and are ob-
ligate intracellular bacteria. They have long been known to cause tick-borne fever in
ungulates, and have been identified more recently as the causative agent of the emerg-
ing disease human granulocytic anaplasmosis (HGA). A. marginale can be transmit-
ted mechanically among cattle by the blood-contaminated mouthparts of biting f lies;
it is transmitted biologically by ticks [16] . About 20 tick species have been shown to
transmit anaplasmosis, although field evidence indicating that the tick is the princi-
Tab le 1. Causative agents and vectors of tick-borne diseases in Europe
Disease Causative agents Vectors
Lyme disease Borrelia burgdorferi s.l. Ixodes ricinus
Anaplasmosis Anaplasma phagocytophilum Ixodes ricinus
Relapsing fever Anaplasma marginale
Borrelia duttonii Ornithodoros moubata
Borrelia crocidurae Ornithodoros sonrai
Borrelia hispanica Ornithodoros erraticus
Tularemia Francisella tularensis Ixodes ricinus
Dermacentor reticulatus
Dermacentor variabilis
Tick-borne encephalitis TBEV Ixodes ticks
Rickettsiosis Rickettsia conorii conorii Rhipicephalus sanguineus
Rickettsia conorii israelensis
Rickettsia conorii caspia
Rickettsia sibirica mongolitimonae Hyalomma anatolicum excavatum
Rhipicephalus pusillus
Rickettsia slovaca Dermacentor sp.
Rickettsia aeschlimannii Hyalomma sp.
Rickettsia massiliae Rhipicephalus sanguineus
Rhipicephalus turanicus
Rickettsia helvetica Ixodes ricinus
Rickettsia raoultii Dermacentor nuttalli
Dermacentor silvarum
Dermacentor reticulatus
Rhipicephalus pumilio
TBEV = Tick-borne encephalitis virus.
132 Bitam ⴢ Raoult
pal disease vector is lacking [17] . A. phagocytophilum is transstadially and not trans-
ovarially transmitted by tick vector Ixodes ricinus in Europe [18] . The geographic
occurrence of endemic cycles of A. phagocytophilum correlates with the geographic
occurrence of tick vectors [19] . Thus, the natural maintenance of A. phagocytophilum
is dependent on horizontal transmission involving either acutely or persistently in-
fected mammals and ticks.
Epidemiology
Although 5 Anaplasmataceae members, including A. phagocytophilum, infect hu-
mans, it is this particular bacteria that infects granulocytes and causes HGA [15] . The
agent of human granulocytic anaplasmosis is a tick-borne pathogen, which is not fre-
quently found in Europe. The disease occurs year-round with most of the infections
occurring during May through August. A. phagocytophilum is found in I. ricinus [20] .
The first case of clinically recognized human granulocy tic anaplasmosis was described
in the USA in 1994 [21] . Soon after, the disease emerged in Europe in 1997, in Slovenia
[22] . Thereafter, seroepidemiologic surveys have found a prevalence of antibodies in a
range of 0–2.9% in blood donors, in 1.5% of patients who live in I. ricinus- exposed ar-
eas, in 8.6% of tick-exposed individuals in southern Europe [23, 24] and in 1.5–24.4%
of tick-exposed people throughout northern and central Europe [25] .
Several clinical cases have been reported in Europe, including Slovenia [26, 27] ,
The Netherlands [28] , Spain [29] , Sweden [30] , Croatia [31] , Poland [32] and France
[33] . More recently, a study carried out in southern Europe characterized A. phagocy-
tophilum infections in humans. A. phagocytophilum is maintained in cattle, donkeys,
deer and birds, and is most likely transmitted by several ticks species in southern Eu-
rope [16] . The presence of concurrent infections in cattle and deer suggests that these
pathogens may multiply in the same reservoir host, and illustrates the complexity of
the epidemiology of bovine and human anaplasmosis in southern Europe.
Signs and Symptoms
The diseases of ruminants such as cattle, sheep and goats (‘pasture fever’ or ‘tick-borne
fever’ [18] ) and humans (HGA) appear most commonly as an undifferentiated febrile
illness occurring in spring or summer [34] . The incubation period following the tick-
bite is 7–10 days. Symptoms include high fever, rigors, generalized myalgia, severe
headaches and malaise [32, 35] . Anorexia, arthralgia, nausea and a nonproductive
cough are frequent. Leucopenia and thrombocytopenia are often seen, and less fre-
quently anemia. The disease may be severe, particularly in the elderly, when there is
concomitant chronic illnesses and a lack of/delayed specific antibiotic treatment [35] .
The case fatality rate is low for HGA (0.7%) in the USA, but is not described for Europe.
Other Tick-Borne Diseases in Europe 133
It is related to complicating opportunistic infections, although poor outcomes are also
associated with antecedent medical conditions, such as diabetes mellitus [35] .
Laboratory Findings
Laboratory confirmation of HGA is based on several tests that are not widely avail-
able for routine use at present [36] . Anaplasma
sp. are Gram-negative and not motile;
these bacteria are small (often pleomorphic or coccoid) cells ranging from 0.3 to 0.4
m in diameter, and they are found in cytoplasmic inclusion bodies (morula) in ma-
ture or immature hematopoietic mammalian cells. As for in vitro cultivation diagno-
sis, there are only a small number of practicing laboratories because this technique
requires the application of antibiotic-free cell culture methods, not available in clini-
cal laboratories. Although both pathogens are able to grow in several different cell
lines, HGA is most often isolated by inoculation of mononuclear leukocytes from
density gradients into the DH82 canine histiocytic cell line [37] . Prior doxycycline
treatment diminishes the sensitivity of culture to a greater degree than it does for PCR
or blood smear examination [38] .
Indirect immunofluorescence assay remains the most widely available test. A 4-
fold rise or fall in the antibody titer, with a minimum peak of 1:
64 and a single serum
antibody titer greater than or equal to 1:
128, is necessary for the diagnosis. However,
limitations include a delay in seroconversion (early sera will often return negative), as
well as possible false-positive detection due to cross-reacting bacteria [24] .
PCR performed using EDTA or citrate anticoagulated blood is rapidly becoming
the diagnostic test of choice at or shortly after presentation. PCR obviates the need
for culture. PCR detection sensitivity is relatively high; it is reported to range between
67 and 90% [35, 39] . Recent advances in molecular methods promise even greater
analytical sensitivity, and multiplex testing that could identify several agents of ana-
plasmosis from a single test has been described elsewhere [40] .
T r e a t m e n t
Although no clinical trials have been conducted, empirical data show that all forms
of ehrlichiosis respond to tetracyclines [41] . When the antibiotic susceptibilities of 8
strains of A. phagocytophilum were recent ly tested in vitro, doxycycline and rifampin
were the most active drugs [42] . However, levofloxacin was also active [36] . Doxycy-
cline therapy is highly efficacious, relapse after therapy has never been reported [41] ,
and it can be used to treat both infections in adults and children. For children ! 8
years of age who are not seriously ill, the recommended approach is doxycycline treat-
ment for 3 days after the patient’s fever has abated [20] .
134 Bitam ⴢ Raoult
Relapsing Fever
Introduction
Relapsing fever, an infectious disease with a sudden onset of high fever with septice-
mic signs and symptoms, is characterized by the occurrence of 1 or more spells of
fever after the subsidence of the primary febrile attack [43] . Endemic tick-borne re-
lapsing fever (TBRF) is due to at least 16 distinctive Borrelia species harbored in soft
ticks of the genus Ornithodoros (Alectorobius) [44] . Clinically, the manifestations of
louse-borne relapsing fever and TBRF are quite similar. TBRF is a serious disease
with, if untreated, a mortality rate of up to 5%. TBRF acquired during pregnancy
poses a high risk of pregnancy loss, up to 50%.
Neu rolog ical sy mptoms have been repor te d fo r 9% of the pat ients with TBR F. S uch
findings were reported previously among TBRF patients in Senegal and TBRF pa-
tients returning from Senegal to Europe. Tetracycline or doxycycline effectively elim-
inates the spirochetemia [45] .
Epidemiology and Transmission
TBRF is a zoonotic disease transmitted worldwide by soft body ticks of the genus
Ornithodoros . The disease was mentioned in 1857 by Livingston, who described a re-
current febrile illness among African natives who were exposed to ticks [46] . The
causative link with ticks was reported in 1905 by Dutton and Todd, who demonstrat-
ed spirochetes in Ornithodoros moubata in East Africa [47] . Ornithodoros ticks are
included in the soft tick family Argasidae [48] .
These arthropods are hematophagous at all growing stages. Ticks are infected dur-
ing a blood meal on a spirochetemic vertebrate. Borrelia then spread to all tissues of
the tick, including the ovaries (responsible for transmission between the different tick
developmental stages and between generations), salivary glands and excretory or-
gans. Vertebrates and humans become infected during a blood meal through con-
tamination of the feeding site by salivary and/or coxal secretions [48] . The soft body
tick feeds for a short time only (usually less than half an hour), then returns to the
earth or the floor/walls of the house. In Africa, humans are believed to be the only
reservoir for B. duttonii transmitted by O. moubata , which is unlike the situation for
B. crocidurae and B. tillae by O. zumpti , where rodents and other insectivores are res-
ervoirs [49] .
Six TBRF borrelioses are known to occur in Europe or close to its boundaries. At
present, the greatest endemic risk in Europe lies in the Iberian peninsula, particu-
larly in the Mediterranean part [46] . Twenty-two species of Ornithodoros have been
reported in humans, and 12 species are frequently found [50] . Transmission of TBRF
has also occurred through transfusion or laboratory contamination, and during preg-
Other Tick-Borne Diseases in Europe 135
nancy [48] . A few cases of relapsing fever are diagnosed every year in France in trav-
elers from disease-endemic countries [51] (http://www.pasteur.fr/sante/clre/cadrecnr/
borrelia-index.html).
Relapsing fever-associated Borrelia species have been named on the basis of the
cospeciation concept, taking into account the geographic endemicity of the vectors.
Some of these organisms have a worldwide distribution, e.g. B. recurrentis is trans-
mitted by human body lice [52] , while other species are geographically restricted.
The specificity of the association between Borrelia species and vectors has been ques-
tioned as B. duttonii , B. crocidurae and B. hispanica , which are naturally transmitted
in nature by O. moubata , O. sonrai (formerly O. erraticus sonrai ) and O. erraticus
(formerly O. erraticus erraticus ), respectively, could be experimentally adapted to lice
[52] . B. hispanica is found in Spain, Portugal, Cyprus, Greece and North Africa. This
species has been isolated in O. erraticus , an endophilic tick commonly found under
meso-Mediterranean vegetation in south-western Europe. This tick species usually
lives in the burrows of wild rodents, its natural host. In Spain and Portugal, how-
ever, it has adapted to bite domestic pigs that are continuously grazed and sometimes
kept in overnight in large burrows or inside old buildings, and the tick has adapted
to live in these habitats [50, 53] . Humans may be bitten, and hence relapsing fever
was sporadically reported in countries such as Spain during the 20th century, prob-
ably with an underestimated incidence [48, 53] . The disease caused by B. hispanica
is one of the less severe TBRF, and presents with neurological signs in less than 5%
of cases [48] .
Signs and Symptoms
The disease is transmitted either by tick saliva during feeding or in coxal fluid ex-
creted during feeding [54] . TBRF begins between 4 and 14 days after the tick bite, with
an acute onset of high fever, chills, constitutional symptoms and iritis [55, 56] . The
clinical characterization is recurrent episodes of fever and spirochetemia [57] . Sever-
ity of the symptoms varies according to the infecting species of Borrelia . The average
inoculation period is 1 week. Influenza-like symptoms, arthralgia (possibly severe),
dizziness, nausea and vomiting are common. Fever is usually high (greater than
40
° C), irregular in pattern and sometimes associated with delirium. Most patients
have splenomegaly and meningeal signs may be present. Other complications can in-
clude epistaxis, hemoptysis, iridocyclitis, coma, cranial nerve palsy, pneumonitis,
myocarditis and rupture of the spleen [58] .
The first cases to be recognized among pregnant women have been fulminant and,
if untreated, led to death within 36–48 h. Even when treatment was available, these
patients had preterm deliveries or spontaneous abortions [57] .
136 Bitam ⴢ Raoult
D i a g n o s i s
Diagnosis is usua lly made during the primary attack, by observation of spirochetemia
on thin or thick blood smears with dark-field microscopy or with conventional mi-
croscopy after Giemsa, Wright or Diff-Quick 쏐 staining [46] . Thick blood smears pro-
vide 20 times the sensitivity of thin blood smears. Quantitative buffy coat fluores-
cence analysis has also been described as a very sensitive and specific technique for
detecting Borrelia in blood [43] . Mouse inoculation has been used for a long time for
the isolation of TBRF Borrelia , but some of the TBRF Borrelia species can be cultured
on axenic medium. Kelly’s medium serves as the basis for Barbour-Stoenner-Kelly
medium, which has been used for the cultivation of Lyme disease spirochetes as well
as for the recent successes with TBRF Borrelia [59] . These TBRF Borrelia species have
fastidious culture requirements, although cultivation of a strain of B. duttonii and B.
crocidurae was reported by Cutler et al. [60] . In contrast, B. hermsii , B. turicatae and
B. parkeri are easily cultivable [61] . Molecular methods are being used with increas-
ing frequency, and offer the possibility of species identification [46] . To date, specific
serological assays are not available for most of the known TBRF because of the lack
of available antigens. If they were available, they could be useful when the blood
smear is negative and PCR is unavailable.
Tre atment
The treatment of choice is doxycycline (100 mg orally, twice a day, for 5 to 10 days).
Alternative therapy includes erythromycin (500 mg orally 4 times per day, for 5 to 10
days). Therapy may lead to a Jarisch-Herxheimer reaction (i.e. generalized malaise,
headache, fever, swe ati ng, rigors, seizures or stroke), especially if g iven du ring the late
febrile stage. Administering acetaminophen 2 h before and after antibiotic adminis-
tration may lessen the severity of the reaction. Steroids and nonsteroidal anti-inf lam-
matory drugs do not prevent or modify the cardiopulmonary disturbances of the
reaction [62] .
Tularemia
Introduction
Tularemia (also known as rabbit fever) is an infectious disease caused by the small,
pleomorphic, heat-labile, Gram-negative, rod-shaped bacterium Francisella tularen-
sis . The subspecies holarctica is the only subspecies found in Europe, but it is spread
over the whole northern hemisphere [63] . In humans or in rabbits, strains belonging
to subspecies F. tularensis cause the most severe form of the disease, but strains be-
Other Tick-Borne Diseases in Europe 137
longing to all subspecies are highly virulent in mice. The aggressive features of sub-
species F. tularensis have been an important basis for the designation of F. tularensis
as 1 of 6 category A agents, i.e. agents that would have a great adverse impact on pub-
lic health if used for bioterrorism [64] . The microorganism is a facultative intracel-
lular pathogen affecting a wide range of animal species.
Epidemiology
Three subspecies are known: F. tularensis subsp . tularensis occurring in North Amer-
ica and Europe; F. tularensis subsp. palaearctica (holarctica) occurring in Europe [65] ,
Asia and to a minor extent in North America; and F. tularensis subsp. mediasiatica ,
found only in the Central Asian region. F. tularensis subsp. tularensis is highly viru-
lent for mammals and causes severe illness in humans [66] . Tularemia outbreaks have
been commonly reported in some areas of Europe, such as in Sweden, Finland, Spain
and Kosovo [67, 68] . In 2000, 270 cases in Sweden and 327 cases in Kosovo were re-
ported [67, 68] . In some endemic regions, outbreaks occur frequently, whereas adja-
cent parts of the same country may be completely free of the disease [67] .
The disease has been reported in many countries in the northern hemisphere, but,
for unknown reasons, never in the southern hemisphere [69] . Usually, cases are re-
ported during the summer, from June to September. The most common route is
through microlesions in the skin of hunters who have skinned infected rabbits. In the
summer, human transmission occurs also via ticks and deer flies. The tick vectors
include I. ricinus and Dermacentor variabilis. D. reticulatus was also found positive
for F. tularensis from Portugal [70] , as were horse flies. Although less common, con-
sumption of undercooked infected meat and contaminated water can also lead to in-
fection [71] . In particular, increases in rodent tularemia appear to be closely linked to
epidemic outbreaks of human tularemia [69] .
Signs and Symptoms
After an incubation period of 3–5 days (range 1–25 days), 7 clinical forms – according
to route of inoculation (skin, mucous membranes, gastrointestinal tract, eyes, respi-
ratory tract), dose of the inoculum and virulence of the organism (types A or B) – can
be identified [72, 73] ( table 2 ).
The different presentations include pneumonic, ulceroglandular, typhoidal, glan-
dular, oculoglandular, oropharyngeal and septicemic. After inoculation, F. tularensis
is ingested by and multiplies within macrophages.
Usually, whatever the clinical form, the onset of tularemia is abrupt, with fever,
chills, myalgia, arthralgia, headache, coryza, sore throat, and sometimes pulse-tem-
perature dissociation, nausea, vomiting and diarrhea [74] .
138 Bitam ⴢ Raoult
Tab le 2. Summary of clinical and biological description of tularemia
Clinical features
Incubation period: 3–5 days
Ulceroglandular tularemia (most common form: 75–85%)
Local papule at the site of inoculation associated with fever and aches
Papule pruritic ulcer ] enlarges to pustule ulcer ] ruptures to painful indolent ulcer,
which may be covered by an eschar
Tender enlargement of >1 regional lymph node, which may become fluctuant and rupture
releasing caseous material
Serological diagnosis and PCR on cutaneous biopsy or adenopathies
Glandular tularemia
Lymphadenopathy and fever
No ulcer
Serological diagnosis and PCR on lymph nodes
Oculoglandular tularemia
Purulent conjunctivitis, chemosis, conjunctival nodules or ulceration, periorbital edema
Tender preauricular or cervical lymphadenopathy
Serological diagnosis and PCR
Tularemia pneumonia (primary and secondary pneumonia)
Inhalational exposure presents as an acute flu-like illness
Progression to severe pneumonia with bloody sputum, respiratory failure and death if
appropriate treatment is not started
Chest radiography: peribronchial infiltrates, bronchopneumonia, pleural effusions and hilar
lymphadenopathy
Serological diagnosis
Oropharyngeal tularemia
Stomatitis, exudative pharyngitis or tonsillitis with painful mucosal ulceration
Retropharyngeal abscess or suppuration of regional lymph nodes
Serological diagnosis
Typhoidal tularemia
Acute flu-like illness
Diarrhea, vomiting, headache, chills, rigors, myalgia, arthralgia, weight loss, prostration
No indication of inoculation site
No anatomic localization of infection
Serological diagnosis
Tularemia sepsis
Nonspecific signs of confusion
Septic shock, disseminated intravascular coagulation and hemorrhage, acute respiratory
distress syndrome, organ failure and coma
Diagnosis
Confirmatory tests for identification of F. tularensis
Isolation of F. tularensis from a clinical specimen
Demonstration of a specific antibody response in serially obtained sera
PCR
For probable case
A single high titer
Detection of F. tularensis in a clinical specimen by fluorescent assay
Other Tick-Borne Diseases in Europe 139
D i a g n o s i s
Tularemia should be suspected if the patient has been exposed to rabbits, wild ro-
dents, or ticks, or has characteristic symptoms, such a primary pustular lesion on an
extremity. Isolation of the organism from skin lesions, lymph nodes or sputum is di-
agnostic, but dangerous because the organism can be highly infectious. This bacteria
is considered as a potential biologic weapon. PCR after inactivation of the bacteria
could be therefore an efficient and safe diagnostic method. Extreme caution should
be maintained when handling infected tissues or culture media. Acute and convales-
cent titers also can confirm the diagnosis. Leukocytosis is common, but the white
blood cell count may be normal. Abnormal chest radiographic findings (i.e. a triad of
oval opacities, hilar adenopathy and pleural eff usions) are more likely with tularemia
than in other tick-borne diseases [75, 76] .
Rapid methods for the identification of F. tularensis, such as the immunofluores-
cence assay and the enzyme-linked immunosorbent assay for the detection of anti-
gens and the RNA hybridization assay, have been tried, but have so far not been in-
cluded in routine diagnostics [77] . The use of PCR for the direct diagnosis of ulcero-
glandular tularemia is thus highly promising, and more work on the conditions that
might influence the assay seems to be warranted.
T r e a t m e n t
Many guidelines have been published for treatments and prophylaxis of tularemia
[72, 78] . Treatment should begin before confirmatory laboratory tests are obtained. If
available, the treatment of choice for tularemia is streptomycin (0.5 g intramuscu-
larly every 12 h until the patient’s body temperature is normal; thereafter, 0.5 g per
day for 5 days). Gentamicin (3–5 mg/kg/day, intramuscularly or intravenously, in 3
Treatment
Private room placement for patients with pneumonia is NOT necessary
Treatment of choice: streptomycin or gentamicin (10 days)
Quinolones are an effective alternative (10–14 days)
Tetracyclines and chloramphenicol are associated with a high relapse rate (therapy at least
14–21 days)
Combination of aminoglycosides and fluoroquinolones in severe cases
Post-exposure prophylaxis
Streptomycin, gentamicin, doxycycline or ciprofloxacin (14 days)
Vaccination is NOT recommended for post-exposure prophylaxis
Table 2 (continued)
140 Bitam ⴢ Raoult
divided doses for 7 to 14 days) is also effective [72] . If renal disease is present, the dose
of gentamicin needs to be reduced. Chloramphenicol or tetracyclines have also been
used, but relapses occasionally occur with these medications, and they may not pre-
vent node suppuration [79] .
Tick-Borne Encephalitis
Introduction
Tick-borne encephalitis (TBE) is caused by an RNA virus belonging to the Flavivirus
genus. The species tick-borne encephalitis virus (TBEV) includes 3 subtypes (Euro-
pean, Far-Eastern and Siberian) based on the sequencing and geographic data [80,
81] .
Epidemiology
Ixodes ticks that transmit TBEV in European climates complete their development
cycle within 3 years, and the infection is transmissible even in the nymph phase [82] .
During the years 1991–1998, at least 1,230 cases of TBE were reported in Germany,
with a mean incidence in Baden-Württemberg of 1.2 per 100,000 inhabitants per year
and a case fatality rate of 1% [81] . In a highly endemic area in Baden-Württemberg, a
seroprevalence of 9% was found [83] . Also, there has been a recent diffusion of TBEV
into southern European countries coming from Euro-Asiatic forests, and in part from
the Danube basin [84] . The Far Eastern subtype, responsible for severer infections
and also known as Russian spring-summer encephalitis, is dispersed across Russia,
the Czech Republic, Austria, Poland, Hungary and the former Yugoslavia. The Euro-
pean subtype, responsible for a milder form called central European encephalitis, is
scattered across this geographic area, but has also spread to regions bordering Austria
(Italy and former Yugoslavia) [85] .
In recent years, the virus has reached some Italian regions, e.g. northeast and cen-
tral Italy, and has also been reported in Piedmont (northwest region). Moreover,
TBEV (strain Neudörfl) has been reported in Denmark [86] , Scandinavia [87] and
Greece [88] . TBEV, in addition to tick bites, is also transmitted by unpasteurized milk
and infected aerosols [85] . Its incubation period ranges from 1 to 2 weeks [85] . In Po-
land, during 1993–2002, 1,996 cases of TBE were reported [89] , and in Russia, over
10,000 cases a year are recorded; about 3,000 cases per year are possible in the rest of
Europe [90] .
Other Tick-Borne Diseases in Europe 141
Signs and Symptoms
TBE typically takes a biphasic course. After an incubation period, usually between 7
and 14 days, the prodromal symptoms (uncharacteristic influenza-like illness with
fever, headache, malaise and myalgia) are followed by CNS involvement. After an afe-
brile interval of approximately 1 week the second stage develops. TBE may manifest
as isolated meningitis, meningoencephalitis or meningoencephalomyelitis [91] ; data
on the clinical course and outcome of large series of patients with TBE are sparse. The
mortality was about 1%, but a higher percentage of neurologic sequelae were signaled
[92] . The Russian-type disease (spring-summer encephalitis) is severer, with mortal-
ity also above 20% in patients with neurologic complications [85, 93] . In Germany,
from 1991–2000, 1,500 patients were diagnosed with symptomatic infection of TBEV;
neurologic manifestations were described in 47% of the cases (42% with meningoen-
cephalitis and 11% with meningoencephalomyelitis) [94] .
Diagnosis
Diagnosis of TBE can be performed by viral isolation and neutralization tests (with
biohazards) or by using classical serologic tests, including complement fixation and
enzyme immunoassay for IgM research [95] , and more recently by more specific rE-
D3 enzyme-linked immunosorbent assay (rE-D3 ELISA) and Western blot tests. The
rE-D3 ELISA permits a differential diagnosis with respect to other tick-borne zoono-
ses [96] . Also, in recent years, real-time RT-PCR for detection and quantitation of
TBEV RNA that also permits strain differentiation has been used [97] .
Treatment and Prevention
There is no specific treatment for TBE. Two vaccines that prevent infection are avai lable.
Although these have a good protection rate and good efficacy, there are few data on
long-term immunity. The inactivated vaccine manufactured by the Baxter Company in
Austria has been extensively used in large-scale programs, which have demonstrated a
significant decrease in the number of TBE cases in Austria and Germany [97] .
Tick-Borne Babesiosis
Introduction
Babesiosis is an intraerythrocytic parasitic infection caused by protozoa of the genus
Babesia and transmitted through the bite of the Ixodes tick, the same vector respon-
142 Bitam ⴢ Raoult
sible for transmission of Lyme disease. The first description of Babesia was given by
Babès in 1888 in his evaluation of the cause of febrile hemoglobinuria in cattle in Ro-
mania [98–100] . While most cases are tick-borne, transfusion and transplacental
transmissions have been reported.
Babesiosis is a zoonotic disease maintained by the interaction of tick vectors, trans-
port hosts and animal reservoirs. The primary vectors of the parasite are ticks of the
genus Ixodes . In Europe, I. ricinus appears to be the primary tick vector. In each lo-
cation, the Ixodes tick vector for Babesia is the same vector that locally transmits
B. burgdorferi , the agent implicated in Lyme disease. The primary animal reservoir is
cattle.
Ticks ingest Babesia while feeding of the host, and the parasite multiplies within
the tick’s gut wall. The parasites then spread to the tick’s salivary glands. Inoculation
into a vertebrate host occurs by a larva, nymph or adult tick [99, 100] . Infection in
humans usually occurs from late spring to early fall.
After an infectious tick bite, the parasites invade red blood cells and a trophozoite
differentiates, replicating asexually by budding with the formation of 2–4 merozoites;
these disrupt the red blood cells and go on to invade other red blood cells. This leads
to hemolytic anemia, thrombocytopenia and atypical lymphocyte formation. Altera-
tions in red blood cell membranes cause decreased conformability and increased red
blood cell adherence, which can lead to development of acute respiratory distress syn-
drome among those severely affected.
E p i d e m i o l o g y
The first case of human babesiosis was reported in 1957 from Yugoslavia in an as-
plenic farmer [101] . Approximately 40 cases have been reported since then, mostly in
Ireland, the UK and France; 23 of these cases were caused by B. divergens [102, 103] .
Babesiosis affects all age groups with similar frequency; however, patients older
than 50 years are at increased risk of severe infection and death. Patients report trav-
eling to an endemic area between the months of May and September; however, most
do not recall the tick bite. The incubation period is between 1 and 4 weeks. The signs
and symptoms mimic malaria, and range in severity from asymptomatic to septic
shock.
Signs and Symptoms
Most of the patients described in Europe were asplenic, presented with acute febrile
hemolytic disease, and their clinical courses have almost always been fatal [99,
100] .
Other Tick-Borne Diseases in Europe 143
Symptoms include high fever (up to 40 ° C), chills, diaphoresis, weakness, fatigue,
anorexia and headache. Later in the course of the illness, the patient may develop
jaundice and dark urine. Physical examination may reveal hepatomegaly and spleno-
megaly or evidence of shock. Rash is an uncommon symptom in babesiosis [98–100,
104]
. Signs of CNS involvement include headache, photophobia, neck and back stiff-
ness, altered sensorium and emotional lability [100, 104, 105] .
D i a g n o s i s
A Wright- or Giem sa- stai ned per ipheral blo od s mea r is mo st com mon ly used to d em-
onstrate the presence of intraerythrocytic parasites. The organisms are intraerythro-
cytic ring forms closely resembling Plasmodium . Serologic evaluation is performed
by an indirect immunofluorescent antibody test with the use of B. microti antigen.
Inoculation of susceptible animals with whole blood from a suspected case is an-
other diagnostic technique. Classically, hamsters are used to isolate B. microti [10 6] . In-
oculation of the animal requires monitoring via blood smear examination for up to 6
weeks [107] . Thus, although this system is fairly sensitive (300 organisms per ml of blood
for B. microti [10 6] ), it is ti me-c ons um ing a nd e xp ensive. T his me th odolo gy is mor e use-
ful for a retrospective diagnosis, especially when a rapid diagnosis is essential.
DNA amplification by PCR has been proposed as an even more sensitive method
to detect Babesia infection, particularly when these infections are subclinical or par-
asitemias are low [10 8] . The 18S rRNA gene is targeted because there are multiple cop-
ies present in each organism, the sequence is phylogenetically informative, and there
are conserved regions that allow for the development of general primers to identify
previously under-described Babesia parasites.
The immunofluorescent-antibody test remains the serodiagnostic test of choice
for detection of antibodies against babesial parasites. The antigens of B. divergens also
cross-react with several Plasmodium and Babesia spp. [102] . Alternatives, such as an
ELISA using recombinant antigens, are being developed [109, 110] , and may provide
a tool for rapid screening of a large number of samples. Soluble whole parasite antigen
has been used for ELISA tests for B. divergens for screening of cattle, and was found
useful for the detection of recent infections only in these hosts [111] .
T r e a t m e n t
Treatment of B. divergens must be rapid and aggressive. A massive blood exchange
transfusion (2–3 times blood volume), followed by 10 days of intravenous clindamy-
cin (600 mg, 3–4 times per day) is recommended [111] . The current treatment recom-
mendation for human infection with B. microti is combined oral quinine (650 mg, 3
times per day) and oral clindamycin (1,200 mg, twice per day) for 7 days [107] .
144 Bitam ⴢ Raoult
Tick-Borne Rickettsiosis
The genus Rickettsia includes bacteria of the order Rickettsiales in the ␣ -subdivision
of Proteobacteria. They are Gram-negative coccobacilli bacteria in obligatory asso-
ciation with eukaryote cells. The spotted fever group (SFG) includes 21 valid species,
mostly vectored by ticks and causing different types of spotted fever in different parts
of the world. Several already described SFG species are considered to be of unknown
pathogenicity because their reports have been restricted to invertebrate hosts, mostly
ticks [112–114] . Ixodid
ticks (hard ticks) are bloodsucking arthropods throughout all
of their developmental stages. The percentage of infected eggs obtained from females
of the same tick species infected with the same rickettsial strain may vary, depending
on factors that have yet to be elucidated.
In this section, we will describe the Rickettsia conorii complex, including R. cono-
rii subsp . conorii (the agent of Mediterranean spotted fever; MSF), R. conorii israelen-
sis (Israeli spotted fever rickettsia; ISFR), R. conorii caspia (Astrakhan spotted fever
rickettsia), R. sibirica mongolitimonae (lymphangitis-associated rickettsioses), R. slo-
vaca (tick-borne lymphadenopathy or Dermacentor -borne necrosis erythema lymph-
adenopathy), R. aeschlimannii , R. massiliae and R. raoultii .
Rickettsia conorii Complex
The classification within Rickettsiales is continually modified as new data become
available. Polyphasic taxonomy, which integrates phenotypic and phylogenic data,
seems to be particularly useful for rickettsial taxonomy. However, experts in the field
of rickettsiology frequently disagree over species definitions. Until 2005, Rickettsia of
the so-called R. conorii complex, including the R. conorii strain Malish (MSF),
R. conorii israelensis (ISFR) and R. conorii caspia (Astrakhan spotted fever rickettsia),
were considered to be members of the same species. Phylogenetically, these rickett-
siae constitute a homogeneous cluster supported by a significant bootstrap value and
are distinct from other Rickettsia species. Zhu et al. [115] proposed a nomenclature of
the R. conorii species, with the creation of the following subspecies: R. conorii subsp.
conorii subs p. nov. (t ype s trai n Mal ish , ATC C VR-613), R. conorii subsp. caspia subsp.
nov. (type strain A-167, formerly Astrakhan fever rickettsia) and R. conorii subsp. is-
raelensis subsp. nov. (type ISTT CDC1, formerly ISFR).
Rickettsia conorii subsp. conorii
This Rickettsia was first reported in Tunisia in 1910 by Conor and Bruch. In the 1930s,
the role of Rhipicephalus sanguineus and the causative agent, subsequently named R.
conorii, were described. Three strains of R. conorii subsp. conorii include (1) Seven or
Malish, (2) Kenya and (3) Moroccan (which is apparently a unique isolate). In 2001,
the genome of R. conorii stra in Seven was fully sequenced, a nd revealed several u nique
characteristics among bacteria genomes.
Other Tick-Borne Diseases in Europe 145
Rickettsia conorii is transmitted by R. sanguineus , the brown dog tick. This bacte-
rium does not normally infect humans during its natural cycle between its arthropod
host and vertebrate one, the dog. R. sanguineus probably has the most widespread
distribution of all Ixodid ticks. Despite this, its distribution is patchy in that it is con-
fined to localities within urban, suburban, periurban and rural areas in which there
are both domestic dogs and human dwellings or man-made structures. R. sanguineus
lives in peridomestic environments shared with dogs, but has relatively low affinity
for humans.
MSF is endemic in the Mediterranean area, including northern Africa and south-
ern Europe. Cases continue to be identified in new locations within this region, as
some cases were recently described in Turkey, Malta, Cyprus, Slovenia, Croatia,
Greece and Bulgaria. In Italy, the national incidence rate is 1.6 cases per 100,000 per-
sons; however, when considering the Sicilian region, this incidence is much higher (10
cases per 100,000 persons). MSF is a reportable disease in Portugal, where the annual
incidence rate of 9.8 cases per 100,000 persons was highest of the rates of all Mediter-
ranean countries in the 1990s. In Spain, estimated incidence was 23–45 cases per
100,000 persons in 1983–1985. Sporadic cases in nonendemic countries are also fre-
quently observed as a consequence of tourism, and, in North America, MSF is one of
the most frequently imported rickettsioses with African tick-bite fever. Some cases
have been sporadically reported in northern and Central Europe, including Belgium,
Switzerland and northern France, where R. sanguineus can be imported with dogs
and survive in peridomestic environments providing there are acceptable microcli-
matic conditions.
After an asymptomatic incubation of 6 days, the onset of MSF is abrupt, and typi-
cal cases present with high fever (39
° C), flu-like symptoms and a black eschar (tache
noire) at the site of the tick bite. In a few cases, the inoculation occurred through con-
junctivae, and patients presented with conjunctivitis. One to 7 days (median, 4 days)
following the onset of fever, a generalized maculopapular rash that often involves the
palms and soles, but spares the face, develops. However, severe forms, including ma-
jor homological manifestations and multiorgan involvement may occur in 5–6% of
the cases. The mortality rate is usually estimated as around 2.5% among diagnosed
cases. Classic risk factors for severe forms include advanced age, immunocompro-
mised situations, chronic alcoholism and glucose-6-phosphate dehydrogenase defi-
ciency.
Rickettsia conorii subsp. israelensis (Israeli Spotted Fever)
The first case of rickettsia spotted fever in Israel was reported in the late 1940s [114] .
In 1971, the agent of ISFR was isolated from a patient. Two other antigenically identi-
cal agents were isolated from R. sanguineus ticks collected on the dogs of 2 patients
with serologically documented ISFR. These 3 isolates were rickettsiae closely related
to, but slightly different from, R. conorii isolates obtained from patients with MSF.
This observation has been confirmed by recent molecular studies [115] .
146 Bitam ⴢ Raoult
Rickettsia conorii subsp. israelensis outside of Israel was isolated from 3 patients
living in semirural areas along the River Tejo in Portugal in 1999. Recently, de Sou-
sa et al. [116 ] reported the clinical data of 44 patients infected with R. conorii subsp.
israelensis in Portugal between 1999 and 2004, and in ticks collected in Bragança,
Montesinho Natural Park, and Portalegre City. Cases were confirmed by isolation
of the Rickettsia from blood or a PCR on skin biopsy specimens. A clinical retro-
spective analysis in western Sicily, from 1987 to 2001, identified by molecular-se-
quence-based techniques 5 out 24 patients infected with R. conorii subsp. israelen-
sis . Recently, R. conorii subsp. israelensis wa s detec ted in Sicil ia n R. sanguineus ticks
[117] .
The eschar at the inoculation site is absent in 90% of cases, whereas splenomeg-
aly and hepatomegaly are seen in 30–35% of patients.
Rickettsia conorii subsp. caspia (Astrakhan Fever)
In Astrakhan, a region of Russia located by the Caspian Sea, where cases of febrile
exanthema were observed in patients in rural areas during the 1970s, most of the pa-
tients had dogs and reported having contact with R. sanguineus dog ticks. The agent,
a member of the R. conorii complex, was described in 1991, and the suspected vector
of this eruptive summer disease is the dog tick R. sanguineus pumilio [118] . The name
R. conorii ssp. caspia ssp. nov. has been proposed for the agent of Astrakhan spotted
fever [115] . The disease seemed to be transmitted by R. sanguineus , with 8% of ticks
shown to be infected by the hemolymph test.
Astrakhan fever was detected in 321 cases from prospective surveillance during
1983–1988; most patients were adults (94%), specifically males (61%). The disease was
similar to MSF. During the summer of 2001, French United Nations troops in Kosovo
collected ticks on asymptomatic soldiers and dogs in the Morina region. By molecular
methods, R. conorii subsp. caspia was detected in four R. sanguineus organisms, com-
prising 3 collected on dogs and 1 taken from an asymptomatic soldier [112] .
R. conorii subsp. caspia (Astrakhan fever) is a similar disease to MSF, including
fever associated with a maculopapular rash in 94% of the cases. However, the presence
of a tache noire was reported in only 23% of the patients. Conjunctivitis was seen in
32% of the cases. No fatal cases were reported.
Rickettsia sibirica subsp. mongolitimonae
In 1991, a rickettsia was isolated from Hyalomma asiaticum ticks collected in Inner
Mongolia in China. The isolate HA-91 differed antigenically and genotypically from
other SFG rickettsiae. In 1996, the first case of human infection with ‘R. mongoliti-
monae’ was documented by culture and PCR, a genetically indistinguishable isolate
was obtained from the blood and the skin of a 63-year-old patient in southern France.
This patient was a resident of Marseille and had no travel history; however, the patient
had collected compost from a garden where migratory birds were resting. A second
human case of infection with R. sibirica subsp. mongolitimonae was diagnosed in
1998 in an HIV patient who had gardened in a rural area of Marseille. That is why the
Other Tick-Borne Diseases in Europe 147
initial hypothesis was that the rickettsiae were transmitted by ticks occasionally car-
ried by birds from Asia. The name ‘Rickettsia mongolitimonae’ was then first pro-
posed for this rickettsia, referring the disparate sources of the isolates (i.e. Mongolia
and La Timone Hospital in Marseille). Using gene-sequence-based criteria to define
Rickettsia species [118 , 119] , R. mongolitimonae
was identified as a member of the
R. sibirica species complex. Nevertheless, all strains of R. mongolitimonae group to-
gether in phylogenetic clusters separated from other strains of R. sibirica .
S p e c i f i c v e c t o r s a n d r e s e r v o i r s o f R. sibirica mongolitimonae have yet to be de-
scribed, particularly in southern France. It has been hypothesized that ticks from
migratory birds may have bitten French patients. The detection of R. sibirica mongoli-
timonae in Hyalomma spp. in Mongolia and Niger suggests a possible association of
this rickettsia with ticks of this genus that are also prevalent in southern France. More
arguments for this hypothesis were provided recently, when 2 cases of R. sibirica mon-
golitimonae were documented in C rete, Greece . In 1 patient, t his ricke ttsia was si mul-
taneously detected on a H. anatolicum excavatum tick that had fed on him. Recently
in Portugal, R. sibirica mongolitimonae has been identified in one R. pusillus tick col-
lected on a dead Egyptian mongoose. It now seems that the distribution area of
R. sibirica mongolitimonae coincides with or at least corresponds to the distribution
of Hyalomma spp. ticks worldwide.
From January 2000 to June 2004, a total of 7 culture- or PCR-proven cases of in-
fection due to R. sibirica mongolitimonae were documented in southern France, 1
of them having returned from a trip in northern Africa, suggesting that this disease
is likely to be more widespread than originally expected. In 3 patients, the bacteri-
um was cultivated from the inoculation eschar. The other 4 patients were diagnosed
with use of PCR of samples obtained from the eschar (2 patients) or blood (2 pa-
tients), plus specific Western blotting before (2 patients) and after (2 patients) cross-
adsorption [120] . On the basis of evaluation of these 9 cases, R. sibirica mongoliti-
monae infection differs from other tick-borne rickettsioses in the Mediterranean
area. More recently, 1 case was documented in a patient returning to France after a
trip to Algeria. She presented with fever and 2 inoculation eschars. She had been in
contact with camels, which are highly parasitized by ticks. Another European case
has been recently reported. An isolate was recovered in 2004 from a 73-year-old
Portuguese woman who suffered from acute febrile illness with a maculopapular
rash over the body. R. sibirica subsp. mongolitimonae infection was presented clin-
ically by fever, headache, an eschar, lymphangitis and painful satellite lymphade-
nopathy.
Rickettsia slovaca (The Agent of Tick-Borne Lymphadenopathy and
Dermacentor-Borne Necrosis Erythema Lymphadenopathy)
A novel SFG rickettsia was isolated in 1968 from D. marginatus ticks in Czechoslova-
kia [121] . Based on serological studies and C+G content, 2 strains were found to be
close but not identical to R. sibirica and R. conorii . Thorough studies revealed that
148 Bitam ⴢ Raoult
these strains differed from all prototype strains known at that time, and a new spe-
cies of SFG rickettsia, R. slovaca , was proposed. Subsequently, it has been detected or
isolated from ticks in all European countries where D. marginatus and D. reticulatus
have been evaluated for rickettsiae.
R. slovaca is an example of a human-disease-causing rickettsia that was consid-
ered as a ‘nonpathogenic rickettsia’ for more than 20 years following its discovery.
In 1997, the first documented case of human infection with R. slovaca was reported
in a woman who presented with a single eschar of the scalp and enlarged cervical
lymph nodes following the bite of Dermacentor sp. ticks in France [118] . Clinically
similar but undocumented cases had been seen previously in France, Slovakia and
Hungary. This rickettsiosis is called tick-borne lymphadenopathy because the most
pronounced sign is lymph node enlargement. In Spain, the same condition is called
Dermacentor -borne necrosis erythema lymphadenopathy (for tick-borne lymph-
adenopathy) [122] . From January 1996 through April 2000, the role of R. slovaca
infection in this syndrome was evaluated in 67 patients from France and Hungary
presenting with tick-borne lymphadenopathy. Infections were most likely to occur
in children and in patients who were bitten during the colder months of the year.
Cases have also been reported in Bulgaria and Spain. More recently, 14 new patients
were reported with tick-borne lymphadenopathy from southern France, who sought
treatment between January 2004 and May 2005, and the features of these patients
were compared with those in whom MSF was diagnosed during the same period
[122] .
Rickettsia aeschlimannii
R. aeschlimannii was first isolated from H. marginatum marginatum ticks in Moroc-
co in 1992, and then characterized as a new SFG rickettsia in 1997 [12 3] . The first hu-
man infection caused by R. aeschlimannii was reported in a patient returning from
Morocco to France. This patient presented with typical clinical signs of spotted fe-
ver.
R. aeschlimannii was detected in H. m. rufipes in southern Europe and North and
sub-Saharan Africa. In Europe, it has been recently identified in H. m. marginatum
in Croatia, from 6 tick species in Spain, including H. m. marginatum , and from H. m.
marginatum in Cephalonia, the largest Ionian island of Greece. This Rickettsia was
recently isolated from H. m. rufipes collected on migratory birds coming from Africa
and collected in Croatia. R. aeschlimannii was shown to be transstadially and trans-
ovarially transmitted in ticks, indicating that Hyalomma ticks may be not only vec-
tors but also reservoirs of R. aeschlimannii .
The first cases of human infection by R. aeschlimannii were reported in 2002 in a
patient who was returning to France from Morocco, and also a South African patient
who, on returning from a hunting and fishing trip, discovered a Rhipicephalus ap-
pendiculatus tick attached to his right thigh and an eschar around the attachment site.
The patient was aware of the risk of tick-transmitted disease; after removing the tick,
Other Tick-Borne Diseases in Europe 149
he immediately self-prescribed doxycycline [124] . Other cases were described in Al-
geria (unpublished data). R. aeschlimannii was clinically presented by eschar fever
and a maculopapular rash.
Rickettsia massiliae
R. massiliae was isolated from Rhipicephalus ticks collected near Marseille in 1992.
In Europe, this rickettsia has been detected by molecular methods in R. sanguineus
in Greece and R. turanicus in Portugal. In 1996, a variant strain of R. massiliae (Bar
29) was isolated in R. sanguineus ticks from Catalonia, Spain. The first documented
human infection with R. massiliae occurred in 2005.
I n E u r o p e , t h i s Rickettsia has also been detected by molecular methods in R. san-
guineus in Greece
and R. turanicus in Portugal. In 1996, a variant strain of R. mas-
siliae ( Bar 29) was isolated in an R. sanguineus tick from Catalonia and identified in
ticks removed from humans in Castilla, Spain. The transstadial and transovarial
transmission of R. massiliae Bar 29 occurs in ticks of the R. sanguineus group, which
may also be considered to be reservoirs [112] . R. massiliae
was isolated in 1985 from
the blood of a 45-year-old man hospitalized in Palermo, Italy, with fever, a necrotic
eschar, a maculopapular rash involving the palms and soles, and mild hepatomegaly.
Twenty years after, the isolate was recognized as R. massiliae, when human infection
occurred in 2005 [112] . Thus, R. massiliae
was described in 2 patients who clinically
presented with fever, necrotic eschar, a maculopapular rash involving the palms and
soles, and mild hepatomegaly.
Rickettsia helvetica
R. helvetica , first isolated in I. ricinus ticks in Switzerland in 1979, was considered a
nonpathogenic rickettsia for approximately 20 years after its discovery. In 2000, se-
roconversion to R. helvetica was described for a French patient with a nonspecific fe-
brile illness [125] . One patient from France and 3 patients from Italy were also diag-
nosed using serological criteria. All 4 reported tick bites and 1 developed an eschar
[126] . In 1999, R. helvetica
was implicated in fatal perimyocarditis in several patients
in Sweden. Infection was documented by electron microscopy, PCR and serology
[127] . In 2003, serological findings in patients with tick bites from Switzerland were
suggestive of acute or past R. helvetica infection. Five cases of SFG rickettsiosis, pos-
sibly caused by R. helvetica, we re reported in patients livi ng at t he c ent ra l Th ai-Myan-
mar border. Two patients reported a tick bite, 1 presented with an eschar and anoth-
er patient presented with rash. Infection were documented by microimmunofluores-
cence and Western blot assays. Three more cases, in patients from eastern Thailand
with undifferentiated febrile illness, were serologically documented. Additional eval-
uation and isolation of the bacterium from clinical samples are, however, needed to
confirm the pathogenicity of R. helvetica .
The transstadial and transovarial transmission of R. helvetica has been demon-
strated in I. ricinus ; this tick represents both a potential vector and a natural reservoir
150 Bitam ⴢ Raoult
of R. helvetica . This Rickettsia has been identified in I. ricinus ticks in many Euro-
pean countries, including France, Sweden, Slovenia, Spain, Portugal, Italy and Bul-
garia where the average infection rate is approximately 10%.
Rickettsia raoultii
This Rickettsia has been known for a long time as a novel genotype identified in Ixo-
did ticks collected in Russia using amplification and sequencing of rrs (16S rDNA),
gltA , and ompA . Rickettsia sp. provisionally called ‘genotype DnS14’, was initially de-
tected from the D. nuttalli tick collected in Sibirica, whereas ‘genotype RpA4’ was
detected from R. pumilio ticks from the Astrakhan region. Due to their phylogenetic
homogeneity, it was suggested that Rickettsia sp. genotype DnS14 and RpA4 belonged
to the same new species.
The pathogenicity of R. raoultii was suggested by the amplification of its DNA
from the blood of patients with a clinical picture of R. slovaca -like infection.
Several years later, the isolates of this Rickettsia were obtained using cell culture
from D. silvarum ticks collected in Far-Eastern Russia and Sibirica and D. reticulatus
and D. marginatus ticks from France and Russia. A recent study demonstrated that
Dermacento r ticks naturally infected with R. raoultii , and that transovarial and trans-
stadial transmissions occurred [12 8] .
T r e a t m e n t s
The treatment of rickettsioses is based around doxycycline. Currently, it is recom-
mended for adults (200 mg/day) and children [112] . The putative risk of tooth staining
has not been established for doxycycline, and the risk of the disease is sufficient to
prescribe doxycycline in children. The duration of the treatment has not been estab-
lished; however, studies have shown that single-day treatment is efficient. In any case,
treatment prolonged for 24 h after the obtention of apyrexia has proved to be efficient.
Ne w macrolide s have been prop ose d in children and c hlo ramphenico l ha s be en w ide -
ly used in the past for the treatment of rickettsioses.
References
1 C enters for Disease Cont rol: Lyme diseas e – United
States, 1987 and 1988. MMWR Morb Mortal Wkly
Rep 1989;
38: 668–672.
2 Spach DH, Liles WC, Campbell GL, et al: Tick-
borne diseases in the US. N Engl J Med 1993;
329:
936–947.
3 Myers SA, Sex ton DJ: Dermatologic manifestat ions
of arthropod-borne diseases. Infect Dis Clin North
Am 1994;
8: 689–712.
4 Cary NRB, Fox B, Wright DJM, et al: Fatal Lyme
carditis and endodermal heterotopia of the atrio-
ventricular node. Postgrad Med J 1990;
66: 134–
136.
5 Paddock CD, Sumner JW, Shore GM, et a l: Isolation
and characterization of Ehrli chia chaffe ensis strains
from patients with fatal ehrlichiosis. J Clin Micro-
biol 1997;
10: 2496–2502.
Other Tick-Borne Diseases in Europe 151
6 Hardalo CJ, Quagliarello V, Dumler JS: Human
granulocytic ehrlichiosis in Connecticut: report of
a fatal case. Clin Infect Dis 1995;
4: 910–914.
7 Kirsch M, Ruben FL, Steere AC, et al: Fatal adult
respiratory distress syndrome in a patient with
Lyme disease. JAMA 1988;
259: 2737–2739.
8 Berglund J, Eitrem R, Ornstein K, et al: An epide-
miologic study of Lyme disease in southern Swe-
den. N Engl J Med 1995;
333: 1319–1327.
9 Sonenshine DE, Azad AF: Ticks and mites in dis-
ease transmission; in Strickland GT (ed): Hunter’s
Tropical Medicine, ed 7. Philadelphia, WB Saun-
ders, 1991, pp 971–981.
10 Peavy CA, Lane RS, Kleinjan JE: Role of small
mamma ls in the ecology of B. burgdorferi in a peri-
urban park in north coastal California. Exp Appl
Acarol 1997;
21: 569-584.
11 Fritz CL, Kjemtrup AM, Conrad PA, et al: Seroepi-
demiology of emerging tick-borne infectious dis-
eases i n a northern Ca lifornia n community. J Infe ct
Dis 1997;
175: 14 32–1439.
12 Middleton DB: Tick-borne infections: what starts
as a tiny bite may have a serious outcome. Postgrad
Med J 1994;
5: 131–139.
13 Oksi J, Viljanen MK, Kalimo H, et al: Fatal enceph-
alitis caused by concomitant infection with tick-
borne encephalitis virus and Borrelia burgdorferi .
Clin Infect Dis 1993;
16: 392–396.
14 Strle F, Maraspin V, Lotric-Furlan S, et al: Epide-
miologic study of a cohort of adult patients with
erythema migrans registered in Slovenia in 1993.
Eur J Epidemiol 1996;
5: 503–507.
15 Sa ntos AS, Bacell ar F, Dumler JS: Human E xposure
to Anaplasma phagocytophilum in Portugal. Ann
NY Acad Sci 2006;
1078: 100–105.
16 Naranjo V, Ruiz-Fons F, Höfle U, Fernandez de
Mera IG, Villanua D, Almazan C, et al: Molecular
epidemiology of human and bovine anaplasmosis
in southern Europe. Ann NY Acad Sci 2006;
1078:
95–99.
17 Inokuma H: Vectors and reservoir hosts of Ana-
plasmataceae; in Raoult D, Parola P (eds): Rickett-
sial Diseases, ed 1. New York, Informa Healthcare,
2007.
18 Brouqui P, Matsumoto K : Bacteriology and phylog-
eny of Anaplasmataceae; in Raoult D, Parola P
(eds): Rickett sial Disease s, ed 1. New York, Inform a
Healthcare, 2007.
19 Barlough JE, Madigan JE, Kramer VL, Clover JR,
Hui LT, Vredevoe LK: Ehrlichia phagocytophila
genogroup rickettsiae in ixodid ticks from Califor-
nia collected in 1995 and 1996. J Clin Microbiol
1997;
35: 2018–2021.
20 Dumler JS, Madigan JE, Pusterla N, Bakken JS:
Ehrlichiosis in humans: epidemiology, clinic al pre-
sentat ion, d iag nosi s, an d tre atme nt. C lin I nfe ct Di s
2007;
45: 45–51.
21 Chen S, Dumler JS, Bakken JS, Walker DH: Identi-
fication of a granulocytotropic Ehrlichia species as
the etiologic agent of human disease. J Clin Micro-
biol 1994;
32: 589–595.
22 Petrovec M, Lotric Furlan S, Avsic Zupanc T, Strle
F, Brouqui P, Roux V, et al: Human disease in Eu-
rope caused by a granulocytic Ehrlichia species. J
Clin Microbiol 1997;
35: 1556–1559.
23 Cinco M, Padovan D, Murgia R, Heldtander M,
Engvall EO: Detection of HGE agent-like Ehrlichia
in Ixodes ricinus ticks in northern Italy by PCR.
Wien Klin Wochenschr 1998;
110: 898–900.
24 Nuti M, Serafini DA, Bassetti D, Ghionni A, Rus-
sino F, Rombola P, et al: Ehrlichia infection in Italy.
Emerg Infect Dis 1998;
4: 663–665.
25 Blanco JR, Oteo JA: Human granulocytic ehrlichi-
osis in Europe. Clin Microbiol Infect 2002;
8: 763–
772.
26 Arnez M, Petrovec M, Lotric-Furlan S, Zupanc AT,
Strle F: First European pediatric case of human
granu locytic ehrl ichiosis. J Clin M icrobiol 2001;
39:
4591–4592.
27 Lotric-Furlan S, Petrovec M, Zupanc T, Nicholson
W, Summer J, Childs J, et al: Human granulocytic
ehrlich iosis in Europe: cli nical and lab oratory find-
ings for four p atie nts fr om Sloveni a. Cl in In fect D is
1998;
27: 424–428.
28 van Dobbenburgh A, van Dam AP, Fikrig E: Hu-
man granulocytic ehrlichiosis in western Europe.
New Engl J Med 1999;
340: 1214–1216.
29 Oteo JA, Blanco JR, Martinez de Artola V: First re-
port of human granulocytic ehrlichiosis from
southern Europe (Spain). Emerg Infect Dis 2000;
6:
430–432.
30 Bjoersdorff A, Wittesjö B, Berglund J, Massung RF,
Eliasson I: Human granulocytic ehrlichiosis as a
common cause of tick-associated fever in southeast
Sweden: report from a prospective clinical study.
Scand J Infect Dis 2002;
34: 187–191.
31 Misic-Majerus LJ, Bujic N, Madjaric V, Janes-Poje
V: First descrip tion of the human gr anulocyt ic ehr-
lichiosis in Croatia. Clin Microbiol Infect 2000;
25:
194–195.
32 Tylewska-Wierzbanowska S, Chmielewski T, Kon-
drusik M, Hermanowska-Szpakowicz T, Sawiki W,
Sulek K: First cases of acute human granulocytic
ehrlichiosis in Poland. Eur J Clin Microbiol 2001;
20: 196–198.
33 Remy V, Hansmann Y, De Martino S, Christmann
D, Brouqui P: Human anaplasmosis presenting as
atypical pneumonitis in France. Clin Infect Dis
2003;
37: 846–848.
34 Olano JP, Walker DH: Human ehrlichioses. Med
Clin North Am 2002;
86: 375–392.
35 Bakken JS, Dumler JS: Human granulocytic ehr-
lichiosis. Clin Infect Dis 2000;
31: 554–560.
152 Bitam ⴢ Raoult
36 Parol a P, Davoust B, Raoult D: Tick- and f lea-borne
rickettsial emerging zoonoses. Vet Res 2005;
36:
469–492.
37 Rikihisa Y, Stills H, Zimmerman G: Isolation and
continuous culture of Neorickettsia helminthoeca
in a macrophage cell line. J Clin Microbiol 1991;
29:
1928–1933.
38 Bak ken JS, Dumler JS: Clinical d iagnosis and treat-
ment of human granulotropic anaplasmosis. Ann
NY Acad Sci 2006;
1078: 236–247.
39 Horowitz HW, Aguero-Rosenfeld ME, Mckenna
DF, Holmgren D, Hsieh TC, Varde SA, et al: Clini-
cal and laboratory spectrum of culture-proven hu-
man granulocytic ehrlichiosis: comparison with
culture-negative cases. Clin Infect Dis 1998;
27:
1314–1317.
40 Doyle CK, Labruna MB, Breitschwerdt EB, Tang
YW, Corstvet RE, Hegarty BC, et al: Detection of
medica lly importa nt Ehrlichia by quantitative mul-
ticolor TaqMan real-time polymerase chain reac-
tion of the dsb gene. J Mol Diagn 2005;
7: 504–510.
41 Bakken JS, Dumler JS: Ehrlichia and Anaplasma
species; in Yu V, Weber R, Raoult D (eds): Antimi-
crobial Therapy and Vaccines, ed 2. New York, Ap-
ple Trees Productions, 2002.
42 Maurin M, Bakken JS, Dumler JS: Antibiotic sus-
ceptibilities of Anaplasma ( Ehrlichia ) phagocyto-
philum st rains from va rious geograph ic areas in the
United States . Antimicrob A gents Chemother 2003 ;
47: 413–415.
43 Van Dam AP, van Gool T, Weststeyn JCFM,
Dankert J: Tick-borne relapsing fever imported
from West Africa: diagnosis by quantitative buffy
coat analysis and in vitro culture of Borrelia croc-
idurae . J Clin Microbiol 1999;
37: 2027–2030.
44 Lecompte Y, Trape JF: La fièvre récurrente à tique
d’Afrique de l’ouest. Ann Biol Clin (Paris) 2003;
61:
541–548.
45 Brouqui P, Raoult D: Arthropod-borne diseases in
homeless. Ann NY Acad Sci 2006;
1078: 223–235.
46 R ebaudet S, Pa rola P: E pidemi ology o f relapsing fe-
ver borreliosis. FEMS Immunol Med Microbiol
2006;
48: 11–15.
47 Cutler SJ, Brow ning P, Scott JC: Ornithodoros mou-
bata , a soft tick vector for Rickettsia in east Africa?
Ann NY Acad Sci 2006;
1078: 373–377.
48 Parola P, Raoult D: Ticks and tickborne bacterial
diseases in humans: an emerging infectious threat.
Clin Infect Dis 2001;
32: 897–928.
49 Vial L, Diatta G, Tall A, et al: Incidence of tick-
borne relapsing fever in West Africa: longitudinal
study. Lancet 2006;
368: 37–43.
50 Estrada-Pena A, Jongejan F: Ticks feeding on hu-
mans: a rev iew of records on human-biti ng Ixodoi-
dea with special reference to pathogen transmis-
sion. Exp Appl Acarol 1999;
23: 685–715.
51 Wplosz B, Mi haila-Amrouche L , Baixenh MT, et al :
Importe d tick-borne relapsing fever, Fra nce. Emerg
Infect Dis 2005;
11: 1801–1803.
52 Felsenfeld O: Borreliae, human relapsing fever, and
parasite-vector-host relationships. Bacteriol Rev
1965;
29: 46–74.
53 Anda P, Sanchez-Yebra W, del Mar Vitutia M, et al:
A new Borrelia species isolated from patients with
relapsing fever in Spain. Lancet 1996;
348: 162–165.
54 Cutler SJ: Possibilities for relapsing fever re-emer-
gence. Emerg Infect Dis 2006;
12: 369–374.
55 Johnson WD: Borrelia species (relapsing fever); in
Mandell GL, Bennett JE, Dolin R (eds): Principles
and Prac tice of Infect ious Diseases , ed 4. New York,
Churchill Livingstone, 1995, pp 1816–1819.
56 Johnson WD, Golightly LM: Borrelia species (re-
lapsing fever); in Mandell GL, Bennett JE, Dolin R
(eds): Mandell, Douglas, and Bennett’s Principles
and Prac tice of Infect ious Diseases , ed 5. New York,
Churchill Livingstone, 2000.
57 Dupont HT, La Scola B, Williams R, Raoult D: A
focus of tick-borne relapsing fever in Southern
Zaire. Clin Infect Dis 1997;
25: 139–144.
58 Bratton RL, Corey GR: Tick-borne disease. Am
Family Physician 2005:
72: 2323–2330.
59 Cutler SJ, A kintunde COK, Moss J, et al: Successful
in vitro c ultivation of Borrelia duttonii and its c om-
parison with Borrelia recurrentis . Int J Syst Bacte-
riol 1999;
49: 1793–1799.
60 Cutler SJ, Fekade D, Hussein K, et al: Successful in-
vitro cultivation of Borrelia recurrentis . Lancet
1994;
343: 242.
61 Marti Ras N, La Scola B, Postic D, et al: Phylogen-
esis of relapsing fever Borrelia spp. Int J Syst Bact
1996;
46: 859–865.
62 Cadavid D, Barbour AG: Neuroborreliosis during
relapsing fever: review of the clinical manifesta-
tions, pat hology, and treatment of infections in hu-
mans and experimental animals. Clin Infect Dis
1998;
26: 151–164 .
63 Müller W, Bocklish H, Schüler G, Hotzel H, Neu-
bauer H, Otto P: Detection of Francisella tularensis
subsp. holarctica in a European brown hare ( Lepus
europaeus ) in Thuringia, Germany. Vet Microbiol
2007;
123: 225–229.
64 Jiang J, Parker CE, Fuller JR, Kawula TH, Borchers
CH: An immunoaffinity tandem mass spectrome-
try (iMALDI) assay for detection of Francisella .
Anal Chim Acta 2007;
605: 70–79.
65 Chaudhui RR, Reu CP, Desmond L, et al: Genome
sequencing shows that European isotopes of Fran-
cisella tularensis subspecies tularensis are almost
id ent ic al to U S la bor at or y st ra in Sch u S 4. P loS ON E
2007;
2:e352.
66 Gur ycova D: First isolat ion of Francisella tularensis
subsp. tularensis in Europe. Eur J Epidemiol 1998;
14: 797–802.
Other Tick-Borne Diseases in Europe 153
67 E lias son H, L indbäck J, Nuort i J, Ar nebor n M, Gie-
secke J, Tegnell A: The 2000 tularemia outbreak: a
case- control study of ris k factors in dis ease-endem-
ic and emergent areas, Sweden. Emerg Infect Dis
2002;
8: 956–960.
6 8 Reintjes R, Dedu shaj I, Gjini A, et a l: Tularem ia out-
break investigation in Kosovo: case control and en-
vironmental studies. Emerg Infect Dis 2002;
8: 969–
973.
69 Johansson A, Forsman M, Sjöstedt A: The develop-
ment of tools for diagnosis of tularemia and typing
of Francisella tularensis . APMIS 2004; 112: 898–907.
70 De Cavalho IL, Escudero R, Garcia-Amil C, Falcao
H, Anda P, Nuncio MS: Francisella tularensis , Por-
tugal. Emerg Infect Dis 2007;
13: 666–667.
71 Bratton RL, Corey GR: Tick-borne disease. Am
Fam Phys 2005;
71: 2323–2330.
72 Dennis DT, Inglesby TV, Henderson DA, et al: Tu-
laremia as a biological weapon: medical and Public
Health Management. JAMA 2001;
285: 2763–2773.
73 Evans M, Gregory D, Schaffner W, McGee ZA: Tu-
laremia: a 30-year experience with 88 cases. Medi-
cine (Baltimore) 1985;
64: 251–269.
74 Bossi P, Tegnell A, Baka A, et al: Bichat guidelines
for the clinical management of tularaemia and bio-
terrorism-related tularaemia. Euro Survei ll 2004;
9:
E9–E10.
75 Miller RP, Bates JH: Pleuropulmonar y tularemia: a
re view of 29 patients. Am Rev Respir Dis 1969;
99:
31–41.
76 Rubin SA: Radiog raphic spect rum of pleuropulmo -
nary tularemia. AJR Am J Roentgenol 1978;
131:
277–281.
77 Forsman M, Kuoppa K, Sjöstedt A, Tärnvik A: Use
of RNA hybridization in the diagnosis of a case of
ulceroglandular tularemia. Eur J Clin Microbiol
Infect Dis 1990;
9: 784–785.
78 Ellis J, O yston PC, Green M, Tit ball RW: Tularemi a.
Clin Microbiol Rev 2002;
15: 631–646.
79 Beers MH, Berkow R: The Merck Manual of Diag-
nosis and Therapy, ed 17. Whitehouse Station,
Merck Research Laboratories, 1999.
80 Rizzoli A, Rosa R, Mantelli B, et al: Ixodes ricinus ,
transmitted diseases and reservoirs (in Italian).
Parassitologia 2004;
46: 119–122.
81 Kaiser R: The clinical and epidemiological profile
of tick-borne encephalitis in southern Germany
1994–1998: a prospective study of 656 patients.
Brain 1999;
122: 2067–2078.
82 Kaiser R, Kern A, Kampa D, Neumannhaefelin D:
Prevalence of antibodies to Borrelia burgdorferi
a nd tic k-bor ne encepha liti s vir us in an endemic re-
gion in southern Germany. Zentralbl Bakteriol
1997;
286: 534–541.
83 Pugliesse A, Beltramo T, Torre D: Seroprevalence
study of tick-borne encephalitis, Borrelia burgdor-
feri , dengue and Toscana virus in Turin province.
Cell Biochem Funct 2007;
25: 185–188.
84 Skarphedinsson S, Jensen PM, Kristiansen K: Sur-
vey of tick-borne infections in Denmark. Emerg
Infect Dis 2005;
11: 1055–1061.
85 Haglund M, Vene S, Forsgren M, et al: Character-
ization of human tick-borne encephalitis virus
from Sweden. J Med Virol 2003;
71: 610–621.
8 6 J auss aud R , Mag y N, S tra dy A, D upon d JL , Dev ille
JF: Tick-borne enceph alitis. Re v Med Interne 2001;
22: 542–548.
87 Charrel RN, Attoui H, Butenko AM, et al: Tick-
borne virus diseases of human interest in Europe.
Clin Microbiol Infect 2004;
10: 1040–1055.
88 Kondrusik M, Biedzinska T, Pancewicz S, et al:
Tick-borne encepha litis (TBE) case s in Bialostock i
and Podlaski regions in years 1993–2002. Przegl
Epidemiol 2004;
58: 273–280.
89 Gritsun TS, Nutt all PA, Gould EA: Tick-borne f la-
viviruses. Adv Virus Res 2003;
61: 317–371.
90 Ackermann R, Krüger K, Roggendorf M, et al:
Spread of early summer meningoencephalitis in
the Federal Republic of Germany. Dtsch Med
Wochen schr 198 6;
111: 927–933.
91 Kaiser R: Tick-borne encephalitis (TBE) in Ger-
many and clinical course of the disease. Int J Med
Microbiol 2002;
291(suppl 33):58–61.
92 Seligman SJ, Gould EA: Life f lavivirus vaccines:
reasons for caution. Lancet 2004;
363: 2073–2075.
93 Pugliesse A, Beltramo T, Torre D: Emerging and
re-emerging viral infections in Europe. Cell Bio-
chem Funct 2007;
25: 1–13.
94 Sa mbri V, Marangon i A, Storni E, et a l: Tick-borne
zoonosis: selected clinical and diagnostic aspects.
Parassitologia 2004;
46: 109–113.
95 Holbrook MR, Shope RE, Barrett ADT: Use of re-
combinant E protein domain III-based enzyme-
linked immunosorbent assays for differentiation
of tick-borne encephalitis serocomplex flavivirus-
es from mosquito-borne flaviviruses. J Clin Mi-
crobiol 2004;
42: 4101–4110.
96 Schwaiger M, Cassinotti P: Development of a
quantitative real-time RT-PCR assay with internal
control for the laboratory detection of tick-borne
encepha litis viru s (TBEV) RNA. J Cli n Virol 2003;
27: 136–145.
97 Kunz C : TBE vaccination a nd the Austria n experi-
ence. Vaccine 2003;
21:S50–S55.
98 Gefland JA: Babesia; in Mandell GL, Bennett JE,
Dolin R (eds): Pri nciples and Pract ice of Infectious
Diseases, ed 4. New York, Churchill Livingstone,
1995, pp 2497–2499.
99 Boustani MR, Gelfand JA: Babesiosis. Clin Infect
Dis 1996;
22: 611–615.
100 Pruthi RK, Marshall WF, Wiltsie JC, Persing DH:
Human babesiosis. Mayo Clin Proc 1995;
70: 853–
862.
101 Skrabalo Z, Deanovic Z: Piroplasmosis in man.
Doc Med Geogr Trop 1957;
9: 11–16.
154 Bitam ⴢ Raoult
102 Gorenflot AK, Moubri AK, Precigout E, Carcy B,
Schetters TP: Human babesiosis. Ann Trop Med
Parasit 1998;
92: 489–500.
103 Denes E, Rogez JP, Dardé ML, Weinbreack P:
Management of Babes ia divergens babesiosis with-
out a complete course of quinine treatment. Eur J
Clin Microbiol Infect Dis 1999;
18: 672–673.
104 Spach DH, Liles W, Campbell G, Quick R, Ander-
son D, Fritsche T: Tick-borne diseases in the Unit-
ed States. N Engl J Med 1993;
329: 936–947.
105 Ruebush TK, Cassaday PB, Marsh HJ, et al: Hu-
man babesiosis on Nantucket Island: clinical fea-
tures. Ann Intern Med 1977;
86: 6–9.
106 Etkind P, Piesma n J, Ruebush TK 2nd, Spiel man A,
Juranek DD: Me thods for detec ting Babe sia micro-
ti infection in wild rodents. J Parasitol 1980;
66:
107–110.
107 Tel ford S R 3rd, S pielm an A: Babesiosi s of humans ;
in Col li er L , Ba low s A, Sus sma n M , Kr eie r JP ( eds) :
Topley and Wilson’s Microbiology and Microbial
Infections, ed 9. London, Edward Arnold, 1997.
108 Persing DH, Mathiesen D, Marshall WF, et al: De-
tection of Babesia microti by poly merase chain re-
action. J Clin Microbiol 1992;
30: 2097–2103.
109 Homer MJ, Aguilar-Delfin I, Telford SR 3rd,
Kranse PJ, Persing DH: Babesiosis. Clin Microbiol
Rev 2000;
13: 451–469.
110 L odes MJ, Houghton RL , Bruinsma ES , et al: Sero-
logical expression cloning of novel immunoreac-
tive antigens of Babesia microti . Infect Immun
2000;
68: 2783–2790.
111 Chauvin A, L’Hotis M, Valentin A, et al: Babesia
divergens : an ELISA with soluble parasite antigen
for monitoring the epidemiology of bovine babe-
siosis. Parasite 1995;
2: 257–262.
112 Parola P, Paddock CD, Raoult D: Tick-borne rick-
ettsioses around the world: emerging diseases
challenging old concepts. Clin Microbiol Rev
2005;
18: 719–756.
113 Brouqui P, Matsumoto K: Bacteriology and phy-
logeny of Anaplasmataceae; in Raoult D, Parola P
(eds): Rickettsial Diseases, ed 1. New York, Infor-
ma Healthcare, 2007.
114 Valero A: Rocky Mountain spotted fever in Pales-
tine. Harefuah 1949;
36: 99–101.
115 Zhu Y, Fournier PE, Eremeeva M, Raoult D: Pro-
posal to create subspecies of Rickettsia conorii
based on multi-locus sequence typing and an
emended description of Rickettsia conorii . BMC
Microbiol 2005;
5: 11.
Didier Raoult
Unité des Rickettsies CNRS-IRD UMR 6236
Faculté de Médecine, Université de la Méditerranée
27, Bd Jean Moulin, FR–13385 Marseille Cedex 5 (France)
Tel. +33 4 91 32 43 75, Fax +33 4 91 38 77 72, E-Mail didier.raoult@gmail.com
116 de Sousa R, Santos-Silva M, Santos AS, et al: Rick-
ettsia conorii Israeli tick typhus strain isolated
from Rhipicephalus sanguineus ticks in Portugal.
Vector Borne Zoonotic Dis 2007;
7: 444–447.
117 Giammanco GM, Vitale G, Mansueto S, Capra G,
Caleca MP, Ammatuna P: Presence of R. conorii
subsp. israelensis , the causative agent of Israeli
spotted fe ver, in Sicily, Ital y, ascerta ined in a retro-
spective study. J Clin Microbiol 2005;
43: 6027–
6031.
118 Raoult D, Roux V: Rickettsioses as paradigms of
new or emerging infectious diseases. Clin Micro-
biol Rev 1997;
10: 694–719.
119 Fournier PE, Dumler JS, Greub G, Zhang JZ, Wu
YM, Raoult D: Gene sequence-based criteria for
identification of new Rickettsia isolates and de-
scription of Rickettsia heilongjiangensis sp. nov. J
Clin Microbiol 2003;
41: 5456–5465.
120 Fou rnier PE, Gourie t F, Brouqui P, Lucht F, Raoult
D: Lymphangitis-associated rickettsiosis, a new
ricket tsiosis caused by Ric ket tsi a sib iric a mo ngol o-
timonae : seven new cases and review of the litera-
ture. Clin Infect Dis 2005;
40: 1435–1444.
121 Rehacek J: Rickettsia slovaca , the organism and its
ecology. Acta Sci Nat Brno 1984;
18: 1–50.
122 Gouriet F, Rolain JM, Raoult D: Rickettsia slovaca
infection, France. Emerg Infect Dis 2006;
12: 521–
523.
123 Beati L, Meskini M, Thiers B, Raoult D: Rickettsia
aeschlimannii sp. nov., a new spotted fever group
rickettsia associated with Hyalomma marginatum
ticks. Int J Syst Bacteriol 1997;
47: 548–554.
124 P retorius AM, Birtles RJ: Rickettsia aeschlimannii :
a new pat hogenetic spotted fe ver group Rickettsia,
South Africa. Emerg Infect Dis 2002;
8: 874.
125 Fou rnier PE, Gu nnenberger F, Jaul hac B, Gast inger
G, Raou lt D : Evi denc e of Rickettsia helvetica infec-
tion in humans, Eastern France. Emerg Infect Dis
2000;
6: 389–392.
126 Fournier PE, Allombert C, Supputamongkol Y,
Caruso G, Brouqui P, Raoult D: Aneruptive fever
associated with antibodies to Rickettsia helvetica
in Europe a nd Thailand . J Clin Microbiol 2004;
42:
816–818.
127 Nilsson K, Lindquist O, Pahlson C: Association of
Rickettsia helvetica with chronic perimyocarditis
in sudden cardiac death. Lancet 1999;
354: 1169 –
1173.
128 Mediannikov O, Parola P, Raoult D: Other tick-
borne rickettsioses; in Raoult D, Parola P (eds):
Rickettsial Diseases. New York, Informa Health-
care, 2007, pp 139–162.
Frequently Asked Questions about Lyme Borreliosis
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 155–166
A b s t r a c t
Ixodes ricinus is the commonest tick species in Europe, and transmits Lyme borreliosis, tick-borne
encephalitis, ehrlichiosis, tularemia, rickettsiosis, and babesiosis. The risk of Borrelia burgdorferi
infection increases with the time of tick engorgement, but not every infection necessarily causes
eryth ema migrans or Lyme borreliosis. Th erefore, the finding of B. burgdorferi DNA in a tick does not
prove that the patient will subsequently develop Lyme borreliosis. Ticks should be removed as
early as possible with fine tweezers, taking the tick’s head with the forceps. Antibiotic prophylactic
therapy after a tick bite is not generally recommended. Tick bites can potentially be prevented by
covering the body as much as possible or by applying repellents to the body and permethrin to
clothes. Tick bite areas shou ld be inspected for 1 month. Lyme borreliosis sho uld be s usp ect ed w hen
an erythema at the tick bite site or a febrile illness develop. Copyright © 2009 S . Karger AG, Basel
Tick Vectors in Europe
More than 800 tick species have been reported worldwide, although only about 30
ticks feed on humans; among these is Ixodes ricinus, which is the commonest tick
species in most European countries [1] . Besides I. ricinus , I. persulcatus was reported
in the eastern part of Latvia [2] . Other ticks that feed on humans have also been re-
ported, e.g. in Spain: besides I. ricinus (12.4%), Dermacentor marginatus (55.7%) and
Rhipicephalus bursa (11.9%) [3] ; in Slovakia, D. marginatus and D. reticulatus [4] ; and
in Hungary, Dermacentor spp. [5] . More than 300 animal species have been reported
as natural hosts for I. ricinus, and 50 vertebrate species have been identified as reser-
voir hosts for Borrelia burgdorferi . The tick density in some areas can be about 300
ticks/100 m
2 [1] . In a forestry area in England, the average density of nymphs col-
lected from the vegetation was 14.1/10 m
2 . Children have tick bites on the head, neck
and axillary region much more frequently than adults (48 vs. 10%), whereas adults are
more often bitten on the lower legs [6] .
What Should One Do in Case of a Tick Bite?
Elisabeth Aberer
Depar tment of Dermatology, Medical University of Graz, Graz , Austria
156 Aberer
Diseases Transmitted by Ticks
The spectrum of transmitted diseases comprises infections by the tick-borne enceph-
alitis (TBE) virus, B. burgdorferi [7] , Francisella tularensis [8] , and Ehrlichia (Ana-
plasma) phagocytophilum [9] . Furthermore, 85.1% of D. marginatus ticks in Spain
were Rickettsia- infected; 26.7% of positives were infected by Rickettsia slovaca , the
causative agent of tick-borne lymphadenopathy [10] . Lakos [5] described tick-borne
lymphadenopathy in 86 patients following tick bites caused by R. slovaca in Hun-
gary.
The reported data show that the risk of tick bites depends on the geographic area,
climatic factors, temperature and humidity, gender [11] , the investigation method,
and the infected vectors or samples (ticks, tissue of reservoir animals or their sera,
human sera, or record of diseases). Thus, different rates of infections have been iden-
tified by different researchers in various countries [2, 12] . On the outskirts of Berlin,
Germany, 47% of investigated I. ricinus nymphs showed microbial pathogenic DNA.
B. afzelii was the commonest pathogen, followed by Rickettsia helvetica [13] . I n n o r t h -
west Poland, 1,414 I. ricinus ticks were investigated by PCR, and 8.9% were found to
be infected with B. burgdorferi s.l; B. burgdorferi s.s. was most prevalent (96%), fol-
lowed by B. garinii (1.3%) [14] . In altitudes between 789 m and 1,350 m in Styria, Aus-
tria, the overall positivity rate for B. burgdorferi in ticks was 10.9%, as investigated by
dark-field microscopy, culture and by real-time PCR. Ten specimens yielded B. afzelii
and 5 showed B. garinii by culture or PCR [15] . In the area around Bonn, western
Germany, 17.9% of 1,394 investigated ticks were infected with B. burgdorferi [16] . Us-
ing genospecies-specific oligonucleotide probes, Borrelia infections could be assigned
to B. afzelii in 39.5% of ticks, B. garinii in 27.9 %, B. burgdorferi s.s. in 15.7%, and B.
valaisiana in 8.6% by DNA hybridization. In a forested area in England, infection
rates were 5.2–17.0%, determined by PCR and immunofluorescence, and the geno-
species B. valaisiana and B. garinii were detected [6] .
Risk of Tick Bites
In southeastern Sweden, patient records focusing on exposure to tick bites, epidemi-
ology, gender, and the clinical picture of Lyme borreliosis (LB) were analyzed retro-
spectively and prospectively. Women aged 40 years and older had a 48% higher risk
of attracting tick bites than men of the same age group. The annual incidence rate of
erythema migrans (EM) in women was 506 and in men 423 cases per 100,000 inhab-
itants [17] . In a study from the Aland Islands, the incidence of tick bites, with possible
implications concerning the spread of LB, was recorded from 519 individuals [18] : 441
persons (85%) had been bitten by ticks, 146 of these more than 10 times. Fourteen
persons had EM, and 73 had other rashes around the tick bite. In The Netherlands,
all general practitioners were asked to record the number of cases of tick bites and EM
What to Do in Case of a Tick Bite 157
in 2001 [19] . They reported seeing approximately 61,000 patients with tick bites and
12,000 patients with EM in 1 year. So, the incidence of EM was estimated at 73 cases
per 100,000 habitants. The number of patients with tick bites and EM had doubled
between 1994 and 2001.
B. burgdorferi – Seropositivity in Healthy Individuals
The seroprevalence of antibodies to B. burgdorferi was investigated in blood samples
of 4,368 forestry workers in southwestern Germany, and ranged from 18 to 52%. An-
tibodies to the TBE virus were present in 0–42%, and antibodies for Ehrlichia spp. in
5–16% [20] . In France, 15.2% of forestry workers were seropositive for antibodies to
B. burgdorferi [21] , and 70% of them reported tick bites. No active LB was reported;
thus, asymptomatic infections are predominant.
The prevalence of antibodies to B. burgdorferi was investigated in hunters in Bur-
genland, a part of eastern Austria. Blood samples of 1,214 men and 39 women were
tested, and their history of tick bites was obtained by questionnaire [22] . A total of 673
(54%) sera tested positive for IgG antibodies (55% of men and 26% of women). Sero-
positivity was 33% among persons younger than 29 years, and 83% in those older than
70 years. The increase in seroprevalence with age and duration of hunting reflects
repeated tick exposure. The seroprevalence of B. burgdorferi and A. phagocytophilum
was also investigated in workers in 4 Italian regions. From a total of 712 serum sam-
ples, 387 were from workers at risk of tick bites and 325 were from individuals not
considered at risk (the control group) [23] . Antibodies to B. burgdorferi were found in
7.5% of subjects at risk and 1.2% of the control group. Antibodies to both B. burgdor-
feri and A. phagocytophilum were detected in 1.6%. The prevalence of antibodies to
B. burgdorferi was investigated in blood donors in southern Germany [24] , and found
to be 5.5% (hemagglutination test). The results were confirmed by immunoblotting,
showing 2.7% with B. burgdorferi -specific antibodies. No seroconversion was ob-
served in the recipients of blood transfusions.
Transmission of LB by Ticks
Epidemiology: Probability of Transmission
In most of Europe, the transmission risk of LB after a tick bite is low to moderate
within the first 24 h of feeding, but increases to 1 70% after only 36 h [25] . Since the
exact time of tick attachment cannot always be given, a scutal index can be deter-
mined (the ratio between tick abdominal length and scutum width) as a good mea-
sure of the level of tick engorgement; in 85–93% of people, this gives a good indication
of the time of attachment.
158 Aberer
The time of feeding and method of tick removal, potentially crucial for B. burg-
dorferi transmission, was studied in gerbils by Kahl et al. [26] . All gerbils with ticks
removed after more than 47 h were infected. After 16.7 and 28.9 h of tick feeding,
approximately 50% of gerbils were infected. Ticks were pulled out with forceps, or
after 3 min of intensive squeezing, or after applying nail polish to the ticks 1.1 h
before removal. The tick removal method had no significant effect on B. burgdorferi
infection. The time of attachment was also studied in relation to the engorgement
index [27] . Between 0 and 24 h of attachment, no detectable change was seen; only
after 24 h, all engorgement indices continuously increased. So, the inspection of
ticks is helpful in indicating the time of engorgement, and thus the probability of
infection.
In a study in southwestern Germany, ticks were collected from 730 patients and
examined by PCR for B. burgdorferi [28] . Patients were clinically and serologically
examined after tick removal. Eighty-four ticks (11.3%) were PCR positive, and a total
transmission rate of 2.6% (19 patients) was observed. The authors recommend ex-
amination of ticks, and antibiotic prophylaxis in cases of positivity.
Heininger et al. [29] reported that every fifth tick is infected. Transmission does
not occur with every bite, and infection does not always lead to disease. Therefore,
the risk of infection after tick bite was investigated in the area of Erlangen, Ger-
many. In 69 patients, initially seronegative, seroconversion was detected in 4 in-
stances, 2 of whom were asymptomatic, 1 had unspecific symptoms and 1 lympho-
cytoma. The conclusion was that antibiotic treatment after a tick bite cannot be
recommended.
A n t i b o d i e s t o B. burgdorferi were investigated in a population living in an endem-
ic area in Sweden, and detected in 25.7% of people [30] . Subjects were tested over a
2-year period. In the first year, 4.6% developed LB, and in the second year 3.2%. An
earlier episode of LB or an elevated antibody titer did not seem to protect subjects
from reinfections.
In New York State, B. burgdorferi was cultured from skin biopsies at tick bite sites
in 2/48 samples with tick attachment for 24 h [31] . In a Polish study of 131 residents
who had suffered from Lyme disease in the past, arthritis sufferers recorded a sig-
nificantly higher frequency of tick bites and significantly reduced EM [32] . The au-
thors concluded that multiple exposures to B. burgdorferi promote manifestation of
the disease in the form of arthritis and less frequently result in EM.
Risk of EM or Other Symptoms of LB
To evaluate the risk of LB after a tick bite in Switzerland, paired serum samples of
people who had been bitten very recently were investigated for seroconversion. Sero-
conversion was observed in 4.5% of the 376 subjects [33] , which can be broken down
into 3. 4% of 266 pat ients wi tho ut cli nic al manifestation s and 7.2% o f 110 p atients with
What to Do in Case of a Tick Bite 159
a local skin reaction. EM developed in 3 subjects who seroconverted and 5 subjects
without seroconversion. Ticks from 160 patients were available. Borrelia detection in
ticks did not correlate significantly with the risk of LB.
In a prospective study, patients with a tick-borne febrile illness within 6 weeks
after the tick bite were analyzed [7] . Cases of TBE in 27%, LB in 7.7%, Ehrlichia in-
fection in 3.1%, and infection by multiple organisms in 14.6% were identified. In an-
other Slovenian study on 86 febrile children with a history of a tick bite within 6
weeks previously, tick-borne illness was diagnosed in 53% [34] . The most common
diagnosis was TBE in 64%, followed by LB in 46%, of acute and convalescent serum
samples. In 21%, there was evidence of infection with more than 1 tick-borne agent.
In Poland, paired sera of 68 patients who had fever 4 weeks after tick bite were inves-
tigated. TBE was detected in 49 patients, this was concurrent in 3 patients with EM
or LB, in 5 patients with possible LB, and in 2 patients with A. phagocytophilum in-
fection; a further 16 patients had LB [35] . In Sw itzerla nd, 75 pat ients with fever with-
in 3 weeks of a tick bite were studied [36] . Tick-borne infections were confirmed or
possible in 48% of the cases; 9% had EM and 8% other specific manifestations of LB,
8% LB presenting as a nonspecific febrile illness, 11% TBE, and 10% granulocytic
ehrlichiosis.
Local Reactions after Tick Bites
Nonspecific local skin reactions and itching frequently occur after a tick bite. Red
macules and papules usually disappear within 1 week. In the USA, a case definition
for EM specifies that the erythema should have a size of at least 5 cm for a diagnosis
of acute LB [37] . In Europe, the lesions of EM can be smaller according to the defini-
tion of the European Union Concerted Action on LB [38] . In cases of erythema after
a tick bite persisting for more than 1 week, a ‘mini’-EM should be suspected and an-
tibiotic treatment should be considered [37] . A definite diagnosis of a Borrelia infec-
tion in this case can only be proven by Borrelia culture or positive PCR for B. burg-
dorferi DNA. A persistent atypical lymphocytic proliferation was noted on a tick bite
area of a 6-year-old girl that lasted for more than 1 year [39] .
In another report, 15 skin biopsies of tick bite areas were investigated histopatho-
logically [40] . The capillaries and postcapillary venules of the superficial and deep
vascular plexus adherent to the attachment site were filled with thrombi potentially
related to secretory products of the tick’s saliva during inoculation.
The inserted hypostome of an I. scapularis female adult was investigated by elec-
tron microscopy [41] . A homogenous cement-like substance was observed under
scanning electron microscopy on the dorsal hypostome, which continued into the
dermis. After tick removal, no tick parts were seen in the patient’s skin with a mag-
nifying glass. Scanning microscopy of the removed tick hypostome showed some
chipped and missing denticles. Two months later, the skin area which the tick had
160 Aberer
been attached to was investigated, and showed a perivascular und periadnexal infil-
trate consisting of plasma cells and lymphocytes with some foreign body cells con-
taining yellowish-brown particles.
Hypersensitivity was observed in 2 forest workers who had skin reactions follow-
ing tick bites. Both patients had specific IgE antibodies to wood ticks, and 1 patient
had immediate positive reactions to a skin prick test and an intradermal test [42] .
Removal of Ticks
Handling of Patients after Tick Bite
Several tick removal methods have been tested, but none using controlled prospective
studies. Ticks are best removed as soon as possible because the risk of disease trans-
mission increases significantly after 24 h of attachment [43] . Stressed ticks have been
suspected to salivate or regurgitate into the host.
In over 40 reports, the application of various chemical and physical methods, in-
cluding petrolatum jelly, isopropyl alcohol, nail polish, hot matches, Vaseline, olive
oil, vinegar, gasoline, and adhesive tape, have been recommended to aid tick removal
[44] . The chemical treatments failed to induce self-detachment of the ticks within 30
min [43] ; while the occlusive techniques may guarantee the removal of an intact tick,
they unnecessarily extend the duration of attachment and are therefore redundant
[44, 45] .
The crushing of ticks during forceps extraction has been thought to increase the
risk of transmission of tick-borne infections. Two methods of mechanical removal
of the ticks were compared: (1) pulling them straight out with a blunt forceps, and
(2) rotation of the tick around its body axis [46] . Pulling frequently resulted in the
complete removal of the tick, but quite often large fragments of the mouthparts re-
mained in the skin. When removing the tick with rotation without pulling, the tip
of the hypostome usually broke off. The use of a blunt, medium-tipped, angled for-
ceps offered the best results [43] . The tick bite should then be inspected carefully for
any retained mouthparts, which the authors recommend should be excised. The area
should then be cleaned with antiseptic solution, and the patient instructed to moni-
tor for signs of local or systemic illness. Routine antibiotic prophylaxis following tick
removal is not generally indicated. Removal of ticks by using disposable razors has
been reported. This method instantly cuts off the tick vector’s body; thus, keeping
the risk of B. burgdorferi infection to a minimum [47] . Another removal method has
been described in the article Ticks in Australia [48] . Here, a local anesthetic was in-
filtrated into the tick implantation site, which immobilized the tick and led to the
eversion of mouthparts. Slow vertical traction with forceps could then be used to re-
move the tick with ease. Despite careful attempts, removal of ticks frequently led to
breakage, and left the mouthparts (hypostomes) in the skin. The risk of transmission
What to Do in Case of a Tick Bite 161
of LB or spotted fever was evaluated when different methods for the removal of ar-
thropods were used [49] . The removal of ticks by pulling with fine tweezers and
later disinfecting the area gave significant protection from the development of com-
plications and infections.
Antibiotic Therapy after Tick Bite
In 1992, a double-blind placebo-controlled trial was performed in Connecticut on
387 subjects to assess the risk of infection with B. burgdorferi after tick bite and the
efficacy of prophylactic antimicrobial treatment [50] . Amoxicillin or placebo was giv-
en for 10 days. Two persons in the placebo group developed EM, compared to none
in the amoxicillin group. There was no asymptomatic seroconversion. Fifteen percent
of ticks were infected. A prophylaxis with single-dose doxycycline was performed in
482 subjects who had removed ticks within 72 h [51] . EM developed in 1/235 subjects
in the doxycycline group and 8/247 in the placebo group. The efficacy of treatment
was 87%. No asymptomatic seroconversion occurred. As a result of these publica-
tions, a long discussion process has started on whether antimicrobial prophylaxis
should be given or not. Currently, the Center for Disease Control and Prevention does
not recommend antibiotics routinely [52] . Nevertheless, this treatment may be ben-
eficial for some persons, and health care providers must determine whether the ad-
vantages of prescribing antibiotics after a tick bite outweigh the disadvantages. In
Connecticut, 267 physicians were asked how they treat tick bites and EM [53] . Sev-
enty (26%) prescribe antibiotic prophylaxis for patients with tick bites; serology
was ordered by 31% of physicians for patients with tick bites and by 49% for patients
with EM.
Prophylactic antibiotic treatment is not generally recommended for European pa-
tients, and different antibiotics registered for LB have been prescribed after tick bites
for several reasons. In one study, 7 of 5,056 patients (0.14%) developed EM after hav-
ing received antibiotic treatment [54] . From this study, it was assumed that antibiotic
prophylaxis for LB after a tick bite, at least in Europe, is not entirely effective. Stanek
and Kahl [55] therefore recommend a ‘wait and watch’ policy for European patients.
One author from France also could not recommend antimicrobial prophylaxis, as the
risk of transmission of LB after a tick bite is only 4% [56] and the currently available
data seem to be insufficient to make a strong case for systematic antibiotic prophy-
laxis [57] . Most cases of LB result from unrecognized tick bites, since the great major-
ity of attached ticks that are recognized are removed within 48 h of the time they
began to feed, before they are likely to transmit infection [58, 59] . Checking carefully
for ticks and removing them promptly may be the most effective strategy for prevent-
ing LB [60] .
162 Aberer
Analysis of Removed Ticks
To analyze the infection in ticks and to give further therapeutic advice, 185 tick spec-
imens were collected from 179 Spanish patients: 26 ticks carried DNA from Rickettsia
spp., 2 from B. burgdorferi and 7 from A. phagocytophilum [3] . It is cumbersome and
expensive to analyze removed ticks, which can only be performed in special labora-
tories. Proof of a tick infection does not necessarily predict that the patient will actu-
ally become infected. Further, seroconversion does not always mean concomitant
disease, as can be seen by the high seropositivity rate of healthy persons in endemic
areas.
Prevention of Tick Bites
Strategies for the prevention of LB are to reduce the populations of ticks or host
mammals, which are expensive and need to be repeated annually [56] . The primary
method could be personal preventive measures, such as reducing the amount of ex-
posed skin, wearing light-colored clothing for easy identification of crawling ticks,
wearing protective garments and closed shoes, and frequently checking for ticks [61] .
Further, tick repellents can be applied to the skin or to the clothing, including
N
,
N
-
diethyl-m-toluamide (DEET), 2-ethyl-1,3-hexanediol, and dimethylphthalate. A
study was performed upon an at-risk population in Switzerland to assess the effec-
tiveness of a commercially available repellent spray containing both DEET and eth-
yl-butyl-acetyl-aminopropionate (EBAAP) [62] . The average number of tick bites per
hour of exposure differed significantly between individuals receiving the placebo or
the repellent. Total repellent effectiveness against tick attachment was 41.1%, and
66% on the arms. The authors concluded that an easily applied repellent is moder-
ately effective in reducing the risk of tick bites. Permethrin is the most effective
clothing repellent. DEET plus a permethrin-containing clothing repellent offers the
best overall protection [61] . Rapid tick removal with fine tweezers or specials forceps
followed by disinfection of the bite site appears to be the best technique. Patient edu-
cation has a great inf luence on their behavior and leads to a reduction in tick-borne
diseases. This was shown in a controlled study where there was a lower rate of tick-
borne illnesses in educated participants, who were significantly more likely to take
precautions as a result [63] .
Conclusion – What to Do in Case of a Tick Bite
I. ricinus is the commonest tick species in Europe, and transmits LB, TBE, ehrlichio-
sis, tularemia, rickettsiosis, and babesiosis. In eastern Europe and in Spain, ticks of
the Dermacentor species have been reported, which transmit Rickettsia infections.
What to Do in Case of a Tick Bite 163
The risk of tick bites and their infection rates with B. burgdorferi vary across dif-
ferent geographical areas. B. burgdorferi transmission increases with the time of tick
engorgement. Reported data are hardly comparable since different study concepts
and the investigation methods used provide different data. The seropositivity rate of
healthy individuals is dependent on the amount and kind of outdoor activities, the
age, and the infection rate of ticks.
Even when the tick is infected, a tick bite does not necessarily cause EM or LB. So
finding B. burgdorferi DNA in ticks does not prove that the patient will develop LB.
Seropositivity does not prevent another B. burgdorferi infection. When seroconver-
sion occurs, serologic follow-up can only tell individuals that they have acquired a B.
burgdorferi infection, with or without manifested disease. Ticks should be removed
as early as possible with fine tweezers, taking the tick’s head with the forceps. Any
remaining mouthparts do not harm the patient. Tick granulomas and atypical lym-
phomatoid reactions are rare; therefore, mouthparts should not be excised or biop-
si ed. Mouthpart s can not be com pletely removed b y ne edle m an ipu lat ion, so unneces-
sary trauma should be avoided. Antibiotic prophylactic therapy after a tick bite is not
generally recommended. The same procedures should also be used in pregnant and
breastfeeding women and in children. Small babies should be protected from contact
with grass in areas with high tick populations, and they should not be placed on un-
folded blankets in the grass.
Tick bites can be partially prevented by applying repellents to the body and per-
methrin to clothes. Repellents should be handled in children by carefully following
the instructions. Furthermore, covering the body as much as possible with light-col-
ored garments can also prevent tick contact, and allows identification of ticks on the
clothes. Moreover, regularly checking all body sites once a day for ticks and taking a
shower with soap after outdoor activities can help to identify ticks within 24 h. Ticks
should be removed as soon as possible. The tick bite area should be inspected regu-
larly for about 1 month. Unspecific papules at the tick bite site should decrease in size
and vanish within about 1 week. In case of persistent ery thema for longer than 1 week,
the erythema should be seen by a dermatologist since Borrelia infection cannot be
excluded. Furthermore, the patient should be aware of any febrile illness within 6
weeks of the tick bite, which is a sign of possible disseminated LB.
Tick bites should be seen as a natural occurrence for individuals participating in
outdoor activities. LB is a treatable disease, in contrast to TBE where vaccination pro-
vides protection against infection. The fear of getting LB after a tick bite is exagger-
ated, and can be diminished or even abolished with adequate information.
164 Aberer
References
1 Gern L: The biology of the Ixodes ricinus tick (in
German). Ther Umsch 2005;
62: 707–712.
2 Bormane A, Lucenko I, Duks A, Mavtchoutko V,
Ranka R, Salmina K, Baumanis V: Vectors of tick-
borne diseases and epidemiological situation in
Latvia in 1993–2002. Int J Med Microbiol 2004;
293:(suppl 37):36–47.
3 Merino FJ, Nebreda T, Serrano JL, Fernandez-Soto
P, Encinas A, Perez-Sanchez R: Tick species and
tick-borne infections identified in population from
a rural area of Spain. Epidemiol Infect 2005;
133:
943–949.
4 Smetanova K, Schwarzova K, Kocianova E: Detec-
tion of Anaplasma phagocytophilum , Coxiella bur-
netii , Rickettsia spp., and Borrelia burgdorferi s.l. in
ticks, and wild-living animals in western and mid-
dle Slovakia. Ann NY Acad Sci 2006;
1078: 312–
315.
5 Lakos A: Tick-borne lymphadenopathy (TIBOLA).
Wien Klin Wochenschr 2002;
114: 648–654.
6 Robertson JN, Gray JS, Stewart P: Tick bite and
Lyme borreliosis risk at a recreational site in Eng-
land. Eur J Epidemiol 2000;
16: 647–652.
7 L ot ric -F url an S, Pe tro ve c M, Avs ic -Zu pa nc T, Ni ch-
olson WL, Sumner JW, Childs JE, Strle F: Prospec-
tive assessment of the etiology of acute febrile ill-
ness after a tick bite in Slovenia. Clin Infect Dis
2001;
33: 503–510.
8 Golubic D, Zember S: Dual infection: Tularemia
and Lyme borreliosis acquired by single tick bite in
northwest Croatia. Acta Med Croatica 2001;
55:
207–209.
9 Strle F: Human granulocytic ehrlichiosis in Eu-
rope. Int J Med Microbiol 2004;
293(suppl 37):27–
35.
10 Marquez FJ, Rojas A, Ibarra V, Cantero A, Rojas J,
Oteo JA, Muniain MA: Prevalence data of Rickett-
sia slovaca and other SFG Rickettsiae species in
Dermacentor marginatus in the southeastern Ibe-
rian peninsula. Ann NY Acad Sci 2006;
1078: 328–
330.
11 Bennet L, Halling A, Berglund J: Increased inci-
dence of Lyme borreliosis in southern Sweden fol-
lowing m ild winters a nd during war m, humid sum-
mers. Eur J Clin Microbiol Infect Dis 2006;
25:
426–432.
12 Rizzoli A, Rosa R, Mantelli B, Pecchioli E, Hauffe
H, Tagl iapietra V, Beni nati T, Neteler M, Genchi C:
Ixodes ricinus , transmitted diseases and reservoirs
(in Italian). Parassitologia 2004;
46: 119–122.
13 Pichon B, Kahl O, Hammer B, Gray JS: Pathogens
and host DNA in Ixodes ricinus nympha l ticks from
a German forest. Vector Borne Zoonotic Dis 2006;
6: 382–387.
14 Wodecka B, Skotarczak B: Genet ic diversity of Bor-
relia burgdorferi sensu lato in Ixodes ricinus ticks
collected in north - west Poland (in Polish). Wiad
Parazytol 2000;
46: 475–485.
15 Stunzner D, Hubalek Z, Halouzka J, Wendelin I,
Six l W, Mar th E: Pr evalence of Borrelia burgdorferi
sensu lato in the tick Ixodes ricinus in the Styrian
mountains of Austria. Wien Klin Wochenschr
2006;
118: 682–685.
16 Maetzel D, Maier WA, Kampen H: Borrelia burg-
dorferi infection prev alences in quest ing Ixodes ric-
inus ticks (Acari: Ixodidae) in urban and suburban
Bonn, western Germany. Parasitol Res 2005;
95: 5–
12.
17 B ennet L , Stje rnber g L, Be rglund J: Effect of gende r
on clin ical and epidemiolog ic features of Lyme bor-
reliosis. Vector Borne Zoonotic Dis 2007;
7: 34–41.
18 Wahlberg P: Incidence of tick-bite in man i n Aland
islands: reference to the spread of Lyme borrel iosis.
Scand J Infect Dis 1990;
22: 59–62.
19 den Boon S, Schellekens JF, Schouls LM, Suijker-
buijk AW, Docters van Leeuwen B, van Pelt W:
Doubling of the number of cases of tick bites and
Lyme borreliosis seen by general practitioners in
the Net herlands (in Dutch). Ned Tijdsc hr Geneeskd
2004;
148: 665–670.
20 Oehme R, Hartelt K, Backe H, Brockmann S, Kim-
mig P: Foci of t ick-borne disease s in southwest Ger-
many. Int J Med Microbiol 2002;
291(suppl 33):22–
29.
21 Zhioua E, Rodhain F, Binet P, Perez-Eid C: Preva-
lence of antibodies to Borrelia burgdorferi in for-
estry workers of Ile de France, France. Eur J Epide-
miol 1997;
13: 959–962.
22 Cetin E, Sotoudeh M, Auer H, Stanek G: Paradigm
Burgenland: risk of Borrelia burgdorferi sensu lato
infec tion indicated by va riable seropreval ence rates
in hunters. Wien Klin Wochenschr 2006;
118: 677–
681.
23 Santino I, Cammarata E, Franco S, Ga ldiero F, Oli-
va B, Sessa R, Cipriani P, Tempera G, Del Piano M:
Multicentric study of seroprevalence of Borrelia
burgdorferi and Anaplasma phagocytophila in
high-risk groups in regions of central and southern
Italy. Int J Immunopathol Pharmacol 2004;
17: 219–
223.
24 Bohme M, Schembra J, Bocklage H, Schwenecke S,
Fuchs E, Karch H, Wiebecke D: Infections with
Borrelia burgdorferi in Wurzburg bloo d donors: an-
tibody prevalence , clinical aspects and pathogen
detection in antibody positive donors (in German).
Beitr Infusionsther 1992;
30: 96–99.
What to Do in Case of a Tick Bite 165
25 Meiners T, Hammer B, Gobel UB, Kahl O: Deter-
mining the tick scutal index allows assessment of
tick feeding duration and estimation of infection
risk with Borrelia burgdorferi sen su lato in a person
bi tt en b y a n Ixodes ricinus nymph. Int J Med Mic ro-
biol 2006;
296(suppl 40):103–107.
26 Kahl O, Janetzki-Mittmann C, Gray JS, Jonas R,
Stein J, de Boer R: Risk of infection with Borrelia
burgdorferi sensu lato for a host in relation to the
duration of ny mphal Ixodes ricinus feeding and the
method of tick removal. Zentralbl Bakteriol 1998;
287: 41–52.
27 Yeh MT, Bak JM, Hu R, Nicholson MC, Kelly C,
Mather TN: Determining the duration of Ixodes
scapularis (Acari: Ixodidae) attachment to tick-bite
victims. J Med Entomol 1995;
32: 853–858.
28 Maiwald M, Oehme R, March O, Petney TN, Kim-
mig P, Naser K, Zappe HA, Hassler D, von Knebel
Doeberitz M: Transmission risk of Borrelia burg-
dorferi sensu lato from Ixodes ricinus ticks to hu-
mans in southwest Germany. Epidemiol Infect
1998;
121: 103–108 .
29 Heininger U, Zimmermann T, Schoerner C, Brade
V, Stehr K: Tick bite and Lyme borreliosis: an epi-
demiologic s tudy in the Erlan gen area (in German).
Monatsschr Kinderheilkd 1993;
141: 874–877.
30 Gustafson R, Svenungsson B, Forsgren M, Gardulf
A, Granstrom M: Two-year sur vey of the incidence
of Lyme borrel iosis and tick-borne encepha litis in a
high-risk population in Sweden. Eur J Clin Micro-
biol Infect Dis 1992;
11: 894–900.
31 Berger BW, Johnson RC, Kodner C, Coleman L:
Cultivation of Borrelia burgdorferi from human
tick bite sites: a guide to the risk of infection. J Am
Acad Dermatol 1995;
32: 184 –187.
32 Zalezny W, Flisiak R, Prokopowicz D: Effect of ex-
posure to tick - bites on the course of Lyme borrelio-
sis in Bia lowieza residents (in Poli sh). Przeg l Epide-
miol 2002;
56: 419–424.
33 Nahimana I, Gern L, Blanc DS, Praz G, Francioli P,
Peter O: Risk of Borrelia burgdorferi infection in
western Sw itzerland follow ing a tick bite. Eu r J Clin
Microbiol Infect Dis 2004;
23: 603–608.
34 Arnez M, Luznik-Bufon T, Avsic-Zupanc T, Ruzic-
Sabljic E, Petrovec M, Lotric-Furlan S, Strle F:
Causes of febrile illnesses after a tick bite in Slove-
nian children. Pediatr Infect Dis J 2003;
22: 1078–
1083.
35 Grzeszczuk A, Ziarko S, Kovalchuk O, Stanczak J:
Etiology of tick-borne febrile il lnesses in adult resi-
dents of north-eastern Poland: report from a pro-
spective clinical study. Int J Med Microbiol 2006;
296(suppl 40):242–249.
36 Baumann D, Pusterla N, Peter O, Grimm F, Four-
nier PE, Sc har G, Bossa rt W, Lutz H, Weber R: Fever
afte r a tick bite: clinic al manifes tations and diag no-
sis of acute tick bite - associated infections in north-
eastern Switzerland (in German). Dtsch Med
Wochenschr 2003;
128: 104 2–1047.
37 Weber K, Wilske B: Mi ni eryt hema migra ns – a sign
of early Lyme borreliosis. Dermatology 2006;
212:
113–116.
38 Stanek G, O’Connell S, Cimmino M, Aberer E,
Kri stoferitsch W, Granstrom M, Guy E, Gray J: Eu-
ropean Union Concerted Action on Risk Assess-
ment in Lyme Borreliosis: clinical case definitions
for Lyme borreliosis. Wien Klin Wochenschr 1996;
108: 741–747.
39 Hwong H, Jones D, Prieto VG, Schulz C, Duvic M:
Persistent at ypical lympho cytic hyp erplasia follow-
ing tick bite in a child: report of a case and review
of the literature. Pediatr Dermatol 2001;
18: 481–
484.
40 Stefanato CM, Phelps RG, Goldberg LJ, Perry AE,
Bhawan J: Type-I cryoglobulinemia-like histopath-
ologic changes in tick bites: a useful clue for tissue
diagnosis in the absence of tick parts. J Cutan
Pathol 2002;
29: 101–106.
41 Aoki K, Kamata H, Iida T, Suzuki H: Tick bite: two
cases studied by scanning electron microscopy. Br
J Dermatol 1984;
110: 233–240.
42 Beaudouin E, Kanny G, Guerin B, Guerin L, Plenat
F, Moneret-Vautrin DA: Unusual manifestations of
hypersensitivity after a tick bite: report of two cas-
es. Ann Allergy Asthma Immunol 1997;
79: 43–46.
43 Gammons M, Salam G: Tick removal. Am Fam
Physician 2002;
66: 643–645.
44 Lanschuetzer CM, Wieser M, Laimer M, Emberger
M, Hintner H: Improving the removal of intact
ticks. Australas J Dermatol 2003;
44: 301.
45 Fingerle V, Wilske B: Ticks , tick bites and how best
to remove the tick (in German). MMW Fortschr
Med 2006;
148: 30–32.
46 De Boer R, van den Bogaard AE: Removal of at-
tached nymphs and adults of Ixodes ricinus (Acari:
Ixodidae). J Med Entomol 1993;
30: 748–752.
47 Moehrle M, Rassner G: How to remove ticks? Der-
matology 2002;
204: 303–304.
48 Storer E, Sheridan AT, Warren L, Wayte J: Ticks in
Australia. Australas J Dermatol 2003;
44: 83–89.
49 Oteo JA, Martinez de Artola V, Gomez-Cadinanos
R, Casas JM, Blanco JR, Rosel L: Evaluation of
methods of t ick removal in human i xodidiasis. Rev
Clin Esp 1996;
196: 584–587.
50 Shapiro ED, Gerber MA, Holabird NB, Berg AT,
Feder HM Jr, Bell GL, Rys PN, Persing DH: A con-
trolled trial of antimicrobial prophylaxis for Lyme
disea se after deer-t ick bites. N Engl J Med 1992 ;
327:
1769–1773.
166 Aberer
Prof. Elisabeth Aberer, MD
Depar tment of Dermatology, Medical University of Graz, Austria
Auenbrugger Platz 8
AT–8036 Graz (Austria)
Tel. +43 316 385 80317, Fax +43 316 385 2466, E-Mail elisabeth.aberer@medunigraz.at
51 Nadelman RB, Nowakowski J, Fish D, Falco RC,
Freeman K, McKe nna D, Welch P, Marcus R, Agu e-
ro-Rosenfeld ME, Dennis DT, Wormser GP: Pro-
phylaxis with single-dose doxycycline for the pre-
vention of Lyme disease after an Ixodes scapularis
tick bite. N Engl J Med 2001;
345: 79–84.
52 www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_
Prevention_Antibiotics.htm.
53 Murray T, Feder HM Jr: Management of tick bites
and early Lyme disease: a survey of Connecticut
physicians. Pediatrics 2001;
108: 1367–1370.
54 Maraspin V, Lotric-Furlan S, Strle F: Development
of erythema migrans in spite of treatment with an-
tibiotics after a tick bite. Wien Klin Wochenschr
2002;
114: 616 –619.
55 Stanek G, Kahl O: Chemoprophylaxis for Lyme
borreliosis? Zentralbl Bakteriol 1999;
289: 655–665.
56 Guy N: Lyme disease: Basis for treatment strategy,
primary preventive care and secondary preventive
care (in French). Med Mal Infect 2007;
37: 381–393.
57 Patey O: Lyme disease: prophylaxis after tick bite
(in French). Med Mal Infect 2007;
37: 446–455.
58 Shapiro ED: Doxycycline for tick bites – not for ev-
eryone. N Engl J Med 2001;
345: 133–134.
59 Falco RC, Fish D, Piesman J: Duration of tick bites
in a Lyme disease-endemic area. Am J Epidemiol
1996;
143: 187–192.
60 des Vignes F, Piesman J, Heffernan R, Schulze TL,
Stafford KC 3rd, Fish D: Effect of tick removal on
transmission of Borrelia burgdorferi and Ehrlichia
phagocytophila by Ixodes scapularis nymphs. J In-
fect Dis 2001;
183: 773–778.
61 Couch P, Johnson CE: Prevention of Lyme disease.
Am J Hosp Pharm 1992;
49: 1164–1173.
62 Staub D, Debrunner M, Amsler L, Steffen R: Effec-
tiveness of a re pellent contai ning DEET and E BAAP
for preventing tick bites. Wilderness Environ Med
2002;
13: 12–20.
63 Daltroy LH, Phillips C, Lew R, Wright E, Shadick
NA, Liang MH: A controlled trial of a novel pri-
mary prevention program for Lyme disease and
other tic k-borne il lnesses. Hea lth Educ Behav 200 7;
34: 531–542.
Frequently Asked Questions about Lyme Borreliosis
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 167–177
A b s t r a c t
Despite significant progress in the diagnostics of Lyme borreliosis, including molecular methods,
the detection of a specific antibody response remains the mainstay in the laboratory diagnosis of
the disease. Current guidelines propose the combination of highly sensitive screening assays, such
as ELIS As, w ith ver y spe cif ic co nfirma tor y tes ts, such as immun obl ots , to g uara ntee a co st-eff ect ive,
sensitive and specific diagnostic approach. For a correct interpretation of the serological findings,
the investigator must always consider a whole series of clinical and laboratory facts. Here, we sum-
marize current laboratory algorithms in the diagnosis of Lyme borreliosis, with a special emphasis
on when to order a Western blot and how to interpret it correctly in the context of additional clini-
cal and laboratory information. Copyri ght © 2009 S. Karger AG, Ba sel
Despite the substantial advancements in our knowledge of the biological properties
of Borrelia burgdorferi and the introduction of molecular detection methods, the de-
tection of antibodies still remains the mainstay in the laboratory diagnosis of Lyme
borreliosis mainly because specimen collection is simple and convenient [1–3] . In this
context, the introduction of immunoblot assays using constantly improving panels of
whole cell and/or recombinant antigen preparations led to a very diverse armamen-
tarium of tests, which are usually employed as part of 2-tier testing protocols ( fig. 1 )
in the serodiagnosis of Lyme borreliosis [1, 2 , 4–8] .
When Is the Best Time to Order a Western
Blot and How Should It Be Interpreted?
K.-P. Hunfeld ⭈ P. K raic z y
Institute of Medical Microbiology and Infection Control, Hospital of the Johann Wolfgang Goethe-University
Frankfurt, Frankfurt am Main , Germany
168 Hunfeld ⴢ Kraiczy
Positive/borderline
Screening test: ELISA (IgG/IgM)
Negative
Negative report,
follow-up
Positive
Confirmatory assay: immunoblot (IgG/IgM)
Negative
Negative
report
Positive
report
Borderline
Additional testing,
follow-up
Fig. 1. Laboratory diagnosis of
Lyme borreliosis: rational step-
wise serological testing.
OspC
VlsE-Mix
p39
DbpA-Mix
DbpA-Pko
p58
p83
OspC
VlsE-Mix
p39
DbpA-Mix
p100
VlsE
p39
p41
OspC-Mix
p41/i B. garinii
p41/i B. afzelii
p18
Recombinant
immunoblot
IgM IgG
Whole cell
immunoblot
IgM IgG
p58p58
p41 FlaB
p39 BmpA
OspC
Osp17
IgG control
OspC
p41 FlaB
Line
immunoblot
IgM IgG
Fig. 2. Examples of the variable antigen preparations and diagnostic formats of currently available
immunoblot assays.
When to Order a Western Blot and How to Interpret It 169
Western Blot Techniques for Serological Antibody Detection in Lyme Borreliosis
Diagnostics
The classical Western blot technique is based on the transfer of proteins already sep-
arated by SDS polyacrylamide gel electrophoresis (SDS-PAGE) to a nitrocellulose or
polyvinyl difluoride (PVDF) membrane. Line immunoblots represent a modification
of conventional immunoblots, where various recombinant antigens of proven diag-
nostic value are produced, purified and directly sprayed onto the membrane without
previous denaturation through electrophoretic separation [4, 9, 10] . In both approach-
es, proteins remain fixed to the membrane due to hydrophobic interactions, and such
prepared membranes can easily be stored for longer time periods. The number and
kind of antigens used (native or recombinant) for such tests are essential for diagnos-
tic quality. Although immunoblots are mainly used as confirmatory tests, in general,
such assays offer both high sensitivity and specificity [1, 2, 4] . In contrast to the qual-
itative and quantitative test results of ELISA, the immunoblot provides a qualitative
result. One particular advantage of this technique, however, is that it can provide both
reliable information on the class and antigen specificities of the immune response for
a large number of Borrelia -specific antigens ( fig. 2 ; table 1 ). In general, an immuno-
blot is carried out by incubating antigen-loaded blot strips with the patient’s serum.
Specific antibodies then bind to the proteins and can be identified/visualized as
marked bands after specific staining with enzyme-labeled anti-human immunoglo b-
ulins, similar to the sandwich principle used in ELISA. Each band then specifically
corresponds to an antigen-antibody reaction with the underlying fraction of proteins.
However, unlike the ELISA technique, this method does not just detect the presence
of antibodies but, instead, the nature and number of detected bands in an immuno-
Tab le 1 . Immunodominant antigens of B. burgdorferi s.l. according to their occurrence in the course
of infection (early or late) with a special notion on specificity and cross-reactivities (modified from
[1])
Protein Phase in which antigen
expressed
Specificity Cross-reactivity
p83/100 late high infrequent
p58 early/late fair infrequent
p43 early/late fair infrequent
p41 (flagellin) early/late low common
p39 (BmpA) late fair infrequent
OspA late fair infrequent
OspC early/late high infrequent
Osp17/p18 (DbpA) late fair infrequent
VlsE early/late high infrequent
p41 (flagellin, internal fragment) early/late fair infrequent
170 Hunfeld ⴢ Kraiczy
blot ( fig. 1 ; table 1 ), and therefore permits additional analysis of the individual class-
and antigen-specific antibody patterns expressed by the patient [1, 2] . In regard to the
currently available diagnostic tests, 3 different assay types have to be distinguished:
whole cell antigen immunoblots, recombinant immunoblots, and the so-called line
immunoblots that have been more recently developed.
Whole Cell Antigen Immunoblot
Borrelia whole cell extracts of a defined borrelial strain obtained during the exponen-
tial growth phase provide the starting material for the classical immunoblot ( fig. 2 ).
The advantage of this method is that all the naturally occurring antigens of a defined
strain are available for antibody detection. In addition to highly specific immuno-
dominant antigens, numerous less specific or non-spec ific cross-react ive ant igens a re
present for blot testing [1, 2] . Because both highly specific and less specific antigens
can react with antibodies from the patient (IgM and/or IgG) such tests need a high
level of test standardization and expertise of the investigator to avoid false-positive
test results. In addition, reliable identification and correct evaluation of the bands are
decisive for the quality of the diagnosis. To improve handling and specificity of such
tests, the Centers of Disease Control and Prevention and the German Society for Hy-
giene and Medical Microbiology (DGHM) developed standard criteria ( table 2 ) for
the laboratory evaluation of immunoblot test results [1, 2, 11, 12] . A set of interpreta-
tion rules has also been defined on the basis of a multicentric European study [14] .
Because of a general lack of standardization and the highly variable format and anti-
gen composition of the currently available commercial assays, however, the diagnos-
tic assessment of a given test has to be performed according to the evaluation criteria
of the individual manufacturer. Although the assay evaluation depends greatly on the
individual diagnostic algorithm of the test manufacturer, in general, the detection of
specific IgM antibodies by whole cell antigen immunoblot is regarded as reliable and
specific if at least 2 of the following 3 bands are detected: OspC, p39 (BmpA) and p41
(flagellin). Similarly, the presence of several of the following bands is regarded as par-
ticularly important for the reliable and specific detection of specific IgG antibodies:
Osp17/p18 (DbpA), OspC, OspA, p58, p39 (BmpA), p41 (flagellin), p66 (Oms66), VlsE
and p83/100.
Another diagnostic difficulty is that the immunodominant antigens of the 4 Bor-
relia species so far known to be pathogenic in humans (B. burgdorferi s.s., B. afzelii ,
B. garinii and B. spielmanii) tend to show a significant amount of variability [4, 6, 9,
15, 16] . Serological studies performed in the US and Europe pertaining to this prob-
lem have demonstrated that the currently available strains are not equally suitable as
an antigen source for whole cell antigen immunoblot production [2, 11, 12] . Com-
parative serological evaluations revealed that the antigens of B. afzelii isolate Pko are
particularly suitable for the sensitive and specific diagnosis of specific antibodies by
When to Order a Western Blot and How to Interpret It 171
immunoblot, at least in the European context [10, 14, 16] . This is why the users of
whole cell antigen immunoblots should critically evaluate the source and preparation
of antigens used for their specific assays for the diagnostic suitability in a given epi-
demiological setting [1, 2] .
Recombinant Immunoblot
The recombinant immunoblot ( fig. 2 ) commonly uses defined highly purified bor-
relial proteins produced by genetic engineering [3] . These antigens are then trans-
ferred to the blot membrane aft er pur if ication and s eparat ion by SDS -PAGE [1 , 10, 14] .
A positive test result corresponds to the specific staining of the binding of the patient’s
antibodies (IgM and/or IgG) to selected highly specific immunodominant Borrelia -
specific antigens such as p83/100, VlsE, p58, p41 (flagellin), internal fragment of p41
(p41i), p39 (BmpA), OspA, OspC and Osp17/p18 (DbpA) [2, 4, 9] . As compared to
whole cell antigen immunoblots, the recombinant ones are easier to read and are gen-
erally better standardized. It is helpful to combine different antigen preparations from
different Borrelia species on a single blot, so that antibodies to specific antigenic de-
terminants of all 4 pathogens responsible for human Lyme borreliosis (B. burgdorferi
s.s., B. afzelii, B. garinii and also B. spielmanii) can be detected in a single test [4, 6] .
They also allow users to incorporate antigens which are expressed in vivo only (e.g.
VlsE). One disadvantage of these tests, however, is their substantially higher cost. The
diagnostic evaluation of the recombinant immunoblot test is based on the previously
cited criteria, but depends on the given standards and precautions of the individual
manufacturer and also on the particular immunoblot batch [1, 2, 4–6] .
Tab le 2 . Current published interpretative criteria for recombinant and whole cell antigen immuno-
blots in the serodiagnosis of Lyme borreliosis in Europe and the USA
B. afzelii (strain PKo) whole cell antigen immunoblot evaluation criteria for Europe according to
Hauser et al. [10]
IgG positive: ≥2 bands IgM positive: ≥1 bands
p100, p58, p43, p39, p30, OspC, p21, Osp17, p14 p41 (strongly positive), p39, OspC, Osp17
B. burgdorferi s.s. (strain G39/40) whole cell antigen immunoblot evaluation criteria according to
the CDC recommendations for the USA only [11, 12]
IgG positive: ≥5 bands IgM positive: ≥2 bands
p83/100, p66, p58, p45, p41, p39, p30, p28, OspC,
or p18
p39, OspC, p41
Recombinant immunoblot, according to Wilske et al. [13] and Schulte-Spechtel et al. [6]
IgG positive: ≥2 bands IgM positive: ≥2 bands
p100, p58, p39, VlsE, OspC, p41 internal fragment,
Osp17/p18
p39, OspC, p41 internal fragment, Osp17/
p18; or strong reaction against OspC only
172 Hunfeld ⴢ Kraiczy
Line Immunoblot
Antigens used for the production of line immunoblots ( fig. 2 ) are essentially the same
as those applied in the regular recombinant immunoblots. The production and fur-
ther processing of the antigens is mainly identical. However, no electrophoretic sepa-
ration step is necessary prior to the blotting procedure. For such tests, the individual
antigens are sprayed on the membranes without conventional blotting procedures. In
doing so, several homologous immunodominant antigens of different borrelial stra ins
with identical or similar molecular weights can be combined in diagnostic groups on
a single strip [4] . The line immunoblot technology thus allows for a much more vari-
able combination and application of very diverse antigen panels on individual test
strips. As such, a broad spectrum of antigens derived from various different strains
belonging to the diagnostically important genospecies of B. burgdorferi s.l. can be
covered by the assay to improve diagnostic sensitivity and guarantee high specificity
[4, 9] . An additional advantage of the line immunoblot is the application of non-de-
naturated antigens for the detection of immunoreactive antibodies directed exclu-
sively to native structural determinants [17] .
Stage-Dependent Antibody Kinetics in Lyme Borreliosis
For the critical evaluation of immunoblot results and the correct interpretation of se-
rological findings in the context of given clinical symptoms, a good knowledge of the
temporal course of the antibody response directed against the major immunodomi-
nant antigens ( table 1 ) is essential [1, 2] . The antigenic specificities of the outer mem-
brane proteins and flagellin from B. burgdorferi have been the subjects of extensive
investigations. By contrast, there is still fragmentary information available on struc-
ture and immunological significance of many other potential immunodominant anti-
gens [1, 3] . Specific antibodies directed against borrelial antigens can usually be de-
tected by any test 3–6 weeks after the infection has taken place. The development of
IgM antibodies usually precedes that of IgG antibodies, but in individual cases IgM
production may be delayed or even absent [1, 2] . This remains true also in cases of re-
infection, where a broad IgG antibody response without significant IgM production
can be expected. Early on in the infection, the primary immune response to both class-
es of immu nog lobu lin is dire cte d agai nst a na rrow spec trum of b orrelial antigens only.
Such antigens comprise, in particular, the flagellin (p41), the VlsE and the outer sur-
face protein OspC of B. burgdorferi. Antibodies directed against VlsE and OspC are of
particular diagnostic relevance because they are regarded as highly specific [2] . How-
ever, a substantial proportion of false-negatives should be expected in the early stages
of Lyme borreliosis, as in many patients a significant antibody titer may develop very
slowly after initial infection. Correspondingly, seroprevalence studies show a serolog-
ically detectable antibody response in 20–60% of European patients with localized in-
When to Order a Western Blot and How to Interpret It 173
fection (stage I: erythema migrans) mainly depending on the assay and test criteria
used [1, 2, 12] . Among seropositive patients, IgM antibodies can be detected in up to
90% of cases, but a corresponding IgG response is only present in up to 70% of the
cases. The number of seropositive patients increases as borrelial infection progresses
to the early disseminated stage (stage II) and reaches almost 100% for IgG in late dis-
seminated disease manifestations (stage III) [1, 2] . IgG antibodies directed against a
broad spectrum of borrelial antigens are characteristic of early disseminated and late
disseminated disease manifestations (stages II and III of Lyme borreliosis). Antibodies
against specific antigens such as the p83/100 protein, p58, p38 (BmpA), the internal
fragment of p41 (flagellin) and Osp17/p18 (DbpA) are of particularly high diagnostic
significance. In contrast, antibodies against OspA, which is also specific, are rare (ex-
cept at the late stage, i.e. in Lyme arthritis cases) because of a switch in antigen expres-
sion from OspA to OspC by the pathogen upon entering the mammalian host.
As with other serological tests, normal immune status and the ability of the patient
to produce antibodies remains an important prerequisite for the serological detection
of antibodies by immunoblotting. Seronegative Lyme borreliosis is extremely rare,
except in the very early course of the disease, but should be borne in mind in patients
with a short duration of the disease and clinically unambiguous symptoms. In such
cases, direct detection of the pathogen should always be considered if Lyme borrelio-
sis is strongly suspected clinically in immunocompromised patients or when unam-
biguous or borderline findings are repeatedly obtained by serological tests [1] .
Value of Immunoblot Testing for the Laboratory Diagnosis of Lyme Borreliosis
In the serodiagnosis of many bacterial and viral pathogens, as a general principle,
highly sensitive screening methods such as ELISA are best combined with very spe-
cific confirmatory tests such as immunoblots to guarantee a cost effective, sensitive
and specific diagnostic approach ( fig. 1 ) [1, 2, 18] . This is why the general application
of immunoblots as first-line tests for the serodiagnosis of Lyme borreliosis is rejected
by most European (DGHM, EUCALB) and American diagnostic guidelines [1, 2, 11,
12]
. Using immunoblots as a first-line test will also increase the asymptomatic sero-
prevalence of the pathogen and decrease the clinical value of the result.
Unfortunately, diagnostic assays for Lyme borreliosis do not require peer-reviewed
competent pre-market approval in the majority of countries outside the USA, and
therefore a wide range of commercial and home-brewed tests with substantially dif-
ferent diagnostic qualities are currently being used by diagnostic laboratories [18] . As
such, the level of test standardization and the diagnostic quality of serological testing
for Lyme borreliosis still lags far behind when compared to syphilis diagnostics [19] .
Immunoblots, especially those using recombinant antigens, represent confirmatory
tests of high specificity and sensitivity when antigens included are accurately selected
[1, 2 , 4] . Keeping in mind the inclusion of recombinant homologues, truncated pro-
174 Hunfeld ⴢ Kraiczy
teins or fusion proteins derived from different Borrelia species can broaden the diag-
nostic coverage of such tests in regard to the pronounced antigenic heterogeneity of
the different B. burgdorferi s.l. isolates [4, 9] . By creating recombinant protein com-
positions that include conserved amino acid sequences which are recognized by an-
tibodies to antigens from all 4 species pathogenic in humans, such ‘designer’ immu-
noblots are highly sensitive, standardized and more easily interpretable than most
currently available whole cell immunoblots [1, 4] . When performed carefully, the im-
munoblot can fairly reliably distinguish between antibody responses to specific and
non-specific proteins. Although test quality has steadily increased during recent
years, it should be mentioned that immunoblot testing for diagnosing of Borrelia in-
fection in individual cases can be significantly influenced by 3 major factors: (1) the
kind of strain infecting the individual patient, (2) the kind of antigens and type of as-
say used for serological testing, and (3) the individual course and duration of the in-
fection. Moreover, the evaluation and interpretation of test results depends largely on
the individual diagnostic expertise of the investigator.
When to Order a Western Blot and How to Interpret Serological Findings
Combinations of Tests for Standard Diagnostics
In recent years, there have been many studies dealing with the improvement and
standardization of serological diagnostics in Lyme borreliosis [1, 3, 5, 10, 14, 18, 20] .
In truth, it is almost impossible for serological test methods to combine absolute
specificity with best possible sensitivity [1, 2, 18] . To come close to this objective,
therefore, a combination of very sensitive screening tests with highly specific confir-
matory tests is commonly used to provide serological diagnostics which are both re-
liable and economic. The improved selection of specific antigens has made possible
the replacement of earlier diagnostic protocols by means of 3 steps (IHAT, IFA/
ELISA, immunoblot) by 2-tier testing protocols using ELISA and immunoblot
( fig. 1 ). Our own experience also shows that a combination of a screening test (ELISA)
with a confirmatory test (whole cell antigen immunoblot, recombinant immunoblot
or line immunoblot) is in most cases sensitive and reliable for assessing Lyme bor-
reliosis infection status [1, 2] . The use of other test combinations, or the use of ELISA
or immunoblot in a single step only, is not currently recommended as it increases the
risk of false-positive results by reducing test specificity [1, 2 , 18] .
How to Perform Rational Stepwise Diagnostics
The currently employed rational stepwise serological procedure for Lyme borreliosis
is described briefly below:
When to Order a Western Blot and How to Interpret It 175
– If the screening test is negative, it is usually not helpful to carry out further im-
munoblot testing and the Lyme borreliosis serology is reported as negative. How-
ever, it is not possible to exclude a Borrelia infection because seronegative courses
are common in the early stages of the disease, and therefore a serological follow-up
should be performed 2–3 weeks later if clinical suspicion remains.
– If, on the other hand, the screening test is positive, it is indicated to perform fur-
ther i nve st iga tions w ith confir mat or y te st s such as i mmu noblot assays . In add ition
to the whole cell antigen immunoblot, recombinant immunoblots and line immu-
noblots are now available for different Borrelia genospecies. In many cases, confir-
matory tests, carried out to affirm an initially positive or borderline screening test
result, remain negative, and from a serological point of view the presence of spe-
cif ic anti bo dies in suc h c as es ca nnot be sub st an ti ate d. Such fi nd in gs, however, may
be consistent with early stage I or II of the disease, and again carrying out a sero-
logical follow-up 3–4 weeks later can be helpful if clinical suspicion persists. If the
following-up test turns out positive for antibodies (IgM and IgG) against specific
antigens of B. burgdorferi s.l., clearly indicating seroconversion, an infection with
the pathogen is regarded as having been established [1, 2] .
– If, however, a borderline or positive screening test is supported by specific immu-
noblot testing according to the previously mentioned rules of interpretation, the
criteria for a positive Borrelia serology are fulfilled. The resulting laboratory report
should clearly state the number and kind of Borrelia -specific antigens (bands) as
recognized by corresponding antibodies in the patient’s serum [1, 2] . This is the
only way to allow for comparison with the findings from follow-up samples and to
permit the clinician to answer the question of whether or not the serological find-
ings comply with the clinical picture, i.e. with early- or late-stage manifestations
of the disease.
Rational Interpretation of Serological Findings
For a correct interpretation of the serological findings, the investigator must consid-
er a whole series of questions and facts in the evaluation of immunoblot results. The
first point to establish is whether the findings provide sufficient evidence to support
the fact that borrelial infection did occur. If specific antibodies have been detected, it
is necessary to clarify whether the findings obtained are suspicious of a more recent
infection or whether they may reflect a long-lasting or past infection [1, 2] . Most im-
portantly, the findings concerning the subclass of specific antibodies (IgM, IgG) and
the pattern of detected antigens must fit into the clinical context of the patient (ery-
thema migrans, neuroborreliosis, acrodermatitis chronica atrophicans, arthritis,
etc.). For example, on the one hand, solely IgM-positive immunoblot findings and a
narrow pattern of antigens such as flagellin (p41), and its internal fragment (p41i),
and OspC clearly exclude clinical suspicion of late-stage disease manifestations, but
176 Hunfeld ⴢ Kraiczy
References
1 Hunfeld KP, Oschmann P, Kaiser R, Schulze J,
Brade V: Diagnostics; in Oschmann P, Kraiczy P,
Halperin J, Brade V (eds): Lyme-Borreliosis and
Tick-Borne Encephalitis. Bremen, Unimed, 1999,
pp 80–108.
2 W i ls ke B, Fi ng er le V, Sc hu lt e- Sp e cht e l U: Mi cr ob io -
logical and serological diagnosis of Lyme borrelio-
sis. FEMS Immunol Med Microbiol 2007;
49: 13–
21.
3 Hunfeld KP, Ernst M, Zachary P, Jaulhac B, Son-
neborn HH, Brade V: Development and laboratory
evaluation of a new recombinant ELISA for the se-
rodiagnosis of Lyme disease. Wien Klin Wochen-
schr 2002;
114: 580–585.
4 Goettner G, Schulte-Spechtel U, Hillermann R,
Liegl G, Wilske B, Fingerle V: Improvement of
Lyme borreliosis serodiagnosis by a newly devel-
oped recombinant immunoglobulin G (IgG) and
IgM line immunoblot assay and addition of VlsE
and DbpA homologues. J Clin Microbiol 2005;
43:
3602–3609.
5 Magnarelli LA, Fikrig E, Padula SJ, Anderson JF,
Flavell R A: Use of recombinant ant igens of Borrelia
burgdorferi in serologic tests for diagnosis of Lyme
borreliosis. J Clin Microbiol 1996;
34: 237–240.
6 Schulte-Spechtel U, Lehnert G, Liegl G, Fingerle V,
Heimerl C, Johnson BJ, Wilske B: Significant im-
provement of the recombinant Borrelia-specific
immunog lobulin G immunoblot t est by addition of
VlsE and a DbpA homolog ue derived from Borrelia
garinii for diagnosis of early neuroborreliosis. J
Clin Microbiol 2003;
41: 1299–1303.
7 Wilske B, Fingerle V, Herzer P, Hofmann A, Leh-
ne rt G , Pet ers H, Pf is ter HW, Pr eac -Mur sic V, So ut-
schek E, Weber K: R ecombinant immuno blot in the
serodiagnosis of Lyme borreliosis: comparison
with indirect immunof luorescence and enzyme-
linked immunosorbent assay. Med Microbiol Im-
munol 1993;
182: 255–270.
8 Wi l sk e B , Fi ng e rl e V, Pr e ac -M ur s ic V, J au r is - He ip ke
S, Hofmann A, Loy H, Pfister HW, Rössler D, Sout-
schek E: Immunoblot using recombinant antigens
derived f rom different genos pecies of Borrelia burg-
dorferi sensu lato. Med Microbiol Immunol 1994;
183: 43–59.
9 Schulte-Spechtel U, Fingerle V, Goettner G, Rogge
S, Wilske B: Molecular analysis of decorin-binding
protein A (DbpA) reveals five major groups among
European Borrelia burgdorferi sensu lato strains
with impact for the development of serological as-
says and indicates lateral gene transfer of the dbpA
gene. Int J Med Microbiol 2006;
296(suppl 40):250–
266.
10 Ha user U, L ehner t G, Lobentan zer R, Wilske B: In-
terpretat ion criteria for sta ndardized Wester n blots
for three European species of Borrelia burgdorferi
sensu lato. J Clin Microbiol 1997;
35: 1433–1444.
11 Recommendations for test performance and inter-
pretation from the Second National Conference on
Serologic Diagnosis of Lyme Disease. MMWR
Morb Mortal Wkly Rep 1995;
44: 590–591.
12 A g u e r o- R o s en f e ld M E , Wa n g G , S c h w ar t z I , W or m -
ser GP: Diagnosis of Lyme borreliosis. Clin Micro-
biol Rev 2005;
18: 484–509.
13 Wilske B, Habermann C, Fingerle V, Hillenbrand
B, Jauris-Heipke S, Lehnert G, Pradel I, Rössler D,
Schulte- Spechtel U: An improved recombinant IgG
immunoblot for serodiagnosis of Lyme borreliosis.
Med Microbiol Immunol 1999;
188: 139–144.
14 Robertson J, Guy E, Andrews N, Wilske B, Anda P,
Granström M, Hauser U, Moosmann Y, Sambri V,
Schellekens J, Stanek G, Gray J: A European multi-
center study of i mmunoblotting i n serodiagnosi s of
Lyme borreliosis. J Clin Microbiol 2000;
38: 2097–
2102.
15 Hauser U, Krahl H, Peters H, Fingerle V, Wilske B:
Impact of strain heterogeneity on Lyme disease se-
rology in Europe: comparison of enzyme-linked
immunosorbent assays using different species of
Borrelia burgdorferi sensu lato. J Clin Microbiol
1998;
36: 427–436.
are consistent with a recent infection. In the latter case, seroconversion can be dem-
onstrated upon serological follow-up, such findings are a clear proof of a very recent
time point of infection. On the other hand, a predominant IgG response and a broad
pattern of positive antigens in the immunoblot [p83/100, VlsE, p58, Oms66/p66,
OspA, p39 (BmpA), Osp17/p18 (DbpA)] are clearly consistent with late-stage disease
manifestations or past infection ( table 1 ) but, with the exception of re-infection, clear-
ly argue against a recent time point of infection [1, 2] .
When to Order a Western Blot and How to Interpret It 177
16 Wilske B, Hauser U, Lehnert G, Jauris-Heipke S:
Genospecies and their influence on immunoblot
results. Wien Klin Wochenschr 1998;
110: 882–885.
17 Rossmann E, Kitiratschky V, Hofmann H, Kraiczy
P, Simon MM, Wallich R : Borrelia burgdorferi com-
plement regulator-acquiring surface protein 1 of
the Lyme disease spirochetes is expressed in hu-
mans and induces antibody responses restricted to
nondenaturated structural determinants. Infect
Immun 2006;
74: 7024–7028.
18 Hunfeld KP, Stanek G, Straube E, Hagedorn HJ,
Schörner C, Mühlschlegel F, Brade V: Quality of
Lyme disease serology: lessons from the German
Proficiency Testing P rogram 1999–2001. A preli m-
inary report. Wien Klin Wochenschr 2002;
114:
591–600.
19 Muller I, Brade V, Hagedorn HJ, Straube E, Schör-
ner C, Frosch M, Hlobil H, Stanek G, Hunfeld KP:
Is serologica l testing a relia ble tool in laboratory di-
agnosis of syphilis? Meta-analysis of eight external
quality control surveys performed by the German
Infection Serology Proficiency Testing Program. J
Clin Microbiol 2006;
44: 1335–1341.
20 Ledue TB, Collins MF, Craig WY: New laboratory
guidelines for serologic diagnosis of Lyme disease:
evaluation of the two-test protocol. J Clin Micro-
biol 1996;
34: 2343–2350.
K.-P. Hunfeld, MD, MPH
Institute of Medical Microbiology and Infection Control
Hospital of the Johann Wolfgang Goethe-University Frankfurt
Paul-Ehrlich-Strasse 40
DE–60596 Frankfurt am Main (Germany)
Tel. +49 69 6301 6441, Fax +49 69 6301 5767, E-Mail k.hunfeld@em.uni-frank furt.de
Frequently Asked Questions about Lyme Borreliosis
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 178–182
A b s t r a c t
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 p atients. Since cultivation of the etiologic agent, Borrelia burgdorferi sensu lato,
and polymerase chain reac tion are also inadequate for this purpose, the assessme nt of patients with
cutaneous manifestations of Lyme borreliosis in the follow-up rests primarily on the clinical pic-
ture. Copy right © 2009 S. Karger AG , Basel
The typical cutaneous manifestations of Lyme borreliosis (LB), a multisystem infec-
tious disease caused by Borrelia burgdorferi sensu lato ( B. burgdorferi s.l.), are ery-
thema migrans (EM), borrelial lymphocytoma (BL), and acrodermatitis chronica
atrophicans (ACA) [1] . The extrapolated incidence of these 3 entities is about
200/100,000 people per year. EM, the hallmark of early LB, is clinically defined as an
expanding round to oval, sharply demarcated, red to bluish-red skin lesion of at least
5 cm in diameter, sometimes disseminated and/or accompanied by extracutaneous
signs and symptoms. BL, a B cell pseudolymphoma, represents a subacute lesion and
predominantly affects children. Clinically, it is a sharply demarcated, soft bluish-red
nodule or plaque of 1–5 cm, typically on the ear, breast, or scrotum, rarely with ex-
tracutaneous symptoms. ACA is the characteristic cutaneous manifestation of late-
Is Serological Follow-Up Useful for
Patients with Cutaneous Lyme Borreliosis?
R.R. Müllegger a ⭈ M. Glatz b
a Depar tment of Dermatology, State Hospital Wiener Neustadt, Wiener Neustadt , and
b Depar tment of Dermatology, Medical University Graz, Graz , Austria
Lyme Borreliosis: Serological Follow- Up 179
stage LB. It mostly affects elderly woman and typically develops on the extensor sur-
faces of the distal extremities. It slowly (weeks to months) progresses from an early
inflammatory stage with bluish-red discoloration and doughy swelling to a chronic
persistent stage with thinning and wrinkling of the skin.
Antibiotic therapy is obligatory in every case of cutaneous LB to eliminate B. burg-
dorferi s.l., resolve skin changes, and prevent extracutaneous complications. Response
to appropriate therapy (usually doxycycline, amoxicillin or cefuroxime) is generally
excellent for cutaneous and extracutaneous features in EM and BL, although delayed
by weeks to months in the latter [1] . However, major complications (including men-
ingitis) or minor symptoms over a period of several months to 1 year after therapy
persist or newly develop in a small percentage of patients, particularly after EM. In
ACA, inflammatory changes (erythema and swelling) gradually subside over a period
of 1 year after treatment, whereas atrophy, telangiectases, and pseudo-scleroderma-
tous changes are usually not influenced by antimicrobials. Peripheral neuropathy,
which is associated with ACA in about two thirds of patients, improves very slowly,
if at all. True therapy failures (persistence or recurrence of cutaneous or associated
signs and symptoms and/or survival of B. burgdorferi s. l.) have to b e retreated, where -
as sustained subjective symptoms, such as fatigue, musculoskeletal pain, and cogni-
tive dysfunction (‘post-Lyme disease syndrome’), which are not caused by B. burgdor-
feri s.l. persistence, do not respond to repeated antimicrobial treatment. Thus, labora-
tory tests would be desirable to prove the efficacy of treatment. To date, great
uncertainty exists about the application and interpretation of such tests, particularly
regarding serologic follow-up examinations. Analyses of skin biopsy samples for the
presence of B. burgdorferi s.l. (-specific DNA) from the site of infection by cultivation
or (quantitative) polymerase chain reaction (PCR) are very specific, but their sensitiv-
ity is insufficient, and they are available only in specialized laboratories [2, 3] . PCR is
a quick method, but cultivation of B. burgdorferi s.l. is laborious and does not yield
timely results. Also, both procedures are invasive and do not provide any evidence
about possible (residual) B. burgdorferi s.l. infection of organs other than the skin.
Culture or PCR testing of other clinical samples (e.g. blood or urine) is even far less
valuable [2, 3] . In 2 post-treatment studies, PCR analyses of previous dermatobor-
relioses sites proved to be a reliable method for demonstrating eradication of the spi-
rochete [4, 5] . Molecular analyses were consistent with clinical response in most cas-
es; in 2% of patients, PCR results were positive, but they were asymptomatic clini-
cally [4] .
So far, analyses of serum anti- B. burgdorferi s.l. antibodies have been frequently
used because of the misconception that serologic follow-up examinations could sup-
port the assessment of the clinical course after treatment. They are convenient to use
and generally available, although not cheap. However, interpretation of serologic re-
sults is difficult due to several possibilities of false-positive (e.g. seroprevalence, im-
munologic cross-reactions) or false-negative (e.g. lack of seroconversion early in the
infection) outcomes [1, 6] . Also, results from different assays and laboratories are not
180 Müllegger ⴢ Glatz
comparable because of missing standardization. Serology is most reliable in substan-
tiating the clinical diagnosis of ACA (100% positive) and BL (about 90% positive),
but without value for EM [1, 6] . In the convalescent phase, up to 1 month after ther-
apy in EM, seroconversion (increase in antibody titers) is found in at least two thirds
of patients [1, 6] . Thus, analyses of sequential serum samples may ironically be diag-
nostically helpful instead of indicating successful therapy. On the other hand, about
ha lf of E M pa tient s re main seronegative du ri ng t heir who le d isea se c our se, includ ing
on follow-up examinations [6–9] . This may be due to a nti biot ic abro gation [6] or that
EM (in Europe) may represent a localized infection without systemic immune re-
sponse. IgG and/or IgM antibodies can persist in 10–60% of EM patients for (many)
years after adequate therapy [6, 7, 10–12] . It could be speculated that persistence of
the antibody response is associated with the survival of spirochetes due to treatment
failure. It has been proven, however, by PCR from skin lesions before and after ther-
apy that antibiotic treatment leads to bacterial eradication in most cases [5] . It is in-
stead plausible that the persistence of antibody response results from unspecific
polyclonal activation of memory B cells [12 , 13] . Several studies [6–8, 11] , including
a large investigation of more than 100 patients with serial serologic analyses [6] over
a follow-up period of a minimum of 1 year, found no correlation between develop-
ment of serologic titers and type of therapy or post-treatment clinical course. In a
recent study, immunoblot analyses confirmed the missing correlation between anti-
body kinetics to specific B. burgdorferi s.l. antigens and clinical outcome in EM pa-
tients [14] . It was initially thought that serologic follow-up using a novel ELISA test
based on C6 (part of VlsE, variable major protein-like sequence, expressed) is a bet-
ter indicator of therapy efficacy (fast decrease of IgG antibody titers after antibiotic
therapy), but serology was not put into statistical correlation with clinical character-
istics [15, 16] . In contrast, other studies found a persistent IgG antibody response to
C6 in clinically successfully treated EM patients [17] . Consequently, retreatment of
EM patients solely based on a positive antibody titer after treatment without persis-
tent or newly developed specific symptoms is not indicated, although everyday prac-
tice shows that less experienced physicians tend to reapply antibiotics in such cases,
often driven by demanding patients. For BL patients who test positive for anti-
B. burgdorferi s.l. IgG and/or IgM antibodies before therapy (70–95%) [1] , only 1
study provides data on serologic development after therapy. One quarter to half of
patients remain seropositive during a follow-up of 2 months. Seropositivity seems to
be independent from type of therapy or disease course after therapy, although this
aspect was not specifically looked into [18] . Several studies, in which ACA patients
were followed up after therapy, have demonstrated a (clear) decline in the serologic
response to B. burgdorferi s.l. over 1 to several years, although IgG titers (the pre-
dominant antibody class in ACA) remain positive in the great majority of patients
[8–11, 19] . It was assumed that the observed serologic decline is due to effective ther-
apy, but the course of seroreactivity and the type of treatment or clinical outcome
were not correlated [8, 11, 19] . In accordance, we found essentially unchanged anti-
Lyme Borreliosis: Serological Follow- Up 181
body titers during an average observation period of 18 months after treatment in 82
ACA patients, irrespective of the kind of therapy or time to clinical resolution of the
skin lesion [unpublished data]. Thus, persistent antibody titers do not necessarily
indicate a treatment failure, but rather represent a serologic scar after a chronic spi-
rochetosis that is without clinical relevance.
I n c o n c l u s i o n , a n t i - B. burgdorferi s.l. antibody titers after therapy develop differ-
ently in the 3 dermatoborrelioses. Antibody kinetics are unpredictable and variable,
but generally independent of the clinical outcome and duration and type of antibi-
otic treatment. Importantly, persistent positive IgG and/or IgM antibody titers do
not indicate treatment failure. Therefore, repeated serologic testing is of very lim-
ited value for the evaluation of therapy efficacy, and not recommended in the fol-
low-up of dermatoborrelioses patients. To date, the key assessment parameter in
follow-up examinations of patients with cutaneous manifestations of LB is the clin-
ical picture.
References
1 Müllegger RR: Dermatological manifestations of
Lyme borreliosis. Eur J Dermatol 2004;
14: 296–
309.
2 Dumler JS: Molecular diagnosis of Lyme disease:
review and meta-analysis. Mol Diagn 2001;
6: 1–11.
3 Lebech AM, Ha nsen K, Bandr up F, Clemmens en O,
Halkier-Sorensen L: Diagnostic value of PCR for
detection of Borrelia burgdorferi DNA in clinical
specimens from patients with erythema migrans
and Lyme neur oborreliosis. Mol D iagn 200 0;
5: 139–
150.
4 Hunfeld KP, Ruzic-Sabljic E, Norris DE, Kraiczy P,
Strle F: In vitro susceptibility testing of Borrelia
burgdorferi sensu lato isolates cultured from pa-
tients with erythema migrans before and after an-
timicrobial chemotherapy. Antimicrob Agents
Chemother 2005;
49: 1294–1301.
5 Müllegger RR, Zöchling N, Schlüpen EM, Soyer
HP, Hödl S, Kerl H, Volkenandt M: Polymerase
chain reaction control of antibiotic treatment in
dermatoborreliosis. Infection 1996;
24: 76–79.
6 Glatz M, Golestani M, Kerl H, Müllegger RR: Clin-
ical relevance of different IgG and IgM serum anti-
body responses to Borrelia burgdorferi after anti-
biotic therapy for erythema migrans: long-term
follow-up study of 113 patients. Arch Dermatol
2006;
142: 862–868.
7 Fe der HM Jr, Gerber MA, Luger S W, Ryan RW: Per-
sistence of serum a ntibodies to Borrelia burgdorferi
in patient s treated for Lyme disease. Clin In fect Dis
1992;
15: 788–793.
8 Hulshof MM, Vandenbroucke JP, Nohlmans LM,
Spanjaard L, Bavnick JN, Dijkmans BA: Long-term
prognosis in patients treated for erythema chroni-
cum mig rans and acrodermatitis chronic a atrophi-
cans. Arch Dermatol 1997;
133: 33–37.
9 Lomholt H, Lebech AM, Hansen K, Bandrup F,
Halkier-Sorensen L: Long-term serological follow-
up of patients treated for chronic cutaneous bor-
rel ios is or c ult ure -posi tiv e ery the ma mi gra ns. Acta
Derm Venereol 2000;
80: 362–366.
10 Asbrink E, Hovmark A, Hederstedt B: Serologic
studies of erythema chronicum migrans Afzelius
and acrodermat itis chronica atrophic ans with indi-
rect immunofluorescence and enzyme-linked im-
munosorbent assays. Acta Derm Venereol 1985;
65:
509–514.
11 Hammers-Berggren S, Lebech AM, Karlsson M,
Svenungsson B, Hansen K, Stiernstedt G: Serologi-
cal follow-up after treatment of patients with ery-
thema migrans and neuroborreliosis. J Cl in Micro-
biol 1994;
32: 1519–1525.
12 K a li s h R A , M c Hu g h G , G r a nq u is t J, Sh e a B , Ru t ha z -
er R, Steere AC: Persistence of immunoglobulin M
or immunoglobulin G antibody responses to Bor-
relia burgdorferi 10–20 years after active Lyme dis-
ease. Clin Infect Dis 2001;
33: 780–785.
13 Bernas coni NL, Trag giai E , Lanzavec chia A: Main-
tenance of serological memory by polyclonal acti-
vation of huma n memory B-cel ls. Science 20 02;
298:
2199–2202.
182 Müllegger ⴢ Glatz
14 Gl atz M, Fi ngerle V, Wil ske B, Ambros-Rudolph C ,
Kerl H, Müllegger RR: Immunoblot analysis of the
seroreactivity to recombinant Borrelia burgdorferi
sensu lato antigens, including VlsE, in the long-
term course of treated patients with erythema mi-
grans. Dermatology 2008;216:
93–103.
15 Marangoni A, Sambri V, Accardo S, Cavrini F,
Mondardini V, Moroni A, Storni E, Cevenini R: A
decrease in the immunoglobulin G antibody re-
sponse against the VlsE protein of Borrelia burg-
dorferi sensu lato correlates with the resolution of
clinical signs in antibiotic-treated patients with
early Lyme disease. Clin Vaccine Immunol 2006;
13: 525–529.
16 Philipp MT, Wormser GP, Marques AR, Bittker S,
Martin DS, Nowakowski J, Dally LG: A decline in
C6 antibody titer occurs in successfully treated pa-
tients with culture-confirmed early localized or
early disseminated Lyme borreliosis. Clin Diagn
Lab Immunol 2005;
12: 1069 –1074.
17 Peltomaa M, McHugh G, Steere AC: Persistence of
the antibody response to the sixth invariant region
(IR6) peptide of Borrelia burgdorferi after success-
ful antibiotic treatment of Lyme disease. J Infect
Dis 2003;
187: 1178–1186.
18 Maraspin V, Cimperman J, Lotric-Furlan S, Ruzic-
Sabljic E, Jurca T, Picken R, Strle F: Solitary bor-
relial lymphocytoma in adult patients. Wien Klin
Wochen schr 20 02;
114: 515–523.
19 Olsson I, Asbrink E, von-Stedingk M, von-Stedingk
LV: Changes in Borrelia burgdorferi -specific serum
IgG antibody levels in patients treated for acroder-
matitis chronica atrophicans. Acta Derm Venereol
(Stockh) 1994;
74: 424–428.
Prof. Dr. Robert Müllegger
Depar tment of Dermatology, State Hospital Wiener Neustadt
Corvinusring 3–5
AT–2700 Wiener Neustadt (Austria)
Tel. +43 2622 321 4901, Fax +43 2622 321 4905, E-Mail robert.muellegger@wienerneustadt.lknoe.at
Frequently Asked Questions about Lyme Borreliosis
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 183–190
A b s t r a c t
In this report, we present basic data pertinent to the current understanding of borrelial infection in
pregnancy, and propose a rationale for the management of Lyme borreliosis in pregnant women.
We advocate early detection of attached ticks and their prompt removal. We do not recommend
the use of prophylactic antibiotics in pregnant women but support the ‘wait and watch’ strategy,
including early treatment with antibiotic s if signs/symptoms of the disease arise. We encourage the
approach that antibiotic treatment of pregnant patients is restricted to those having a reliable clin-
ical diagnosis of Lyme borreliosis, and propose intravenous antibiotic treatment with penicillin, or
preferably ceftriaxone 2 g daily for 14 days, not only for patients with early disseminated disease
but also for those with solitary erythema migrans. Copyright © 20 09 S. Karger AG, Basel
The objectives of this report are to present basic data pertinent to the current under-
standing of borrelial infection in pregnancy, and to propose a rationale for the man-
agement of Lyme borreliosis in pregnant women.
Management of pregnancy encompasses management of the woman herself and of
her fetus. Although this distinction is usually somewhat artificial, it is useful for ap-
preciation of the suggestions presented here for management of tick bites in pregnant
women and for treatment of Lyme borreliosis during pregnancy, both of which are
based on rather elusive evidence.
There are no precise data on the natural course and outcome of Lyme borreliosis
during pregnancy, but there is a general belief that there are no substantial differ-
ences between pregnant and nonpregnant individuals with Lyme borreliosis, and that
pregnant women treated for Lyme borreliosis have an outcome similar to those of the
corresponding adult population. However, to our best knowledge there has been no
direct comparison of the outcome of treatment for individual clinical manifestations
of Lyme borreliosis in pregnant and non-pregnant women of comparable age.
How Do I Manage Tick Bites and
Lyme Borreliosis in Pregnant Women?
Vera Maraspin ⭈ Franc Strle
Depar tment of Infectious Diseases, University Medical Center Ljubljana, Ljubljana , Slovenia
184 Maraspin ⴢ Strle
Information on the influence of borrelial infection on the fetus is also incomplete.
In general, circumstances in which an infection of a pregnant woman may have det-
rimental influence on the fetus include: (1) severe illness of the mother, associated
with circulatory instability and/or other harmful effects that subsequently damage
her fetus, (2) induction of immunological mechanisms and/or (3) production of tox-
ins that damage the fetus directly or indirectly through impairment of the placenta,
and/or (4) damage of the fetus by the microorganisms causing the illness in the preg-
nant woman either directly or indirectly through damage of the placenta. The pre-
requisite for the latter outcome is (hematogenous) dissemination of the causative
agent to the placenta and eventually to the fetus.
With the possible exception of complete atrioventricular block (which is a fairly
rare clinical manifestation), Lyme borreliosis in adults is not an acute life-threatening
illness causing circulatory instability [1, 2] . It has also never been known to induce
severe immune reactions or production of toxins, and thus does not detrimentally
influence the fetus in this mode [1, 2] . However, it is recognized that in Lyme bor-
reliosis patients, borreliae do enter the blood [1–7] , although it is less well established
precisely when in the course of the illness the dissemination begins, what the dura-
tion of this dissemination is, whether it is continuous or intermittent, and if it occurs
only during the initial illness or also later in the course of the disease.
The majority of patients with Lyme borreliosis present with erythema migrans, an
early clinical manifestation of the disease. Erythema migrans usually develops at the
site of a tick bite and consequent inoculation of the causative agent ( Borrelia burgdor-
feri sensu lato) into the skin. In some patients not (properly) treated for their erythe-
ma migrans, days to months later skin, neurologic, cardiac, joint and/or ocular man-
ifestations of Lyme borreliosis may appear; these are interpreted as the result of he-
matogenous dissemination of borreliae from the infected skin to other tissues or
organs [1, 2] . According to current information, the presence of B. burgdorferi sensu
lato in blood, as determined by culture, has been reported nearly exclusively in the
course of early Lyme borreliosis, i.e. in patients with solitary or multiple erythema
migrans, but – with a few exceptions indicated by individual case reports – not in
other manifestations of Lyme borreliosis [3–6] . In patients with erythema migrans,
blood-borne borreliae have been found more often (in up to 44%) [6] in the USA,
where the only known causative agent of Lyme borreliosis in humans is B. burgdorferi
sensu stricto [1, 2] , than in Europe (in 9% children and in 1.2% adults), where the pre-
dominant agent associated with erythema migrans is B. afzelii [1, 2, 4, 5] . Neverthe-
less, because of methodological dissimilarities, including the precise volume of blood
cultured for the presence of borreliae, the differences are not completely reliable and
should be interpreted with caution. Whereas the majority (up to 89%) of American
patients with erythema migrans and borreliae present in their blood had systemic
symptoms such as fatigue, arthralgia, myalgia, headache, fever and/or stiff neck [7] ,
the proportion of corresponding adult European patients with systemic symptoms
was much lower (7/35, 20%) [4] . Thus, at least in Europe, in a patient with solitary
Tick Bites and Lyme Borreliosis in Pregnant Women 185
erythema migrans, no reliable simple surrogate clinical indicator of the presence of
borreliae in blood is available. We were not able to find any systematic analysis on the
presence of blood-borne B. burgdorferi sensu lato in manifestations of Lyme borrelio-
sis other than in solitary and multiple erythema migrans. Thus, although the absence
of spirochetemia later in the course of Lyme borreliosis seems logical and is gener-
ally acknowledged, it is based on assumptions and is not supported by facts.
A lt houg h it i s we ll kn ow n t hat B. burgdorferi sensu lato may be present in the blood
early in the course of Lyme borreliosis, the consequences of this for the fetus are not
clear cut. It is recognized that in spirochetal diseases, such as syphilis, relapsing fever
and leptospirosis, the causative agents can pass transplacentally from the infected
mother to the offspring and cause an adverse outcome [8] . In Lyme borreliosis, in
utero transmission of B. burgdorferi sensu lato during pregnancy, resulting in fetal
involvement, has been reported in humans [9–12] and in animals such as cows, hors-
es, dogs and mice [13 –15] . Nevertheless, several reports of fetal involvement in hu-
mans are limited to the description of single cases, and in some articles the proof of
borrelial infection is rather vague by present standards.
Suggested Measures after a Tick Bite in a Pregnant Woman
Early Detection of the Attached Tick and its Prompt Removal
After returning from outdoor activities, pregnant women should make careful in-
spection of their entire body for attached ticks, and in Lyme borreliosis endemic areas
routine daily checking is warranted [16] .
The risk of transmission of borreliae increases with the duration of attachment;
therefore, prompt removal of the attached ticks is important in preventing the disease
[1, 2, 16] . The tick should be grasped with fine (sharply pointed) forceps as close as
possible to the poi nt of attachment and pu lled out with a steady mot ion d irected away
from the skin. Local disinfection is required [1, 2, 16] .
Testing Ticks for the Presence of B. burgdorferi sensu lato
Testing ticks for tick-borne infectious agents is not recommended, except in research
studies [16] .
Chemoprophylaxis with Antibiotics after a Tick Bite
Chemoprophylaxis after a tick bite has most probably been used extensively in every-
day clinical practice in several European countries and in the USA, in spite of the
186 Maraspin ⴢ Strle
absence of official general recommendations for such an approach. The prophylaxis
is most probably based on the belief that antimicrobial agents, given within a short
period after a tick bite, could eradicate an incubating borrelial infection and prevent
the illness. Data on the effectiveness of this measure are limited and mainly restrict-
ed to information from the USA. In several studies, the efficacy of prophylactic anti-
biotics, such as phenoxymethylpenicillin [17, 1 8] , doxycycline [19] or amoxicillin [20] ,
was not ascertained (theoretically, at least partly because the studies were statisti-
cally underpowered). However, a single dose of 200 mg doxycycline given within
72 h after tick detachment has been shown to prevent Lyme borreliosis in 87% (95%
CI: 25–98%) of individuals [21] . An expert panel of the Infectious Diseases Society of
America (IDSA) recently updated guidelines on the management of Lyme disease
(American Lyme borreliosis) [16] . According to IDSA, the routine use of prophylaxis
with antibiotics is not recommended, but a single dose of doxycycline ‘may be offered
when all of the following circumstances exist: (1) the attached tick can be reliably
identified as an adult or nymphal Ixodes scapularis tick that is estimated to have been
attached for 6 36 h on the basis of the degree of engorgement of the tick with blood
or of certainty about the time of exposure to the tick; (2) prophylaxis can be started
within 72 h of the time that the tick was removed; (3) ecologic information indicates
that the local rate of infection of these ticks with B. burgdorferi is 6 20%; (4) doxycy-
cline treatment is not contraindicated’. Because doxycycline is known to have several
adverse effects, including slowed bone growth, enamel hypoplasia, permanent yel-
lowing of the teeth and increased susceptibility to cavities in offspring, and occasion-
ally induces liver failure in pregnant women, it is contraindicated during pregnancy.
The panel ‘does not believe that amoxicillin should be substituted for doxycycline in
persons for whom doxycycline prophylaxis is contraindicated because of the absence
of data on an effective short-course regimen for prophylaxis, the likely need for a
multi-day regimen (and its associated side effects), the excellent efficacy of antibiotic
treatment of Lyme disease if infection were to develop, and the extremely low risk that
a person with a recognized bite will develop a serious complication of Lyme disease’
[16] . The reported findings on the effectiveness of prophylaxis with doxycycline are
valid for I. scapularis ticks and B. burgdorferi sensu stricto, and might not be the same
for other Ixodes or Borrelia species. The value of antibiotic prophylaxis is also restrict-
ed by potential side effects, and by the danger of inducing antimicrobial resistance as
a consequence of antibiotic overuse [2] . We therefore do not recommend antibiotic
prophylaxis in a pregnant woman after a tick bite.
Other Measures
The skin should be carefully observed for eventual development of erythema migrans
for at least a month after removal of a tick. If signs and symptoms of Lyme borreliosis
appear, prompt antibiotic treatment is warranted [1, 2, 2 2] .
Tick Bites and Lyme Borreliosis in Pregnant Women 187
Suggested Treatment of Lyme Borreliosis in Pregnant Women
Treatment with antibiotics is beneficial in all stages of Lyme borreliosis; however, its
effectiveness is highest in early disease [1, 2, 22] . Antibiotic therapy not only reduces
the duration of erythema migrans and alleviates and shortens associated symptoms,
but is also reasonably effective in preventing further progression of the illness.
Through early recognition and prompt treatment of erythema migrans, later mani-
festations of Lyme borreliosis can be effectively prevented [1, 2, 22] .
From the standpoint of the health of pregnant women, approaches for treatment
of Lyme borreliosis could be the same as those for nonpregnant women. However,
because of potential harmful effects on the fetus of some of the recommended anti-
biotics there are several restrictions, and it is probable that somewhat different ap-
proaches are warranted to ensure effective prevention and treatment of potential Bor-
relia infection of the placenta and/or the fetus.
In general, pregnant women, even more so than for other patients, should not be
given antibiotics without strong evidence of a bacterial infection. Use of any antibi-
otic during pregnancy should be based on whether benefits outweigh risk, which may
vary by trimester. The chosen antibiotic has to be effective in the treatment of infec-
tion, and safe for both the mother and the developing fetus. All antimicrobial agents
cross the placenta to some degree, enabling not only the possibility of effective anti-
biotic treatment, but also exposure of the fetus to the potentially adverse effect of the
drug. Taking into account the level of risk the drug poses to the fetus, the Food and
Drug Administration (FDA) has assigned drugs into categories A, B, C, D and X. Cur-
rently, there are no completely safe antibiotics for treatment in pregnancy (category
A – studies in pregnant women show no risk). Several antibiotics, including peni-
cillins, cephalosporins, erythromycin and some other macrolides, metronidazole,
monobactams and the majority of carbapenems, are classified as category B. These
drugs are thought to be relatively safe (animal studies show no risk, but human data
are insufficient; or animal studies show toxicity, but human data show no risk) and
are an appropriate choice for treatment in pregnancy. Among the less safe antimicro-
bial drugs belonging to FDA group C (animal studies show toxicity, human data are
insufficient, but clinical benefit may exceed risk) are antibiotics such as fluoroquino-
lones, some aminoglycosides, linezolid, telithromycin and teicoplanin. For use, risk
and benefits must be carefully evaluated. Among drugs that should be avoided (FDA
group D – there is evidence of human risk, but clinical benefits may outweigh the
risk), unless necessary for serious or life-threatening infections during pregnancy, are
tetracyclines, tigecycline, and some aminoglycosides.
However, for antibiotics that cross the placenta, not only their safety but also their
effectiveness must be considered. Dosages of drugs often need to be adjusted (usu-
ally increased) to accommodate changes deriving from physiologic alterations in
pregnancy.
188 Maraspin ⴢ Strle
For the treatment of Lyme borreliosis, antibiotics such as tetracyclines (usually
doxycycline), penicillins (including amoxicillin, penicillin V and penicillin G), sec-
ond-generation cephalosporins (cefuroxime axetil), third-generation cephalosporins
(ceftriaxone, cefotaxime) and some macrolides (predominantly for patients allergic
to  -lactam antibiotics) are usually recommended [1, 2, 16, 22] . Patients with (soli-
tary) erythema migrans are normally treated with oral antibiotics, whereas the main
indication for intravenous treatment is (potential) nervous system involvement [1, 2,
16, 22] . Recommendations for the treatment of gestational Lyme borreliosis are di-
verse. There is consensus that tetracyclines should be avoided during pregnancy and
that the antibiotics of choice are penicillins and cephalosporins, but there are dis-
agreements on several other issues. Some clinicians recommend treatment of gesta-
tional Lyme borreliosis with penicillins or cephalosporins determined by clinical
manifestation and severity of the infection. This usually consists of oral antibiotic
treatment for early localized Lyme borreliosis and intravenous treatment for early
disseminated and late disease, because of their impression that the actual risk of de-
velopment of congenital Lyme borreliosis is exceedingly low and that there is no need
for more aggressive treatment of gestational Lyme borreliosis [16] . Other clinicians,
concerned about (potential) transplacental spread of borreliae, recommend longer
[23] or more aggressive therapy such as intravenous antibiotic treatment for (all cases
of) gestational Lyme borreliosis [22, 23] . No investigation comparing the efficacy of
these 3 approaches (i.e. an approach similar to that used in the general population,
prolonged treatment, or more aggressive treatment) has been published. There are
also no reliable studies on the outcome of Lyme borreliosis after treatment with the
approach as used in the nonpregnant population, or with longer treatment using iden-
tical antibiotics, dosages and mode of application as used for the nonpregnant popu-
lation. The only published prospective study on treatment of Lyme borreliosis during
pregnancy is a report on 58 consecutively enrolled patients treated for gestational
erythema migrans with ceftriaxone 2 g daily for 14 days [24] and its extension with
the addition of 47 further patients [25] . According to these 2 reports, none of the 105
consecutive pregnant women so treated for erythema migrans developed any subse-
quent manifestation of Lyme borreliosis. The majority of them (93/105, 88.6%) gave
birth at term to healthy babies with normal later psychomotor development. The
other 12 (11.4%) pregnancies ended with abortion in 2 cases (1 missed abortion at 9
weeks, 1 spontaneous abortion at 10 weeks), preterm delivery in 6 cases (2 of these 6
babies died, 1 was established as having heart abnormality) and congenital abnor-
malities in 4 babies delivered at term (urinary tract abnormalities in 3, syndactylia in
1). A causative relationship with borrelial infection was not established in any of these
12 cases, and in several of them acceptable alternative explanations for the unfavor-
able outcomes were found [24, 25] .
Based on the encouraging results of these studies and in the absence of reliable in-
formation on the efficacy of other therapeutic approaches, we propose intravenous
antibiotic therapy, preferably with ceftriaxone 2 g daily for 14 days, for all gestational
Tick Bites and Lyme Borreliosis in Pregnant Women 189
Lyme borreliosis. This suggestion is offered because case reports, although rare, have
suggested that Lyme borreliosis during pregnancy may be associated with adverse
outcomes for the fetus [9–12] , and out of concern that neither the occurrence of trans-
placental dissemination nor the timing of such an occurrence during the acute infec-
tion can be accurately assessed.
Lactating patients may be treated in the same way as nonlactating patients with
the same disease manifestations, except that doxycycline should be avoided [16] .
C o n c l u s i o n s
We advocate early detection of attached ticks and their prompt removal. We do not
recommend the use of prophylactic antibiotics in pregnant women but support the
‘wait and watch’ strategy, including early treatment with antibiotics if signs/symp-
toms of the disease arise.
We encourage the approach that antibiotic treatment of pregnant patients is re-
stricted to those having a reliable clinical diagnosis of Lyme borreliosis, and propose
intravenous antibiotic treatment with penicillin, or preferably ceftriaxone 2 g daily
for 14 days, not only for patients with early disseminated disease but also for those
with solitary erythema migrans.
Lactating patients may be treated in the same way as nonlactating patients with
the same disease manifestations, except that doxycycline should be avoided.
References
1 Steere AC: Lyme disease. N Engl J Med 2001; 345:
115–125.
2 Stanek G, Strle F: Lyme borreliosis. Lancet 2003;
362: 1639–1647.
3 Nadelman RB, Pavia CS, Magnarelli LA, Wormser
GP: Isolation of Borrelia burgdorferi from the blood
of seven patients with Lyme disease. Am J Med
1990 ;
88: 21–26.
4 Maraspin V, Ružić-Sabljić E, Cimperman J, Lotrič-
Furlan S, Jurca T, Picken RN, Strle F: Isolation of
Borrelia burgdorferi sensu lato from blood of pa-
tients with erythema migrans. Infection 2001;
29:
65–70.
5 Arnez M, Ružić-Sabljić E, Ahcan J, Radsel-Med-
vescek A, Pleterski-Rigler D, Strle: Isolation of Bor-
relia burgdorferi sensu lato from blood of children
with solitary erythema migrans. Pediatr Infect Dis
J 2001;
20: 251–255.
6 Wormser GP, Bittker S, Cooper D, Nowakowsky J,
Nadelma n RB, Pavia C: Yield of l arge-volume blood
cultures in patients with early Lyme disease. J In-
fect Dis 2001;
184: 1070–1072.
7 Wormser GP, McKenna D, Carlin J, Nadelman RB,
Cavaliere LF, Holmgren D, Byrne DW, Nowakow-
ski J: Hematogenous dissemination in early Lyme
disease. Ann Intern Med 2005;
142: 751–755.
8 Taber LH, Feigin RD: Spirochetal infections. Pedi-
atr Clin North Am 1979;
26: 377–413.
9 Schlesinger PA, Duray PH, Burke SA, Steere AC,
Stillman MT: Maternal-fetal transmission of the
Lyme disease spirochete, Borrelia burgdorferi . Ann
Intern Med 1985;
103: 67–68.
10 Markowitz LE, Steere AC, Benach JL, Slade JD,
Broome CV: Lyme disease during pregnancy.
JAMA 1986;
255: 3394–3396.
11 MacDonald AB, Benach JL, Burgdorfer W: Still-
birth following maternal Lyme disease. NY State J
Med 1987;
87: 615–616.
190 Maraspin ⴢ Strle
12 Weber K, Bratzke HJ, Neubert U, Wilske B, Duray
PH: Borrelia burgdorferi in a newborn despite oral
penicillin for Lyme borreliosis during pregnancy.
Pediatr Infect Dis J 1988;
7: 286–289.
13 Burgess EC: Borrelia burgdorferi infection in Wis-
consin horses and cows. Ann NY Acad Sci 1988;
539: 235–243.
14 Gustafson J, Burges EC, Wachal MD, Steinberg H:
Intrauterine transmission of B. burgdorferi in dogs.
Am J Vet Res 1993;
54: 882–890.
15 Silver R, Yang L, Daynes R A, Branch DW, Salafia
CM, Weis JJ: Fetal outcome in murine Lyme dis-
ease. Infect Immun 1995;
63: 66–72.
16 Wormser GP, Dattwyler RJ, Shapiro ED, Halperin
JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS,
Strle F, Stanek G, Bockenstedt L, Fish D, Dumler S,
Nadelman R: The clinical assessment, treatment,
and prevention of Lyme disease, human granulo-
cyt ic anaplasmosis , and babesiosis : clinical pr actice
guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2006;
43: 1089–1134.
17 Costello CM, Steere AC, Pinkerton RJ, Feder HM
Jr: A prospective study of tick bites in an endemic
area for Lyme disease. J Infect Dis 1989;
159: 136–
139.
18 Agre F, Schwartz R: The value of early treatment of
deer tick bites for the prevention of Lyme disease.
Am J Dis Child 1993;
147: 945–947.
19 Korenberg EI, Vorobyeva NN, Moskvitina HG, Ya
Gorban L: Prevention of borreliosis in persons bit-
ten by infected ticks. Infection 1996;
24: 187–189.
20 Shapiro ED, Gerber MA, Holabird ND, Berg AT,
Feder HM Jr, Bell GL, Rys PN, Persing DH: A con-
trolled trial of antimicrobial prophylaxis for Lyme
disea se after deer-t ick bites. N Engl J Med 1992 ;
327:
1769–1773.
21 Nadelman RB, Nowakowski J, Fish D, Falco RC,
Freeman K, McKe nna D, Welch P, Marcus R, Agu e-
ro-Rosenfeld ME, Dennis DT, Wormser GP: Pro-
phylaxis with single-dose doxycycline for the pre-
vention of Lyme disease after an Ixodes scapularis
tick bite. N Engl J Med 2001;
345: 79–84.
22 Strle F: Principles of the diagnosis and antibiotic
treatment of Lyme borreliosis. Wien Klin Wochen-
schr 1999;
111: 911–915.
23 Gardner T: Lyme disease; in Remington JS, Klein
JO (eds): Infectious Diseases of the Fetus and New-
born Infant. Philadelphia, WB Saunders, 2001, pp
519– 641.
24 Maraspin V, Cimperman J, Lotric-Furlan S, Pleter-
ski-Rigler D, Strle F: Treatment of erythema mi-
grans in pregnancy. Clin Infect Dis 1996;
22: 788–
793.
25 Maraspin V, Cimperman J, Lotric-Furlan S, Pleter-
ski-Rigler D, Strle F: Erythema migrans in preg-
nancy. Wien Klin Wochenschr 1999;
111: 933–940.
Vera Maraspin, MD, PhD
Depar tment of Infectious Diseases, University Medical Center Ljubljana
Japljeva 2
SI–1525 Ljubljana (Slovenia)
Tel. +386 1 522 2110, Fax +386 1 522 2456, E-Mail vera.maraspin@kclj.si
Frequently Asked Questions about Lyme Borreliosis
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 191–199
A b s t r a c t
The most common cause of treatment failure is incorrect diagnosis. Most patients cured of Lyme
disease remain seropositive for long periods, and no laboratory test allows one to differentiate be-
tween cured and active infection. The first step is to check that the patient fulfils the diagnostic
criteria for Lyme disease and that the antibiotic regimen has been administered according to the
current recommendations. In the case of persistent arthritis after a first course of antibiotics, it is
generally recommended to give a second course of treatment with a different drug. Ceftriaxone
should be administered intravenously fo r arthritis that did not respond to previous oral therapy w ith
doxycycline or amoxicillin. Despite resolution of the objective manifestations of Lyme disease after
antibiotic treatment, a small proportion of patients still complain of subjective musculoskeletal
pain, fatigue, difficulties with concentration or short-term memory, or all these symptoms. Given
the risk of serious adverse events and the lack of efficacy, a consensus has emerged that repeated
courses of antibiotic therapy are not indicated for persistent subjective symptoms following Lyme
disease. The patient should be thoroughly examined for medical conditions that could explain the
symptoms. If a diagnosis is made for which no specific treatment can be proposed, emotional sup-
port and management of pain, fatigue and other symptoms is required.
Copy right © 2009 S. Karger AG , Basel
The persistence of complaints in a patient with a prior diagnosis of Lyme disease raises
a number of issues [1] : (1) The most common cause of treatment failure is incorrect di-
agnosis. Thus, in patients with chronic objective complaints, a lack of response to ther-
apy suggests above all the possibility of initial misdiagnosis and the need for prompt
reassessment rather than retreatment. (2) True persistent infection is a rare situation,
and persistence or progression of the disease has only been documented with the use of
lower-do se or shor ter-du rat ion ant ibiotic t her apy than is now rec ommend ed. The most
likely explanation is that the initial regimen was inappropriate due to insufficient tissue
What Should Be Done in Case of
Persistent Symptoms after Adequate
Antibiotic Treatment for Lyme Disease?
Xavier Puéchal a ⭈ Jean Sibilia b
a Service de Rhumatologie, Centre Hospitalier du Mans, Le Mans , et
b Service de Rhumatologie,
Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg , France
192 Puéchal ⴢ Sibilia
penetration or concentration of the antibiotic. Many such patients can be cured by a
longer duration or higher dose of antibiotics [2] . (3) Another possible explanation in
some situations is the long time lapse before achieving a complete cure. (4) Irreversible
tissue damage exists in some clinical situations, and can be misinterpreted in some pa-
tients as evolving Lyme disease. (5) Local immune reactivity to poorly degraded anti-
gens or evolution towards a ‘reactive’ or autoimmune process can explain persistent
arthritis in certain patients. (6) Although some patients relapse with objective symp-
toms despite an appropriate antibiotic regimen, very few with persisting complaints fall
into this category. It is generally recommended that a different drug, a longer duration
and/or a higher dose of a previous antibiotic be given for a second course of treatment.
There may have been inadequate penetration of the first drug to privileged sites where
the spirochetes reside, ‘resistance’, intracellular survival of the organism [1] or reinfec-
tion [3] . (7) Finally, in some individuals who have had Lyme disease, there have been
reports of subjective musculoskeletal complaints, fatigue and disorders of sleep. The
management of such patients will be discussed in the final section of this chapter.
The management of a patient with persistent symptoms of Lyme disease requires
this type of structured reasoning, bearing in mind that no laboratory test currently
available allows differentiation between cured and active infection and that most pa-
tients with cured Lyme disease remain seropositive for long periods. Specialist advice
is often necessary to explain the absence of a need for further antibiotic treatment
potentially involving significant side effects and costs.
After having checked that the patient fulfils the international diagnostic criteria
for Lyme disease and that the antibiotic regimen has been administered according to
the actual recommendations, the management of these patients varies according to
the clinical features.
Persistent Cutaneous Manifestations of Early Lyme Disease
Natural Evolution of Erythema Migrans
The cutaneous symptoms of the early manifestations of Lyme borreliosis may last
several weeks after the end of an appropriate antibiotic regimen. This delay should
not be interpreted as a treatment failure.
Management
In this clinical setting, there is no need to extend the duration of antibiotic treatment
or to give an additional antibiotics [4] . However, if lesions persist more than 3 months
after the end of treatment, the diagnosis of erythema migrans should be reconsid-
ered. A cutaneous biopsy is then indicated.
Persistent Symptoms after Adequate Antibiotic Treatment 193
Persistent Arthritis
Natural Evolution of Arthritis
The natural evolution of Lyme arthritis has been documented in historical cohorts
before the use of antibiotics [5, 6] . Lyme arthritis, which had a tendency to persist dur-
ing the second and third years of the disease [7] , finally healed after a few years despite
the absence of antibiotic therapy [7, 8] .
In patients with arthritis, clinical recovery typically coincides with antibiotic ther-
apy. In a cost-effectiveness analysis, Magid et al. [9] found that oral doxycycline was
effective in 70% of cases and intravenous ceftriaxone in 50%. Despite antibiotic treat-
ment, joint swelling persists for some months to a few years in about 10% of adults
with Lyme arthritis [5, 6, 10] and may be associated with bone and cartilaginous dam-
age. Refractory Lyme arthritis is defined as chronic persistent arthritis sometimes
with destructive changes, and with no improvement after at least a 2-month course
of antibiotic therapy.
Management
In the case of persistent arthritis after a first course of antibiotics, it is generally rec-
ommended to give a second course of treatment with a different drug. Ceftriaxone
should be administered intravenously for arthritis that did not respond to previous
oral therapy with doxycycline or amoxicillin.
In the case of non-response despite correct diagnosis and antibiotic treatment, it is
important for the clinician to document evidence of inflammation and consider other
causes of arthralgia or arthritis. Non-inflammatory joint pain after Lyme disease is
not Lyme arthritis. Quadriceps femoris muscle atrophy can result from Lyme arthritis
and may cause mechanical patellofemoral joint dysfunction and pain. In this case,
physiotherapy should restore normal quadriceps tone. Mechanical pain may also re-
sult from long-standing arthritis with subsequent cartilage damage, and analgesics or
nonsteroidal anti-inflammatory drugs (NSAID) can improve the pain and function.
Polymerase Chain Reaction Analysis
At this stage, an arthrocentesis should be performed to confirm the synovial inflam-
mation and allow synovial fluid to be studied by PCR analysis with specific primers.
When possible, a synovia l tissue biopsy should be analyzed since it is a more sensitive
medium than synovial fluid for the PCR detection of Borrelia burgdorferi .
The persistence of organisms or of some of their antigens may be crucial for the
perpetuation of a local inflammatory reaction. B. burgdorferi DNA can be detected
194 Puéchal ⴢ Sibilia
by PCR in the synovial fluid of up to 96% of patients with Lyme arthritis having re-
ceived no treatment or only short courses of oral antibiotics [11] . Its detection is less
frequently successful in patients who had received previous antibiotic therapy, and
even more rare in patients with chronic refractory Lyme arthritis after several cours-
es of antibiotics. The mechanisms of treatment resistance in Lyme arthritis remain
controversial. The theory of intra-articular survival of bacteria opposes that of the
induction of a self-perpetuating autoreactive reaction by cross-reactivity between
certain bacterial antigens and host components.
When PCR gives a positive result for B. burgdorferi , another course of antibiotic treat-
ment should be given using a drug different from the one previously prescribed. Local
treatment should be proposed if the PCR results are negative. This strategy generally
cures the joint inflammation, although it does not always prevent cartilage damage.
Intra-Articular Corticosteroid Injections
In chronic Lyme arthritis, intra-articular corticosteroids are useful to immediately
relieve a symptomatic joint effusion [8, 12, 13] . Nevertheless, since a few studies have
provided weak methodological evidence of a deleterious effect, it would seem advis-
able not to carry out articular injections before or during antibiotic therapy. Injec-
tions are recommended for patients whose joint effusion persists after antibiotic
treatment [12] or despite 2 courses of oral therapy or 1 course of IV therapy antibiot-
ics [13] . Some authors [7, 8, 14] argue that injections should only be performed after
having checked that PCR results in the joint fluid are negative.
Chemical or Radiation Synovectomy
A few isolated case reports have pointed to the efficacy of chemical (osmic acid) or
radiation synovectomy (rhenium, yttrium) in refractory Lyme arthritis [15] . Radia-
tion synovectomy may be indicated in persistent synovitis after antibiotics and before
a surgical procedure. Further studies will be necessary to address its role in the local
therapeutic arsenal. Chemical or radiation synovectomy is not at present mentioned
in the IDSA (Infectious Diseases Society of America) recommendations [13] .
Arthroscopic Synovectomy
Arthroscopic synovectomy can reduce the period of joint inf lammation when persis-
tent synovitis is associated with significant pain or limited function [8, 13] . Several
authors recommend opting for this procedure only when the synovitis persists after
2 months of antibiotics and the PCR joint test is negative [7] . On the other hand, ar-
Persistent Symptoms after Adequate Antibiotic Treatment 195
throscopic synovectomy remains a matter of debate in refractory Lyme arthritis giv-
en its inconstant efficacy [16] and the possibility of postoperative sequelae [17] , par-
ticularly in childhood [4] . These aspects are to be considered in the light of the spon-
taneous favorable outcomes of most cases of Lyme arthritis after a few years, even
without antibiotic therapy.
Disease Modifying Anti-Rheumatic Drugs
Hydroxychloroquine has been described to be of some benefit [8] , but this has not
been confirmed [12] . Disease-modifying anti-rheumatic drugs used in reactive ar-
thritis, such as methotrexate or sulfasalazine, have not been evaluated in appropriate
studies of refractory Lyme arthritis.
Systemic Corticosteroids
There are concordant experimental data showing that systemic corticosteroids are
deleterious and their use is not indicated in Lyme disease.
Nonsteroidal Anti-Inflammatory Drugs
NSAID are often prescribed for their non-specific symptomatic effects [5, 10] . Symp-
tomatic treatment with NSAID is recommended in the case of persistent arthritis [13] .
In summary, after a second course of antibiotic therapy for refractory Lyme arthri-
tis, negative PCR results for synovial fluid generally indicate removal of synovial
fluid and local injection of long-term corticosteroids. Analgesics and NSAID are also
useful. In the case of failure or relapse after a few weeks, another injection may be
performed. On the other hand, one should give an additional course of antibiotics ac-
cording to the usual recommendations [4, 13] if the PCR results are positive. In the
very rare instance of relapse after this therapy, radiation or mechanical synovectomy
should be discussed. The outcome is usually favorable.
Persistent Neurological Symptoms
Natural Evolution of Neuroborreliosis
In the majority of patients with early neuroborreliosis, the pain intensity diminishes
markedly after 1–4 days [18] . After an average of 1–2 months and up to 12 months of
196 Puéchal ⴢ Sibilia
treatment for early neuroborreliosis, 20% of patients still complain of intermittent
radicular pain and dysesthesia. A mean period of 7–8 weeks is required for complete
recovery of motor deficits [19] . Significant disabling sequelae are mainly reported in
patients with central nervous system involvement, although some individuals with
motor weakness may display residual deficits after treatment, such as mild seventh
nerve palsy. Sensory complaints may also persist [18] .
In patients with long-lasting meningitis or chronic encephalomyelitis, the onset of
improvement after therapy is slower, but nevertheless marked [18] .
Management
Patients whose condition does not improve after appropriate antibiotic therapy may
have irreversible damage to the nervous system, particularly if the prior disease has
been of long duration. There is no evidence in the literature to support additional an-
tibiotic treatment in patients with persistent neurological symptoms after an ade-
quate first course of antibiotics. Nevertheless, as the equivalence of tetracyclines and
ceftriaxone remains to be established, a course of ceftriaxone should be administered
to patients previously treated with oral drugs. In the event of relapse after a 2-week
course of intravenous ceftriaxone, the most likely explanation is failure to complete-
ly eradicate the spirochete, and a 1-month course usually leads to improvement [20] .
Analgesics and medications used for neuropathic pain are often useful. Systemic cor-
ticosteroids have been proposed to obtain analgesia more quickly [21] , but this treat-
ment cannot be recommended on account of the low level of supporting evidence and
possible deleterious effects.
Persistent Fatigue Immediately after Treatment of Lyme Disease
Up to 10% of patients with Lyme disease in some endemic areas are coinfected with
babesiosis (due to Babesia microti ) [22] . Other tick-transmitted zoonoses such as hu-
man granulocytic ehrlichiosis (rickettsiosis due to Anaplasma phagocytophilum ) also
occur in areas where these 2 pathogens are endemic.
Patients with Lyme disease and laboratory evidence of coinfection with babesiosis
are more likely to present constitutional symptoms (e.g. fatigue, headache, sweats,
chills) than patients with isolated Lyme disease [22] . Persistent and debilitating fa-
tigue is characteristic of coinfection. Persistent symptoms lasting for 3 months or
more, among which fatigue is the most common, are encountered in half of coinfect-
ed patients, but are very unusual (4%) in individuals with isolated Lyme disease. Se-
rologic testing for babesiosis should be performed in patients with fatigue persisting
for more than 2 months after a history of Lyme disease. Anti-babesial therapy consists
of clindamycin and quinine. It should be pointed out that coexposure to B. burgdor-
Persistent Symptoms after Adequate Antibiotic Treatment 197
feri and Babesia microti does not worsen the long-term outcome of Lyme disease [23] .
Patients examined years after coinfection do not display any differences in regard to
the prevalence of constitutional, musculoskeletal or neurological complaints as com-
pared to those affected by isolated Lyme disease. There is thus no reason to search for
coinfection in patients with symptoms persisting years after Lyme disease.
A search for dual infection with the agents of Lyme borreliosis and human granu-
locytic ehrlichiosis cannot be recommended for persistent symptoms following Lyme
disease because it remains to be determined whether this coinfection may result in
more prolonged disease than infection with either agent alone [24] .
Persistent Subjective Symptoms after Treatment of Lyme Disease
Despite resolution of the objective manifestations of Lyme disease after antibiotic
treatment, a small proportion of patients still complain of subjective musculoskeletal
pain, fatigue, difficulties with concentration or short term memory, or all these symp-
toms [25] .
Natural Evolution of Lyme Disease
In prospective studies of patients with erythema migrans, subjective symptoms were
present 1 year or more after treatment in 0.5–13.1% of cases [26] . Whether this prev-
alence exceeds that of such symptoms in the general population is unknown, since
none of these studies included a control group [25] . Moreover, nearly 40% of these
patients with subjective symptoms following Lyme disease had a positive response to
placebo [27] .
Several lines of evidence suggest that symptoms occurring after Lyme disease are
not caused by an active occult infection of the central nervous system [4, 25] . There
is no inflammation in the cerebrospinal f luid [27, 28] , the results of both cultures and
PCR assays for B. burgdorferi in the cerebrospinal fluid are negative [27] , there are no
structural abnormalities of the brain parenchyma, neurological function is normal
and antibiotic treatment has no effect (as compared to placebo) on cognitive function
[28, 29] .
Management
Three double-blind randomized placebo-controlled studies have shown that there is
a substantial risk, with little or no benefit, associated with additional antibiotic treat-
ment in patients who have long-standing subjective symptoms after appropriate ini-
tial treatment of Lyme disease [27–29] . Given the risk of serious adverse events, a con-
198 Puéchal ⴢ Sibilia
sensus has emerged that repeated courses of antibiotic therapy are not indicated for
persistent subjective symptoms following Lyme disease, including those related to
fatigue and cognitive dysfunction [28] .
The patient should be thoroughly examined for medical conditions which could
explain the symptoms [25] . The scientific evidence against the concept of chronic
Lyme disease should be discussed, and the patient should be informed about the risk
of unnecessary antibiotic therapy. If a diagnosis is made for which no specific treat-
ment can be proposed, emotional support and management of pain, fatigue and oth-
er symptoms are required [25] .
References
1 Si gal LH: Persisti ng complaints attr ibuted to chron-
ic Lyme disease: possible mechanisms and implica-
tions for management. Am J Med 1994;
96: 365–374.
2 Steere AC, Hutchinson GJ, Rahn DW, Sigal LH,
Craft JE, DeSanna ET, et al: Treatment of the early
manifestations of Lyme disease. Ann Intern Med
1983;
99: 22–26.
3 Krause PJ, Foley DT, Burke GS, Christianson D,
Closter L, Spielman A; Tick-Borne Disease Study
Group: Reinfection and relapse in early Lyme dis-
ease. Am J Trop Med Hyg 2006;
75: 1090–1094.
4 SPILF: 16ème conférence de consensus en thérapie
anti-infectieuse. Borréliose de Lyme: démarches
diagnostiques, thérapeutiques et préventives.
http://www.infectiologie.com/site/medias/_
documents/consensus/2006-lyme-long.pdf
5 Steere AC, Schoen RT, Taylor E: The clinical evolu-
tion of Lyme arthritis. Ann Intern Med 1987;
107:
725–731.
6 Szer IS, Taylor E, Steere AC: The long-term course
of Lyme arthritis in children. N Engl J Med 1991;
325: 159 –163.
7 Steere AC: Diagnosis a nd treatment of Lyme ar thri-
tis. Med Clin North Am 1997;
81: 179–194.
8 Steere AC, Levin RE, Molloy PJ, Kalish RA, Abra-
ham JH 3rd, Liu NY, Schmid CH: Treatment of
Lyme arthritis. Arthritis Rheum 1994;
37: 878–888.
9 Magid D, Schwartz B, Craft J, Schwartz JS: Preven-
tion of Lyme disease after tick bites: a cost-effec-
tiveness analysis. N Engl J Med 1992;
327: 534–541.
10 Steere AC, Green J, Schoen RT, Taylor E, Hutchin-
son GJ, Rahn DW, Malawista SE: Successful paren-
teral penicillin therapy of established Lyme arthri-
tis. N Engl J Med 1985;
312: 869–874.
11 Nocton JJ, Dressler F, Rutledge BJ, Rys PN, Persing
DH, Steere AC: Detection of Borrelia burgdorferi
DNA by polymerase chain react ion in synovial f lu-
id from patients with Lyme arthritis. N Engl J Med
1994;
330: 229–234.
12 Cimmino MA, Moggiana GL, Parisi M, Accardo S:
Treatment of Lyme arthritis. Infection 1996;
24: 91–
93.
13 Wormser GP, Nadelman RB, Dattwyler RJ, Dennis
DT, Shapiro ED, Steere AC, Rush TJ, Rahn DW,
Coyle PK, Persing DH, Fish D, Luft BJ: Practice
guidelines for the treatment of Lyme disease. The
Infectious Diseases Society of America. Clin Infect
Dis 2000;
31(suppl 1):1–14.
14 Sood SK, Ilowite NT: Lyme arthritis in children: is
chronic arthritis a common complication? J Rheu-
matol 2000;
27: 1836–1838.
15 Limbach FX, Jaulhac B, Puéchal X, Monteil H,
Kuntz JL, Piemont Y, Sibilia J: Treatment resistant
Lyme arthritis caused by Borrelia garinii. Ann
Rheum Dis 2001;
60: 284–286.
16 Benta s W, Karch H, Huppertz H I: Lyme arthr itis in
children and adolescents: outcome 12 months after
initiation of antibiotic therapy. J Rheumatol 2000;
27: 2025–2030.
17 Steere AC, Gibofsky A, Patarroyo ME, Winchester
RJ, Hardin JA, Malawista SE: Chronic Lyme art hri-
tis: clinical and immunogenetic differentiation
from rheumatoid arthritis. Ann Intern Med 1979;
90: 896–901.
18 Hansen K, Lebech AM: The clinical and epidemio-
logical profile of Lyme neuroborreliosis in Den-
mark 1985–1990: a prospective study of 187 pa-
tients with Borrelia burgdorferi specif ic intrathecal
antibody production. Brain 1992;
115: 399–423.
19 Pachner AR, Steere AC: The triad of neurologic
manifestations of Lyme disease: meningitis, cranial
neuritis, and radiculoneuritis. Neurology 1985;
35:
47–53.
20 Logigian EL, Kaplan Steere AC: Chronic neurolog-
ic manifestations of Lyme disease. N Engl J Med
1990 ;
323: 1438–1444.
Persistent Symptoms after Adequate Antibiotic Treatment 199
21 Pfister HW, Einhäupl KM, Franz P, Garner C: Cor-
ticosteroids for radicular pain in Bannwarth’s syn-
drome: a double-blind, randomized, placebo-con-
trolled trial. Ann NY Acad Sci 1988;
539: 485–487.
22 Krause PJ, Telford SR 3rd, Spielman A, Sikand V,
Ryan R, Christianson D, et al: Concurrent Lyme
disease and babesiosis: evidence for increased se-
verity and duration of illness. JAMA 1996;
275:
1657–1660.
23 Wang TJ, Liang MH, Sangha O, Phillips CB, Lew
RA, Wright EA, et al: Coexposure to Borrelia burg-
dorferi and Babesia microti does not worsen the
long-term outcome of Lyme d isease. Cli n Infect Dis
2000;
31: 1149–1154.
24 Nadelman RB, Horowitz HW, Hsieh TC, Wu JM,
Aguero-Rosenfeld ME, Schwartz I, et al: Simulta-
neous human granulocytic ehrlichiosis and Lyme
borreliosis. N Engl J Med 1997;
337: 27–30.
25 Feder HM Jr, Johnson BJ, O’Connell S, Shapiro ED,
Steere AC, Wormser GP; Ad Hoc International
Lyme Disease Group, et al: A critical appraisal of
‘chronic Lyme disease’. N Engl J Med 2007;
357:
1422–1430.
26 Shapiro ED, Dattwyler R, Nadelman RB, Wormser
GP: Response to meta-analysis of Lyme borreliosis
symptoms. Int J Epidemiol 2005;
34: 1437–14 39.
27 Klempner MS, Hu LT, Evans J, Sch mid CH, Johnson
GM, Trevino RP, et al: Two controlled trials of an-
tibiotic treatment in patients with persistent symp-
toms and a history of Lyme disease. N Engl J Med
2001;
345: 85–92.
28 Krupp LB, Hyman LG, Grimson R, Coyle PK, Mel-
vil le P, Ahnn S, Dat twyler R , Chandler B: Study a nd
treatment of post Lyme disease (STOP-LD): a ran-
domized double masked clinical trial. Neurology
2003;
60: 1923–1930.
29 Kaplan RF, Trevino RP, Johnson GM, Levy L,
Dornbush R, Hu LT, et al: Cognitive function in
post-treatment Lyme disease: do additional antibi-
otics help? Neurology 2003;
60: 1916–1922.
Xavier Puéchal, MD, PhD
Service de Rhumatologie, Centre Hospitalier du Mans
194, avenue Rubillard
FR–72037 Le Mans Cedex 9 (France)
Tel. +33 2 43 43 26 56, Fax +33 2 43 43 28 10, E-Mail xpuechal@ch-lemans.fr
Frequently Asked Questions about Lyme Borreliosis
Lipsker D, Jaulhac B (eds): Lyme Borreliosis.
Curr Probl Dermatol. Basel, Karger, 2009, vol 37, pp 200–206
A b s t r a c t
Lyme neuroborre liosis (LNB) is a tick-borne disease of the nervous system, caused by the spirochete
Borrelia burgdorferi . Having entered the host at the site of the tick bite, the spirochetes can initially
cause a local inflammatory reaction, called er ythema migrans. If left untreated, the Borrelia can dis-
seminate in the second stage of the disease and invade the central nervous system, causing LNB.
The diagnosis of LNB is based on a compatible clinical picture (meningitis, cranial neuritis or radicu-
loneuritis), lymphocytic pleocytosis in the cerebrospinal fluid (CSF) and intrathecal Borrelia burg-
dorferi -specific antibody production. As the clinical picture of LNB may be unspecific, a lumbar
puncture to analyze the CSF is usually mandatory for confirmation of the suspected diagnosis. The
indications for a lumbar puncture and the limitations of the different diagnostic procedures are the
main topics of this review. In addition, a short overview of the epidemiology and the therapeutic
principles of LNB is given. Co pyright © 2009 S. Karge r AG, Basel
Lyme borreliosis is the most common human tick-borne disease in the northern
hemisphere. The prevalence is estimated to be 20–100 cases per 100,000 people in the
USA and about 100–130 cases per 100,000 in Europe [1, 2] . It is caused by the spiro-
chete Borrelia burgdorferi sensu lato. B. burgdorferi can be divided into 4 human
pathogenic species: B. burgdorferi sensu stricto (the only human pathogenic species
present in the USA), B. afzelii , B. garinii and B. spielmanii [3] . The infection by B. burg-
dorferi is a complex process beginning with the transition from the gut to the salivary
glands of the tick during the feeding process on the host. After invasion into the skin,
B. burgdorferi can cause a local infection called erythema migrans. During the sec-
ond stage of Lyme disease, B. burgdorferi can spread from the site of the tick bite on
the skin to various secondary organs throughout the body, including the heart, joints,
and the peripheral and central nervous systems (CNS) [4] .
What Are the Indications for Lumbar
Puncture in Patients with Lyme Disease?
Tobias A. Rupprecht ⭈ Hans-Walter Pfister
Depar tment of Neurology, Ludwig-Maximilians Universit y, Munich , Germany
Lumbar Puncture in Lyme Borreliosis 201
Lyme Neuroborreliosis
Up to 10% of untreated erythema migrans patients in Europe develop a borrelial in-
fection of the nervous system, called Lyme neuroborreliosis (LNB) [2] . The most fre-
quent manifestation of LNB in Europe is meningoradiculitis, the so-called Garin-
Bujadoux-Bannwarth’s syndrome (GBBS) [5] . It is characterized by intense lancinat-
ing radicular pain especially at night, paresis of the cranial nerves (for example the
facial or the abducens nerve) or the extremities, and inflammatory cerebrospinal
fluid (CSF) changes. In GBBS, the most frequent species isolated from the CSF is B.
garinii [6, 7] . In parallel, GBBS rarely occurs in the USA, where B. burgdorferi sensu
stricto but not B. garinii is found, and instead meningitis is the predominant neuro-
logical manifestation, suggesting a certain organotropism of the different genospecies
[8] . In contrast to its frequency in adults, GBBS is rather rare in children, occurring
in less than 5% of the patients with neuroborreliosis. The most common manifesta-
tions in children with neuroborreliosis are acute facial nerve palsy (55% of patients)
and lymphocytic meningitis (27%) [9] . Apart from GBBS and lymphocytic meningi-
tis, other neurological manifestations of Lyme borreliosis during stage II are cranial
neuritis, plexus neuritis, mononeuritis multiplex, and, rarely, acute encephalitis and
myelitis [4, 8] . In contrast to the acute form of LNB, chronic neuroborreliosis is a rare
manifestation, so far only observed months to years after infection in untreated pa-
tients. It mainly includes chronic progressive encephalomyelitis and cerebral vascu-
litis. Furthermore, acrodermatitis chronica atrophicans may be associated with axo-
nal polyneuropathy in about 40% of patients [10] .
Diagnosis of LNB: When Is a Lumbar Puncture Indicated?
The diagnosis of a nervous system infection with B. burgdorferi is based on a clinical
picture compatible with LNB, lymphocytic pleocytosis in the CSF and intrathecal B.
burgdorferi -specific antibody production ( table 1 ) [10] . Therefore, the analysis of the
CSF is mandatory for a reliable diagnosis.
However, when is a lumbar puncture indicated in patients with a borrelial infec-
tion and when should a LNB be suspected? There are several arguments to be consid-
ered:
Should Every Patient with a Local or Systemic Infection with B. burgdorferi
Undergo a Lumbar Puncture?
Patients with a local or systemic infection with B. burgdorferi – either with a derma-
tologic manifestation, like erythema migrans, lymphocytoma or acrodermatitis
chronica atrophicans, or an extracutaneous finding, like carditis or arthritis – do not
202 Rupprecht ⴢ Pfister
need a routine lumbar puncture, as long as they do not have clinical signs of central
or peripheral nervous system involvement. Only patients with neurological symp-
toms and signs compatible with LNB should undergo a lumbar puncture.
Are There Certain Constellations Where the Presence of Serum Antibodies Is
Sufficient for the Diagnosis of LNB?
The combination of radicular signs and B. burgdorferi -specific antibodies in the se-
rum is not sufficient for the definite diagnosis of LNB. Positive B. burgdorferi -spe-
cific antibodies can be detected in the serum of 5–25% of healthy persons [11] . There-
fore, an analysis of the serum alone is insufficient, and would lead to a high rate of
false-positive diagnoses. There might be the exception of a patient with characteristic
GBBS, presenting with lancinating pain exacerbated at night and, for example, a facial
palsy and a tick bite or even an erythema migrans in the recent history, where one has
sufficient arguments for LNB. However, a lumbar puncture would be recommended
even in this case, as only the CSF analysis can confirm the suspected diagnosis and
exclude differential diagnoses.
Does the Detection of B. burgdorferi -Specific IgM Antibodies Indicate an Acute
Infection with B. burgdorferi ?
In contrast to many other microbial infections, B. burgdorferi -specific IgM antibod-
ies do not necessarily indicate an acute infection. These IgM antibodies can persist
for years, and even after sufficient antibiotic therapy [12] . Therefore, only an inf lam-
matory reaction in the CSF (i.e. lymphocytic pleocytosis) documents the active infec-
Tab le 1. Diagnostic criteria of LNB
Possible neuroborreliosis
Typical clinical features (e.g. meningitis, meningoradiculitis, cranial nerve deficits)
B. burgdorferi-specific IgG and/or IgM serum antibodies
CSF findings not available/lumbar puncture not performed
Probable neuroborreliosis
Criteria of possible neuroborreliosis plus:
Inflammatory CSF changes (lymphocytic pleocytosis, elevated protein content, intrathecal
IgG antibody production)
Exclusion of other causes
Definite (proven) neuroborreliosis
Criteria of probable neuroborreliosis plus:
Intrathecal B. burgdorferi-specific antibody production (and/or positive culture or PCR)
Lumbar Puncture in Lyme Borreliosis 203
tion and helps to distinguish acute infectious causes from previous neuroborreliosis
(as the B. burgdorferi -specific antibodies might only be an indicator of an earlier, cur-
rently not active, borrelial infection) [10] . On the other hand, the lack of serum or CSF
B. burgdorferi -specific IgM antibodies does not contradict a very recent primary in-
fection, as IgM-antibodies might be absent in early stages of the disease and do not
have to precede the production of B. burgdorferi -specific IgG antibodies [12] . Taken
together, the presence or absence of B. burgdorferi -specific IgM antibodies in the se-
rum neither proves nor excludes an acute infection. Therefore, the measurement of
IgM antibodies is not a substitute for a lumbar puncture.
In conclusion, the only method to prove the diagnosis of acute LNB is the analysis
of the CSF. Lumbar puncture is indicated in every patient with a clinical picture com-
patible with LNB and no otherwise obvious causes, even in the absence of other man-
ifestations of borreliosis or a documented tick bite. Many tick bites may have occurred
without being noticed and the involvement of organs other than the brain could have
passed unrecognized. Even negative serum antibodies do not exclude a LNB in early
phases of infection, as the immune reaction in the CSF might precede the production
of antibodies in the blood. Up to now, no blood parameter has been found that could
replace CSF analysis.
Analysis of the CSF
The CSF has to be analyzed for several factors. First, the inflammatory reaction of the
CNS has to be documented. A minimal routine analysis, including the count and dif-
ferentiation of the CSF leukocytes, the total amount of CSF protein and the CSF-to-
serum glucose ratio, is mandatory. Patients with acute LNB generally have moderate,
lymphocytic pleocytosis (30–1,000 cells/mm
3 ), a moderate to severely disturbed
blood-brain barrier (resulting in an increased total CSF protein of up to several hun-
dred mg/dl), and a normal CSF-to-serum glucose ratio [5] . Additional parameters are
the CSF albumin-, IgM-, IgG-, and IgA-to-serum ratio and the presence of oligoclonal
IgG bands. Obtaining these further data can aid in the interpretation of borderline
values of the routine analysis.
The Borrelia -specificity of the infection can be detected in several ways. The most
common method is to calculate the CSF-to-serum antibody index (AI) [5] . This
Borrelia AI is the ratio of B. burgdorferi -specific CSF-to-serum antibodies and the
CSF-to-serum ratio of albumin or IgG. It allows discrimination between elevated CSF
B. burgdorferi -specific antibodies caused by a passive transfer due to a blood-CSF
barrier dysfunction and those caused by intrathecal production. In contrast to this
diagnostic gold standard, the cultivation of B. burgdorferi from the CSF is possible in
only 10–15% of patients with GBBS in specialized laboratories [13] . A similar diag-
nostic yield can be achieved by PCR analysis to detect B. burgdorferi DNA in the
CSF.
204 Rupprecht ⴢ Pfister
A promising diagnostic marker for the future might be the chemokine CXCL13,
which was found to be highly elevated in the CSF of LNB patients, but not in other
inflammatory and noninf lammatory CNS diseases [14] . In contrast to B. burgdorferi -
specific antibodies, which are found to be absent in 20–30% of cases in the first 2
weeks, CXCL13 was already highly elevated in early stages [15] . Finally, its concentra-
tion quickly decreases during therapy [14] , making it a promising tool for differentia-
tion between an active or an earlier infection. However, the sensitivity and specificity
of CXCL13 has to be evaluated in further prospective studies, and it can therefore not
yet be recommended for routine analysis.
On the other hand, there are several further laboratory methods that have not been
validated in adequate clinical studies, even though they are already used by some cli-
nicians in the diagnostic workup. Among them are antigen detection from body flu-
ids other than the serum or CSF, PCR of serum or urine, the lymphocytic transfor-
mation test, and the so-called ‘visual contrast sensitivity test’ [10] . All these tests are
not suitable for the diagnosis of LNB, and therefore cannot be recommended.
Differential Diagnoses
Several differential diagnoses of LNB have to be considered. The intense radicular
pain of BS can be mistaken for a herniated disc or herpes zoster. While the first war-
rants a CT or MRI scan of the spine, the latter (apart from the typical rash) would
result in moderate lymphocytic CSF pleocytosis, just as LNB but without the finding
of intrathecal B. burgdorferi -specific antibody production. In cases with a predomi-
nant meningitis, other forms of meningeal infection or inflammation have to be ex-
cluded – among them viral meningitis, carcinomatous meningitis, neurosarcoidosis,
fungal meningitis, and other spirochetal infections such as syphilis, leptospirosis and
relapsing fever. These differential diagnoses have to be discriminated by microbio-
logical and/or serological methods as the extent of the CSF pleocytosis can be similar
to LNB. The facial palsy requires diagnostic differentiation from Guillain-Barré syn-
drome, Miller-Fisher syndrome and Bell’s palsy. These entities can be distinguished
from LNB by the lack of an elevated CSF cell count, while they can have similarly el-
evated total CSF protein resulting from a disturbance in the blood-brain barrier. Fi-
nally, chronic progressive Lyme encephalomyelitis has to be differentiated from mul-
tiple sclerosis. This can be a diagnostic challenge as the clinical picture in both dis-
eases may be very similar, and both might lead to increased signal intensity of
periventricular distribution on T
2 -weighted MRI scans. However, the CSF pleocyto-
sis is most ly higher in pat ients w ith LN B ( 1 30 cells/ l), and the absence of intrathecal
B. burgdorferi -specific antibody production as well as a relapsing-remitting course of
the disease would exclude a chronic neuroborreliosis. Taken together, only a CSF
analysis can reliably differentiate between all these diagnoses, and this further un-
derlines the value of the lumbar puncture in the diagnostic workup of LNB.
Lumbar Puncture in Lyme Borreliosis 205
Therapeutic Principles
In contrast to the sometimes challenging diagnostic workup, the therapy is rather
straightforward. The standard treatment of LNB is ceftriaxone 2 g/day for 2–3 weeks,
the latter being recommended for chronic cases [10] . Doxycycline is an alternative in
early LNB especially in case of cephalosporin allergy [16] . Though there are no con-
trolled studies comparing different dosages, 300 mg/day might be necessary in view
of the low blood-brain barrier penetration of this agent.
When Is a Repeat Lumbar Puncture Indicated?
A repeat puncture is not necessary in patients who become free of symptoms within
days to weeks during/after antibiotic therapy. A progression of the infection after ad-
equate antibiotic therapy hardly ever occurs. Symptoms evolving the first time after
adequate therapy are merely due to reinfection or other non- Borrelia associated causes,
rather than representing ongoing infection. A repeat puncture is indicated in suspect-
ed treatment failures or relapses. On the one hand, it reveals the course of the inflam-
matory CNS response. A decrease or normalization of the CSF cell count indicates an
adequate treatment response. In case of a persistent clinical syndrome, there might be
either irreversible defects independent of the microbiological cure (as the radicular
symptoms in LNB are not always reversible [5, 17] ), or other noninflammatory reasons
are responsible for the clinical picture. It is of note, however, that the normalization of
the CSF cell count might take weeks to sometimes months; therefore, a regression of
the CSF pleocytosis without normalization within 6 months after treatment does not
necessarily indicate a treatment failure and has to be interpreted cautiously. The pre-
viously mentioned chemokine, CXCL13, as a diagnostic marker that rapidly decreases
during antibiotic treatment, might be an alternative in these cases [14] .
On the other hand, a repeat puncture gives the opportunity for additional micro-
biological testing. In addition, it allows the reanalysis of the different antibody titers,
as a significant increase in a certain antibody titer would indicate an active infection
with the respective causative organism, and implies a different diagnosis which should
lead to treatment adaptation. However, as the diagnosis of LNB is definite in most
cases, treatment failures are rare and the rapid decrease in pain in GBBS within 3–5
days after the initiation of therapy is a suitable indicator for an adequate treatment
response, the necessity of a repeat puncture should be an exception.
C o n c l u s i o n
In conclusion, lumbar puncture is the main tool in the diagnosis of LNB. As this infec-
tion can be effectively treated with antibiotics and lumbar puncture is a rapid and safe
206 Rupprecht ⴢ Pfister
procedure (except, for example, in the case of bleeding abnormalities), every patient
with a suspected LNB should undergo a CSF analysis. This can help us to avoid a treat-
ment delay (with potentially irreversible deficits) in confirmed cases and non-indicated
ineffective antibiotic treatments, as well as false expectations in misdiagnoses.
Acknowledgment
We thank Ms. Katie Ogston for copyediting the manuscript.
References
1 Huppertz HI, Bohme M, Standaert SM, Karch H,
Plotkin SA: Incidence of Lyme borreliosis in the
Wurzburg reg ion of Germany. Eur J Clin M icrobiol
Infect Dis 1999;
18: 697–703.
2 Hengge UR, Tannapfel A, Tyring SK, Erbel R, Ar-
endt G, Ruzicka T: Lyme borreliosis. Lancet Infect
Dis 2003;
3: 489–500.
3 W ils ke B, F inge rle V, Sc hult e-Specht el U: M icrob io-
logical and serological diagnosis of Lyme borrelio-
sis. FEMS Immunol Med Microbiol 2007;
49: 13–21.
4 Pfister HW, Wilske B, Weber K: Lyme borreliosis:
basic science and clinical aspects. Lancet 1994;
343:
1013–1016.
5 Hansen K, Lebech AM: The clinical and epidemio-
logical profile of Lyme neuroborreliosis in Den-
mark 1985–1990 : a prospective stud y of 187 patients
with Borrelia burgdorferi specific intrathecal anti-
body production. Brain 1992;
115(part 2):399–423.
6 Wilske B, Busch U, Eiffert H, Fingerle V, Pfister
HW, Rossler D, Preac-Mursic V: Diversity of OspA
and OspC among cerebrospinal f luid isolates of
Borrelia burgdorferi sensu lato from patients with
neuroborreliosis in Germany. Med Microbiol Im-
munol (Berl) 1996;
184: 195–201.
7 Ornstein K, Berglund J, Nilsson I, Norrby R, Berg-
strom S: Characterization of Lyme borreliosis iso-
lates from patients with erythema migrans and
neuroborre liosis in southern Sweden . J Clin Micro-
biol 2001;
39: 1294–1298.
8 Steere AC: Lyme disease. N Engl J Med 2001;
345:
115–125.
9 Christen HJ: Lyme neuroborreliosis in children.
Ann Med 1996;
28: 235–240.
10 Pfister HW, Rupprecht TA: Clinical aspects of neu-
roborreliosis and post-Lyme disease syndrome in
adult patients. Int J Med Microbiol 2006;
9: 11–16.
11 Kai ser R, Kern A, Kampa D, Neu mann-Haefelin D:
Prevalence of antibodies to Borrelia burgdorferi
and tick-borne encephalitis virus in an endemic re-
gion in southern Germany. Zentralbl Bakteriol
1997;
286: 534–541.
12 Hammers-Berggren S, Hansen K, Lebech AM,
Karlsson M: Borrelia burgdorferi -specific intrathe-
cal antibody production in neuroborreliosis: a fol-
low-up study. Neurology 1993;
43: 169–175.
13 Karlsson M, Hovind-Hougen K, Svenungsson B,
Stiernstedt G: Cultivation and characterization of
spirochetes from cerebrospina l fluid of patients with
Lyme borreliosis. J Clin Microbiol 1990;
28: 473–479.
14 Rupprecht TA, Pfister HW, Angele B, Kastenbauer
S, Wilske B, Koedel U: The chemokine CXCL13
(BLC): a putative diagnostic marker for neurobor-
reliosis. Neurology 2005;
65: 448–450.
1 5 R upp re cht TA, Koe de l U, An gel e B , Fi ng erl e V, P fi s-
ter HW: Cytokine CXCL13 – a possible early CSF
marker for neuroborreliosis (in German). Nerven-
arzt 2006;
77: 470–473.
16 Halperin JJ, Shapiro ED, Logigian E, Belman AL,
Dotevall L, Wormser GP, Krupp L, Gronseth G,
Bever CT Jr: Practice parameter: treatment of ner-
vous system Lyme disease (an evidence-based re-
view): report of the Quality Standards Subcom-
mittee of the American Academy of Neurology.
Neurology 2007;
69: 91–102.
17 Kalish RA, Kaplan RF, Taylor E, Jones-Woodward
L, Workman K, Steere AC: Evaluation of study pa-
tients with Lyme disease, 10–20-year follow-up. J
Infect Dis 2001;
183: 453–460.
Hans-Walter Pfister, MD
Depar tment of Neurology, Klinikum Grosshadern, Ludwig-Maximilians University
Marchioninistrasse 15, DE–81377 Munich (Germany)
Tel. +49 89 7095 3676, Fax +49 89 7095 6673, E-Mail hans-walter.pfister@med.uni-muenchen.de
207
Aberer, E. 155
Baranton, G. 1
Bitam, I. 130
De Martino, S.J. 1
Gern, L. 18
Glatz, M. 178
Hansmann, Y. 111
Hubálek, Z. 31
Hunfeld, K.-P. 167
Kraiczy, P. 167
Author Index
Maraspin, V. 183
Müllegger, R.R. 178
Pfister, H.-W. 200
Puéchal, X. 191
Raoult, D. 130
Rupprecht, T.A. 200
Sibilia, J. 191
Stanek, G. 51
Strle, F. 51, 183
Acrodermatitis chronica atrophicans (ACA)
antibiotic therapy 121, 122
Borrelia induction 13
clinical characteristics 64, 65, 82
diagnosis 65, 66
differential diagnosis 66
etiology 62
frequency 62
histologic findings 63, 64
Lyme borreliosis diagnosis 53
tick bite history 63
Age distribution, Lyme borreliosis 38, 39,
44
Altitude, Lyme borreliosis influences 37
Anaplasmosis
clinical presentation 132, 133
epidemiology 132
laboratory findings 133
pathogens 131
treatment 133
vectors 131, 132
Antibiotic therapy
acrodermatitis chronica atrophicans 121,
122
anaplasmosis 133
borrelial lymphocytoma 121
early disseminated and late Lyme
borreliosis
Lyme ar thritis 117–119
Lyme neuroborreliosis 117–120
overview 115–117
early Lyme borreliosis 113–115
erythema migrans 111, 112, 161
Lyme carditis 122
persistent symptoms following treatment
cutaneous manifestations 192
Subject Index
fatigue 196, 197
Lyme arthritis 193–195
Lyme neuroborreliosis 195, 196
overview 191, 192
subjective symptoms 197, 198
post-Lyme disease and late-stage
borreliosis 120, 121
pregnant patients with Lyme borreliosis
prophylaxis 185, 186
treatment 187–189
prophylaxis after tick bites 126, 127, 161
rickettsiosis 150
spectrum of activity against Borrelia 112,
113
tick-borne relapsing fever 136
tularemia 139, 140
Antibody serology
antigen preparations and diagnostic
formats 168, 169
follow-up in cutaneous Lyme borreliosis
178–181
Lyme borreliosis diagnosis 98–100
rational stepwise testing 167, 168, 174–176
Western blot
diagnostic value 173, 174
interpretation 175, 176
line immunoblot 172
overview 169, 170
recombinant immunoblot 171
stage-dependent antibody kinetics 172,
173
whole cell antigen immunoblot 170,
171
Arthritis, see Lyme arthritis
Astrakhan fever, features 146
Subject Index 209
Babesiosis
clinical presentation 142, 143
diagnosis 143
epidemiology 142
pathogens and vectors 141, 142
treatment 143
BbK32, pathogenicity factor 4
BgP, pathogenicity factor 4
Borrelia afzelii 8
Borrelia andersonii 10
Borrelia bisettii 8, 9
Borrelia burgdorferi sensu lato complex, see
also individual species
antibiotic activit y 112, 113
Borrelia burgdorferi sensu stricto 5–7
genetic diversity analysis 2, 3
genome 11, 12, 22–26
genomospecies 2, 10
geographic distribution 10, 21, 22
hosts 11, 12, 22–26
invasiveness 12, 13
life cycle 21–26
organotropism and lateral transfer 13
pathogenicity 3–5, 13
seropositivity in healthy individuals 157
taxonomy 1, 2, 21, 200
transmission 2, 27–29
vectors 11, 12, 22–26
Borrelia californiensis 10
Borrelia garinii 7
Borrelia japonica 9
Borrelia lonestari 2
Borrelia lusitaniae 9, 12
Borrelia sinica 9
Borrelia spielmanii 8
Borrelia tanukii 9
Borrelia turdi 9
Borrelia valaisiana 9, 12
Borrelial lymphocytoma, see Lymphocytoma,
borrelial
Carditis, see Lyme carditis
Cerebrospinal fluid (CSF), Lyme neurobor-
reliosis findings 96, 97, 100, 203, 204
Chronic Lyme borreliosis, features 93, 94
Complement regulator-acquiring surface
factors 4
Culture, Lyme borreliosis diagnosis 97
Cutaneous lymphoma, clinical findings 68, 69
Dbp proteins, pathogenicity factors 4
Dermatomyositis, Lyme borreliosis 93
Diagnosis
acrodermatitis chronica atrophicans 65, 66
borrelial lymphocytoma 61, 62
erythema migrans 58
Lyme arthritis 89
Lyme borreliosis
laboratory diagnosis 96–100
overview 52–54
Lyme carditis 77, 78
Lyme neuroborreliosis 73, 74
tick-borne relapsing fever 136
tularemia 138, 139
Enzyme-linked immunosorbent assay (ELISA)
Lyme borreliosis diagnosis 98–100
tick-borne encephalitis 141
Eosinophilic fasciitis, Lyme borreliosis 93
Epidemiology, Lyme borreliosis
age distribution 38, 39, 44
altitude influences 37
geographic distribution 31–35
incidence
rates 33–36
trends 36
latitude influences 36, 37
occupational factors 44, 50
risk assessment
behavior 44
duration of tick attachment 42
indices 43, 44
seroconversion rate 158, 159
transmission 41, 42, 157, 158
vector tick stage 41
seasonal distribution 38
sex differences 39, 40, 44
surveillance 44, 45
urban versus rural differences 40
weather influences 40, 41
Erythema migrans (EM)
antibiotic therapy 111, 112, 161
Borrelia induction 13
clinical characteristics 56–58, 80
definition 54, 55
diagnosis 58
differential diagnosis 58, 59
etiology 55, 56
eye involvement 91
frequency 55
210 Subject Index
Erythema migrans (EM) (continued)
histologic findings 56, 81
immunocompromised patients 94–96
Lyme borreliosis diagnosis 53
natural evolution 192
persistent disease management
corticosteroid injections
intra-articular 194
systemic 195
disease modifying anti-rheumatic
drugs 195
nonsteroidal anti-inf lammatory drugs
195
synovectomy 194, 195
risk assessment 158, 159
tick bite lesions 56
Eye involvement, Lyme borreliosis 91–93
Fatigue, persistence after Lyme borreliosis
196, 197
Francisella tularensis, see Tula remi a
Geographic distribution
Borrelia burgdorferi sensu lato complex
10, 21, 22
Ixodes ricinus 19
Lyme borreliosis 31–35
Hydroxychloroquine, Lyme arthritis
management 195
Hypersensitivity reactions, tick bites 160
Immunocompromised patients, Lyme
borreliosis 94–96
Immunofluorescence assay (IFA), Lyme
borreliosis diagnosis 98, 99
Incidence, see Epidemiology
Israeli spotted fever, features 145, 146
Ixodes ricinus
borreliosis transmission 2, 27–29
geographic distribution 19
life cycle 19–21
Latitude, Lyme borreliosis inf luences 36, 37
Lichen sclerosus et atrophicus, clinical
findings 67, 68
Lumbar puncture, see Lyme neuroborreliosis
Lyme arthritis
antibiotic therapy 117–119
clinical characteristics 85–89
diagnosis 89
differential diagnosis 90
etiology 84
frequency 83, 84
histologic findings 85
natural evolution 193
pathogenesis 84, 85
persistent disease management 195
polymerase chain reaction analysis 193,
194
treatment 193–195
Lyme carditis
antibiotic therapy 122
clinical characteristics 76, 77
diagnosis 77, 78
differential diagnosis 78
etiology 75
frequency 75
histology 76
tick bite history 75
Lyme neuroborreliosis (LNB)
antibiotic therapy 117–120
clinical characteristics
early disease 72, 73
late disease 73
clinical presentation 201
diagnosis 73, 74, 96, 97, 202, 203
differential diagnosis 75, 204
etiology 69, 70
frequency 70, 71
histology 71, 72
lumbar puncture
cerebrospinal fluid findings 96, 97, 100,
203, 204
indications 201, 202
repeat puncture 205
natural evolution 195
persistent disease management 196
tick bite history 71
Lymphocytoma, borrelial
antibiotic therapy 121
biopsy 81
clinical characteristics 60, 61, 81
definition 59
diagnosis 61, 62
differential diagnosis 62
etiology 59
frequency 59
Lymphoma, see Cutaneous lymphoma
Subject Index 211
Mediterranean spotted fever, features 146
Methotrexate, Lyme arthritis management
195
Morphea, see Scleroderma circumscripta
Multilocus sequence typing (MLST), Borrelia
burgdorferi sensu lato complex diversity
analysis 3
Myositis, Lyme borreliosis 93
Neuroborreliosis, see Lyme neuroborreliosis
Nodular fasciitis, Lyme borreliosis 93
Occupation, Lyme borreliosis risks 44, 50
OspA, pathogenicity factor 4, 5
OspC, pathogenicity factor 5, 12, 13
Osteomyelitis, Lyme borreliosis 93
Panniculitis, Lyme borreliosis 93
Polymerase chain reaction (PCR), Borrelia
burgdorferi sensu lato complex diversity
analysis 3
anaplasmosis 133
babesiosis 143
Lyme arthritis analysis 193, 194
Lyme borreliosis diagnosis 97, 98
tularemia 139
Pregnancy
Lyme borreliosis
antibiotic therapy 187–189
clinical presentation 184, 185
course 183, 184
fetal effects 184
ticks
antibiotic prophylaxis 185, 186
detection and removal 185
follow-up of bite 186
tick testing 185
P66, pathogenicity factor 4
Rickettsiosis
Rickettsia aeschlimannii 148, 149
Rickettsia conorii complex 144
Rickettsia conorii subsp. caspia 146
Rickettsia conorii subsp. conorii 144,
145
Rickettsia conorii subsp. israelensis 145,
146
Rickettsia helvetica 149, 150
Rickettsia massilae 149
Rickettsia raoulti 150
Rickettsia sibirica subsp. mongolitimonae
146, 147
Rickettsia slovaca 147, 14 8
treatment 150
Scleroderma circumscripta, clinical findings
67, 68
Seasonal distribution, Lyme borreliosis
38
Serology, see Antibody serology
Sex differences, Lyme borreliosis incidence
39, 40, 44
Subjective symptoms
management 196, 197
natural evolution 196
Sulfasalazine, Lyme arthritis management
195
Surveillance, Lyme borreliosis 44, 45
Synovectomy, Lyme arthritis management
194,
195
Tick-borne encephalitis (TBE)
clinical presentation 141
diagnosis 138, 139
epidemiology 140
pathogen 140
risk assessment 159
treatment 139
Tick-borne relapsing fever (TBRF)
clinical presentation 135
diagnosis 136
epidemiology 134, 135
pathogens 134
transmission 134, 135
treatment 136
vectors 134
Ticks, see also Ixodes ricinus
analysis of removed ticks 162
bites
local reactions 159, 160
management 162, 163
prevention 123, 124, 162
prophylaxis after bites 126, 127
risks 156, 158
diseases, see specific diseases
pregnant patients
antibiotic prophylaxis 185, 186
detection and removal 185
follow-up of bite 186
tick testing 185
212 Subject Index
Ticks, see also Ixodes ricinus (conti nued)
removal 123, 124, 160, 161
repellents 123
vectors, agents, and diseases 131, 155, 156
Transplant patients, Lyme borreliosis 96
Tula rem ia
clinical presentation 137, 138
diagnosis 141
epidemiology 137
pathogen 136, 137
treatment 141
Vaccines, Lyme disease 126
VlsE, pathogenicity factor 4
Weather, Lyme borreliosis influence 40, 41
Western blot, Lyme borreliosis diagnosis
diagnostic value 173, 174
interpretation 175, 176
line immunoblot 172
overview 169, 170
recombinant immunoblot 171
stage-dependent antibody kinetics 172,
173
whole cell antigen immunoblot 170, 171
