Borrelia infection, Lyme disease and rheumatic disease 3.68/5 (19)

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Definition

Borrelia infection (Borreliosis) is due to infection with the bacterium Borrelia burgdorferi which can be transmitted by biting ticks. Both children and adults can be attacked, but only approx. 2% of those bitten become ill. Arthritis (arthritis) are among the possible complications. Borrelia infection is distinguished from infection with TBE ("Tick Born Encephalitis") due to a virus that can also be transmitted by forest ticks. Towards TBE exists vaccine. Hunting ticks (hyalomma marginatum) are three times larger than forest ticks and can (rarely) transmit a virus that causes the disease hemorrhagic criminal fever, but hardly in Norway.

Occurrence

Tick
Ticks in various stages By Alan R Walker - Own work, CC BY-SA 3.0, https://commons.wikimedia.org

Forest ticks exists in Norway along the coast from Østfold to the Helgeland coast. The risk of infection depends on the proportion of Ixodes Ricinus which contain Borrelia bacterium in itself. Infection has been found in anywhere from 1% to over 60% of the ticks. How long the tick is allowed to suck blood before it is removed is also important.

Symptoms

A tick that has sucked blood causes common itching, much like a mosquito bite. The itch continues a few days after the tick has been removed. If parts of the tick remain, the itching may continue.

Borrelia/Lyme disease
Borrelia infection with erythema migrans in 9 years old boy. Orczyk K, 2017. CC BY 4.0

Stadium 1

Erythema migrans is a rash that occurs in approx. 80% of those infected within the first 1-4 weeks. A ring-shaped rash grows from the injection site and becomes several cm in diameter. The rash causes little trouble, fades and recedes on its own, but to prevent the risk of Stage 2 (see below) antibiotic treatment is important. There are no special blood tests that detect infection at this early stage.

Stage 2

Symptoms from joints, nerves or the heart can occur 1-3 months after the tick bite. Samples from blood, synovial fluid and/or spinal fluid show typical results.

Hovent right knee (arthritis) during borrelia infection. Stinco G, Ruscio, ScientificWorldJournal (2014). Open-in

Arthritis (arthritis)

Arthritis and joint pain is the most common complication at this stage (60%). Borrelia arthritis most often occurs in one knee which feels stiff, swollen and somewhat painful. The synovial fluid is examined to ensure the diagnosis.

Nervous system (neuro-lyme disease)

About 15% of those infected get symptoms from the nervous system at this stage. Symptoms appear weeks to months after infection. New symptoms are usually evident. Nerves can be attacked so that numbness (an early symptom) or pain is felt in the skin in certain areas. Some people get radiating (neurogenic) pain (radiculitis) and muscle pain. Paralysis of the facial nerve (n. Facialis) (Bell's palsy) are among the most common symptoms. Certain sheep meningitis (meningitis) with headache, nausea, double vision (diplopia), reduced hearing and walking difficulties. The infection in the nervous system is detected by analyzes of the spinal fluid (increased number of lymphocytes, increased IgM, antibody against Borrelia and PCR examinations).

Heart

Inflammation of the heart muscle (myocarditis) can be detected by dysrhythmia in EKG (AV block?) and special examinations are necessary.

Stadium 3

Chronic borrelia infection
Lyme disease: chronic atrophic dermatitis of the left foot. Stinco G, 2014. CC Openi

Months to years after an infected tick bite, chronic symptoms can occur if earlier stages are not adequately treated. Most common is red-blue/violet, thin paper-like skin on the stretched side of the arms or legs (acrodermatitis chronica atrophicans). For unknown reasons, women over the age of 40 get this most commonly. Often nerves in the same area are affected so that the area feels numb. Hard knots beneath the skin above the joints or above larger parts of the body (like at morfea) can also be seen. Chronic arthritis, most often in the knee can also be seen in this stage (approx. 10%).

Unusual Lyme infectioner

Borrelia burgdorferi meaningful summer is the most common borrelia bacterium that is transmitted via tick bites (10-30%). Unusual Lyme infections are: Candidatus Neoehrlichia mikurensis (2-17%), Anaplasma phagocytophilum (0-4%) and Borrelia miyamoti (1%). These can also be infected via tick bites in Norway. People with a weakened immune system (for example, when using immunosuppressive drugs for rheumatic disease) are most susceptible to infection. Symptoms of infection can then be milder and harder to recognize. Infection with Borrelia miyamoti is suspected to be one of the causes Recurrent fever syndrome.

Examinations

Medical history in the case of Lyme infection is based on typical symptoms after a tick bite (see above). Not everyone has noticed the tick bite and the symptoms can be difficult to interpret.

Clinical examination includes assessment of the skin, joints, heart and nervous system. Fever is uncommon.

Blood tests and/or synovial fluid can show typical results in Borrelia antibody. However, these only appear after 6-8 weeks from being infected. B. burgdorferi DNA in synovial fluid was previously detected by «polymerase chain reaction »(PCR) and ensures the diagnosis. Other blood tests: CRP, sedimentation rate (ESR), CK and liver enzymes (AST, ALT) are slightly to moderate increased in some.

Up to 18% of healthy subjects have borrelia antibodies in blood (serum) and some also in spinal fluid, most often due to previous infection. This does not give symptoms and is not a treatment indication.

Imaging may include ultrasound, possibly also MRI of the affected joint. An X-ray is taken if other infectious/septic arthritis with potential bone damage is suspected.

Spinal fluid and skin biopsies can, if necessary, be examined with PCR.

Similar conditions / differential diagnoses)

Treatment

A forest tick must be removed from the skin as soon as it is discovered. It should not be scraped or pinched off, but pulled straight out, either with fingers or special tweezers available from pharmacies. A disinfectant cream (for example Brulidine) can be applied to the bite site. Antibiotic tablets are not recommended for every tick bite. However, if complications occur, an antibiotic must be given.

There are different recommendations for treatment. Penicillin, doxycycline, amoxicillin, azithromycin or ceftriaxone are drugs used for various indications. You can follow updated advice from National Competence Center for Tick-Borne Diseases (Flåttenteret.no) or equivalent from Public Health.

Vaccines. There is no vaccine against Borrelia infection in Norway. Vaccine against encephalitis virus (TBE vaccine) which can also be transmitted by tick bites does not prevent Lyme disease.

Pregnancy and breast-feeding

Many have been described pregnancy where the pregnant woman is infected. However, it is uncertain whether the infection can cause damage. In any case, it is appropriate to start antibiotic treatment as soon as the diagnosis is established (Weddell LA, 2018). Antibiotics are used with the exception of types that should not be used by pregnant women (this applies, among other things, to doxycycline). Borrelia infection is not transmitted to children through breastfeeding.

Prognosis

An uncomplicated tick bite is itchy, red and swollen a few days after the tick is removed. The symptoms then disappear without the need for treatment. In the case of Lyme infection, any Lyme infection is expected to pass without further complications after antibiotic treatment.

Recommendations / guidelines

EULAR recommendations for early arthritis (Combe B, 2016).

Literature


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