Granuloma Annulare and Morphea: Correlation with Borrelia burgdorferi Infections and Chlamydia-related Bacteria.

A retrospective study of 109 skin biopsies with granuloma annulare (GA) or morphea histology from patients with suspected tick bite was performed. Biopsies were tested for cutaneous Borrelia burgdorferi DNA using PCR. The same biopsies were analysed for tick-borne novel agents, Chlamydia-related bacteria (members of the Chlamydiales order), using a PCR-based method. Borrelia DNA was detected in 7/73 (9.6%) biopsies with GA and in 1/36 (2.8 %) biopsies with morphea, while Chlamydiales DNA was found in 53/73 (72.6%) biopsies with GA and 25/34 (73.4%) biopsies with morphea. All Borrelia DNA-positive GA samples were also positive for Chlamydiales DNA. The Chlamydiales sequences detected in GA were heterogeneous and contained Waddliaceae and Rhabdochlamydiaceae bacteria, which are also present in Ixodes ricinus ticks, while the Chlamydiales sequences detected in morphea closely resembled those found in healthy skin. In conclusion, tick-mediated infections can trigger GA in some cases, while correlation of either Borrelia or Chlamydiales with morphea is unlikely.

A boy with a tight skin: Borrelia-associated early-onset morphea.

We present a case of a 16-year-old boy with morphea caused by Borrelia burgdorferi. We re-emphasise an immunohistochemical method, focus floating microscopy (FFM), to detect Borrelia burgdorferi spirochetes in tissue sections. Focus floating microscopy (FFM) proved to be more sensitive than polymerase chain reaction (PCR) and nearly equally specific.

Evaluation of skin thickness lesions in patients with Lyme disease measured by modified Rodnan total skin score.

Recently, a possible etiological connection between infection with Borrelia burgdorferi and various skin lesions, including morphea and systemic sclerosis (SSc), has been discussed. The aim of our study was the evaluation of frequency of skin thickening typical of SSc or morphea in the group of patients with Lyme disease (LD) with frequent exposition to tick bites. The group consisted of 110 patients with LD frequently exposed to tick bites form the northeastern Poland, which is an endemic area for this disease. To measure the skin lesions, the modified Rodnan total skin score (RTSS) was used. In the analyzed group, no skin changes typical of morphea or skin thickening were found. According to RTSS, all patients scored 0 points. Raynaud's phenomenon in all patients was not found. The relationship between scleroderma or morphea and LD is still a matter of controversy. Described by some authors, cases with LD and scleroderma may be associated with co-existence of B. burgdorferi infection with autoimmune process.

Borrelia in granuloma annulare, morphea and lichen sclerosus: a PCR-based study and review of the literature.

BACKGROUND: Morphea, granuloma annulare (GA) and lichen sclerosus et atrophicans (LSA) have also been suggested to be linked to Borrelia infection. Previous studies based on serologic data or detection of Borrelia by immunohistochemistry and polymerase chain reaction (PCR) reported contradictory results. Thus, we examined skin biopsies of morphea, GA and LSA by PCR to assess the prevalence of Borrelia DNA in an endemic area and to compare our results with data in the literature. METHODS: Amplification of DNA sequences of Borrelia burgdorferi sensu lato by nested PCR from formalin-fixed and paraffin-embedded skin biopsies of morphea, GA and LSA, followed by automated sequencing of amplification products. PCR-based studies on Borrelia species in these disorders published until July 2009 were retrieved by a literature search. RESULTS: Borrelia DNA was detected in 3 of 112 skin biopsies (2.7%) including one of 49 morphea biopsies (2.0%), one of 48 GA biopsies (2.1%) and one of 15 LSA biopsies (6.6%). Amplification products belonged to B. burgdorferi sensu stricto in two cases available for sequence analysis. CONCLUSIONS: The results of our and most of other PCR-based studies do not argue for a significant association of B. burgdorferi sensu lato with morphea, GA, LSA.

[Using the polymerase chain reaction to Borrelia burgdorferi infection in localized scleroderma injure (morphea), in Venezuelan patients]. / Uso de la reacción en cadena de la polimerasa para Borrelia burgdorferi en lesiones de esclerodermia localizada (Morfea), en pacientes venezolanos.

Borrelia burgdorferi is the causative agent of Lyme Borreliosis, an infectious multisystemic disease transmitted to humans by the Ixodes ticks bite. A possible association of Borrelia burgdorferi with localized scleroderma has been postulated. However, published data do not provide unequivocal results. Previous serologic analysis of patients with localized scleroderma in South American countries (including Venezuela), have been reported as yielding some reactivity. The present study looked for evidence of Borrelia burgdorferi infection in venezuelan patients with localized scleroderma, using the polymerase chain reaction to analyze 21 skin samples of patients with this skin condition. The results were negative in all the samples studied. Our data do not support an association of Borrelia burgdorferi infection and the sclerotic lesions of localized scleroderma; but do not rule out the possibility of a relationship between localized scleroderma and an unknown geno-specie of Borrelia burgdorferi sensu lato complex, a different Borrelia specie or a different spirochetal organism, as the etiological agents of the skin lesions in this area.

"Borrelia-associated early-onset morphea": a particular type of scleroderma in childhood and adolescence with high titer antinuclear antibodies? Results of a cohort analysis and presentation of three cases.

BACKGROUND: Morphea is an inflammatory autoimmune skin sclerosis of unknown etiology. A causative role of Borrelia burgdorferi infection has been controversially discussed, but no conclusive solution has yet been achieved. OBJECTIVE: Intrigued by 3 young patients with severe Borrelia-associated morphea and high-titer antinuclear antibodies, we retrospectively examined the relationship between Borrelia exposure, serologic autoimmune phenomena and age at disease onset in morphea patients. METHODS: In 90 morphea patients the presence of Borrelia-specific serum antibodies was correlated to the age at disease onset and the presence and titers of antinuclear antibodies. Patients with active Borrelia infection or high-titer antinuclear antibodies due to systemic sclerosis or lupus erythematosus served as controls. RESULTS: We observed a statistically highly significant association between morphea, serologic evidence of Borrelia infection, and high-titer antinuclear antibodies when disease onset was in childhood or adolescence. LIMITATIONS: Because pathogenic Borrelia species may vary in different geographic regions the relevance of Borrelia infection in morphea induction may show regional variations. CONCLUSION: B burgdorferi infection may be relevant for the induction of a distinct autoimmune type of scleroderma; it may be called "Borrelia-associated early onset morphea" and is characterized by the combination of disease onset at younger age, infection with B burgdorferi, and evident autoimmune phenomena as reflected by high-titer antinuclear antibodies. As exemplified by the case reports, it may take a particularly severe course and require treatment of both infection and skin inflammation.

The expanding spectrum of cutaneous borreliosis.

The known spectrum of skin manifestations in cutaneous Lyme disease is continuously expanding and can not be regarded as completed. Besides the classical manifestations of cutaneous borreliosis like erythema (chronicum) migrans, borrelial lymphocytoma and acrodermatitis chronica atrophicans evidence is growing that at least in part also other skin manifestations, especially morphea, lichen sclerosus and cases of cutaneous B-cell lymphoma are causally related to infections with Borrelia. Also granuloma annulare and interstitial granulomatous dermatitis might be partly caused by Borrelia burgdorferi or similar strains. There are also single reports of other skin manifestations to be associated with borrelial infections like cutaneous sarcoidosis, necrobiosis lipoidica and necrobiotic xanthogranuloma. In addition, as the modern chameleon of dermatology, cutaneous borreliosis, especially borrelial lymphocytoma, mimics other skin conditions, as has been shown for erythema annulare centrifugum or lymphocytic infiltration (Jessner Kanof) of the skin.

Is Localized Scleroderma Caused by Borrelia burgdorferi?

Despite considerable achievements in the study of localized scleroderma, the etiology of the disease has not been investigated completely. Borrelia burgdorferi-the agent of Lyme disease-is suggested to be one of the possible etiological factors of localized scleroderma. However, among scientists, this hypothesis is quite controversial. We have conducted investigations of the level of IgM and IgG class antibodies to B. burgdorferi in the serum of patients with localized scleroderma. To rationally substantiate the role of B. burgdorferi in the occurrence of localized scleroderma, thirty-two patients with localized scleroderma treated at an in-patient department were examined. The level of anti-Borrelia antibodies was determined in ELISA. Diagnostic levels of IgM and/or IgG were detected in 18.8% of patients with localized scleroderma, which is more than in the population (p < 0.01). Positive levels of anti-Borrelia antibodies in patients with localized scleroderma confirm the borreliosis nature of the disease, requiring conduction of complex antimicrobial treatment.

No evidence for Borrelia burgdorferi-specific DNA in lesions of localized scleroderma.

A possible association of Borrelia burgdorferi with localized scleroderma is currently the focus of intense research and discussion. Skin biopsies from 30 patients with localized scleroderma (28 of the plaque type/morphea; two linear scleroderma) were analyzed for the presence of Borrelia burgdorferi using three different polymerase chain reaction systems for amplification of segments of borrelial genes. Formalin-fixed, paraffin-embedded biopsies of 14 patients and fresh-frozen, cryo-conserved biopsies of 16 patients with localized scleroderma were obtained. Lesions of all patients showed clear signs of scleroderma and disease progression at the time of biopsy. Fresh-frozen as well as formalin-fixed biopsies from patients with erythema migrans or acrodermatitis chronica atrophicans were used as positive controls. With all three polymerase chain reaction systems, borrelial DNA was detected in none of the 30 specimens of localized scleroderma. In contrast, with one polymerase chain reaction system, Borrelia burgdorferi-specific DNA was found in 24 of 27 frozen biopsies from patients with erythema migrans and in all 5 analyzed frozen biopsies of patients with acrodermatitis chronica atrophicans. In approximately half of the paraffin-embedded biopsies from patients with erythema migrans (nine of 23) and acrodermatitis chronica atrophicans (13 of 27), Borrelia burgdorferi-specific DNA was identified. These results question the association of localized scleroderma with known subtypes of Borrelia burgdorferi.

Further evidence for Borrelia burgdorferi infection in morphea and lichen sclerosus et atrophicus confirmed by DNA amplification.

We present further evidence in support of the notion that Borrelia burgdorferi is possibly involved in the pathogenesis of morphea and lichen sclerosus et atrophicus (LSA). Running a nested polymerase chain reaction (PCR) with a primer set specific for the flagellin gene of B. burgdorferi enabled us to demonstrate the presence of Borrelia DNA in skin biopsies of patients with morphea (nine of nine) of LSA (six of six). Biopsy specimens obtained from patients with erythema chronicum migrans (two patients, four of four samples) and acrodermatitis chronica atrophicans (one patient, one of one sample) also showed positive PCR results. By contrast, there was no amplification of Borrelia DNA in control biopsies either from patients with chronic eczema (three of three) or psoriasis (two of two) or from normal skin (three of three). Antibodies directed against B. burgdorferi were only detected in the serum of patients with erythema chronicum migrans (two of two) and acrodermatitis chronica atrophicans (one of one) but were not present in cases of morphea (five of five), LSA (three of three), or in control subjects (three of three). These data suggest that B. burgdorferi may play a role in the pathogenesis of both morphea and LSA. Furthermore, we conclude that PCR analysis provides an important diagnostic tool, even in seronegative Borrelia infections.

Hypodermitis sclerodermiformis and unusual acid-fast bacteria.

We described two patients with localized, chronic, painful, scleroderma-like lesions of the lower part of the leg associated with venous stasis. This type of lesion has been termed "hypodermitis sclerodermiformis," and we review the literature pertinent to this entity. In addition, skin biopsy material was studied for the presence of acid-fast microbes. In both cases, Fite-Faraco-stained tissue sections contained many acid-fast coccoid and giant microbial forms suggestive of transitional L forms. Culture of the lesion in both cases was positive for Staphylococcus epidermidis. Until the cause is fully clarified, the search for acid-fast bacteria appears warranted in formed of pseudoscleroderma such as hypodermitis sclerodermiformis.

Detection of Borrelia burgdorferi DNA (B garinii or B afzelii) in morphea and lichen sclerosus et atrophicus tissues of German and Japanese but not of US patients.

OBJECTIVE: To elucidate the geographic and genospecific association of Borrelia with morphea and lichen sclerosus et atrophicus (LSA). DESIGN: The association of Borrelia burgdorferi with morphea and LSA has been reported, but is still controversial. We conducted a retrospective survey of Borrelia DNA in skin biopsy specimens. SETTINGS: The samples were collected from the outpatient clinic of university hospitals and a dermatopathology laboratory. PATIENTS: Skin biopsy specimens (19 morphea and 34 LSA) were obtained from patients in the United States, Japan, and Germany. DNA samples were subjected to amplification with polymerase chain reaction for B burgdorferi flagellin gene, and for the genotype-specific detection of B burgdorferi sensu stricto, Borrelia garinii, and Borrelia afzelii. RESULTS: Five cases of morphea and 2 cases of LSA in Germany and Japan yielded positive signals for B garinii or B afzelii, the European species. None of the American samples were positive for Borrelia polymerase chain reaction. Borrelia burgdorferi sensu stricto was not detected in any of the specimens. CONCLUSION: Morphea and LSA in Germany and Japan can be related with European genotypes of Borrelia.

Nodular scleroderma and pleomorphic acid-fast bacteria.

This report describes a rare form of scleroderma associated with multiple, elevated, dermal nodules. In addition, rare acid-fast bacteria, and less rare non-acid-fast coccoid forms were seen in histologic sections from the nodules. Skin culture isolates in thioglycolate broth were positive for both intermittently acid-fast coccobacilli, as well as non-acid-fast cocci compatible with Staphylococcus epidermidis. These findings reconfirm the existence of pleomorphic, acid-fast bacteria in scleroderma. The possibility is discussed that these tissue and culture forms may be related to certain similar morphologic forms currently designated as "cell-wall-deficient L forms" or may be related to previously described unusual growth forms of mycobacteria. Further investigations for microbes both in skin culture and in histologic sections from patients with scleroderma may prove helpful in elucidating any possible role that bacteria might have in the pathogenesis of this disease.

Pleomorphic, variably acid-fast bacteria in an adult patient with disabling pansclerotic morphea.

Disabling pansclerotic morphea (DPM) is a rare variant of scleroderma, characterized by immunologic abnormalities and peripheral blood eosinophilia. Sclerodermatous skin specimens from a 24-year-old woman with DPM were studied for the presence of acid-fast bacteria in bacteriologic culture and in microscopic sections. On three of four occasions, a highly pleomorphic organism was cultured from the skin lesions. Detailed bacteriologic investigations indicated that the microbe had unstable and vacillating morphologic characteristics and peculiar acid-fast properties. The organism could be identified as Staphylococcus epidermidis, but it also had stages of growth with morphologic forms more characteristic of a Corynebacterium-like or actinomycetelike microbe. Variably acid-fast coccoid forms, and variably eosinophilic- and basophilic-staining coccoid forms were observed in vivo. The morphologic forms observed in vivo were similar in appearance to some of the growth forms of the microbe observed in vitro, suggesting that such an organism might be implicated to the pathogenesis of DPM.

A case of generalized morphea with a high titer of anti-Borrelia burgdorferi antibodies.

A 69-year-old male had noticed pruritus on the back for the previous 3-4 years and cutaneous sclerosis with swelling of the dorsum of the neck had developed in the last one and a half years. However, he had never complained of Raynaud's phenomenon of the fingers, dry mouth, or dry eyes. At this first visit to our hospital, he complained of erythematous cutaneous sclerosis with swelling of the dorsum of the neck. Histopathological findings biopsied from the neck showed epidermal hyperplasia with elongation of rete ridges and homogeneous and fibromatous changes of the dermis with dense perivascular cell infiltration consisting of mononuclear cells or lymphocytes with several nests of incontinentia pigmenti. However, there were no sclerotic changes in blood vessels in the upper dermis biopsied from the forearm skin, although slightly homogeneous and fibromatous changes of the dermis were seen. In the clinical course, the cutaneous sclerotic change enlarged to extend to the bottom of the cheek, forearm, and lower legs. These clinical features and histopathological findings led to the diagnosis of generalized morphea. Hematologic examination showed positive anti-Borrelia burgdorferi IgM antibodies, although there were no positive anti-Borrelia burgdorferi IgG antibodies. These results revealed that there can be a close association of localized scleroderma with Borrelia burgdorferi and that generalized morphea may also represent a Borrelia infection.

[Borrelia burgdorferi antibodies in scleroderma circumscripta, lichen sclerosus et atrophicus, erythema nodosum, granuloma annulare, erythema annulare and chronic urticaria]. / Protilátky proti Borrelia burgdorferi pri sclerodermia circumscripta, lichen sclerosus et atrophicus, erythema nodosum, granuloma anulare, erythema anulare a urticaria chronica.

OBJECTIVES: The role of B. burgdorferi in the etiology of sclerodermia circumscripta (SC) and lichen sclerosus et atrophicus (LSA) are is reported in numerous, however controversial studies. The objective of our study is to approximate the solution of the given problem and to widen these consideration by other diagnoses with multifactorial and unclear etiology such as erythema nodosum (EN), granuloma anulare (GA), erythema anulare (EA) and urticaria chronica. MATERIAL AND METHODS: 124 probands were divided into groups according the diagnoses presented above and compared with the negative control group of 131 probands with dermatologic diagnoses, in which the etiologic agent of B. burgdorferi was not assumed and positive group of 55 probands with lyme boreliosis. Indirect immunofluorescent test was used to find out the tieter of antibodies against B. burgdorferi in all groups by using the endemic strains as antigens, which has caused a higher value of the so-called cut-off. RESULTS: The negative control had a positive titer in 44 cases (n = 131, i.e. in 33.6%). The positive titer was found in 11 probands from the SC group (34.4% =, n = 32), 5 probands in LSA (71.4%, n = 7), 9 probands in the EN group (64.3%, n = 14), 6 probands in the EA and GA groups (42.3%, n = 14) and 19 probands in the group of urticaria chronica (33.3%, n = 57). CONCLUSION: We assume that in the probands with high titers of antibodies, B. burgdorferi could play a role in the etiology of the given diseases titers of antibodies against B. burgdorferi. The draft problem could be solved by modern method including PCR with the use of several primers focused on different antigens regarding the certain epidemiologic regions. (Fig. 7, Ref. 17.)

Lack of IgG antibody seropositivity to Borrelia burgdorferi in patients with Parry-Romberg syndrome and linear morphea en coup de sabre in Mexico.

BACKGROUND: Progressive hemifacial atrophy or Parry-Romberg Syndrome (PRS) is a rare, acquired, progressive dysplasia of subcutaneous tissue and bone characterized by unilateral facial involvement. Its etiology is unknown, but theories about its pathogenesis include infectious, degenerative, autoimmune, and traumatic causes among others. The causal relationship of PRS and linear morphea en coup de sabre (LMCS) with Borrelia burgdorferi infection remains controversial. Our goal was to serologically determine anti-B. burgdorferi antibodies in patients diagnosed with PRS and LMCS to establish a possible association as a causative agent. METHODS: We conducted a serology study with patients belonging to a group of 21 individuals diagnosed with PRS, six with LMCS, and 21 matched controls. Anti-Borrelia IgG antibodies were determined by ELISA. A descriptive statistical analysis and Fischer's exact test were done. RESULTS: In serological tests, only two cases had borderline values and were further analyzed by Western blot with non-confirmatory results. For both the PRS and LMCS group, the association test was not significant, suggesting a lack of association between PRS or LMCS and the presence of anti-Borrelia antibodies. CONCLUSION: In Mexico there are no previous studies on Borrelia infection and its relationship between PRS or LMCS. Our result showed a lack of association of either clinical entities with anti-Borrelia-antibodies. Former reports of this association may suggest coincidental findings without causal relationship.