Analysis index

Antibody demonstration: 2 ml serum, 2 ml CSF (on suspicion of neuroborreliosis)

PCR: 1 – 2 ml CSF, joint puncture material, skin biopsy (native or in approximately 1 ml physiological sodium chloride solution)

Antibodies in serum:

IgG: < 20 – 24 U/ml

IgM: < 20 – 24 U/ml

IgG (VIsE): < 10 – 15 AU/ml

Immunoblot: please see findings report

PCR: negative

No

Infections with borrelia do not fall under the mandatory reporting requirements. However, as meningitis falls under the mandatory reporting requirements, independent of the type of pathogen, all meningitic courses of borrelia infection must be reported.

Infection by tick bite (please also refer to FSME, Ehrlichiosis). There are three stages of clinical symptoms:

1^st stage: Erythema migrans: A few days, usually within three weeks and very rarely a few months after a tick bite, there is an expanding circular reddening with central fading and a wide red circle on the outside (so-called “bull´s eye”). The term chronic erythema migrans is only recommended, when this rash remains longer than 6 months. General symptoms such as fever, headaches, myalgia, arthralgia, meningism and lymph node swelling are possible. An erythema migrans is not present in all borrelia infections.

2^nd stage: (Weeks to months after infection) Generalized borrelia infection: Main symptom is the lymphocytic Bannwarth’s meningoradiculitis, characterized by burning radicular pains with or without paralysis (polyradiculitis). Furthermore, there may be facial nerve paresis, meningitis (especially in children), myocarditis with I - III. degree AV-block and arthritis. Borrelia lymphocytoma: Blue livid skin changes, especially around the ears, chest or genitalia.

3^rd stage: (> 6 months after infection) Lyme arthritis (intermittent or chronic mono- or oligo arthritis, often of the knee joint), acrodermatitis chronica atrophicans (ACA), polyneuropathy, rarely chronic encephalomyelitis.

Serological diagnostics: Pathogens of borreliosis in Europe are B. afzelii (mainly skin manifestations), B. garinii (mainly CNS-infections) and B. burgdorferi sensu stricto (mainly arthritis).

Antibody production against borrelia is at least partially genotype-specific. Depending on which test-antigens are used, antibodies, which are directed against different genotypes, may remain undetected. This problem is specifically relevant for the diagnostics of neuroborreliosis (B. garinii infections) and affects both antibody screening as well as antibody confirmation. For optimal borreliosis diagnostics it is important to know the clinical question, in order to modify the test spectrum if need be.

Despite definite clinical symptoms, antibodies might not be present in the early stages of infection. During acute infection, isolated IgM- as well as IgG-immune responses may be possible. Therefore, in general, and independent of the clinical stage, IgM and IgG-antibodies should be tested concomitantly. IgG-antibodies dominate in case of chronic infection. Significant titer-peaks are possible during therapy. It is important to check the antibodies after therapy as this will be the base value for potential further progress checks. Specific IgM-antibodies can remain detectable even after effective treatment, sometimes for a long period (up to several years). Usually, a positive borrelia antibody status alone is not an indication for therapy. It is crucial that the laboratory findings are evaluated in conjunction with the clinical symptoms.

Laboratory diagnosis of neuroborreliosis: It is required to do compared testing of CSF and serum samples, taken concomitantly, by the methods of CSF basic diagnostics (IgG, IgM, IgA, albumin in serum and CSF, CSF cell count and cell differentiation) and specific IgG- and IgM-antibody demonstration with calculation of the CSF/serum antibody quotient.

PCR diagnostics: Of special importance is the pathogen demonstration by PCR from synovial fluid or synovial membrane biopsies for differential diagnostic clarification of arthritis (sensitivity 70 – 80 %). In case of neuroborreliosis, the sensitivity of the method, with up to 40 % in CSF, is insufficient and should only be used in exceptional cases. A PCR from peripheral blood is impractical due to the only very brief presence of borrelia in the circulation.

Therapy: Patients with negative laboratory findings but unquestionable clinical symptoms of acute borrelia infection should commence antibiotic therapy straight away. In the early stages (adults): Doxycycline 2 x 100 mg/dl or Amoxicillin 3 g/d, taken orally, for 2 – 3 weeks. Lyme arthritis, meningitis, chronic borreliosis: Ceftriaxone (Rocephin) 2 g/d or Cefotaxime 2 x 3 g/d administered as short infusion for about 2 – 3 weeks.