This is a disorder caused by the spirochaete Borrelia Burgdorferi, characterised by relapsing and remitting arthralgia associated with a characteristic skin rash (erythema chronicum nigrans) and neurological features. The organism, related to the treponemes, is prevalent throughout Europe and North America and is carried by ixodes ticks.
Only a minority of persons bitten by an infected tick develop the disease. Spirochactocidal activity in normal serum and the immune response normally provide protection. It rarely occurs in HIV patients. Stage 1: Spring/summer -
Tick bite -» flu-like symptoms, arthralgia and skin rash (erythema chronicum nigrans). Treatment with antibiotics is usually curative.
1 Untreated and small number of treated patients. Stage 2: Several weeks/months later -
Subacute lymphocytic meningitis - both illnesses are often mild, clear
Subacute encephalitis spontaneously and occasionally are unrecognised.
Cranial nerve involvement - Facial nerve palsy with or without subacute lymphocytic meningitis. Peripheral neuropathy - Subacute demyelinating and axonal sensory/motor neuropathy associated with severe root pain (radiculitis). - Bannwarth's syndrome. CSF examination in stage 2: Lymphocytosis Elevated immunoglobulins.
Oligoclonal bands. Elevated awiBurgdorferi antibodies. An unknown proportion progress.
Stage 3: Several months/years later -Arthritis
Diffuse CNS involvement - chronic/subacute encephalitis.
- focal brain disease.
- psychiatric disease with fatigue and diffuse muscle pain.
- Immunofluorescence assay (IFA)
- Enzyme-linked immunoabsorbent assay (ELISA). In endemic areas up to 5% of the population are positive, although with lower titres than symptomatic patients.
In patients from endemic areas:
in serum and CSF.
diagnosis is definite, but in stage 3 this is often uncertain and blind trials of therapy are given.
with meningitis/CN palsy encephalitis/radiculitis + CSF profile + positive serology
Stage 1 - Oral antibiotics: penicillin, erythromycin or tetracycline.
Stage 2 - I.V. penicillin G. 20 million units for 10 days (or cefotaxime).
If symptoms persist - wrong diagnosis with misleading titres, or - immune mediated damage.
Steroids can be used in late stages when symptoms have not responded to antibiotics
PCR if available gives the definitive answer.
MRI is abnormal in 25% with subcortical (T2) white matter lesions.
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