Lyme disease: Gold for Scotland and Bronze for USA

SMJ 2003: 48(1) 6-9 

Marilyn M Davidson, Roger Evans, Darrel O Ho-Yen

Microbiology Department

Raigmore Hospital

Highland Acute Hospitals Trust

Inverness IV2 3UJ

 

Correspondence: Dr Darrel O Ho-Yen

 

Introduction

Since its identification in 1975, Lyme disease has resulted in great interest, research and controversy on both sides of the Atlantic.1,2,3  The causative organism is the spirochaete, Borrelia burgdorferi sensu lato.  In the United Kingdom the hard-bodied tick Ixodes ricinus transmits the organism.  The natural reservoir hosts of I.ricinus are small mammals and birds as well as larger mammals such as sheep and deer.4  Man can be considered an incidental host.  However, infection in man can result in early, early disseminated and late/chronic Lyme disease.  There is little information on the true incidence of Lyme disease in Scotland, but a rate of 1.25-16.5/100,000 has been calculated.5  This is probably an underestimate as many patients are asymptomatic or have non-specific symptoms.

 

In Europe, three pathogenic strains of the B.burgdorferi sensu lato complex have been isolated from patients with Lyme disease: B.burgdorferi sensu stricto, B. garinii and B. afzelii.6   All three strains are present in the UK and B.burgdorferi sensu lato DNA has been detected by polymerase chain reaction (PCR) from ticks (I. ricinus) in Scotland.7,8,9  Isolation of the spirochaete has proven more difficult and until 1998 only one isolate had been reported in the UK.10  Recently twelve isolates of two pathogenic strains (B.burgdorferi sensu stricto and B.afzelii) were grown and kept in culture from ticks collected in the Highlands.9,11  In contrast, only one strain of the B.burgdorferi sensu lato complex  (B.burgdorferi sensu stricto) has been associated with Lyme disease in the United States of America.2,3  Some reports have indicated that there is a close correlation between the clinical presentation of Lyme disease and a specific pathogenic species of B. burgdorferi sensu lato.12  In the USA, rheumatological conditions are more frequently seen, while in Europe neurological conditions predominate.2  Chronic cutaneous manifestations are considered to be due to B.afzelii and B.garinii and so are found in Europe but are rarely seen in the USA.

 

While there is general acceptance of the importance of Lyme disease in Europe and the USA, this is not the case in the UK.  In part, this is due to less awareness of the condition by medical practitioners and the general public in the UK; but also, diagnosis and management is different from Europe and USA.  For Scotland, with its large tick population, it is important that the consequences of Lyme disease are addressed.

 

Clinical Presentation

The initial presentation of early Lyme disease in many patients is erythema migrans (EM).3,13,14  EM is diagnostic of Lyme disease.  Classically, a flat circular erythema, often in the form of a raised red swelling around the tick bite expands in all directions; the edges remain red but there is central clearing of the rash to form a 'target lesion'.  However, uniform erythema is also seen.15  Ticks typically feed in areas of skin folds or creases and in obstructions produced by clothing so these areas should be inspected for EM.  The rash becomes obvious from day 7-10 and develops quickly (2-3 cm a day).14  EM is not usually painful or itchy.  Associated symptoms are myalgias, arthralgias, low-grade fevers, neck pain, stiffness or a flu-like illness.2  Multiple EM may be the presentation in early disseminated disease,16 and is due to haematogenous dissemination of the spirochaete from the original tick bite.  Neurological and cardiac conditions can be observed at this stage.  Important neurological presentations are meningitis, cranial nerve palsy and radiculoneuritis2 and are more commonly found in patients from Europe than the USA. Cardiac disease, usually manifesting itself as conduction system disease, is generally self-limiting,17 although death from Lyme carditis has been reported.18

 

Late Lyme disease is diverse.2,16  Peripheral neuropathy, manifested as paraesthesiae, and rarely, encephalopathy and encephalomyelitis have been reported months to years after infection.19  Ocular manifestations can be found in late Lyme disease.6  In an American study, Lyme arthritis was estimated in 25% of patients.20  However, it is less commonly seen in Europe, probably due to the differences in the genospecies present in these two continents.2,12  Lyme arthritis primarily involves large joints.21  Unusual cutaneous syndromes have been observed: acrodermatitis chronica atrophicans (ACA) develops on a distal extremity, characteristically as a swollen bluish-red appearing skin lesion;22 borrelial lymphocytoma is a tumour-like nodule which typically appears on the pinna of the earlobe or on the nipple or aureola of the breast;22 and Borrelia burgdorferi infection has been associated with cutaneous B-cell lymphoma in the Highlands of Scotland23 as well as other parts of Europe.24  These cutaneous syndromes are rarely seen in the USA but are more commonly found among European and UK patients.  B.afzelii and B.garinii are considered to be the causative organisms of these syndromes12 and this may explain why they are rarely found in the USA as these genospecies are not found there.   Non-specific symptoms such as fevers, sweats, sensitivity to sounds or hearing loss, shortness of breath, abdominal pain, testicular or pelvic pain, dysequilibrium and tremors have been reported.21  In one American study, 34% of patients developed symptoms suggestive of chronic fatigue syndrome.25  There is no indication that Lyme infection during pregnancy affects the baby.26  The large spectrum of clinical presentation in Lyme disease can make recognition difficult and laboratory diagnosis essential.

 

Diagnosis

The diagnosis of Lyme disease poses a number of challenges.  Erythema migrans is the only stage that can be diagnosed clinically,3,13,14 but in the USA only 60-90% of those infected have a rash.13,16  Detection of the organism is not easy and although culture has been recommended,14,27 it can take weeks to months and requires skin biopsies or large volumes of plasma.28,29  Culture from CSF or joint fluids is rarely successful.  An alternative for direct detection is the polymerase chain reaction (PCR) for B.burgdorferi sensu lato DNA.30  One recent study31 showed a sensitivity of 68% for skin biopsies and 73% for joint fluids.  Results on CSF (18%) and plasma (29%) were less impressive.  A meta-analysis demonstrated a relatively high sensitivity (68%) on urine samples but it was difficult to correlate the results with clinical disease.31  Persistence of DNA after therapy makes positive results difficult to interpret so PCR is used with other tests.

 

Serological assays are widely available, and the number of serological tests received in our laboratory from Scotland has increased over the last seven years (Figure 1).  This is partly explained by an increase in the proportion of the Scottish population tested in our laboratory from 51% in 1997 to 80% by 2001.  The enzyme immuno-assay (EIA) tests used have also changed with the introduction of more specific assays.  A two step protocol is recommended13,32 using an initial screening EIA; positive or equivocal results are confirmed by Western Blotting (WB).  This is necessary as the EIA gives false positive results due to cross-reactions with other bacteria or in other conditions;13,33 only 30-35% of EIA positive results are confirmed (Figure 1).  The WB detects antibody to individual proteins of B.burgdorferi sensu lato.  These can be specific (for example, 22kDa, 32kDa, 39kDa, 46kDa and 92kDa) or non-specific (for example, 41 and 60kDa) (Figure 2).  However, since WB is an in-house test it is difficult to standardise criteria for a positive result.  In the USA, where B.burgdorferi sensu stricto is the only known pathogenic strain, official guidelines have been issued.32  In Europe, where all three pathogenic strains are present, the situation is more complicated.34,35,36  A multi-centre group was unable to produce standard guidelines for WB since individual laboratories used different strains and different criteria.37  In Scotland we have developed our own guidelines using a reference B.burgdorferi sensu stricto strain, as those recommended in either the USA or Europe were not applicable to our situation.38  However, seven isolates of B.burgdorferi sensu stricto and five isolates of B.afzelii have been grown in culture from ticks collected in the Highlands of Scotland.9,11  The use of these local isolates in the WB technique may improve the diagnosis of Lyme disease in Scottish patients.

 

In some instances, diagnosis may be difficult.  In early disease, antibody response is often slow and can be aborted by prompt antibiotic treatment.2  In late disease, it is difficult to differentiate between active and past infection.2,14,27  Therefore, laboratory results must be interpreted in conjunction with the clinical picture.  Unfortunately, diverse laboratory tests and guidelines between USA, Europe and UK have resulted in different management approaches.

 

Management

The management of Lyme disease can be divided into two areas: the treatment of patients and prevention of infection.  Antibiotic treatment of all stages is usually successful.16,39,40,41  Erythema migrans and other less serious symptoms (including facial palsy and arthritis) may be treated with oral antibiotics.3,16,42,43  The most effective are oral doxycycline (100 mg bd for 14-21 days) and oral amoxycillin (500 mg tds for 14-21 days).  Erythromycin is used in penicillin sensitive patients.42  Early disseminated disease unresponsive to oral antibiotics or late disease may require parenteral treatment with ceftriaxone (2 g daily) or cefotaxime (1-2 g tds) for 14-28 days.3,16,42  Typical EM, especially after a known tick bite can be treated without laboratory tests.  However, treatment of other symptoms should await laboratory confirmation to avoid over treatment.44

 

Patients often present after a tick bite for advice.  In most circumstances, there is no evidence to suggest that prophylactic antibiotics would be useful.16,42,45,46  No cases of Lyme disease were detected in a year from a recreation site in England even where 5-17% of the ticks were infected.47  Other studies suggest that the risk is less than 10%.3,48  More public awareness of the habits of ticks and how to prevent infection would reduce the risk.  Ticks are detected in urban and semi-urban areas as well as rural areas.49,50  The risk can be as great by walking in a local wood as in hill walking.11  Ticks require a temperate humid environment often in long grass and heavy undergrowth.49  In contrast, open exposed areas in the mountains are less likely to harbour ticks.  Prevention of tick bites can be achieved by wearing long sleeved clothing, tucking trousers into shoes, and using tick repellents.51  A nightly check for attached ticks and their removal is also useful.  Infection is unlikely unless the tick has been feeding for 24-36 hours.16  Ticks require a blood meal to stimulate B. burgdorferi sensu lato to migrate from the tick intestine to the salivary glands.  In America, a vaccine based on an outer surface protein (OspA) of B. burgdorferi sensu stricto has been licensed.52  The vaccine has an unusual mode of action.53  Antibody in the blood of a vaccinated person when ingested by a tick prevents transmission of B. burgdorferi sensu stricto.  This vaccine is unsuitable for use in Europe due to variation in the OspA in the European strains.  The vaccine has, however, been removed from the market due to poor uptake,54 but work is still ongoing.55

 

There has been considerable controversy, especially on the Internet,56,57,58 about “Post Lyme Disease”, where patients with treated Lyme disease have ongoing symptoms.59  Some of these patients are also diagnosed as chronic fatigue syndrome or fibromyalgia.  Evidence suggests that the majority of these patients do not have active Lyme disease, although symptoms may continue for months.42,44  Many patients receive prolonged multiple courses of antibiotics, although they are not recommended42,44,60 and over treatment has even led to patient deaths.61,62  In America there are clinics treating only patients with Lyme disease. In Europe there are a small number of patients who are so treated.63,64  In the UK, management is more conservative than in the USA and Europe with patients rarely being given multiple antibiotic courses.

 

The Future

There have been efforts to improve the sensitivity and specificity of diagnostic assays.  Some EIAs have utilised only B.burgdorferi sensu lato specific recombinant antigens.65,66,67,68  Another approach has been to look for antibody complexed to B.burgdorferi sensu lato to improve the sensitivity of tests in early disease.69,70  A different form of B.burgdorferi sensu lato has recently been detected in vitro and possibly also in vivo.71  This “cyst” like stage may be a survival mechanism allowing chronic infection and new medium has been developed to improve the growth of this stage.72  These findings remain to be confirmed and applied for routine diagnostic use.

 

The WB assay could be improved using local isolates as an antigen source. Sera from Scottish patients with EM of acute onset were tested with local antigens by WB technique.  There was a 40% increase in the sensitivity when two local B.burgdorferi sensu stricto isolates and a local B.afzelii isolate were used compared with the routine, B. burgdorferi sensu stricto, reference strain.  It is recognised that the WB technique performs poorly with sera from patients with EM,73 but the use of these local Scottish isolates improved the results of the current WB method.  Therefore, antigens based on local, Scottish isolates are better than those based on the American B.burgdorferi sensu stricto strain.  Our results demonstrated a wide variation in the bands obtained from a single serum and the different isolates in the WB technique (Figure 2).  The sensitivity of the two step serological testing protocol can be improved if a second sample is tested; in one USA study sensitivity was 40.4% with an acute single serum sample and increased to 66% if a second convalescent serum sample was tested.73  However, the improved sensitivity using a local isolate in the WB assay with a single acute serum could give an earlier diagnosis and so improve patient management.  It is important that further studies are carried out using local isolates and sera from Scottish patients with other presentations of Lyme disease.

 

In Scotland, only two B.burgdorferi sensu lato species have been isolated: B.burgdorferi sensu stricto and B.afzelii.9  A greater number of bands were detected with the B.garinii reference strain than the other two reference strains.  These results may suggest that B.garinii is present in the tick population of Scotland but has not been isolated yet.  Molecular techniques have identified B.burgdorferi sensu lato DNA in ticks; part of the Osp A gene of B.burgdorferi sensu stricto has been detected by PCR in ticks from throughout Scotland but no isolates were grown from these studies.8,10,74  Attempts should be made to isolate and culture other genospecies of B.burgdorferi sensu lato that are present in Scotland.  Our success at growing and keeping in culture B.burgdorferi isolates has been unexpected and so is promising for the future.

 

Despite the growth of knowledge on Lyme disease in the last two decades, controversies still exist.  This is especially true in the USA about how to handle patients with “Post Lyme Disease”.  Public anxiety is high and doctors are under pressure to prescribe antibiotics when the clinical picture and laboratory test results are at best equivocal.44  The situation is exacerbated by the lack of standardisation of laboratory tests.  There are patients, especially with arthritis or late neurological disease who do not respond to antibiotic therapy.  It may be that they do not have Lyme disease or it may be that the infection has triggered an autoimmune response.59  A placebo-controlled trial was stopped because there was no benefit to patients of prolonged antibiotics.60  Therefore it appears that repeat antibiotics are not the answer. The issue does not cause as much debate in Europe possibly because arthritis is not as common.  In Scotland, where we have isolated B.burgdorferi sensu stricto, we would expect to find arthritis as a late complication.

 

It is clear that Lyme disease is different in the USA and Europe in clinical presentation, diagnostic laboratory tests and management.  In Scotland the situation is different from both.  Therefore it is not surprising that the gold medal results for laboratory diagnosis are achieved using local Scottish isolates and that antigens from the USA are in a bronze medal position.

 

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