Lyme disease (lime-borreliosis)

Lyme disease (ixodid tick-borne borreliosis, systemic tick-borne borreliosis, lime-borreliosis) is an inflammatory disease caused by spirochetes and carried by mites; is characterized by early skin lesions and chronic migrating erythema (HME), after which, weeks and months after infection, pathological changes in the nervous system, heart and joints can develop. Diagnosis of Lyme disease is initially clinical, but the detection of antibody titers during illness and recovery can be used. Treatment of Lyme disease is carried out with antibiotics, such as doxycycline or in severe cases ceftriaxone.

ICD-10 codes

• A69.2. Lyme disease. Chronic migratory erythema caused by Borrelia burgdorferi.
• L90.4. Acrodermatitis is chronic atrophic.
• M01.2. Arthritis in Lyme disease.

What causes Lyme disease?

Lyme disease (lime-borreliosis) was identified in 1975 when a number of cases were reported in the Old Lyme area of Connecticut. Since then, it has been encountered in 49 states of the USA, especially in the form of focal flares on the northeast coast from Massachusetts to Maryland, in Wisconsin, Minnesota, California and Oregon. It is also known in Europe and is found on the territory of the former USSR, in China, Japan. People fall ill usually in the summer or early autumn, regardless of gender and age, although in most cases children and young people living in the wooded area suffer.

Lime-borreliosis is transmitted by Ixodes Scapularis, a deer tick. In the United States, the natural reservoir of infection is mainly white-legged hamsters, they are the primary reservoir and the preferred host for nymphs and larvae of ticks. Deer are masters for adult mites, but do not wear Borrelia. Other mammals (eg dogs) can be accidental hosts, and they may develop Lyme disease. In Europe, the owners are sheep, but they never get sick.

B. Burgdorferi penetrate the skin in the place of a tick bite. After the incubation period lasting from 3 to 32 days, they spread in the skin around the bite along the lymphatic ways (regional lymphadenopathy) or with blood flow to other organs and skin areas. The relatively small number of microorganisms in tissues suggests that most clinical manifestations of the disease are associated with the host's immune response, rather than the damaging role of microorganisms.

What are the symptoms of Lyme disease?

Lyme disease has three stages: early localized, early disseminated, late. Early and late stages are usually divided by an asymptomatic period.

Chronic migrans erythema (CML) is the most important clinical sign of Lyme disease in 75% of patients begins with the appearance of a red spot or papule, usually on the proximal limb or trunk (especially on the thighs, buttocks, in the armpits), between 30-32- m day after the tick bite. This formation increases (up to 50 cm in diameter), often pale in the center. Half of the cases soon after the first spot there are many such skin lesions, but smaller ones and without induration in the center. The cultivation of the biopsy material of these secondary lesions can be positive and indicate the dissemination of the infection. Chronic migratory erythema lasts, as a rule, several weeks; in the recovery period, rapid eruptions are possible. Changes in mucous membranes are not observed.

Symptoms of Lyme disease in the early disseminated phase begin several days or weeks after the primary lesions, when the bacteria spread throughout the body. Most often, HME accompanies (sometimes precedes for several days) a symptom complex resembling a flu-like syndrome and including weakness, malaise, chills, fever, headache, stiff neck, myalgia and arthralgia. Because the symptoms of Lyme disease are often nonspecific, the diagnosis is not always established; need a high alertness. At this stage, Frank's arthritis is rare. Less often there are back pain, nausea and vomiting, pain or sore throat, lymphadenopathy and enlarged spleen. Most of the symptoms then appear, then disappear, except for weakness and malaise, which do not go away for weeks. Some patients develop symptoms of fibromyalgia. Rashes in the former places, but much less pronounced, may appear before the onset of arthritis. Severe neurologic disorders develop in about 15% of patients after a few weeks or months of CML (often before arthritis).

Neurological symptoms of Lyme disease develop in approximately 15% of patients, during weeks-months against a background of migrating erythema. Usually they last several months and pass without a trace. The most common are lymphocytic meningitis (pleocytosis in the CSF about 100 / μL), meningoencephalitis, neuritis of the cranial nerves (especially Bell's paralysis, sometimes bilateral), sensory or motor radiculoneuropathies.

Disturbances in myocardial function are observed in 8% of patients a few weeks after the onset of chronic migratory erythema. They consist of symptoms of atrioventricular blockade with a variable degree of severity (1st degree, Wenkebach blockade, 3rd degree), less often - myopericarditis with a decrease in the left ventricular ejection fraction and cardiomegaly.

In untreated patients, the late stage begins months and years after the onset of the disease. Arthritis occurs in approximately 60% of patients with chronic migratory erythema several weeks or months after its onset, but sometimes even later - up to 2 years. Intermittent edema and pain in some large joints, especially in the knee, usually recur for several years. Edema is more pronounced than tenderness; joint hot, sometimes reddened. Baker's cysts can be formed and torn. Such symptoms of Lyme disease as accompanying chronic migraine erythema, such as weakness, malaise and slight fever, may precede or accompany exacerbations of arthritis. Chronic arthritis of the knee joint (more than 6 months) develops in 10% of bumps. Of the late (after years) consequences, chronic atrophic acrodermatitis, susceptible to antibiotic therapy, and chronic neurological disorders such as polyneuropathy, encephalopathy, memory impairment, sleep are noted.

How is Lyme disease diagnosed?

Isolate the pathogen from tissues or body fluids is rarely possible; they should be used to diagnose other pathogens. Identification of the antibody titer at the height of the disease and during the recovery period is of diagnostic significance. If the titer is positive, there must be confirmation by western blotting. However, seroconversion may be late - more than 4 weeks or sometimes absent. A positive IgG antibody titer can talk about a previous infection. PCR analysis of CSF and synovial fluid often yields positive results with the interest of these structures. The diagnosis depends on the results of both tests and the availability of typical clinical data. Classical erythema indicates Lyme disease if there are other data (recent tick bite, stay in an endemic area, typical systemic symptoms).

In the absence of a rash, the diagnosis is difficult, because the remaining symptoms of Lyme disease may not be expressed. Previously, the disseminated phase can mimic juvenile RA in children, reactive arthritis, atypical RA in adults. These diseases can be excluded in the absence of morning stiffness, subcutaneous nodules, iridocyclitis, mucous membrane damage, rheumatoid factor, antinuclear antibodies. Lyme disease, manifested musculo-skeletal, influenza-like syndrome in the summer can be like erlichiosis, tick-borne rickettsiosis. The absence of leukopenia, thrombocytopenia, elevated transaminases and the incorporation of corpuscles into neutrophils make it possible to determine Lyme disease. In some cases, namely, with migrating polyarthritis with ECG changes (prolongation of PQ interval) or chorea (as manifestation of meningoencephalitis), the differential diagnosis includes acute rheumatic attack. When the disease of Lyme is rarely tapped heart murmur, and no indication of preceding streptococcal infection.

At a late stage, the axial skeleton is not involved, in contrast to spondyloarthropathy with lesion of peripheral joints. Lyme disease can cause Bell's paralysis, fibromyalgia, chronic fatigue syndrome, and can mimic lymphocytic meningitis, peripheral neuropathies and similar syndromes of CNS diseases.

In endemic areas, Lyme disease may be suspected in many patients with arthralgia, chronic fatigue, difficulty concentrating, or other disorders. Despite the absence of history of erythema or other symptoms of an early localized or disseminated disease, these patients are really sick. In such patients, an increase in the IgG antibody titer indicates contact in the past, but not a persistent infection, and this often leads to prolonged and useless antibiotic therapy.

How is Lyme disease treated?

Antibacterial treatment of Lyme disease brings positive results at all stages of the disease, but is most effective at an early stage. In the later stages, the use of antibiotics allows eradication of bacteria in most patients, but in some of them the symptoms of arthritis continue to persist. Lyme disease in children is treated similarly, but the use of doxycycline in children younger than 8 years should be ruled out; children's doses correspond to body weight. Duration of treatment in clinical trials is not defined, and the literature data are different.

Treatment of Lyme disease with antibiotics in adults

Early Lyme Disease

• Amoxicillin 500 mg 3 times a day per os 10-21 days or 1 g orally every 8 hours (some experts advise adding a probenicide 500 mg orally 3 times a day, it is not necessary if amoxicillin is prescribed according to the last scheme)
• Doxycycline is administered 2 times a day for 10-21 days
• Cefuroxime-aksetil 500 mg orally 2 times a day 10-21 days
• Azithromycin, 500 mg orally once a day for 7 days (less effective than other regimens)

[1], [2], [3],

Neurological symptoms

• Bell's paralysis (not other neurological manifestations)
• Doxycycline as in the early Meningitis disease (with or without radiculoropathy or encephalitis)
• Ceftriaxone 2.0 g IV once a day 14-28 days
• Benzylpenicillin 5 million units IV every 6 hours 14-28 days
• Doxycycline 100 mg orally 2 times a day 14-28 days
• Chloramphenicol 500 mg orally or iv 4 times per day 14-28 days

When the heart is affected

• Ceftiakson 2 g IV once a day 14-28 days
• Penicillin G 20 million units iv once a day 14-28 days
• Doxycycline 100 mg orally 2 times a day 21 days (with moderately expressed carditis with the first degree of cardiac blockade - PQ less than 30 seconds, normal function of the ventricles)
• Amoxicillin 500 mg orally 3 times a day or 1 g orally every 8 hours 21 days (with moderately expressed carditis with the first degree of cardiac blockade - PQ less than 30 seconds, normal function of the ventricles)

Arthritis

• Amoxicillin 500 mg orally 4 times a day or 1 g orally every 8 hours and probenecid 500 mg orally 4 times a day for 30 days (if there are no neurological lesions)
• Doxycycline 100 mg orally 2 times a day for 30 days (if there are no neurological lesions)
• Ceftriaxone 2.0 g IV once a day 14-28 days
• Penicillin G 20 million units iv once a day 14-28 days

[4], [5], [6], [7]

Chronic atrophic acrodermatitis

• Amoxicillin 1 g orally 1 time a day 30 days
• Doxycycline 100 mg orally 2 times a day for 30 days (if there are no neurological lesions)

1. Pregnant women can receive amoxicillin 500 mg / kg 3 times a day for 21 days. No treatment is required for pregnant women who are seropositive, but do not have clinical symptoms.
2. Without neurological, cardiac and joint injuries. For early Lyme disease, limited to simple migratory erythema, it is enough for 10 days. The optimal duration of therapy is unknown. There are no controlled clinical trials for more than 4 weeks for any neurological manifestations of Lyme disease.

Symptomatic treatment of Lyme disease is based on the use of NSAIDs. A complete heart block may require an artificial pacemaker. With considerable swelling in the knee joint, fluid is drained from it; it is recommended to use crutches. If arthritis of the knee joint antibiotic is ineffective, arthroscopic synovectomy can give good results.

[8], [9]

How to prevent Lyme disease?

Lyme disease can be prevented by preventing tick bites in endemic areas. Nymphs of deer mites that infect humans are extremely small, and it is difficult to see them. Once on the skin, the mite drinks blood for several days. The transfer of B. Burgdorferi occurs when the tick is at the site of the bite for more than 36 hours, which makes it extremely important to search and remove it.

A single oral dose of doxycycline at a dose of 200 mg lowers the likelihood of developing Lyme disease, but many clinicians do not recommend such treatment or spend it only in patients with identified mites. If it is known that a bite has occurred, the patient should be instructed about the need to observe the site of the bite and when the rash appears, go to the doctor; it is much more difficult to decide what to do with the patient in the absence of information about the bite.

Vaccines have insufficient effect and are therefore withdrawn from sale.