Management of patients presenting with generalized musculoskeletal pain and a suspicion of Lyme disease

Lyme disease is caused by bacteria of the B. burgdorferi sensu lato complex, and can give polymorphic clinical manifestations that can affect several organs such as the skin, the central nervous system, or the joints. In recent years, patients’ associations and physicians have been supporting the hypothesis that this infection would manifest as chronic generalized musculoskeletal pain symptoms, named “chronic Lyme disease”. Fibromyalgia is a clinical presentation characterized by chronic generalized musculoskeletal pain with a major impact on quality of life and social and psychological functioning. We analyzed existing literature data on pain syndromes associated with Lyme disease (post-treatment Lyme disease syndrome) or tick bites (polymorphic symptoms after a tick bite). We also analyzed existing data on the diagnosis, pathophysiology, and treatment of fibromyalgia. Our review shows that post-treatment Lyme disease syndrome has characteristics very close to post-infectious fibromyalgia. On the other hand, patients presenting for Lyme disease screening because of chronic generalized musculoskeletal pain symptoms after a tick bite should also be screened for fibromyalgia to allow appropriate management. Antibiotics are not recommended here.     

Lyme disease: Insight from social sciences

This article is a selective literature review of social science works published on Lyme disease that draws on other articles published on similar health hazards. These works present Lyme borreliosis as an “archetypal” example of modern infectious risks. It is an “invisible” risk resulting from interactions between human activities, ecosystems, and pathogens. To tackle this risk, health authorities promote individual-based prevention measures. Perceptions of the general population should thus be better understood: different from the perceptions of experts, the general population's perceptions are socially differentiated, inclined to an “optimism bias”, and influenced by personal stories. One should also not forget the dilemmas faced by the general population when contemplating preventive behavior. The “chronic Lyme disease” controversy illustrates the modern disappointment in science, the leveling of the general population's and experts’ relative opinions, and the progressive interference of the former with expert matters.     

Lyme borreliosis and other tick-borne diseases. Guidelines from the French Scientific Societies (I): prevention,epidemiology, diagnosis

Lyme borreliosis is transmitted en France by the tick Ixodes ricinus, endemic in metropolitan France. In the absence of vaccine licensed for use in humans, primary prevention mostly relies on mechanical protection (clothes covering most parts of the body) that may be completed by chemical protection (repulsives). Secondary prevention relies on early detection of ticks after exposure, and mechanical extraction. There is currently no situation in France when prophylactic antibiotics would be recommended. The incidence of Lyme borreliosis in France, estimated through a network of general practitioners (réseau Sentinelles), and nationwide coding system for hospital stays, has not significantly changed between 2009 and 2017, with a mean incidence estimated at 53 cases/100,000 inhabitants/year, leading to 1.3 hospital admission/100,000 inhabitants/year. Other tick-borne diseases are much more seldom in France: tick-borne encephalitis (around 20 cases/year), spotted-fever rickettsiosis (primarily mediterranean spotted fever, around 10 cases/year), tularemia (50–100 cases/year, of which 20% are transmitted by ticks), human granulocytic anaplasmosis (< 10 cases/year), and babesiosis (< 5 cases/year). The main circumstances of diagnosis for Lyme borreliosis are cutaneous manifestations (primarily erythema migrans, much more rarely borrelial lymphocytoma and atrophic chronic acrodermatitis), neurological (< 15% of cases, mostly meningoradiculitis and cranial nerve palsy, especially facial nerve) and rheumatologic (mostly knee monoarthritis, with recurrences). Cardiac and ophtalmologic manifestations are very rarely encountered.     

Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies (II). Biological diagnosis,treatment, persistent symptoms after documented or suspected Lyme borreliosis

The serodiagnosis of Lyme borreliosis is based on a two-tier strategy: a screening test using an immunoenzymatic technique (ELISA), followed if positive by a confirmatory test with a western blot technique for its better specificity. Lyme serology has poor sensitivity (30–40%) for erythema migrans and should not be performed. The seroconversion occurs after approximately 6 weeks, with IgG detection (sensitivity and specificity both > 90%). Serological follow-up is not recommended as therapeutic success is defined by clinical criteria only. For neuroborreliosis, it is recommended to simultaneously perform ELISA tests in samples of blood and cerebrospinal fluid to test for intrathecal synthesis of Lyme antibodies. Given the continuum between early localized and disseminated borreliosis, and the efficacy of doxycycline for the treatment of neuroborreliosis, doxycycline is preferred as the first-line regimen of erythema migrans (duration, 14 days; alternative: amoxicillin) and neuroborreliosis (duration, 14 days if early, 21 days if late; alternative: ceftriaxone). Treatment of articular manifestations of Lyme borreliosis is based on doxycycline, ceftriaxone, or amoxicillin for 28 days. Patients with persistent symptoms after appropriate treatment of Lyme borreliosis should not be prescribed repeated or prolonged antibacterial treatment. Some patients present with persistent and pleomorphic symptoms after documented or suspected Lyme borreliosis. Another condition is eventually diagnosed in 80% of them.     

Lyme disease and post-treatment Lyme disease syndrome: the neglected disease in our own backyard

Objectives

A survey was developed to assess experience and opinions about Lyme disease and post-treatment Lyme disease syndrome (PTLDS) among faculties in public health. No previous surveys of public health faculties have been found in the literature.

Study design

This is a cross sectional study of public health school faculty members designed to measure knowledge and experience with Lyme disease and PTLDS using an internet survey instrument.

Methods

Participants were recruited using all the publicly available e-mail addresses of faculty members in all the 50 accredited Schools of Public Health in the United States.

Results

A 15% response rate was seen for the survey. 50% of respondents were from Lyme endemic states. Less than 5% of faculty members consider themselves expert in Lyme or PTLDS. Many faculty members had known someone with Lyme disease or PTLDS, but few had been diagnosed themselves. Most believe that PTLDS can be severe and chronic, is not easy to treat, and does not resolve on its own, but were uncertain about its aetiology. Most respondents also felt that the incidence of Lyme disease will increase and that more education is needed.

Conclusions

The need for further understanding and communication presents an opportunity for public health research and education in Lyme disease and the sequelae of PTLDS.     

Patterns of Lyme disease diagnosis and treatment by family physicians in a southeastern state

This study examined how often physicians in Georgia diagnose and treat Lyme disease as well as the criteria they use to reach a diagnosis of Lyme disease. A survey was sent to 1,331 family physicians in Georgia concerning how many cases of Lyme disease the physicians diagnosed, and the criteria used to make the diagnosis, during the preceding 12 months. Of 710 responses, 167 physicians treated 316 cases of Lyme disease without a firm diagnosis. In addition, 125 physicians diagnosed 262 cases of Lyme disease, 130 without serologic testing and 132 with serologic testing. Family Physicians in Georgia diagnose Lyme disease at a rate 40 times greater than the surveillance case rate reported in Georgia.     

Functional signs in patients consulting for presumed Lyme borreliosis

IntroductionLittle is known about the functional symptoms associated with Lyme borreliosis (LB) in Europe. We aimed to assess functional symptoms associated with presumed LB and to compare patients with and without confirmed LB.Materials and methodsWe performed a retrospective monocenter study. Patients consulting for presumed LB were included.ResultsBetween November 2015 and June 2018, 355 patients were included (mean age: 51 years, 52% of women) of which 48 had LB: erythema migrans (42%), early disseminated LB (50%; 35% of neuroborreliosis cases), and late disseminated LB (8%). The most frequently reported functional symptoms were neuropathic pain (23%), arthralgia (23%), and asthenia (17%). Other functional symptoms were rare (≤ 10%). Three hundred and seven (86%) patients did not have LB. Patients with confirmed LB reported fewer functional symptoms than patients without LB (1.8 (± 1.7) vs. 3.6 (± 2.5), P < 0.001) with a shorter duration of symptoms (< 3 months in 48% vs. 16% of cases, P < 0.001). They less often reported asthenia (17% vs. 59%, P < 0.001), widespread pain (10% vs. 31%, P = 0.003), myalgia (10% vs. 32%, P = 0.002), memory disorders (4% vs. 16%, P = 0.03), irritability (2% vs. 23%, P ± 0.001), and sadness (0% vs. 16%, P = 0.003).ConclusionIn patients consulting for presumed LB, patients diagnosed with LB had fewer and shorter functional symptoms than patients without LB.     

天津市蓟县莱姆病流行情况调查

目的 了解天津市蓟县莱姆病的流行病学特征.方法 采用间接免疫荧光试验对该县居民进行血清流行病学调查,并用PCR方法和病原分离培养对临床确诊的莱姆病患者进行病原检测.结果 天津市蓟县人群莱姆病感染率为5.97％,学生感染率为5.28％.山区和半山区感染率高于平原地区;40-49岁年龄组感染率最高.经临床和血清学诊断为莱姆病患者25例,其主要临床表现为关节炎、慢性游走性红斑、面神经麻痹、多发性神经炎、脑膜炎和心脏损害等.收集25例患者的尿液,进行PCR检测,1例阳性.从1例多发性神经炎患者血液中分离出莱姆病螺旋体.结论 首次从天津地区莱姆病患者分离到莱姆病螺旋体.天津蓟县人群中有莱姆病的发生和流行,可能存在莱姆病的自然疫源地,为莱姆病防治提供依据.     

Antibody testing and Lyme disease risk

Lyme disease test results for >9,000 dogs were collected from participating veterinary clinics. Testing was conducted by using the IDEXX 3Dx kit, used widely by Maine veterinarians to screen clinically normal dogs during heartworm season. This study demonstrates how this test can be a valuable public health disease surveillance tool.     

827例拟诊莱姆病患者抗伯氏疏螺旋体抗体检查结果分析

目的分析拟诊莱姆病患者血清学检查结果,明确莱姆病临床病症及地区分布情况,为有效诊治莱姆病提供科学依据。方法2001-2006年应用间接免疫荧光试验和ELISA 2种方法对来自全国各地的827例临床拟诊莱姆病患者血清进行抗伯氏疏螺旋体IgM、IgG抗体检查。结果有135例患者血清抗伯氏疏螺旋体IgM、IgG抗体呈阳性反应,阳性率16.32%。其中神经系统疾病344例,阳性88例;心血管系统疾病39例,阳性3例;皮肤病变193例,阳性30例;发热病人102例,阳性6例;关节痛病人105例,阳性5例;精神障碍病人44例,阳性3例。135例患者应用抗生素治疗后有效率达92%。我国18个省(直辖市、自治区)有莱姆病病例发生,以黑龙江、吉林、内蒙古、新疆最多,其次是青海、四川、贵州、云南、浙江等省。结论我国人群确实存在莱姆病螺旋体散发感染,通过血清学检查能及早发现病人,提高诊疗效率。     

大兴安岭南段莱姆病的调查

1991年4～6月,我们在大兴安岭南段林区,对莱姆病进行了调查,应用间接免疫荧光抗体法检测496人居民血清,38人血清中抗莱姆病螺旋体IgG抗体效价≥1:128。根据临床表现和血清学调查,确诊莱姆病病例22例;从26只全沟硬蜱分离出4株莱姆病螺旋体。     

Seroprevalence of Lyme Borreliosis and tick-borne encephalitis in workers at risk, in eastern France

Objective

The aim of this article was to assess the seroprevalence of Lyme Borreliosis and tick-borne encephalitis (TBE) among occupationally exposed forest workers.

Methods

Workers exposed to tick bites in Eastern France were interviewed by occupational health physicians of the mutualité sociale agricole (MSA) on their sociodemographic features, their occupational activity, their last tick bite, their clinical history, and their means of prevention. Blood sampling was carried out for antibody detection.

Results

Among the 2975 subjects included in the study, the observed seroprevalence was 14.1% for Lyme borreliosis and 3.4% for TBE. Age, occupational activity, and place of residence significantly influenced the serological status of Lyme borreliosis. The seroprevalence was significantly higher among woodcutters (17.5%) than among other occupational categories (p < 0.001). Seroprevalence in Alsace (26.9%) and Lorraine (16.5%) were significantly higher than in other regions (p < 0.001 and p < 0.01, respectively). The seroprevalence of TBE was significantly higher in Alsace (5.5%; p < 0.001). The rates of seroprevalence for both infections varied according to forest areas. The multifactorial analysis of prevention practices revealed three types of behaviors as far as protection was concerned: “rigorous”, “partial”, or “insufficient”.

Conclusion

These results do not change the present French indications for use of TBE vaccine. They highlight the importance of information on these diseases and the need for further studies on microbial ecology and risk-factors identification.     

Economic impact of Lyme disease

To assess the economic impact of Lyme disease (LD), the most common vectorborne inflammatory disease in the United States, cost data were collected in 5 counties of the Maryland Eastern Shore from 1997 to 2000. Patients were divided into 5 diagnosis groups, clinically defined early-stage LD, clinically defined late-stage LD, suspected LD, tick bite, and other related complaints. From 1997 to 2000, the mean per patient direct medical cost of early-stage LD decreased from $1,609 to $464 (p<0.05), and the mean per patient direct medical cost of late-stage LD decreased from $4,240 to $1,380 (p<0.05). The expected median of all costs (direct medical cost, indirect medical cost, nonmedical cost, and productivity loss), aggregated across all diagnosis groups of patients, was approximately $281 per patient. These findings will help assess the economics of current and future prevention and control efforts.     

全沟硬蜱为内蒙大兴安岭莱姆病螺旋体的主要生物媒介

我们于1990年5～8月在内蒙大兴安岭,对莱姆病螺旋体的生物媒介和人群感染进行了调查,全沟硬蜱(Ixodes persulcatus)是当地蜱类的优势种,用直接荧光抗体法检查全沟硬蜱的中肠涂片,发现其带菌率为40%;从46组(380只)全沟硬蜱中分离出19株莱姆病螺旋体。分离出的菌株在单克隆反应上与美国菌株不同。用间接荧光抗体法检测308名居民血清,阳性率为13.3%。以上研究证明,大兴安岭是莱姆病疫区,全沟硬蜱是将莱姆病螺旋体传播到人和动物的主要生物媒介。