Acrodermatitis chronica atrophicans: clinical and microbiological characteristics of a cohort of 693 Slovenian patients.

BACKGROUND: Information on large groups of patients with acrodermatitis chronica atrophicans (ACA) is limited. METHODS: We assessed clinical and microbiological characteristics of patients with ACA diagnosed at a single medical centre and compared findings in periods 1991-2004 vs. 2005-2018. The cohort is representative of Slovenian ACA patients. RESULTS: We assessed 693 patients: 461 females and 232 males, with median age of 64 years. Median duration of ACA before diagnosis was 12 months. In all but 2 patients, the skin lesions were located on extremities, more often on the lower (70.0%) than the upper (45.2%), bilaterally in 42.4%. Reddish-blue discoloration, swelling, thinning and wrinkling of skin were present in 95.2%, 28.1%, 46.4% and 20.5% of patients, respectively. Overall, 64.4% of patients reported constitutional symptoms, 23.1% had local symptoms, and 20.8% had symptoms/signs of peripheral neuropathy. Nodules, arthritis, joint deformity, muscle atrophy and paresis were rare (<3%). Borreliae were isolated from 200/664 (30.1%) skin samples; 92.8% were Borrelia afzelii. B. garinii and B. burgdorferi s.s. were more often isolated from the skin of male patients (OR = 4.17) and from those with arthropathy (OR = 11.74). Patients included in the more recent period were older, complained less often of constitutional symptoms but more often of local symptoms, and more often had local swelling but less often skin atrophy and bilateral involvement, probably as a consequence of earlier diagnosis. CONCLUSIONS: ACA, typically caused by B. afzelii, usually affects older women. Clinical presentation depends on the duration of illness and probably on the Borrelia species causing the disease.

Bacterial infection in elderly nursing home and community-based patients: a prospective cohort study.

PURPOSE: The aim of the study was to assess differences between elderly nursing home (NH) residents and elderly patients living in the community admitted to hospital for bacterial infection. METHODS: We conducted a prospective cohort study with manual data collection. Patients aged 65 years and older from NHs and from the community admitted to hospital for bacterial infection were included in the study. Patient characteristics, site of infection, microorganism profile, and final outcome were assessed and compared between these two subgroups of patients. RESULTS: Two hundred and sixty-two patients were from NHs and 707 were from the community. Patients from NHs were older, had more underlying chronic illnesses, and more often showed characteristics indicating advanced debility. In both groups, the most common site of infection was the respiratory tract. In comparison to the community group, patients from NHs had a higher fatality rate (23.3 vs. 10.9%) and more often experienced functional decline at discharge (27.5 vs. 16.8%). After adjustment for age, sex, presence of comorbidity, and debility, NH residence remained associated with increased in-hospital mortality but not with functional decline. CONCLUSIONS: Elderly patients from NHs admitted to hospital for bacterial infection are older and more debilitated than their counterparts from the community. Microorganisms found in the NH residents are somewhat different from those in the community dwellers. The community dwellers had a better survival rate than those admitted from the NHs after adjusting for age, sex, presence of any comorbidity, and debility.

Isolation of Borrelia burgdorferi sensu lato from blood of adult patients with borrelial lymphocytoma, Lyme neuroborreliosis, Lyme arthritis and acrodermatitis chronica atrophicans.

BACKGROUND: Reports on patients with European Lyme borreliosis in whom borreliae were isolated from the blood are rare and nearly exclusively limited to those with solitary or multiple erythema migrans. Here we report on patients with other manifestations of Lyme borreliosis in whom borreliae were isolated from their blood. PATIENTS AND METHODS: This is a retrospective review of the medical files of patients diagnosed with borrelial lymphocytoma, Lyme neuroborreliosis, Lyme arthritis and acrodermatitis chronica atrophicans at the Department of Infectious Diseases of the UMC Ljubljana, Slovenia, for whom a borrelia blood culture was ordered. The clinical features of patients whose blood culture tested positive for Borrelia burgdorferi sensu lato were reviewed, and the association between the proportion of patients with a positive blood culture and various clinical manifestations was examined. RESULTS: Borrelia burgdorferi sensu lato was isolated from the blood of 1/53 (1.9%) patients with borrelial lymphocytoma, 6/176 (3.4%) patients with Lyme neuroborreliosis, 1/13 (7.7%) patients with Lyme arthritis, and 3/200 (1.5%) patients with acrodermatitis chronica atrophicans. The time interval from the onset of symptoms attributed to Lyme borreliosis and the blood culture ranged from 1 day to >2 years (median 3.5 weeks). At the time of the blood culture, erythema migrans was present in 4/11 (36.4%) borrelia blood culture-positive patients, i.e. in the patient with borrelial lymphocytoma, the patient with Lyme arthritis and the 2/6 patients with Lyme neuroborreliosis. Only two of these 11 (18.2%) patients had fever at the time of the blood culture. CONCLUSIONS: In European patients with Lyme borreliosis, borreliae can be cultured from the blood not only early in the course of the disease but also occasionally later during disease progression.

Comparison of findings for patients with Borrelia garinii and Borrelia afzelii isolated from cerebrospinal fluid.

BACKGROUND: The most common cause of Lyme neuroborreliosis in Europe is Borrelia garinii, followed by Borrelia afzelii. However, no series describing patients with culture-confirmed cases of Lyme neuroborreliosis have been published, and no comparison of findings for patients with B. garinii and B. afzelii isolated from cerebrospinal fluid (CSF) has been reported. METHODS: All adult patients identified at a single medical center during a 10-year period who had borreliae isolated from CSF and typed as B. garinii or B. afzelii (using large DNA fragment patterns obtained with the MluI restriction endonuclease and separated with pulsed-field gel electrophoresis) were included. RESULTS: A comparison of 23 patients who had B. garinii isolated from CSF with 10 patients who had B. afzelii isolated from CSF revealed that a reliable clinical diagnosis of Lyme neuroborreliosis (before obtaining a CSF culture and intrathecal borrelial antibody production result) was established more frequently in the B. garinii group than in the B. afzelii group (19 of 23 patients vs. 1 of 10 patients). Patients in the B. garinii group reported radicular pains and expressed meningeal signs more often, but reported dizziness less often (occurrences of several other symptoms and/or signs were comparable). Lymphocytic pleocytosis, as well as several other CSF abnormalities, were frequent among patients with B. garinii isolated from CSF but were rare among patients in the B. afzelii group. CONCLUSIONS: Patients with B. garinii isolated from their CSF have a distinct clinical presentation, compared with patients with B. afzelii. B. garinii causes what, in Europe, is appreciated as typical early Lyme neuroborreliosis (Bannwarth syndrome), whereas the clinical features associated with B. afzelii are much less specific and more difficult to diagnose.

Molecular subtyping of Borrelia burgdorferi sensu lato isolates from five patients with solitary lymphocytoma.

Solitary lymphocytoma is a rare cutaneous manifestation of Lyme borreliosis that has been reported almost exclusively from Europe. This suggests that its etiologic agent may be absent or extremely rare on the North American continent. All three species of B. burgdorferi sensu lato known to be associated with human Lyme borreliosis (B. burgdorferi sensu stricto, B. garinii, and B. afzelii have been isolated in Europe, whereas only B. burgdorferi sensu stricto has been found in North America. This suggests that either B. garinii or B. afzelii might be the etiologic agent of borrelial lymphocytoma. To investigate this hypothesis we characterized five strains of B. burgdorferi sensu lato isolated from lymphocytoma lesions of patients residing in Slovenia. The methods used included: large restriction fragment pattern analysis of restriction enzyme MluI-digested genomic DNA, plasmid profiling, protein profiling, ribotyping using 5S, 16S, and 23S rDNA probes, and polymerase chain reaction amplification of the rrf (5S)-rrl (23S) intergenic spacer region. Molecular subtyping showed that four of the five isolates belonged to the species B. afzelii; however, this species is the predominant patient isolate in Slovenia and, therefore, may not represent a preferential association with lymphocytoma. The fifth isolate appeared to be most closely related to the DN127 genomic group of organisms. Further characterization of the isolate revealed that it possessed a unique molecular "fingerprint." The results not only show that borrelial lymphocytoma can be caused by B. afzelii but also demonstrate an association with another genomic group of B. burgdorferi sensu lato that is present in North America as well.

Identification of three species of Borrelia burgdorferi sensu lato (B. burgdorferi sensu stricto, B. garinii, and B. afzelii) among isolates from acrodermatitis chronica atrophicans lesions.

In Europe, at least three species of Borrelia are known to be causative agents of Lyme borreliosis: B. burgdorferi sensu stricto, B. garinii, and B. afzelii. Observable differences in the molecular characteristics of the three species have led to speculation that they may also differ in their pathogenic potential and/or tissue tropisms. Several studies have found an association between the chronic skin manifestation of Lyme borreliosis, acrodermatitis chronica atrophicans, and infection by B. afzelii. We sought to find further evidence for such a correlation by studying the genetic profiles of 22 strains of B. burgdorferi sensu lato derived from 21 patients who presented to the University Medical Center, Ljubljana, Slovenia between 1992 and 1995. Strains were isolated in culture from skin biopsies of acrodermatitis chronica atrophicans lesions; in the case of one patient two separate acrodermatitis chronica atrophicans lesions were cultured. All 21 patients had clinically typical lesions with "classic" histopathology and high IgG antibody titers to B. burgdorferi sensu lato. Strains were characterized and typed by 16S ribosomal RNA-specific polymerase chain reaction and determination of their large restriction fragment patterns using pulsed-field gel electrophoresis of MluI-digested genomic DNA. Of the 22 isolates studied, 17 possessed the highly conserved MLa1 pattern characteristic of B. afzelii. The remaining five isolates possessed large restriction fragment patterns that were typical of B. garinii (MLg2, four isolates from three patients) and B. burgdorferi sensu stricto (MLb2, one isolate). The results of 16S ribosomal RNA-specific polymerase chain reaction were concordant with these species designations. These data show that B. afzelii is the predominant, but not the exclusive, etiologic agent of acrodermatitis chronica atrophicans.

Analysis of Borrelia burgdorferi sensu lato isolated from cerebrospinal fluid.

Involvement of the nervous system in Lyme borreliosis may occur with or without erythema migrans and it may present with a variety of neurological symptoms. In this study we analysed phenotypic and genotypic characteristics of 40 Borrelia strains isolated from cerebrospinal fluid (CSF) of 38 Slovenian patients with different clinical manifestations of Lyme borreliosis. In seven of the patients, Borreliae were also isolated from skin lesions. Species identification and plasmid profiles were determined by pulsed-field gel electrophoresis and protein profiles by SDS-PAGE. MluI digestion profiles of Borrelia burgdorferi sensu lato DNA showed that 25 (62.5%) isolates were B. garinii, 14 (35%) B. afzelii, and one (2.5%) B. burgdorferi sensu stricto. All strains, except one, possessed a large plasmid and a varying number of smaller plasmids. Three (7.5%) isolates exhibited an unusual plasmid profile, with a large plasmid dimer or three copies of the large plasmid. In protein analyses, all strains expressed OspA protein. OspB was present significantly more often in B. afzelii than B. garinii strains (p=0.0000), while OspC was more often present in B. garinii than B. afzelii strains (p=0.0052). In the seven patients with Borreliae isolated also from the skin, the CSF and skin isolates were identical, either B. garinii (six patients) or B. afzelii (one patient). Species and plasmid heterogeneity as well as antigen diversity could play a role in the pathogenesis of the infection. When combined with our own earlier data, the results suggest species-related organotropism.

Characterisation of Borrelia burgdorferi sensu lato strains isolated from patients with skin manifestations of Lyme borreliosis residing in Slovenia.

Lyme borreliosis is the most prevalent tick-borne infection in Slovenia. Skin disorders are the most frequent clinical manifestations. The aim of the present study was to assess the phenotypic and genotypic diversity of a large number of human Borrelia burgdorferi sensu lato isolates and to evaluate any association between the isolates and different clinical manifestations. All 103 strains tested were from patients suffering from the skin disorders of Lyme borreliosis. Skin biopsies, cerebrospinal fluid and blood samples from patients were inoculated into modified Kelly Pettenkofer medium. Protein profiles were determined by SDS-PAGE and species identification and plasmid profiles by pulsed-field gel electrophoresis. MluI digestion profiles showed that 87 (84.5%) isolates belonged to B. afzelii, 15 (14.5%) to B. garinii and 1 (1%) to B. burgdorferi sensu stricto. The number of plasmids in each strain varied from three to seven, and the plasmid size ranged from 15 to 65 kb. Four isolates of B. garinii possessed multiple large plasmids and four isolates had a large plasmid dimer (three B. afzelii and one B. garinii). Isolates showed qualitative and quantitative differences in protein expression. The study found differences in the expression of OspB and OspC proteins between B. afzelii and B. garinii strains. OspB was expressed significantly more often by B. afzelii (78 of 87, 89.6%) than by B. garinii (4 of 15, 26.6%) isolates, while OspC protein was expressed significantly more often by B. garinii (14 of 15, 93.3%) than by B. afzelii (51 of 87, 58.6%) isolates. In Slovenia, B. afzelii causes the majority of skin lesions. The isolates investigated showed plasmid and protein diversity. Heterogeneity of the spirochaetes may be important for virulence, and may have implications for pathogenesis and therapy of the infection. Differences in immunodominant proteins also have an important impact on serological testing and vaccine development.

Genotypic and phenotypic characterisation of Borrelia burgdorferi sensu lato strains isolated from human blood.

Lyme borreliosis often presents initially with erythema migrans. Borreliae may disseminate from the primary skin lesion, and different organs and systems could be affected. Borrelia strains were isolated from blood of 70 patients with Lyme borreliosis, including 10 patients from whom borreliae were also isolated from skin. The aim of the present study was to characterise the isolates with regard to their phenotypic and genotypic characteristics. Borreliae were cultivated in MKP medium. Species identification and plasmid profiles were determined by pulsed-field gel electrophoresis (PFGE) and protein profiles by SDS-PAGE. Digestion of Borrelia burgdorferi sensu lato DNA showed 63 (90%) B. afzelii Mla1 and 7 (10%) B. garinii Mlg2. No B. burgdorferi sensu stricto were isolated. Borreliae were isolated from both skin and blood of 10 patients, nine pairs of isolates were identical: seven B. afzelii and two B. garinii. B. afzelii was isolated from the skin and B. garinii from blood of the tenth patient. All but one isolate possessed at least one large plasmid and varying numbers of smaller plasmids. Eight (11.4%) of 70 isolates possessed an unusual plasmid profile (2 of 63 B. afzelii and 6 of 7 B. garinii). Borreliae differed in their protein profiles. OspA and OspB proteins were expressed by all B. afzelii isolates; 85.7% of B. garinii isolates expressed OspA and 71.4% expressed OspB. OspC was expressed by 65% of B. afzelii isolates and all B. garinii isolates. The ratios of B. afzelii and B. garinii isolated from blood and skin were similar. These results do not support the hypothesis that B. garinii has a higher propensity for haematogenous dissemination than B. afzelii. Antigen diversity as well as species and plasmid heterogeneity could play a role in the pathogenesis of the infection, suggesting distinctive strain organotropism.

Ceftriaxone associated hemolysis.

A 48-year-old immunocompetent women treated with ceftriaxone 2 g daily i.v. for late Lyme borreliosis developed severe haemolytic anaemia. The patient had previously received the same antibiotic two times without any side effects. The first clinical signs began to appear on the seventh day of treatment. The patient developed severe anaemia with a haemoglobin level of 45 mg/l on day 10; thereafter she ceased to receive the antibiotic. The outcome was favourable. The clinical course and serologic results suggest that severe anaemia was induced by ceftriaxone and that drug adsorption as well as immune complex mechanisms were involved in the pathogenesis.

Erythema migrans in the immunocompromised host.

From 1990 to 1996 a total of 67 adult patients with typical erythema migrans (EM) and a previously identified immunocompromised condition were investigated at the University Medical Centre, Department of Infectious Diseases, Ljubljana, Slovenia. The course and outcome of borrelial infection were compared with 67 previously healthy age and sex-matched individuals with EM who were examined at our institution in the same year. Clinical characteristics of Lyme borreliosis before treatment and the duration of EM after the institution of therapy with antibiotics including amoxicillin, azithromycin, cefuroxime-axetil, doxycycline, and ceftriaxone were comparable in both groups. The occurrence of early disseminated borrelial infection before treatment and the frequency of treatment failure (defined as the onset of severe minor or major manifestations of Lyme borreliosis, persistence of B. burgdorferi sensu lato in the skin and/or persistence of EM after treatment) were found significantly more often in immunocompromised patients than in the control group (16/67 versus 6/67, respectively; p = 0.0358). Re-treatment was required in 13 (19.4%) patients of the immunocompromised group and only in five (7.5%) patients of the control group (p = 0.0762). However, in spite of the more severe course and the more frequent need for re-treatment among patients whose immune system was impaired, the outcome of borrelial infection after one year was favourable in both groups.

Erythema migrans in pregnancy.

From 1990 through to 1997, 105 pregnant women with typical EM were investigated at the Lyme Borreliosis Outpatients' Clinic of the Department of Infectious Diseases at the University Medical Centre in Ljubljana, Slovenia. Twenty-five (23.8%) patients acquired borrelial infection during the first trimester of pregnancy; eight (7.6%) of them had noticed the skin lesion before they became pregnant. In 43 (40.6%) patients the EM appeared in the second trimester, and in 37 (35%) patients in the third trimester of pregnancy. Two (1.9%) patients received phenoxymethyl penicillin (1 million IU t.i.d.), three (2.9%) benzyl penicillin (10 million IU b.i.d.), and 100 (95.2%) ceftriaxone (2 g daily). All patients were treated for 14 days except three (2.9%) in whom the treatment with ceftriaxone was discontinued because of mild side effects. The outcome of disease was good in all 105 patients. Ninety-three (88.6%) out of 105 patients had normal pregnancies; the infants were delivered at term, were clinically healthy, and subsequently had a normal psychomotor development. In the remaining 12 (11.4%) patients an adverse outcome was observed. Two (1.9%) pregnancies ended with an abortion (one missed abortion at 9 weeks, one spontaneous abortion at 10 weeks), and six (5.7%) with preterm birth. One of the preterm babies had cardiac abnormalities and two died shortly after birth. Four (3.8%) babies born at term were found to have congenital anomalies; one had syndactyly at birth and three had urologic abnormalities which were registered at the age of 5, 7, and 10 months, respectively. A causal association with borrelial infection was not proven in any infant. For at least some unfavourable outcomes a plausible explanation not associated with Lyme borreliosis was found.

Has the presence or absence of Borrelia burgdorferi sensu lato as detected by skin culture any influence on the course of erythema migrans?

The aim of this prospective study was to compare epidemiological and clinical data in patients with a positive Borrelia burgdorferi sensu lato culture and culture-negative erythema migrans skin lesions. Of the 546 adult patients with erythema migrans seen at our institution in 1997 in whom a skin biopsy was performed and the specimen cultured for the presence of B. burgdorferi sensu lato, 235 (43%) had a positive and 311 (57%) a negative skin culture. More women than men were present in both groups and women were also significantly older than men. Tick bites resulting in culture-positive erythema migrans predominated in May (p = 0.012), while in August and September tick bites with subsequent culture-negative skin lesions were more common (p = 0.018 and 0.011, respectively). Similarly, erythema migrans lesions noticed by our patients in May were significantly more often Borrelia culture positive than negative (p = 0.004), while lesions appearing in October were significantly more often culture negative (p = 0.004). In addition to these seasonal differences, the comparison of the large number of Borrelia skin culture-positive and -negative patients with erythema migrans also revealed differences in several clinical parameters including a larger diameter of skin lesions in the culture-positive group (p = 0.007 at presentation, and p = 0.039 at registration, respectively), a lesser number of multiple skin lesions (7/235 versus 27/311, p = 0.006), and a lower frequency of signs/symptoms (p = 0.039) associated with erythema migrans lesions in culture-positive than in culture-negative patients. We have no plausible explanation for the majority of these rather unexpected findings. Of the 59 patients who, prior to biopsy, had received brief courses of antibiotics known to be effective in the treatment of erythema migrans, 12 (20.3%) were culture positive. As anticipated, the ratio of culture positivity in pretreated patients was significantly lower (p < 0.001) than in those without antecedent antibiotic therapy.

Lyme borreliosis and peripheral facial palsy.

From 1994 to 1996, 114 consecutive patients older than 15 years who presented at the Department of Infectious Diseases, University Medical Centre, Ljubljana, fulfilled the criteria for inclusion into this study on the borrelial aetiology of peripheral facial palsy (PFP). The study was restricted to patients without a conceivable explanation for their PFP, erythema migrans or history of erythema migrans, clinical signs/symptoms of frank meningitis or any other neurological manifestation in addition to PFP. In 22 (19.3%) of these 114 patients borrelial infection was confirmed by one of the following: in 3 (13.6%) by the isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid (CSF), in 11 (50%) by the presence of intrathecal antibody production, and in 8 (36.4%) by seroconversion to borrelial antigens. Additional 20 (17.5%) patients interpreted as having had a probable borrelial infection, had positive (> or = 1:256) IFA IgM and/or IgG borrelial serum antibody titres, and in 9 (7.9%) patients borderline borrelial antibody titres (1:128) were found (interpreted as a possible infection). In 63 (55.3%) patients the serological tests remained negative. Lymphocytic pleocytosis was found at the first visit in 12/22 (54.5%) patients with confirmed borrelial infection, in 3/20 (15%) with probable infection, in 1/9 (11.1%) with possible infection, and in 10/63 (15.9%) patients with symptoms of unknown aetiology. Patients with confirmed borrelial infection had abnormal CSF findings significantly more often than did patients with symptoms of unknown aetiology (p = 0.0139 for lymphocytic pleocytosis and/or elevated CSF protein levels, and p = 0.0010 for lymphocytic pleocytosis). Local and systemic signs/-symptoms were also more common in patients with confirmed borrelial infection than in those with an symptoms of unknown aetiology (p = 0.0258). In Slovenia which is a highly endemic region for Lyme borreliosis, borrelial infection is a frequent cause of PFP in adult patients. PFP may occur early in the course of LB, prior to measurable antibody response, indicating the need for serologic follow-up. Abnormal CSF results and the presence of additional local and/or systemic symptoms are factors indicating a higher possibility of borrelial aetiology of PFP and should alert physicians to suspect LB.

Lyme meningitis: a one-year follow up controlled study.

Thirty-six patients with Lyme meningitis diagnosed at the Department of Infectious Diseases, University Medical Centre, Ljubljana in 1993 and 1994 were enrolled in a prospective study. All patients had lymphocytic meningitis, negative serum IgM antibody titres to tick-borne encephalitis virus and met at least one of the following four criteria: i) isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid (2 patients), ii) intrathecal borrelial antibody production (22 patients) iii) seroconversion to borrelial antigens (3 patients) and/or iv) erythema migrans in the period of four months prior to the onset of neurological involvement (21 patients). All patients underwent antibiotic treatment and were followed up for one year. The results of our study revealed that Lyme meningitis frequently occurs without meningeal signs and is often accompanied by additional neurological and/or other manifestations of Lyme borreliosis. During the first year after antibiotic treatment, minor and major manifestations of Lyme borreliosis persisted or occurred for the first time in several patients. They were not infrequent even at the examination performed one year after therapy.

Diffuse reversible alopecia in patients with Lyme meningitis and tick-borne encephalitis.

Alopecia occurring after febrile bacterial and viral infection is a phenomenon well known since the beginning of the century. To evaluate the occurrence of alopecia in tick transmitted disease, 23 adult patients with Lyme meningitis and 71 patients with tick-borne encephalitis were included in a prospective study and were followed up for one year. Diffuse alopecia occurred within three months after the outbreak of disease in 3 out of 23 (13%) patients with Lyme meningitis and in 40 out of 71 (56.3%) patients with tick-borne encephalitis. The mean duration of alopecia was 2 to 3 months and alopecia was reversible in all patients.

Comparison of isolation rate of Borrelia burgdorferi sensu lato in two different culture media, MKP and BSK-H.

The aim of the study was to evaluate two culture media for Borrelia burgdorferi sensu lato isolation from a 5 × 2 × 2 mm skin biopsy that was dissected into two pieces and inoculated into modified Kelly-Pettenkofer (MKP) and Barbour-Stoenner-Kelly-H (BSK-H) medium. Samples were incubated at 33°C for up to 9 weeks. Borrelia species was determined by MluI-restriction of whole genome or by MseI-restriction of PCR product. We determined the proportion of isolation rate, 'slow-growers', contaminated specimens and Borrelia species in the two media. In each of the two media 235 skin specimens were cultivated. We found 90/470 (19.1%) contaminated cultures (BSK-H 67/235, 28.5%; MKP 23/235, 9.8%; p <0.0001). Borrelia growth was ascertained in 59/235 (25.1%) BSK-H and 102/235 (43.4%) MKP cultures (p <0.0001); the corresponding values for non-contaminated cultures were 59/168 (35.1%) and 102/212 (48.1%); (p 0.003). Fourteen specimens were positive only in BSK-H, 57 solely in MKP, and 43 in both culture media. Slow growth was present in 8/59 (13.6%) BSK-H and in 4/98 (4.1%) MKP positive cultures (p 0.019). Borrelia afzelii was identified in 44/51 (86.3%) BSK-H and in 88/98 (89.8%) MKP culture-positive samples; the corresponding findings for Boreelia garinii and B. burgdorferi sensu stricto were 6/51 (11.8%) and 9/98 (9.2%), and 1/51 (1.9%) and 1/98 (1.0%), for BSK-H and MKP, respectively. Comparison of MKP and BSK-H medium for Borrelia culturing from skin specimens of European patients with erythema migrans revealed the advantage of MKP over BSK-H.

Epidemiological study of a cohort of adult patients with Erythema migrans registered in Slovenia in 1993.

Epidemiological characteristics of 892 adult patients with typical Erythema migrans (Em), registered at Lyme borreliosis Outpatients' Clinic, Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia, in 1993, are presented. Data were gathered prospectively by means of a questionnaire. All the patients were seen by at least one of the four authors of this report. There were 57% females and 43% males aged from 15 to 91 years (median value 44 years, mean 44.4 +/- 14.3 years). The highest number of patients was found in age groups from 30 to 59 years. 73% of the patients quoted a tick bite at the site of later Em and 6% an insect bite; 21% didn't remember any bite. 212 out of 638 patients with a tick bite were able to assess the maximal possible duration of tick attachment: two-thirds quoted 24 hours or less. Interval from a tick bite to the appearance of skin changes was one day to six months (median value 15 days, mean 20.3 +/- 20.6 days) and from the beginning of Em to registration one day to 10 months (median value eight days, mean 17.1 +/- 24.2 days). More than half of the patients were registered in June, July and August. The majority of patients with Em resided in the region of Ljubljana. They were bitten by ticks predominantly near their homes but some of them also quite far away. Slovenia is an endemic region for Lyme borreliosis. The number of cases presented in our report is most likely only a fraction of the real number of patients with Em in the region of Ljubljana and is even further underestimated for other parts of Slovenia.

Azithromycin versus doxycycline for treatment of erythema migrans: clinical and microbiological findings.

The effectiveness of azithromycin and doxycycline in the treatment of erythema migrans was compared in a prospective randomized trial. One hundred seven adult patients with typical erythema migrans, examined in the Lyme Borreliosis Outpatients' Clinic, University Department of Infectious Diseases in Ljubljana, were included in the study. Fifty-five patients received azithromycin (500 mg twice daily for the first day, followed by 500 mg once daily for four days) and 52 patients received doxycycline (100 mg twice daily for 14 days). The mean duration of skin lesions after the beginning of treatment was 7.5 +/- 5.9 days (median value 5, range 2-28 days) in the azithromycin group and 11.4 +/- 7.8 days (median value 9, range 2 days--8 weeks) in the doxycycline group (p < 0.05). Borrelia burgdorferi was isolated from erythema migrans in 28 patients before therapy: in 13 out of 52 in the doxycycline group and in 15 out of 55 in the azithromycin group. Three months after therapy, the culture was positive in four out of 13 patients treated with doxycycline and in one of the 15 patients who received azithromycin. A biopsy was repeated in all the patients with a positive isolation from the first skin specimen. During the first 12 months' follow-up, three patients treated with doxycycline but none in the azithromycin group developed major manifestations of Lyme borreliosis, while 15 doxycycline recipients and 10 azithromycin recipients developed minor consecutive manifestations.

Azithromycin and doxycycline for treatment of Borrelia culture-positive erythema migrans.

Adult patients with typical solitary erythema migrans, participating in prospective therapeutic studies on early Lyme borreliosis at the Lyme borreliosis Outpatient's Clinic, University Department of Infectious Diseases in Ljubljana, in 1991 to 1993, and followed up for 1 year, were included in the study. Only patients who were treated with azithromycin or doxycycline and in whom Borrelia burgdorferi was isolated from the border of the skin lesion prior to institution of antibiotic treatment were selected for presentation in this report. Fifty-eight patients received azithromycin (500 mg twice daily for the first day, followed by 500 mg once daily for 4 days) and 42 patients received doxycycline (100 mg twice daily for 14 days). The median duration of skin lesions after the beginning of treatment was 6.5 (2-30) days in the azithromycin group and 8 (2-35) days in the doxycycline group (non-significant difference). During the follow-up of 12 months one patient in each group developed major later manifestations of Lyme borreliosis and in 19 patients minor manifestations appeared: in nine (15.5%) treated with azithromycin and in ten (23.8%) receiving doxycycline. In one patient in the azithromycin group and in one patient in the doxycycline group B. burgdorferi was isolated from normal appearing skin at the site of previous erythema migrans 2 months after the institution of antibiotic therapy. Five (8.6%) patients receiving azithromycin and nine (21.4%) patients receiving doxycycline reported mild to moderate gastrointestinal discomfort. In addition, five patients treated with doxycycline developed photosensitivity.