Infectious Disease Compendium

Borrelia

Microbiology

B. burgdorferi (2014 NEJM Review), B. hermsii, B. lonestari, Borrelia mayonii (named after its discoverers, the always modest Mayo Clinic), B. recurrentis. In Europe there is B. burgdorferi, Borrelia garinii and Borrelia afzelii and B. miyamotoi. There is also a Borrelia from bats and spread to humans from bat ticks (PubMed).

US and European Lyme are NOT the same clinically or immunologically (Pubmed).

Epidemiologic Risks

Tick bites, for US Lyme, the tick needs to be on greater than 4 hours to pass on the B. burgdorferi. B. burgdorferi is predominantly in the US NE and midwest, including urban Chicago. West coast pockets in California including Los Angeles. But. One of many illnesses whose range is changing, perhaps due to global warming.

B. miyamotoi where ever there is Lyme, but in a lower % of ticks, around 1 to 5%. Not uncommon in the NE & Midewest US (PubMed). Can be found in ticks in virtually all of Canada (PubMed). It is also in Europe and Japan (PubMed). There are also strain in California.

B. hermsii is endemic to the western United States including the Bitterroot Valley of western Montana (PubMed) T and southern British Columbia (shown below from PubMed):

B. lonestari is found in the American SE.

B. burgdorferi, B. lonestari (tick has a white spot on back), and B. hermsii: tick.

Where you hike may determine your risk: cattle and goat fields have fewer ticks and the ticks are less likely to have Borrelia (PubMed), but who wants to hike in a cow pasture?

Borrelia mayonii: Lyme like illness (Pubmed).

B. recurrentis: human body louse.

Syndromes

B. recurrentis and B. hermsii: relapsing fever. There are a variety of Borrelia what cause relapsing fever. World wide in distribution. In Russia (but is found in the US and Europe) it can be due to B. miyamotoi.

B. lonestari: causes a ECM like illness with no systemic, secondary or long term problems. Southern Tick Associated Rash Illness (STARI). However this organism has only been isolated in one case of STARI, so probably is not the cause after the Lone Star Tick Bite. STARI has been reported as far north as NY(PubMed).

Borrelia miyamotoi: Meningoencephalitis (chronic) (PubMed), and an acute febrile illness with myalgias, headache, neutropenia, thrombocytopenia, and elevated LFT's (PubMed).

Borrelia mayonii was discovered by the Mayo Clinic in 2015 as a rare cause of Lyme in the US and they modestly named it after themselves (PubMed). Can't hold the Mayo.

B. burgdorferi: Lyme disease. In Europe there is Borrelia garinii and Borrelia afzelii. Of the two, B. garinii causes typical early Lyme neuroborreliosis (PubMed) (Bannwarth syndrome (Pubmed)). B. afzelli is more indolent and not present typically (PubMed).

Stage 1: Local spreading target lesions: erythema chronica migrans. They can be multiple and they may not be present.

The European versions, especially B. afzelii, are more likely to cause a Lymphocytoma(Pubmed)

Stage 2: Disseminated with oligoarticular arthritis, carditis (heart block most common) and/or meningitis (bells palsy is a common manifestation.

Stage 3: Chronic with arthritis and encephalitis. With a Bell's palsy, the patient has aseptic meningitis, painful neuropathy, more symptomatic systemically aka Bannwarths syndrome. There is more garbage out there about Lyme than another other disease. The blood test is excellent, but there are labs that offer, let us say, unusual tests to diagnose Lyme. And a fair number of people seem to be committed to having this disease regardless of the supporting data.

There is encephalitis, encephalopathy, chronic Lyme disease, post-treatment Lyme disease syndrome, and chronic Lyme disease (PubMed) and of the four, there is no chronic Lyme disease (PubMed) (PubMed).

After culture proven Lyme, fatigue is uncommon, perhaps in 3% of patients (PubMed).

There is ECM in the Caribbean of unknown etiology (PubMed).

You make the diagnosis of Lyme by (of course) history and physical and serology.

The standard is the two step in the US: an Elisa and a Western blot. Will not accurately diagnose the European versions of the disease. For European, and perhaps US as well, you need to order a C6 ELISA (PubMed), and perhaps for US cases as well (PubMed) (2016 Review of testing).

CSF CXCL13 levels, a cytokine, may be helpful in diagnosing CNS disease (PubMed).

There are many labs that offer Lyme testing, often in my experience beloved by ND's (it is short for Not a Doctor) that have not been validated.  And remember, if you live in an area with no Lyme (like PDX) a positive test is likely a false positive (PubMed). But try getting the patient to agree.

"CDC and the Food and Drug Administration (FDA) have become aware of commercial laboratories that conduct testing for Lyme disease by using assays whose accuracy and clinical usefulness have not been adequately established. These tests include urine antigen tests, immunofluorescent staining for cell wall--deficient forms of Borrelia burgdorferi, and lymphocyte transformation tests. In addition, some laboratories perform polymerase chain reaction tests for B. burgdorferi DNA on inappropriate specimens such as blood and urine or interpret Western blots using criteria that have not been validated and published in peer-reviewed scientific literature (PubMed)."

In areas of low Lyme disease, patients with 'chronic lyme' have same phenotype of chronic fatigue patients (PubMed) and false positive lyme serologies.

Know your testing facility.  In areas of low prevalence, alternative labs, which are often postive Lyme, are almost certainly false positive (PubMed). In the study the alternative lab was Lab A.  I wish I knew which one, although I have my suspicions.

There is "cross-reactivity of Lyme screening among syphilis-positive sera but not false-positive syphilis screening tests from previous Borrelia burgdorferi infection (PubMed).

Treatment

B. lonestari

Doxycycline. Maybe

Lyme

see IDSA guidelines.

Early infection (ECM): doxycycline 100 mg po bid for 14-21 d, most get 21 days although 10 and 15 days have equal efficacy (PubMed).

OR amoxicillin 500 mg po tid for 20-30 d.

Doxycycline or amoxicillin allergy: Cefuroxime 500 mg po bid for 20-30 d OR erythromycin 250 mg po qid for 20-30 d.

However, since the guidelines were published, there was an article that suggests "patients treated for <=10 days with antibiotic therapy for early Lyme disease have long-term outcomes similar to those of patients treated with longer courses. Treatment failure after appropriately targeted short-course therapy, if it occurs, is exceedingly rare (PubMed)."

And longer iv antibiotics does not help with European Lyme either (Pubmed).

Arthritis: Doxycycline 100 mg po bid for 30-60 d OR amoxicillin,500 mg po qid for 30-60 d. or Ceftriaxone 2 g IV qd for 14-30 d OR penicillin G 20 million U IV in 4 divided doses daily for 14-30 d.

Neurologic abnormalities: Ceftriaxone 2 g IV qd for 14-30 d OR penicillin G 20 million U IV in 4 divided doses daily for 14-30 d. Ceftriaxone or penicillin allergy: Doxycycline 100 mg po tid for 14-30 d.

For European CNS infection, oral doxycycline (100 bid) is equal to intravenous ceftriaxone (2 gm qd) for the treatment of European adults with Lyme neuroborreliosis (PubMed).

Facial palsy, isolated Doxycycline 100 mg po bid for 20-30 d OR amoxicillin 500 mg po tid for 20-30 d. Doxycycline or amoxicillin allergy: Cefuroxime 500 mg po bid for 20-30 d OR erythromycin 250 mg po qid for 20-30 d.

Cardiac involvement: Doxycycline 100 mg po bid for 20-30 d OR amoxicillin 500 mg po tid for 20-30 d. Doxycycline or amoxicillin allergy: Cefuroxime 500 mg po bid for 20-30 d OR erythromycin 250 mg po qid for 20-30 d.

High-degree AV block: Ceftriaxone 2 gm IV qd for 14-30 d OR penicillin G 20 million U IV in 4 divided doses daily for 30 d.

Relapsing Fever Louse borne

Tetracycline 500 mg po x 1 OR Erythromycin 0.5 g in a single po dose, is an equally effective alternative therapy.

Tick-borne relapsing fever: Post-exposure treatment to prevent TBRF due to Borrelia persica (in Israel) use doxycycline 200 mg the first day and then 100 mg per day for four days (PubMed). Tetracycline OR erythromycin, 0.5 g every 6 hours for 5 to 10 days, because of the higher rate of treatment failures and relapses in these patients. Meningitis or encephalitis should be treated with iv penicillin G, cefotaxime, or ceftriaxone, for 14 days or more.

Antibiotic treatment typically induces a Jarisch-Herxheimer reaction.

Notes

There are two schools of thought for the treatment of Lyme: the IDSA and the ILADS.I am strongly in the IDSA camp, but have some ever so slight doubts. But all good data suggests no such thing as chronic Lyme after therapy (PubMed). BTW: long term po amoxicillin po adds NOTHING for Lyme (PubMed).

While many infections can cause post-infectious fatigue, many of the prolonged symptoms after lyme treatment are likely due to other medical issues (Pubmed). And Lyme kills no one (PubMed).

If you are interested in an analysis of 'chronic lyme' might I suggest Lyme: Two Worlds Compared and Contrasted by me and other articles at SBM

To get a hint of the wackaloon therapies offered to patients with chronic Lyme, see Unorthodox Alternative Therapies Marketed to Treat Lyme Disease. And these therapies are not without harm. Long term iv antibiotics leads to serious line infections (PubMed).

Recurrent Lyme is always a reinfection, not a relapsing infection (PubMed).

There is ECM in the Caribbean of unknown etiology (PubMed).