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NR 4-6/2006
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Tick inoculation in
an eyelid region: report on five cases with one complication of
the orbital myositis associated with Lyme borreliosis
Wszczepienie kleszcza w
rejonie powieki oka – przedstawienie pięciu przypadków z
komplikacją w postaci zapalenia mięśnia ocznego spowodowanego
boreliozą
Heinrich Holak1, Nikolai Holak1,
Małgorzata Huzarska3, Sophie Holak2
1 Z Kliniki Okulistycznej w Centrum Medycznym im R.
Virchowa w Salzgitter
Kierownik: dr n. med. Heinrich Holak
2 Z Kliniki Okulistycznej w Schlossparkklinik w
Berlinie
Kierownik: dr.n.med. Christoph Niederstadt
3 Z Zakładu Farmakologii Klinicznej Śląskiej Akademii
Medycznej w Katowicach
Kierownik: prof. dr hab. n. med. Zbigniew Herman |
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| Summary: |
Purpose: To
determine the frequency and dependence of Lyme
borreliosis after tick infestation in the eyelid
region.
Material and methods: Five patients after tick
inoculation were investigated by immunofluorescence
assays for IgM and IgG antibodies to Borrelia
burgdorferi. One positive test was followed with an
enzyme immunoassay and immunoblot (a two step system).
Ophthalmologic evaluation of myositis was supported with
MRI, laboratory, and internal clinical investigations.
Results: Four children showed negative Borrelia
serology after a bite from a tick. In one case the left
abducens nerve palsy was found, which was diagnosed in
MRI as a thickened left lateral rectus muscle. The
diagnosis of myositis with positive Borrelia burgdorferi
serology was consistent with Lyme borreliosis. Other
laboratory examinations were negative. The symptoms were
reduced after treatment with ceftriaxon.
Conclusions: Lyme borreliosis was found in one in
five patients after tick infestation in the eyelid
region. Antibiotic prophylaxis against Lyme borreliosis
with ampicillin is recommended for children after a tick
bite. |
| Słowa kluczowe: |
kleszcz, powieka oka,
borelioza, zapalenie mięśnia ocznego. |
| Key words: |
tick, eye-lid, Borreliosis,
ocular myositis. |
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The incidence of Lyme
borreliosis (Lyme disease) in Niedersachsen is estimated to be
0,5 per 1000 cases of people bitten by ticks (1). 18 cases of
serologically confirmed Lyme borreliosis in second and third
stages of the disease, with different ophthalmic and
neurological symptoms, have been registered in our clinic since
1988 (2,3,4). The transfer of Borrelia burgdorferi (Bb) to the
mammalian host is transmitted mostly by ticks (in Europe through
Ixodes ricinus). However, a few hour survival of Bb was found in
other biting insects, like for example, mosquitos and flies (1).
According to Liebisch (5), tick bites in head of animals are
concentrated in the regions around ears and eyes. Our data for
humans is in agreement with this observation. Here we describe
five patients that were bitten by ticks in the eyelid area. We
also address the question: how often and when these bites lead
to the infection with Bb in eyelids?
Material and methods
We have treated 5 patients from tick bite in eyelid area
since 1989. Four of them were children of between 3 to 10
year-old. After application of the local anesthetic ointment
with 2,5% lidocain and 2,5% prilocain (Emla Astra® Zeneca),
ticks were removed. In case 3 the head of a tick was removed
with a sterile needle. Case 5 comprised a 78 year-old man, who
removed a big tick by himself and we removed the holdover of the
head. All children took the prophylactic treatment for three
weeks after the tick bite with antibiotics: amoxicillin 50 mg/kg
weight/per day. Serological tests for Borrelia burgdorferi with
the immunofluorescence assay (IFA) for IgM (1:48 normal titer
range) and IgG antibodies (1:32 normal titer range), were
carried out for cases 1-3 one and six months after tick bites.
In cases 4 and 5, an additional, more sensitive and specific
enzyme immunoassay (EIA) for Borreliosis (with a normal titer
range for the IgG antibody at 1:160) was also carried out. We
have used a “two step system” (6) that included EIA and
immunoblot for IgG antibody (positive by recognition minimum of
two of five proteins 20, 24, 35, 39, 88 kDa) in the positive EIA
test in case 5. All immunological investigations were carried
out in the same laboratory in Bremen (6). Standard
ophthalmological tests were performed for all patients.
Additionally, an MRI, internal, neurological examinations, and a
Hess screen investigation for paretic strabismus were carried
out for patient 5, with the diagnosed orbital myositis. This
patient was cured after the daily intravenous 2 g ceftriaxon (Rocephin®,
Roche) for 3 weeks and with 60 mg prednison/day for a week.
Results
Fig. 1 shows all cases of tick bites in children. In three
cases (1a, b, c) the tick was localized in the lower lid close
to eyelashes. None of these children developed the erythema
migrans, typical for the Bb infection. In case 4, of a 7
year-old boy, the tick was situated in the temporal lid angle
(1d). We noticed the beginning of an inflammatory reaction.
Serological investigation of the IgG antibody for Bb was
negative in the EIA test after 6 months.
Case 5, with a serologically confirmed Lyme disease, had a tick
bite in the right upper nasal lid angle area with relatively
severe local inflammation (Fig. 2). The patient agreed to a
local treatment with the kanamycin ointment therapy, but refused
any oral or intravenous antibiosis. Serological tests for the Bb
infection showed the IgM concentration at 1:384 and IgG at 1:64
in IFA after 1 month, and therefore the suspected Bb infection
was diagnosed. Double vision and pain in the left orbit was
observed after four months. Neuroophthalmologically, the left
abducens nerve palsy was diagnosed and the B-scan orbital
ultrasonography was carried out. The Hess screen chart showed a
palsy of the left abducens nerve, with typical enlargement of
polygon of the right eye and shortened of the left eye from the
temporal side (Fig. 3). Internal investigations with diverse
laboratory tests did not find any autoimmune conditions (lupus
erythematosus, sarcoidosis, and rheumatoid arthritis), any
intestinal disorders (inflammatory bowel diseases) or virus
infection (herpes zoster). The patient suffered from
hypertension and the coronary heart disease. He used two drugs
long-term: 100 mg/daily acetyl salicylic acid (Aspirin®, Bayer)
and 30 mg/daily (3 pills) nifedipin (Nifehexal®, Hexal). There
was a diagnostic dilemma because of an immense enlargement of
the left external muscle. Our suspicion of myositis was checked
with the MRI. A homogenous thickening, approximately 11x14 mm
diameter and 2,2 cm length, was found in the lateral rectus
muscle, without any cerebral insult (Fig. 4 and 5). Since a
muscle tumor, e.g. sarcoma, was unlikely to happen at the age of
the patient, the diagnosis of myositis seems to be relatively
sure. The Borrelia serology supported this diagnosis and showed
the high IgG concentration in EIA (1:5120) and a positive IgG
immunoblot (four of five proteins) 4 months after the tick bite
(Tab. I). The therapy with prednison and ceftriaxon was started.
Reduction of diplopia was noticed after 2 weeks and all symptoms
were reduced after 2 months. The control MRI after 3 months was
negative. The patient was without any ophthalmological symptoms
in a follow-up, for more than one year.
Discussion
One in five ticks transmitted Bb in our clinical study,
which gave 20% probability of infection after a bite by a tick.
The data on ticks in Germany give different percentage of Bb in
ticks, which is dependent on vegetation (5). The lowest (12%)
was found in north Germany (Niedersachsen), the highest (25%) in
south Germany (Bayern). Interestingly Bb was found in 97 % in
the spittle of Ixodes pacificus, an American species of ticks
(5).
A tick bite in the eyelid area appeared frequently in children
and old disabled patients in our study. Apparently, thin skin
and rich vascular supply are the factors leading to tick
infestation in this region (Fig. 6). The best support for our
hypothesis could be found in elderly patients with atrophic
blepharitis (Fig. 7a, b), with visible vessels through the
thinning skin. A few case reports on tick infestation in the eye
area have been already published (7), but only this work
demonstrates a series of such patients, with one case of ocular
myositis, which is a relatively seldom ophthalmologic
complication of Borreliosis.
If approximately 12% of ticks in the north part of Germany are
infected with Bb (5), prophylactic antibiosis after each tick
bite seems to be exaggerated. On the other hand, we should be
aware that our serological methods for Borreliosis with the
“two-step system” gave specificity between 90-92% (6). It has
been shown that Bb could change its surface antigenic expression
and can be alive and pass through the cellular immunity (8).
Therefore, children should complete an antibiotic therapy with
ampicillin, which is efficient for Borreliosis (Tab. II) and has
minimal toxicity (9,10). As we have seen in Case 4 small,
beginning erythema was noticed around an infested tick. After
the removal of a thick, and completion of ampicillin therapy,
local inflammation disappeared, and the IgM IFA test was
negative and stayed negative for at least 6 months. It should be
pointed out that an early increase of IgM antibodies by
Borreliosis cannot be positively interpreted without clinical
symptomatics, and only IgG antibodies have an increased
specificity (1). According to new approach for treatment of
Borreliosis in children, the best results will be reached only
in an early, localized stage of erythema migrans in which
antibiotics help the local cellular immunity to destroy the
bacterium (9). Doxycycline will be chosen for this reason for
adults, but amoxicillin will be preferred in young children (9).
An interesting question is: for how many hours the Bb from the
infectious tick is found in the skin? In experimental animals it
takes normally 72 hours after a bite, and not earlier than 2
hours (11). Therefore it seems to be important to remove the
tick as soon as possible.
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The
removed tick can be checked for evidence of Bb (11). For this
reason only alive tick should be sent to a parasitic laboratory
in a veterinary medicine school (11). Among diagnostic tests for
Borreliosis some of them (IFA) are used for prime screening.
More sensitive EIA has specificity at 90% and the best of these
diagnostic sera reached 100% (Vidas®, bioMerieux)(7). But the
specificity of EIA should be proved with the immunoblot test,
the so-called “two step system” of serological diagnosis (6).
Since these special diagnostic tests are expensive, they should
be used only for controls during the course of the disease. The
diagnostic problems of Borreliosis are connected with
particularly interesting serologic identity of Borrelia
burgorferi (Bb). From approximately 150 lipoprotein genes of Bb,
some of them protect the bacterium from directly interacting
with the environment such as temperature, chemicals, e.g.
antibiotics (8). The migration of Bb from first mammalian host (e.g.
mice) through a tick to a second mammalian host (e.g. man)
creates something like a “life cycle” in which the bacterium
undergoes modifications (8). These changes in the population of
Bb produce different antigenic expressions and are responsible
for persistence of Borreliosis, despite active immune responses
against the bacterium. Interestingly, cellular immunity is
activated only in the skin by development of erythema migrans;
afterwards Bb will be attacked mostly through the humoral
immunity. The survival of Bb during persistent infection is
possible only through the permanent antigenic adaptation. This
feature of Bb is responsible for immense problems in active
immunization.
Paretic strabismus with diplopia as a complication of an
immunologically assured neuroborreliosis was already described
(3,4). Ocular myositis as a sequel of Borreliosis was however
found seldom (12,13,14). Only in two publications was the
diagnosis confirmed serologically (12,13). A firm proof of a
direct involvement of Bb in myositis can be only achieved
through the demonstration of the bacterium in the muscle. The
evidence of Bb in the muscle biopsy specimens in patients with
serologically proven Borreliosis was described by Reimers (14).
Visualization of Bb in muscles supports the necessity of a
therapeutic use of prednison to achieve the reduction of local
inflammatory symptoms (12).
As already shown by us in 1993, the diagnosis of Borreliosis
should be established by:
1. Positive specific immunoassays for Bb,
2. Prompt improvement of disease after antibiosis,
3. The absence of an alternative cause of ocular disease after
extensive investigation,
4. Endemic exposition (3).
Many clinical reports unfortunately do not conform to this
protocol (6), and therefore overdiagnosis of Borreliosis has
been reported. A very wide spectrum of ophthalmologic
manifestations of Borreliosis is based on many of case reports
(2,3,4,12,15,16). Each clinical group has gathered many cases of
well-documented Borreliosis, and these clinical studies can
extend our diagnostic and therapeutic view of the disease. An
example of such a clinical study can be a proof of our
suggestion in the case report study that the birdshot
retinochoroidopathie may be associated with the serologically
confirmed Borreliosis (3). Statistical analysis in 11 cases by
Suttorp-Schulten et al. showed Borreliosis in two patients has
not confirmed this interesting hypothesis (17). We should be
aware that Borreliosis, as many multisystemic diseases, is
responsible for many generic symptoms, and only the best
specificity can lead to an ambiguous diagnosis. Thus the best
approach and scientific efforts are concentrating today on
immunology of the Bb.
Conclusions
Tick infestation in the eyelid region is found mostly in
children, and the tick should be removed as soon as possible.
While the response of the cellular immunity system (erythema
migrans) to Bb is manifested after few days till weeks, we feel
that an appropriate antibiotic prophylaxis should be undertaken,
before specific IgG antibodies will be found in 3 or more months.
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bei Mensch und Tier. 48-54, Spitta Verlag, 3 Auflage,1997.
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3. Holak H.M., Horst H.: Ophthalmological complications of Lyme
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Adres do korespondencji (Reprint
requests to):
dr med. Heinrich Holak,
Augenklinik im Rudolf-Virchow Ärztehaus,
38226 Salzgitter,
Heckenstrasse 46;
Fax.05341–49433,
E–mail: holak@freenet.de |
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