Erythema Migrans Research Articles

Lyme Borreliosis: Cutaneous and Neurologic Manifestations, CaseDefinitions and Therapy

Lyme borreliosis is the most common zoonosis in Germany with an incidence of up to 138/100 000. More than 90 % of all cases show dermatological manifestations. Early manifestations are erythema migrans, multiple erythemata migrantia, and (less frequently) borrelial lymphocytoma. A typical late manifestation is acrodermatitis chronica atrophicans. Lyme neuroborreliosis is much less common with an incidence of about 0.8/100 000 inhabitants in Germany. Bannwarth's syndrome (painful radiculoneuritis) is the most common manifestation of Lyme neuroborreliosis in adults followed by meningitis. International case definitions exist regarding the likelihood of Lyme neuroborreliosis on the basis of diagnostic test results. A CSF analysis should be performed in patients with suspected Lyme neuroborreliosis. The first line treatment for dermatological manifestations of Lyme borreliosis is doxycycline, in children and pregnant women amoxicillin. Doxycycline and beta-lactam antibiotics show similar efficacy regarding neurological symptoms and adverse effects for treatment of neurological manifestations. Treatment duration for early manifestations is 10 to 14 days, in Lyme neuroborreliosis it should not exceed 21 days. All manifestations, also Lyme neuroborreliosis, usually show a favourable prognosis after antibiotic treatment. Antibiotic treatment does not show any efficacy in patients with unspecific symptoms and concurrent positive anti-borrelial serology.

A Case Report of Early Disseminated Lyme Disease

Lyme disease is a multi-organ infectious disease caused by the spirochete "Borrelia burgdorferi," and transmitted by the "Ixodes" tick. Early disseminated Lyme disease can have varied central nervous system manifestations ranging from meningitis to radiculopathy and cranial neuropathy. If not suspected, misdiagnosis or delayed diagnosis can prove to be fatal. Erythema migrans is the most common clinical presentation, thereby, making dermatological examination extremely crucial in early diagnosis and treatment.

Estimates for Lyme borreliosis infections based on models using sentinel canine and human seroprevalence data.

Two models were developed to estimate Lyme borreliosis (LB) cases. One was based on the seroprevalence of Borrelia infections in human samples. This model used corrections for false negative and false positive results from published test sensitivity and specificity measures. A second model based on Borrelia infections in sentinel dogs was used to quantify the prevalence of Lyme disease Borrelia infections in humans; the reference baseline for this model was human and canine infections in Germany. A comparison of the two models is shown and differences discussed. The relationships between incidence, prevalence and total infection burden for LB were derived from published data and these were used in both models to calculate annual incidence, prevalence and total LB infections. The modelling was conservative and based on medical insurance records coded for erythema migrans. Linear model growth rates were used in place of the commonly adopted exponential growth. The mean of the two models was used to create estimates for various countries and continents. Examples from the analyses for LB estimated for 2018 include: incidence – USA 473,000/year, Germany 471,000/year, France 434,000/year and UK 132,000/year; prevalence – USA 2.4 million, Germany 2.4 million, France 2.2 million and UK 667,000; total infections – USA 10.1 million, Germany 10.0 million, France 9.3 million and UK 2.8 million. Estimates for the world for 2018 are: incidence 12.3 million/year; prevalence 62.1 million; and total infection burden 262.0 million. These figures are far higher than officially published data and reflect not only the underestimation of diagnosed cases, which is acknowledged by health agencies, but also undiagnosed and misdiagnosed cases.

A woman in her fifties with recurrent dizziness.

Vasculitis caused by neuroborreliosis is one of many rare described causes of stroke. A female smoker in her fifties presented with dizziness due to a left cerebellar infarction, and after general stroke workup atherosclerosis was considered the probable cause. In the preceding months she had experienced nonspecific intermittent headache, neck pain and dizziness initially attributed to prior head trauma. Over the following months she presented with relapsing and additional symptoms from the posterior circulation and a new right cerebellar infarction was diagnosed. Contrast-enhanced MRI showed signs of myelitis and meningeal enhancement. CSF examination revealed leukocytes 230 · 106/L (0-4 · 106/L) with 98% mononuclear cells, protein 3.12g/L (0.00-0.45g/L). Borrelia IgG and IgM antibodies were positive in serum and CSF, with ratio examinations consistent with intrathecal synthesis. She had a history of multiple tick bites, but not of erythema migrans. She had satisfactory clinical, biochemical and radiological response to antibiotic treatment with ceftriaxone. Neuroborreliosis was considered the aetiology of her cerebellar infarctions although no definite signs of cerebral vasculitis were evident from CT angiography. Rare causes of stroke, including neuroborreliosis, should be considered in stroke patients without risk factors for cerebrovascular disease and negative primary workup, and in recurrent stroke despite secondary preventive treatment.

Lyme Borreliosis: Serological and Microbiological Diagnostics andDifferential Diagnosis

Lyme borreliosis caused by at least six Borrelia burgdorferi species, is the most important tick-borne disease in the northern hemisphere. With a wide spectrum of possible symptoms, the microbiological diagnosis of this disease isassociated with a wide variety of ideas, divergent approaches and much uncertainty. The aim of the article is to introduce the treating physicians to a meaningful microbiological diagnostic procedure. Most important messages include that (I) the suspected diagnosis of Lyme borreliosis is first based on anamnestic data and clinical symptoms (compare "case definitions") which is substantiated by microbiological examinations; (II) microbiological diagnostics - primarily antibody detection, downstream PCR and culture - are only indicated if there are indicative symptoms, with typical erythema migrans not requiring microbiological diagnostics; (III) keep in mind: The more unspecific the symptoms are the lower the positive and the higher the negative predictive value of microbiological testing; (IV) serological diagnosis should follow a two-step procedure: a sensitive ELISA as first step, if reactive followed by immunoblot (IgM and IgG). Detection rates are ca. 50 % in localized, 70- > 90 % in disseminated early and nearly 100 % (only IgG relevant) in late disease; (V) in the immunoblot early forms of disease show a narrow band spectrum, late forms show a broad spectrum; (VI) methods that are not recommended for diagnostic purposes include lymphocyte activation or transformation tests (LTT, MELISA, ELISPOT), PCR or antigen detection from urine or blood, lymphocyte subpopulations, or direct detection of borreliae from patient material using dark field- or focus floating microscopy.

Epidemiological and clinical aspects of chronic neuroborreliosis with parkinsonism in the Yaroslavl region

To study clinical and epidemiological features of chronic neuroborreliosis (CB) with parkinsonism (PS) in the Yaroslavl region. The study included the main group of patients (n=5) with CB and PS of the average age of 61±3/4, the comparison group (n=6) with Parkinson's disease (PD) of the average age of 54.7±8.3 and a group of 6 healthy people. Diagnostic criteria of Lyme disease based on the recommendation of the US Centers for Disease Control and Prevention and criteria for the diagnosis of PS were used. PD was diagnosed by the criteria of the Parkinson's UK Brain Bank. Serological diagnosis of CB was carried out using immunoenzyme assay and immunoblotting in dynamics. The following scales were administered: HOEHN and YAHR, MMSE, MFI-20, CGI. All patients underwent MRI of the brain and spinal cord. PS in patients with CB in the Yaroslavl region was observed in 2.17% of cases among patients with CB and amounted to 0.25% of all cases of the revealed PS. The features that complicate the diagnosis of PS within chronic borreliosis were: the absence of erythema migrans in the history of 80% of patients and in more than half of the cases of the acute period of the disease, the presence in most patients (60%) of asymmetric onset of the PS with rest tremor in 40% cases and a significant reduction in the severity of PS as a result of therapy with levodopa. The onset of complete regression of the clinical manifestations of PS and reduction of the titer of antibodies and obtaining the negative results during dynamic serological study in response to prolonged antibiotic therapy provided a basis to verify the diagnosis of borreliosis with PS in these patients.

The evaluation of hunters and foresters' knowledge of the possible ways of preventing Borrelia burgdorferi infections

This study is aimed at evaluating the awareness among hunters and foresters concerning the activities undertaken for the prevention of Borrelia burgdorferi infections. The study group included 236 hunters from Poland and 339 foresters from Ukraine. The study was based on an original questionnaire including questions which concerned the applied methods of removing ticks attached to the skin, the kind of preventive measures undertaken to avoid tick bites, the evaluation of knowledge concerning the prevention of tick-borne diseases, as well as the participants' willingness to be educated on this issue. Removing a tick with a pair of tweezers by a simple vertical move was more frequently practiced by the hunters (16.5%). Spreading an oily substance over a tick to make it go out on its own was more often applied by the foresters (18.8%). The occurrence of erythema migrans was more frequently reported by the foresters (47.2%). Among the persons declaring no knowledge of the prevention of tick-borne diseases, 77.8% of the hunters and 61.5% of the foresters were willing to gain such knowledge, and 11.1% of the hunters and 21.2% of the foresters did not want any education on this issue. The hunters more often than the foresters applied repellents and checked their body after returning from green areas. Education is needed in certain groups undertaking hobby or vocational activities in forest areas of Poland and Ukraine. It seems reasonable to undertake research on the preferences concerning the choice of repellents among the groups at risk of tick bites. Med Pr. 2020;71(1):59-68.

Host Metabolic Response in Early Lyme Disease.

Lyme disease is a tick-borne bacterial illness that occurs in areas of North America, Europe, and Asia. Early infection typically presents as generalized symptoms with an erythema migrans (EM) skin lesion. Dissemination of the pathogen Borrelia burgdorferi can result in multiple EM skin lesions or in extracutaneous manifestations such as Lyme neuroborreliosis. Metabolic biosignatures of patients with early Lyme disease can potentially provide diagnostic targets as well as highlight metabolic pathways that contribute to pathogenesis. Sera from well-characterized patients diagnosed with either early localized Lyme disease (ELL) or early disseminated Lyme disease (EDL), plus healthy controls (HC), from the United States were analyzed by liquid chromatography-mass spectrometry (LC-MS). Comparative analyses were performed between ELL, or EDL, or ELL combined with EDL, and the HC to develop biosignatures present in early Lyme disease. A direct comparison between ELL and EDL was also performed to develop a biosignature for stages of early Lyme disease. Metabolic pathway analysis and chemical identification of metabolites with LC-tandem mass spectrometry (LC-MS/MS) demonstrated alterations of eicosanoid, bile acid, sphingolipid, glycerophospholipid, and acylcarnitine metabolic pathways during early Lyme disease. These metabolic alterations were confirmed using a separate set of serum samples for validation. The findings demonstrated that infection of humans with B. burgdorferi alters defined metabolic pathways that are associated with inflammatory responses, liver function, lipid metabolism, and mitochondrial function. Additionally, the data provide evidence that metabolic pathways can be used to mark the progression of early Lyme disease.

The General Symptom Questionnaire-30 (GSQ-30): A Brief Measure of Multi-System Symptom Burden in Lyme Disease.

Introduction: The multi-system symptoms accompanying acute and post-treatment Lyme disease syndrome pose a challenge for time-limited assessment. The General Symptom Questionnaire (GSQ-30) was developed to fill the need for a brief patient-reported measure of multi-system symptom burden. In this study we assess the psychometric properties and sensitivity to change of the GSQ-30.Materials and Methods: 342 adult participants comprised 4 diagnostic groups: Lyme disease (post-treatment Lyme disease syndrome, n = 124; erythema migrans, n = 94); depression, n = 36; traumatic brain injury, n = 51; healthy, n = 37. Participants were recruited from clinical research facilities in Massachusetts, Maryland, and New York. Validation measures for the GSQ-30 included the Patient Health Questionnaire-4 for depression and anxiety, visual analog scales for fatigue and pain, the Sheehan Disability Scale for functional impairment, and one global health question. To assess sensitivity to change, 53 patients with erythema migrans completed the GSQ-30 before treatment and 6 months after 3 weeks of treatment with doxycycline.Results: The GSQ-30 demonstrated excellent internal consistency (Cronbach α = 0.95). The factor structure reflects four core domains: pain/fatigue, neuropsychiatric, neurologic, and viral-like symptoms. Symptom burden was significantly associated with depression (rs = 0.60), anxiety (rs = 0.55), pain (rs = 0.75), fatigue (rs = 0.77), functional impairment (rs = 0.79), and general health (rs = −0.58). The GSQ-30 detected significant change in symptom burden before and after antibiotic therapy; this change correlated with change in functional impairment. The GSQ-30 total score significantly differed for erythema migrans vs. three other groups (post-treatment Lyme disease syndrome, depression, healthy controls). The GSQ-30 total scores for traumatic brain injury and depression were not significantly different from post-treatment Lyme disease syndrome.Conclusions and Relevance: The GSQ-30 is a valid and reliable instrument to assess symptom burden among patients with acute and post-treatment Lyme disease syndrome and is sensitive in the detection of change after treatment among patients with erythema migrans. The GSQ-30 should prove useful in clinical and research settings to assess multi-system symptom burden and to monitor change over time. The GSQ-30 may also prove useful in future precision medicine studies as a clinical measure to correlate with disease-relevant biomarkers.

Lyme disease in children: Data from the Canadian Paediatric Surveillance Program

BackgroundLyme disease (LD) is an infectious disease that is emerging in eastern and central Canada associated with the spread of the tick vector Ixodes scapularis. National surveillance shows that children are an at-risk age group. ObjectivesTo study the epidemiology of LD in Canadian children using the Canadian Paediatric Surveillance Program (CPSP) to better understand exposure history, clinical manifestations, diagnosis and treatment of paediatric LD cases in Canada. MethodsA structured questionnaire was completed by paediatricians for each LD case reported as part of the Canadian Paediatric Surveillance Program from 2014 to 2017. ResultsThere were 95 cases that met inclusion criteria as confirmed or probable cases. The median age was 7 years; 38 % were 5–9 years and 35 % were 10−15 years of age. Most cases were acquired in known Canadian endemic locations; 5 were acquired during travel to the US. Most cases were reported from Nova Scotia and Ontario (46 % and 38 % respectively). The most common clinical presentation was arthritis (59 % of all cases), which is a manifestation of the late disseminated stage of LD. Late disseminated disease presented through the year, whereas early LD (Erythema migrans) and early disseminated LD presented during the summer and fall. Antibiotic choice and duration of therapy generally followed accepted guidelines. ConclusionThis study of the clinical spectrum of LD in Canadian children underlines the need for preventive measures to protect children in Canada from emerging LD, and the need for health care provider awareness.

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, 355patients were included (mean age: 51years, 52% of women) of which 48had 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.

Erythema migrans: the cutaneous manifestation of Lyme disease

Erythema migrans: the cutaneous manifestation of Lyme disease

Early Lyme Borreliosis in Patients Treated with Tumour Necrosis Factor-Alfa Inhibitors.

The study evaluated the course and outcome of erythema migrans in patients receiving tumour necrosis factor-alpha (TNF-α) inhibitors. Among 4157 adults diagnosed with erythema migrans in the period 2009–2018, 16 (2.6%) patients were receiving TNF-α inhibitors (adalimumab, infliximab, etarnecept, golimumab), often in combination with other immunosuppressants, for rheumatic (13 patients) or inflammatory bowel (three patients) disease. Findings in this group were compared with those in 32 sex- and age-matched immunocompetent patients diagnosed with erythema migrans in the same years. In comparison with the control group, the immunocompromised patients had a shorter incubation period (7 vs. 14 days; p = 0.0153), smaller diameter of erythema migrans (10.5 vs. 15.5 cm; p = 0.0014), and more frequent comorbidities other than immune-mediated diseases (62.5% vs. 25%, p = 0.0269), symptoms/signs of disseminated Lyme borreliosis (18.8% vs. 0%, p = 0.0324), and treatment failure (25% vs. 0%, p = 0.0094). After retreatment with an antibiotic, the clinical course of Lyme borreliosis resolved. Continuing TNF inhibitor treatment during concomitant borrelial infection while using identical approaches for antibiotic treatment as in immunocompetent patients resulted in more frequent failure of erythema migrans treatment in patients receiving TNF inhibitors. However, the majority of treatment failures were mild, and the course and outcome of Lyme borreliosis after retreatment with antibiotics was favourable.

Is Doxycycline Appropriate for Routine Treatment of Young Children With Erythema Migrans?

The frequency of permanent staining of teeth of young children from doxycycline is thought to be lower than from older tetracyclines, but the precise risk is uncertain. Until more definitive data become available, doxycycline should not be used routinely to treat young children with erythema migrans, a manifestation of Lyme disease for which other antimicrobials are highly effective.

231. Microbial cell-free DNA Sequencing to Detect Borrelia burgdorferi DNA in the Plasma of Pediatric Patients with Lyme Disease

BackgroundDiagnosing Lyme disease often involves laboratory evaluation, yet available tests have limitations. Serology remains negative for weeks after infection occurs, and may then remain positive for years. Borrelia burgdorferi blood PCR testing has low sensitivity, rendering it unhelpful. We sought to determine whether an emerging technology, next-generation sequencing (NGS) of microbial cell-free DNA (mcfDNA), can detect B. burgdorferi DNA in the plasma of pediatric patients with erythema migrans (EM).MethodsPatients aged 1–17 years with a clinically-identified single or multiple EM were enrolled. Two clinical investigators were required to agree on the EM finding, with no evidence of an alternative diagnosis. Subjects were excluded if they previously had Lyme disease, had received antibiotics within 30 days prior to enrollment, or if the rash had resolved before the first blood draw. Three blood samples were taken during the study period: one before antibiotics were administered, then 1–3 weeks and 2–3 months later. At enrollment, plasma was tested for Lyme disease using C6 antibody with reflex to Western Blot and mcfDNA sequencing (Karius, Inc., Redwood City, CA). Briefly, mcfDNA was extracted from plasma and NGS performed. Human reads were removed and remaining sequences were aligned to a curated microbial database. Only mcfDNA testing was performed at follow-up visits.ResultsWe enrolled 5 subjects (ages 4–15 years old, median age 4). Four subjects had a single EM and negative Lyme serology. One subject had approximately 20 EMs and positive serology (C6-antibody=7.52 (Positive >1.09), 3/3 IgM, 2/10 IgG). All 14 plasma samples, including five pre- and nine post-antibiotic samples, were negative for B. burgdorferi DNA by mcfDNA sequencing. No other infections, including other tick-borne infections, were detected.ConclusionNGS of mcfDNA did not identify B. burgdorferi DNA in the plasma of pediatric patients with active EM rashes. This approach is unlikely to be helpful in diagnosing early localized Lyme disease. This may be because spirochetes are localized to the periphery of the rash in EM and spirochetemia likely occurs at later stages of infection. Follow-up studies are planned to investigate how NGS of mcfDNA performs during early and late disseminated Lyme disease.Disclosures All authors: No reported disclosures.

Borrelial lymphocytoma of the lip

A 15-year-old boy attended our hospital for progressive swelling of the lower lip with firm and slightly tender nodules (figure). He had no fever and was in good general condition. The physical examination was otherwise unremarkable. Blood tests and chest x-ray were normal. An ultrasound did not show any sign of arteriovenous malformation. At this stage, the main differential diagnosis was granulomatous cheilitis or lymphoma. A biopsy of the lip was then done and showed a dense inflammatory infiltrate consisting mainly of small lymphocytes without granulomas or signs of malignancy. The patient did not report a tick bite or erythema migrans but had been on a camping trip in the forest a few weeks earlier. Due to the similarity between our histological findings and borrelial lymphocytoma, we did serological tests for Lyme disease and they were positive. We identified Borrelia afzelii by PCR in the lip biopsy sample. A diagnosis of borrelial lymphocytoma was made and after 4 weeks of treatment with oral doxycycline (100 mg twice a day), the lesion almost completely disappeared.

Measurement of Organ-Specific and Acute-Phase Blood Protein Levels in Early Lyme Disease.

Lyme disease results from infection of humans with the spirochete Borrelia burgdorferi. The first and most common clinical manifestation is the circular, inflamed skin lesion referred to as erythema migrans; later manifestations result from infections of other body sites. Laboratory diagnosis of Lyme disease can be challenging in patients with erythema migrans because of the time delay in the development of specific diagnostic antibodies against Borrelia. Reliable blood biomarkers for the early diagnosis of Lyme disease in patients with erythema migrans are needed. Here, we performed selected reaction monitoring, a targeted mass spectrometry-based approach, to measure selected proteins that (1) are known to be predominantly expressed in one organ (i.e., organ-specific blood proteins) and whose blood concentrations may change as a result of Lyme disease, or (2) are involved in acute immune responses. In a longitudinal cohort of 40 Lyme disease patients and 20 healthy controls, we identified 10 proteins with significantly altered serum levels in patients at the time of diagnosis, and we also developed a 10-protein panel identified through multivariate analysis. In an independent cohort of patients with erythema migrans, six of these proteins, APOA4, C9, CRP, CST6, PGLYRP2, and S100A9, were confirmed to show significantly altered serum levels in patients at time of presentation. Nine of the 10 proteins from the multivariate panel were also verified in the second cohort. These proteins, primarily innate immune response proteins or proteins specific to liver, skin, or white blood cells, may serve as candidate blood biomarkers requiring further validation to aid in the laboratory diagnosis of early Lyme disease.

Rare manifestations of lyme neuroborreliosis

Lyme disease is an endemic infection in many European countries and Russia, including North-West region. Neurological manifestations are reported in about 10%-25% of patients. Lyme neuroborreliosis (LNB) can includes polyradiculoneuritis, meningoradiculitis, meningitis and encephalitis in adults. Two cases of LNB are presented. Patient one: a 46-yrs old man was admitted with a history of dizziness, fever and walking disorder after four months of fishing in endemic ( tick-borne infections) area. On examination patient showed dysarthria, ataxia and hemianopsia. CSF showed mild pleocytosis and elevated total protein. Serological methods (including Western blot test) were positive for LNB. Brain MRI showed subacute ischemic lesions on T2-weighted and T2-FLAIR images on vertebrobasilar territory. Patient two was a 52-yrs old man, hospitalized with general stiffness after two months after tick bite without erythema migrans and fever. Neurological examination revealed a dysarthria, bradykinesia and right sided rigidity. Serological studies were positive for LNB. The CSF total protein content was 0,89 g/l. MRI images showed multifocal lesions of white matter (demyelination, typically seen in inflammatory). Both patients were diagnosed and treated successfully for LNB: they received a 21-day course of 2 g per day ceftriaxone, then benzathine benzylpenicillin every 14 days for 3 months and every 28 days for another 3 months. Corticosteroids and platelet aggregation inhibitors in case one and dopaminergic medications (case two) were also prescribed. A year after treatment patients were free of neurological symptoms. The cases suggest that LNB can manifest rare clinical forms as cerebral vasculitis and parkinsonism.

Lyme snap: A feasibility study of on-line declarations of erythema migrans in a rural area of France

The incidence of Lyme borreliosis remains a matter of debate, but it can be estimated using the incidence of erythema migrans (EM), which is pathognomonic of the first phase. The aim of this prospective pilot study was to assess the feasibility of the on-line declaration of EM in rural areas where the incidence of Lyme borreliosis was previously estimated at 85 per 100,000 inhabitants per year.The study was limited to a rural area (Les Combrailles, Auvergne) of approximately 52,800 inhabitants and was preceded by an information campaign for the inhabitants and the healthcare professionals. Patients who sent a photo of the suspected EM by email or MMS message between April 2017 and April 2018 and who accepted to answer a questionnaire were included in the study. Two physicians then evaluated the quality of the photographs and the probability of EM. In parallel, the number of EM seen by physicians and pharmacists in the area over the given period was recorded.Out of the 113 emails and MMS messages received, 73 people were outside of the trial area or period and 9 did not complete the questionnaire. The photos of the remaining 31 people were analysed. The median age was 51.5 years old ([38–58] IQR) and 18 (58%) were women. Seven people (25%) stated that they did not have a smartphone and in 9 cases (29%) the photo was sent by a third party. The quality of the photos was considered very good in 22 (71%) cases, good in 7 (23%) cases, and average in 2 (6%) cases. The probability of EM was determined to be strong or possible in 12 (38%) cases, i.e. an estimated incidence of 22.7 per 100,000 inhabitants. Over the study period, 40 physicians and 20 pharmacists were contacted on a monthly basis. A median of 5 physicians [3;7] and 4 pharmacists [3 ;7] answered each month for a total of 18 and 36 declared EM respectively. The EM (strong probability/possible) collected by on-line declaration and those declared by healthcare professionals were all sent between April and October 2017. The total time spent on the information campaign and collection has been estimated at 265 h (divided between 10 people) for an overall cost of 10,669 Euros.The incidence of EM recorded by on-line self-declaration in our study seems to be lower than in previous studies, the under-reporting was probably linked to the low use of new technologies in the rural areas. Increasing the human resources and finances appears difficult to achieve in practice over a longer time period but the development of an application for the automatic recognition of EM could be one method for a more exhaustive collection in the long term and at lower cost.

Neuroborreliosis: modern methods of diagnostics and treatment

The lecture deals with human infectious disease — neuroborreliosis, or Lyme disease. The relevance of the topic is due to the wide spread of the disease both in Europe and in Ukraine. Neuroborreliosis is a poly‑organic infectious disease caused by Borrelia burgdorferi penetrating into the human body when it is bitten by a tick. Once in the human body, it causes a primary affect in the form of erythema migrans, and then, depending on the stage of the disease, the central nervous system is damaged. This is a multiorgan infectious disease as, in addition to the nervous system, the skin, the musculoskeletal system, the cardiovascular system, the liver are involved in the process. The incidence of borreliosis is seasonal in nature — the first patients after a tick bite appear in March, the latter sometimes even in October.The pathogen spreads via the lymphogenous, hematogenous and perineural pathways and primarily affects the central nervous system. This entails a cascade system of reactions with apoptosis of defective neurons. The breakdown products of neural tissues, unrecognized by the immune system, become neurospecific antigens that trigger autoimmune mechanisms in the pathogenesis of neuroborreliosis. The variety of clinical manifestations of the disease makes it difficult to diagnosis it timely and, as a consequence, delays treatment. In the first stage, borreliosis meningitis occurs with moderately severe muscle stiffness of the occiput without any change in the cerebrospinal fluid. A few weeks after the onset of the disease (second stage), symptoms of encephalomyelitis appear, which makes it look like multiple sclerosis, especially since the erythema, if it was, disappeared by this time. Progression of encephalomyelitis and polyneuropathy are typical for late chronic neuroborreliosis. There may be violations in the form of speech disorders, memory, sleep, etc.The division into stages is conditional, which requires the doctor to perform complete examination when a patient has a clinic of polyneuropathy, encephalomyelitis, lesion of cranial nerves, especially bilateral lesion of the seventh pair to exclude neuroborreliosis. Stages of the disease may overlap or appear at the same time, all symptoms do not usually appear.The lecture analyzes the clinical features, stages, and pathogenetic mechanisms of the onset of a borreliosis course with central nervous system lesions at different stages of the disease. The treatment regimens for different stages of the disease are given, preventive measures are recommended. Individual prevention is reduced to tight closure of the skin during their stay in the forest, park, use of repellents, a detailed examination of all skin and clothing after returning from a walk. If a tick is detected, it is necessary to contact a medical institution for its correct extraction.