Lyme's disease

Description:

Laymsky disease (Lyme's disease) — a spirochetotic infection with an acute or chronic current at which damages of skin, a musculoskeletal system, nervous, cardiovascular and reticuloendothelial systems are possible. This disease is carried to the natural and focal transmissible infections transferred by ixodic mites.
Lyme's borreliosis is eurysynusic in an area of dwelling of ixodic mites - the northern hemisphere of the planet. High incidence is characteristic of this disease. Russia annually registers 6-8 thousand cases of a disease of Lyme at average incidence of 5-6 people on 100 000 population. Diseases are subject all age groups, more than 10% of total number of the diseased are made by children. In medical institutions of Russia annually 150 000 people ask for the help of a flare on average at a distance. Usually people catch in a residential suburb and on garden and garden sites. Ixodic mites — carriers of several infectious agents, including a virus of a tick-borne encephalitis therefore, attacked by one tick, the person risks to get sick with several infections at once.

Etiologies of Lyme:

The etiology of a disease of Lyme was deciphered in 1982, the unknown a type of borreliya was earlier a disease-producing factor. Now on distinctions in the nucleotide sequences of DNA allocate more than 10 types of borrelliya, kotokry are united in a complex under the name Borrelia burgdorferi sensu lata. Therefore now understand group of infections which and Russia are called ixodic tick-borne borreliosis as Lyme's disease. Among borreliya of the Borrelia burgdorferi sensu lato complex pathogens for the person only three:
- Century of burgdorferi sensu stricto:
- Century of garinii
- Century of qfzelii.

In the USA all circulating strains belong to one type of V. of burgdorferi sensu stricto having artritogenny properties. All three pathogenic look is widespread in Europe. In Russia B.garinii (are associated with defeat of a nervous system) and B.afzelii circulate (are connected with damage of skin). Genomic distinctions can have clinical value as they opredeklyat an antigenic structure of activators on which the disease symptom complex to some extent depends. Borreliya have no TOXINS, lipopolisakharid and contain few bioactive proteins, but it is a lot of lipoproteids. A subject of the most active studying — lipoproteins of an outer membrane (outer sni Ian lipoproteins Osp). So, distinctions in structure of surface membrane protein of OspA formed the basis of serotyping, an OspA weighing 31 kd became a basis of the first vaccine against Lyme's disease.
Despite obvious gene and phenotypical distinctions of activators, all ixodic tick-borne borreliosis have the general first clinical symptom the migrating erythema in the place of suction of a tick which is considered pathognomonic manifestation of an early stage, and in the classical look it is accepted in the main diagnostic marker of a disease.

Pathogeny:

The pathogeny of borreliosis of Lyme is finally not studied. In spite of the fact that borreliya find in many fabrics (blood, heart, a retina, muscles, bones, a spleen and a liver, throw grease covers and a brain), the infection usually proceeds asymptomatically. Development of a humoral and cellular immune response against borreliya leads to elimination of the activator in most cases. In rare instances borreliya can is long to persistirovat, despite intensive development of protective antibodies of a protivoborreliozna. It is known several mechanisms which are partially explaining this phenomenon. So. borreliya express various komplementszyazyvayushchy factors of the owner which connect a complement and protect a microorganism from komnlementoposredovanny destruction.
Borreliya show the expressed antigenic variability and can quickly change antigenic targets on the outer membrane. It is shown that in the course of an infection there is a change of an expression of lipoproteins, i.e. directly immunogens therefore the antibodies developed to them lose a point of application.
Development of a disease is associated with presence of live spirochetes at fabrics, at the same time their quantity does not correlate with weight of a disease. Its manifestations depend on the immunopathological reactions arising in response to infection. Live spirochetes connect and activate various cells of the person, at the same time there is a release of a set of mediators of an inflammation.
- In early stages of a cell of the first line of protection (fibroblasts, macrophages, endothelial cells, etc.) the course of an infection and its outcome produce a set of cytokines defining and the subsequent.
- At later stages if the infection does not eliminirutsya, there is a differentiation on various kliniko-pathogenetic options in which implementation participate:
1. set of immunocompetent cells;
2. immupogenetichesky factors;
3. specific immune response: autoimmune reactions.
Infection of tissues of joint with borreliya is the cornerstone of defeat of a musculoskeletal system. It confirm research SZh and a synovial membrane of patients the Lime arthritis. Such arthritis sometimes accompanies obrazovakny a pannus and erosion of a cartilage and bone. Development of the arthritis morphologically close to RA allowed to consider the Lime arthritis the RZ natural model with the famous infectious agent.
Interest to the Lime arthritis increased after establishment of some of its immunological and genetic markers, in particular HLA-DRB1*04 associated with option, resistant to causal treatment. At this chronic option of arthritis autoimmune antigenspetsifichesky reactions can be mediators of fabric damage along with a persistention of an infection. Development of cross-reactions between epitopes of one of surface membrane proteins of a borreliya (OspA) and the representative of family of integrin - functional lymphocytic antigen can be an example (human lymphocyte functional antigen, III, HECTARE). It is supposed that the epitopic mimicry of these antigens is the cornerstone of development of chronic damage of joints at the Lime borreliosis at nosiktel of HLA-DRBl*04.

Lime Disease symptoms:

The migrating erythema - the first symptom of a disease reflecting an inflammation at infection. Believe that in this is local — stages the activator exists only in the place of an erythema. The erythema arises in the place of suction of a tick at first in the form of a makula or a papule which gradually increases to diameter of 5 cm and more (on average 15-20 cm). Quite often migrating erythema is accompanied by a regional lymphadenopathy. In a debut of a disease there is a grippopodobny syndrome, pains or constraint in a neck, sometimes conjunctivitis, pharyngalgias. In the absence of an erythema in a debut the disease is diagnosed late, and its current is distinguished by more frequent synchronization. The greatest clinical polymorphism is characteristic of a dissimination stage.
Secondary an erythema – secondary markers of dissimination – arise in sites of skin, remote from the place of suction of a tick. They remind primary center both clinically, and morphologically. Carry a single lymphocytoma to characteristic skin manifestations of the period of dissimination.
The high-quality lymphocytoma, or lymphadenosis of skin (lymphadenosk benigna ciihs), represents opukholepodobny consolidation, usually on an ear lobe, in the field of a papilla of the breast or a scrotum (the most frequent localizations) and sometimes on other sites of skin. During this period there can be neurologic symptoms including defeat as central (meningitis, encephalitis. myelitis, encephalopathy), and peripheral (cranial neuropathies, radiculopathies, peripheral neuropathy, multiple mononeurites, humeral plexopathy, lumbosacral plexopathy, Giyena Burra-like syndrome, motor neuropathy, etc.) nervous system. Disturbances of a rhythm and conductivity are characteristic of damage of heart (atrioventricular blocks), seldom find subclinically proceeding mio-and/or a pericardis.
Late stage of a disease. Damage of skin as a chronic atrophic acrodermatitis of rather rare disease with involvement of extensor surfaces of distal departments of extremities is characteristic of a late stage of a disease of Lyme. The beginning of process - an infiltrative and inflammatory phase which in years the atrophic phase follows. Sometimes there is an accession of the sclerous process which is very reminding a scleroderma. Among other manifestations of a late stage polyneuropathy, the progressing encephalomyelitis.
Hematologists show interest in Lyme's disease as essential line of a clinical picture of this infection - not only involvement of a musculoskeletal system, but also damage of internals. Systemacity, tendency to a recurrent and chronic current sometimes lead to the fact that the disease proceeds behind a mask of various RZ. Cases of a disease of Lyme which simulate RA, a disease of Reuters and other arthropathies are described. and also ORL, hard currency, SSD and polymiositis. The eosinophilic fasciitis, a focal scleroderma, fibrosites and fibromyalgia are connected directly with a borreliozny infection.
It should be noted that among displays of laymsky borreliosis arthritis is met very seldom (less than 4%) in comparison with other clinical signs. Damage of joints at laymsky borreliosis in Russia has certain features and differences from the damage of joints for the first time described in the USA. These features allow to distinguish it from group of other diseases of joints. The conducted researches showed that defeat of the musculoskeletal device at Lyme's disease in Russia represents in essence an inflammatory arthropathy at which all structures of a joint are struck. Clinical implication of damage of joints — an arthralgia or arthritis. Arthralgias are similar to arthritises at ixodic tick-borne borreliosis and arthritises can be less expressed, erased reflection of the same process of an inflammation, as. Emergence of damages of joints to which suction of a tick almost at 90% of patients preceded is chronologically connected with a marker of a disease the migrating erythema and happens on average through - 1 month after infection (suction of a tick) the Beginning of arthritis and the period of dissimination is noted at 69% of patients, at the others in the late period. Therefore two options of arthritis depending on time emergence were allocated:
• arthritis of an early stage
• arthritis of a late stage

Course of a disease:
• The early period including:
- a local stage of the migrating erythema arising in the place of a prisasykvaniye of a tick);
- infection dissimination stage.
In the absence of an erythema speak about a bezeritematozny form of a disease.
• The late period is removed from primary displays of a disease for 6-12 months and more. It is observed seldom (approximately in 1% of cases). The long persistention of the activator in fabrics is characteristic of this period of a disease.
Without treatment the disease has a recurrent or chronic current.
Allocate:
- easy current;
- moderately severe;
- heavy current.

Diagnosis:

The factors preceding a disease:
- stay in the wood, suburban forest parks;
- suction of a tick (90%) or the migrating erythema.

General features of symptomatology:
- development locally in the place of suction of a tick (the migrating erythema) in 50-70%;
- involvement of periartikulyarny fabrics (32%);
- a combination to extraarticular displays of a disease of Lyme - defeat of a nervous system (43%), skin (30%) and hearts (22%).

Clinical expressiveness of a local inflammation:
- arthralgias;
- arthritis (poorly or moderately expressed synovitis).
Preferential localization of defeat: large joints (knee, tazobedrenpy, humeral, elbow).
The nature of defeat - monooligoartikulyarny (80%).
Laboratory signs:
- diagnostic increase in level of antiborreliozny antibodies in serum (70 80%);
- absence or tranzitorny increase in the Russian Federation;
- immune disturbances at a third of patients — increase in the AKL level and antiyaderkny antibodies, the CEC and a complement.

HLA-typing: the increased frequency of a haplotype of HLA A2-B15 and OKB1*04.
Efficiency of an antibioticotherapia: recovery and improvement (> 90% of cases).
Diagnosis the Lime arthritis is important as in most cases the state is curable antibiotics. Moreover, it is shown that at the patients receiving antibiotics concerning the migrating erythema, the frequency of development of arthritises was lower in comparison with uncured that allows to consider early antimicrobic therapy primary prevention of rheumatic displays of a disease.
For laboratory verification of a borreliozny infection there are pryakmy (cultivation of the activator from the defeat center, light or elektkronny microscopy of bioptat, polymerase chain reaction) also indirect methods (definition of antiborreliozny antibodies in biological liquids). Effectiveness of diagnostic tests depends on modification of the used antigen, a form and a stage of a disease, the previous treatment by antibiotics. Abroad identifications of antiborreliozny antibodies recommend to carry out the two-stage procedure. At the first stage as screening use indirect reaction of an immunoflyuorestsektion and IFA. Positive or boundary indicators of these tests should be checked by an immunoblotting method (the second stage). Serum is considered positive if at the second stage the positive result is received. In actual practice the diagnosis of borreliosis of Lyme is established first of all on the basis of the data of the epidemiological anamnesis and the typical, accurately outlined clinical manifestations which are objectively determined by the doctor. Increase in tigers of antibodies to borreliya has important, but auxiliary value.

Treatment of the Disease of the Lime:

The purpose of treatment of ixodic tick-borne borreliosis - a full eradikation of an infection. The rational choice of an antibiotic is defined by degree of manifestation of organ defeats, duration of a disease and its clinical form, the feature of a macroorganism preceding therapy, etc.
To hospitalization only patients with severe forms of a disease Unavailability of microbiological criteria of treatment — the main difficulty which meet need, estimating efficiency of medicines at Lyme's disease therefore estimate results of treatment, being based only on dynamics of clinical symptoms. All schemes of treatment offered today have the advisory nature based on empirical experience of certain researchers.
Duration of an antibioticotherapia makes 2-Z weeks, except for azithromycin (a course of 5 days). At treatment of chronic forms of damage of joints and skin (trophic akrodermit) appoint doxycycline to 30 days.
Approximate terms of disability make 1-2 months (after establishment of the correct diagnosis).

Prevention:

The main ways of available prevention of a disease are directed to reducing risk of suction of a tick at stay in the wood, in the country and on the garden site. They include use of repellents, wearing the clothes which are most closing a body surface, frequent surveys of a body and clothes for timely removal of mites. Specific vaccinal prevention of N of Russia is not carried out.
Planning landing in the wood, the park or for the garden and garden site, it is necessary to put on correctly to run заползання a tick under clothes. After stay in the wood it is important to examine himself and children regarding suction of a tick who should be removed as soon as possible. Keep a tick: can be, an opportunity to define whether it is infected will be presented. Consult to the doctor about need of prevention of the diseases transmitted by a tick. Even if there are no simptokm. recommend to investigate blood on antibodies to a disease-producing factor of Lyme through 3-4 sang after suction of a tick. At emergence of redness in the place of its suction visit of the doctor is obligatory. Remember that at correct of a lechekniya most of patients recover.