Guidelines for the diagnosis of tick-borne bacterial diseases in Europe.

Ticks are obligate haematophagous acarines that parasitise every class of vertebrate (including man) and have a worldwide distribution. An increasing awareness of tick-borne diseases among clinicians and scientific researchers has led to the recent description of a number of emerging tick-borne bacterial diseases. Since the identification of Borrelia burgdorferi as the agent of Lyme disease in 1982, 11 tick-borne human bacterial pathogens have been described in Europe. Aetiological diagnosis of tick-transmitted diseases is often difficult and relies on specialised laboratories using very specific tools. Interpretation of laboratory data is very important in order to establish the diagnosis. These guidelines aim to help clinicians and microbiologists in diagnosing infection transmitted by tick bites and to provide the scientific and medical community with a better understanding of these infectious diseases.

CSF findings in Lyme meningitis.

The results of cerebrospinal fluid examination in 59 cases of meningitis caused by Borrelia burgdorferi were analysed and compared with 73 non-Lyme meningitis cases. There was no statistically significant difference in the median cell count of 160 x 10(6)/l in the Lyme meningitis patients and the 150 x 10(6)/l in the non-Lyme cases. The protein level was elevated in both patients groups to 0.9 g/l and 0.8 g/l, respectively. The glucose level of 2.9 mmol/l (1.0-6.1) was, however, significantly (P = 0.005) lower in Lyme meningitis than the 3.3 mmol/l (1.6-5.4) in the non-Lyme cases. The most important observation of the study was the finding of a combination of pleocytosis, elevated protein (greater than 0.6 g/l) and low glucose levels (less than 2.1 mmol/l) (considered to be pathognostic for tuberculous meningitis) in six of 59 cases of Lyme meningitis.

[TIBOLA--a new tick-borne infection]. / TIBOLA--egy új, kullancs által terjesztett betegség.

Twenty-seven cases of a tick-transmitted infection with similar symptoms were seen by the author in the last 14 months. These symptoms do not fit into the known tick-borne infections. The bite caused by a "strikingly big" engorged tick was almost uniformly located on the occipital scalp region. The infection occurred most commonly in young children: the larger half of the patients were less than 10 years of age. The main symptom, presented in all patients, was the enlargement of painful lymph nodes in the region of the tick bite, causing us to name the infection Tick-BOrne LymphAdenopathy ("TIBOLA"). The other major feature, presented more than a half of the cases, was a herpes-like eschar 0.5-3 cm in diameter at the site of the tick bite. The eruption could be surrounded by a circular erythema (6 cases). After healing of the eruption, alopecia remained at the site. The time from the bite to the first symptom varied between 1-30 (mean 8) days. Doxycyclin seemed to shorten the disease. The infection seemed benign since only 4 patients had high fever, while 3 patients had a low grade fever (37-38 degrees C). General symptoms lasted for 3-12 months. Contrary to Lyme borreliosis, which is highly distributed all over in Hungary, the new tick-transmitted infection seems geographically more restricted, with almost all of the patient reporting that the tick bite occurred in a 120 km wide and 200 km long region along the banks of the Danube. Most probably, the disease is caused by a rickettsia infection which is still needed to be proven.

[Effect of an antibiotic combination on the propagation of Borrelia burgdorferi, causative agent of Lyme disease]. / Antibiotikum-kombináció hatása a Lyme-kórt okozó Borrelia burgdorferi szaporodására.

The effects of combined antibiotics (pefloxacin-doxycycline and pefloxacin-ceftriaxone) were tested on the most prevalent European Lyme spirochete species, Borrelia garinii by checkerboard dilution. The influence was judged both microscopically and by the measurement of the pH of the culture medium on the 5th day after inoculation. Borreliae propagated quite well at the concentration of 4 mg/l pefloxacin but the motility and the metabolism of the spirochete injured. Neither synergetic nor additive effect of the combination could be registered. Surprisingly, the pefloxacin at a concentration less than 4 mg/l activated both the propagation and the metabolism of borreliae, showing a clear antagonistic effect with doxycycline and ceftriaxone. Unless well-controlled animal model will prove the contrary, quinolones neither alone nor in combination should be used in Lyme borreliosis.

[First isolation of Borrelia burgdorferi (Lyme spirochaeta) from ticks in Hungary]. / A Borrelia burgdorferi (Lyme spirochaeta) elsö hazai izolálása kullancsokból.

31 field collected Ixodes ricinus adult ticks were investigated for the Lyme-disease spirochete. 5/31 Ixodes ricinus contained Borrelia burgdorferi. The spirochete was successfully cultivated in four cases, and they were found in two ticks by immunofluorescence technique and dark field microscopy, as well. Two of the isolated strains were tested by Western blot. The antigen pattern in both strains showed marked bands in 41 and 60 kD antigen, but only a week band appeared at 32 kD, with the lack of the OspB. The mechanism of infection and the way of prevention is discussed.

[Atrioventricular block caused by tick bite--Lyme's carditis]. / Kullancs csípés okozta atrioventricularis blokk--Lyme carditis.

The authors present the case of a 44-year-old patient who was admitted to the hospital because of AV block of degree III. Six weeks earlier a tick was removed from the left foot of the patient. Two weeks later an erythema of 8 cm in diameter, spreading peripherally as well as painful inguinal lymphadenitis developed at the site of the bite with transient arthralgia and myalgia in the region of the waist and left lower limb. After the temporary use of pacemaker, steroid and atropine therapy applied because of the pronounced bradycardia the block became of degree I on the 4th day however negative T-waves appeared in leads III, aVF, V3. By the 14th day the AV time returned to normal and the pathological signs of repolarization disappeared. Serological examinations revealed increased Borrelia burgdorferi antibody level. Lyme's carditis may be prevented by starting the antibiotic therapy at the time of the chronic erythema migrans. Upon medication the patient may recover from the carditis without remaining symptoms.

Recent lesson from a clinical and seroepidemiological survey: low positive predictive value of Borrelia burgdorferi antibody testing in a high risk population.

PURPOSE: The evaluation of the correspondence between positive Borrelia burgdorferi antibody response and the clinical symptoms attributed to Lyme disease is especially important in labour rights-related issues among forestry workers. MATERIAL AND METHODS: Between 1992 and 1995, 1670 forestry workers were surveyed and tested serologically for Lyme borreliosis in Hungary. The collected data was analysed retrospectively. RESULTS: In the case histories of the forestry employees erythema migrans, polyneuropathy and large joint arthritis were mentioned in 128 (7.7%), 192 (11.5%), and 93 (5.6%) workers, respectively. We found positive Borrelia burgdorferi s.l. antibody reaction in 622 workers out of whom 280 (45%) were free of any signs or symptoms referring to B. burgdorferi s.l. infection in their case histories. The frequency of seropositivity increased with age, number of registered tick bites, and erythema migrans in case history, as well as arthralgia. The frequency of polyneuropathy was somewhat more closely corresponding with age than seropositivity. Women gave account of a smaller number of tick bites, and were less likely seropositive while fewer of them were symptom-free. Since the 45% of seropositive forestry workers were symptom-free and they could not recall any symptoms suggestive for present or past Lyme borreliosis, the positive predictive value of Borrelia antibody testing in this high-risk group is surprisingly low, less than 5%. CONCLUSION: Positive Borrelia antibody test result may be especially misleading in a high-risk population.

A switch therapy protocol with intravenous azithromycin and ciprofloxacin combination for severe, relapsing chronic bacterial prostatitis: a prospective non-comparative pilot study.

Chronic bacterial prostatitis (CBP) is characterized by intense clinical symptoms, frequent relapse episodes and poor quality of life. Aggressive antibacterial therapy is warranted to eradicate the causative pathogens and to achieve a permanent cure. We administered a "switch-therapy" protocol to 30 patients showing severe CBP symptoms and two or more relapse episodes in the previous 12 months. Patients received intravenous azithromycin (500 mg/day) and ciprofloxacin (800 mg/day) for 3 days, followed by oral ciprofloxacin (1 g/day) for 25 days.Twenty-seven (90%) patients showed pathogen eradication at test-of-cure (TOC) visit. Five cases of infection relapse were detected at follow-up. At the TOC visit, 25 patients (83%) showed mild/absent symptoms, measured with the NIH-chronic prostatitis symptom index.These results indicate the efficacy of a "switch-therapy" protocol, based on combined azithromycin and ciprofloxacin. Comparative studies on larger CBP patient populations are warranted to confirm these encouraging results.

Temporary pacing in complete heart block due to Lyme disease: a case report.

The authors present the case of a 44-year-old man who was admitted with complete heart block and signs of severe bradycardia. After steroid administration and temporary pacemaker treatment the complete heart block resolved. During this therapy transient ST segment and T wave abnormalities occurred. The positive Borrelia burgdorferi antibody titer arrived only after therapy had been completed. This is regarded as the first case of Lyme carditis with complete heart block diagnosed in eastern Europe. Carditis resolved without antibiotic treatment and has not recurred.