Perceptions, Representations, and Experiences of Patients Presenting Nonspecific Symptoms in the Context of Suspected Lyme Borreliosis

Background: Some subjective symptoms may be reported at all stages of Lyme borreliosis (LB) and may persist for several months after treatment. Nonspecific symptoms without any objective manifestation of LB are sometimes attributed by patients to a possible tick bite. The aim of our study was to explore the perceptions, representations, and experiences that these patients had of their disease and care paths. Methods: We performed a qualitative study through individual interviews (October 2017–May 2018), based on grounded theory, following the COREQ checklist. A balanced sample of patients with diverse profiles was recruited at consultations with general practitioners and infectious disease physicians. Results: Twelve patients were interviewed. Data saturation was reached at the twelfth interview. For codes, 293 were identified, and classified into 5 themes: (1) the experience of disabling nonspecific symptoms, especially pain, causing confusion and fear, (2) long and difficult care paths for the majority of the patients, experienced as an obstacle course, (3) a break with the previous state of health, causing a negative impact on every sphere of the patient’s life, (4) empowerment of the patients and the self-management of their disease, and (5) the strong expression of a desire for change, with better listening, greater recognition of the symptoms, and simpler care paths. Conclusions: This study allows for the understanding of a patient’s behaviours and the obstacles encountered, the way they are perceived, and the necessary solutions. The patients’ expectations identified here could help physicians better understand the doctor–patient relationship in these complex management situations, which would reduce the burden of the disease. The current development of specialised reference centres could help meet the patients’ demands and those of family physicians

Borrélioses et fièvres récurrentes

National audienceBorrélioses et fièvres récurrentes Les borrélioses récurrentes (br) ou fièvres récurrentes sont dues à des bactéries du genre borrelia, de la famille des spirochètes, transmises à l’homme par des arthro¬podes vecteurs (poux de corps, tiques molles, et tiques dures pour l’une d’entre elles). La br à poux est cosmo¬polite et transmise lors d’épidémies survenant dans le contexte de crises majeures (promiscuité, conditions d’hygiène précaires, crise alimentaire, etc.). Les br à tiques se répartissent par région, selon la borrelia en cause et la distribution géographique de leur tique vec¬trice. Le temps d’incubation varie de 3 à 20jours. La première phase fébrile dure 3jours (1-14jours), suivie d’une phase d’apyrexie avec persistance des autres signes cliniques (rash cutané, pétéchies, céphalées in¬tenses, agitation, polyarthromyalgies, douleurs abdomi¬nales, nausées/vomissements, etc.). La récurrence de la fièvre décrit une périodicité de 7jours en moyenne. La bactériémie est abondante lors des pics fébriles, permet¬tant de poser un diagnostic par examen direct en mi¬croscopie, pcr borrelia ou culture sur milieu spécial, quand celle-ci est possible. Le traitement repose sur la doxycycline, sauf pour les formes neurologiques (ceftriaxone). Le taux de mortalité varie de 2 à 5 % selon la borrelia incriminée. L’évolution est le plus souvent favorable après traitement

Immunoserological Diagnosis of Human Borrelioses: Current Knowledge and Perspectives

International audienceSpirochetes of the genus Borrelia are divided into relapsing fever borreliae and Lyme disease borreliae. Immunoserological assays have been poorly developed for relapsing fever borreliae, where direct detection methods are more adapted to the pathophysiology of these infections presenting with massive bacteraemia. However, emergence of the novel agent of relapsing fever B. miyamotoi has renewed interest in serology in this context. In Lyme disease, because direct detection methods show low sensitivity, serology plays a central role in the diagnostic strategy. This diagnostic strategy is based on a two-tier methodology involving a first test (ELISA) with high sensitivity and acceptable specificity and a second, more specific test (western blot) for diagnostic confirmation. The most frequent limitations and pitfalls of serology are cross reactions, false IgM positivity, a seronegative window period at the early time of the infection, and serologic scars with a suspicion of reinfection. International guidelines have thus been proposed to avoid these difficulties with interpretation. Finally, unconventional diagnostic tests have been developed recently in the context of a highly publicized disease, with widely varying results, some of which have no available evidence-based data. New two-tier testing strategies using two ELISA tests (C6 and WCS for example) to replace immunoblot are currently proposed by some authors and guidelines, and promising new tests such as CXCL-13 in CSF are promising tools for the improvement of the diagnosis of Lyme borreliosis

Borrélioses et fièvres récurrentes

National audienceBorrélioses et fièvres récurrentes Les borrélioses récurrentes (br) ou fièvres récurrentes sont dues à des bactéries du genre borrelia, de la famille des spirochètes, transmises à l’homme par des arthro¬podes vecteurs (poux de corps, tiques molles, et tiques dures pour l’une d’entre elles). La br à poux est cosmo¬polite et transmise lors d’épidémies survenant dans le contexte de crises majeures (promiscuité, conditions d’hygiène précaires, crise alimentaire, etc.). Les br à tiques se répartissent par région, selon la borrelia en cause et la distribution géographique de leur tique vec¬trice. Le temps d’incubation varie de 3 à 20jours. La première phase fébrile dure 3jours (1-14jours), suivie d’une phase d’apyrexie avec persistance des autres signes cliniques (rash cutané, pétéchies, céphalées in¬tenses, agitation, polyarthromyalgies, douleurs abdomi¬nales, nausées/vomissements, etc.). La récurrence de la fièvre décrit une périodicité de 7jours en moyenne. La bactériémie est abondante lors des pics fébriles, permet¬tant de poser un diagnostic par examen direct en mi¬croscopie, pcr borrelia ou culture sur milieu spécial, quand celle-ci est possible. Le traitement repose sur la doxycycline, sauf pour les formes neurologiques (ceftriaxone). Le taux de mortalité varie de 2 à 5 % selon la borrelia incriminée. L’évolution est le plus souvent favorable après traitement

Borréliose de Lyme

National audienceLYME BORRELIOSIS. Lyme borreliosis (LB) is the most common vector-borne disease in the Northern Hemisphere, caused by the bacterium Borrelia burgdorferi sensu lato, transmitted to humans by a bite of ticks Ixodes. Prevention is based on simple measures to evict ticks, and on their rapid extractionin the event of a bite. The diagnosis of LB is based on 3 arguments: an exposure to tick bites; clinically compatible symptoms (cutaneous, neurological or rheumatological manifestations, +/- functional symptoms such as fatigue or polyarthromyalgia), evolving in 3 stages (early localized or erythema migrans, early or late disseminated LB); a positive two-tier serological test (ELISA +/- Western-Blot). Serology can be negative for the first 6 weeks, without excluding the diagnosis. Since serology can remain positive for life, evolution is only evaluated clinically. LB treatment is mainly based on doxycycline for 14 to 28 days, depending on the clinical stage and manifestations, without demonstrated interest in prolonging it, even if symptoms persist. Nonetheless their management is crucial as often responsible for medical wandering. Attentive listening to the patient is essential. The prognosis of LB in the medium-term is favorable, especially if they beneficiate of an early management.La borréliose de Lyme est la principale zoonose vectorielle en France. Elle est due à la bactérie Borrelia burgdorferi sensu lato, transmise lors d’une piqûre de tique infectée du genre Ixodes. Son diagnostic repose sur un trépied diagnostique, parfois incomplet. La prévention consiste en la protection contre les piqûres de tiques, et leur extraction rapide en cas de piqûre. Le traitement repose principalement sur la doxycycline

The control of <i>Hyalomma</i> ticks, vectors of the Crimean–Congo hemorrhagic fever virus: Where are we now and where are we going?

This review was conducted by the ad hoc subgroup from the working expert group on the risks related to Hyalomma ticks at the French Agency for Food, Environmental and Occupational Health & Safety (ANSES) commissioned by the French authorities.International audienceAt a time of major global, societal, and environmental changes, the shifting distribution of pathogen vectors represents a real danger in certain regions of the world as generating opportunities for emergency. For example, the recent arrival of the Hyalomma marginatum ticks in southern France and the concurrent appearance of cases of Crimean–Congo hemorrhagic fever (CCHF)—a disease vectored by this tick species—in neighboring Spain raises many concerns about the associated risks for the European continent. This context has created an urgent need for effective methods for control, surveillance, and risk assessment for ticks and tick-borne diseases with a particular concern regarding Hyalomma sp. Here, we then review the current body of knowledge on different methods of tick control—including chemical, biological, genetical, immunological, and ecological methods—and the latest developments in the field, with a focus on those that have been tested against ticks from the genus Hyalomma. In the absence of a fully and unique efficient approach, we demonstrated that integrated pest management combining several approaches adapted to the local context and species is currently the best strategy for tick control together with a rational use of acaricide. Continued efforts are needed to develop and implement new and innovative methods of tick control

The control of Hyalomma ticks, vectors of the Crimean-Congo hemorrhagic fever virus: Where are we now and where are we going?

At a time of major global, societal, and environmental changes, the shifting distribution of pathogen vectors represents a real danger in certain regions of the world as generating opportunities for emergency. For example, the recent arrival of the Hyalomma marginatum ticks in southern France and the concurrent appearance of cases of Crimean-Congo hemorrhagic fever (CCHF)-a disease vectored by this tick species-in neighboring Spain raises many concerns about the associated risks for the European continent. This context has created an urgent need for effective methods for control, surveillance, and risk assessment for ticks and tick-borne diseases with a particular concern regarding Hyalomma sp. Here, we then review the current body of knowledge on different methods of tick control-including chemical, biological, genetical, immunological, and ecological methods-and the latest developments in the field, with a focus on those that have been tested against ticks from the genus Hyalomma. In the absence of a fully and unique efficient approach, we demonstrated that integrated pest management combining several approaches adapted to the local context and species is currently the best strategy for tick control together with a rational use of acaricide. Continued efforts are needed to develop and implement new and innovative methods of tick control

Lyme borreliosis and medical wandering: what do patients think about multidisciplinary management? A qualitative study in the context of scientific and social controversy

International audienceAbstract Introduction To answer to patients’ medical wandering, often due to “unexplained symptoms” of “unexplained diseases” and to misinformation, multidisciplinary care centers for suspected Lyme borreliosis (LB), such as the 5 Tick-Borne Diseases (TBDs) Reference Centers (TBD-RC), were created a few years ago in France, the Netherlands and Denmark. Our study consisted of a comprehensive analysis of the satisfaction of the patients managed at a TBD-RC for suspected LB in the context of scientific and social controversy. Methods We included all adults who were admitted to one of the TBD-RC from 2017 to 2020. A telephone satisfaction survey was conducted 12 months after their first consultation. It consisted of 5 domains, including 2 free-text items: “What points did you enjoy?” and “What would you like us to change or to improve?”. In the current study, the 2 free-items were analyzed with a qualitative method called reflexive thematic analysis within a semantic and latent approach. Results The answer rate was 61.3% (349/569) and 97 distinctive codes from the 2-free-text items were identified and classified into five themes: (1) multidisciplinarity makes it possible to set up quality time dedicated to patients; (2) multidisciplinarity enables seamless carepaths despite the public hospital crisis compounded by the COVID-19 pandemic; (3) multidisciplinarity is defined as trust in the team’s competences; (4) an ambivalent opinion and uncertainty are barriers to acceptance of the diagnosis, reflecting the strong influence of the controversy around LB; and (5) a lack of adapted communication about TBDs, their management, and ongoing research is present. Conclusion The multidisciplinary management for suspected LB seemed an answer to medical wandering for the majority of patients and helped avoid misinformation, enabling better patient-centered shared information and satisfaction, despite the context of controversy

Methodological Quality Assessment with the AGREE II Scale and a Comparison of European and American Guidelines for the Treatment of Lyme Borreliosis: A Systematic Review

International audienceBackground: Most European and American countries recently updated their guidelines on Lyme borreliosis (LB). The aim of this study was to provide a comparative overview of existing guidelines on the treatment of LB in Europe and America and to assess the methodological quality of their elaboration. Methods: A systematic search was carried out in MEDLINE, Google Scholar, and the national databases of scientific societies from 2014 to 2020. Quality was assessed by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Results: Twelve guidelines were included. The scores for the AGREE II domains (median ± IQR) were: overall assessment 100 ± 22, scope and purpose 85 ± 46, stakeholder involvement 88 ± 48, rigour of development 67 ± 35, clarity of presentation 81 ± 36, applicability 73 ± 52 and editorial independence 79% ± 54%. Cohen’s weighted kappa showed a high agreement (K = 0.90, 95%CI 0.84–0.96). Guidelines were quite homogeneous regarding the recommended molecules (mostly doxycycline in the first intention and ceftriaxone in the second intention), their duration (10 to 28 days), and their dosage. The differences were due to the lack of well-conducted comparative trials. The International Lyme and Associated Diseases Society (ILADS) guidelines were the only ones to suggest longer antibiotics based on an expert consensus. Conclusion: European and American guidelines for the treatment of LB were quite homogeneous but based on moderate- to low-evidence studies. Well-conducted comparative trials are needed to assess the best molecules, the optimal duration and the most effective doses

Multidisciplinary Management of Suspected Lyme Borreliosis: Clinical Features of 569 Patients, and Factors Associated with Recovery at 3 and 12 Months, a Prospective Cohort Study

We are grateful to the following persons for their contribution and support to the TBD-RC and this study: The Tick-Borne Diseases Reference Center-Paris and Northern Region Working Group (Agathe Bounhiol, Kevin Diallo, Danielle Jaafar, Claudine Badr, Soline de Monteynard: Department of Infectious Diseases; Romain Jouenne, Emmanuel Dossou: Department of Internal Medicine; Stéphanie Emilie, Christine Shenouda: Department of Rheumatology; Lydie Lim, Navaneethan Nindulan: Department of Neurology; Sylvie Le Berre, Corinne Canu, Vincent Robin: Department of Algology; Sophie Dellion, Floriane Kouby: Department of Dermatology; Jonas Bantsimba: Department of Geriatrics; Jacques Breuil, Eric Hernandez, Camille Corlouer, Laurence Ghisalberti: Department of Microbiology; Eric Meinadier, Arthur Lefort: Department of Physical Rehabilitation; Aurélie Garraffo, Anne Chace, Emilie Georget: Department of Pediatrics; Ilia Pustilnicov: Department of Health Economics)International audienceIntroduction. Because patients with a suspicion of Lyme borreliosis (LB) may have experienced difficult care paths, the Tick-Borne Diseases Reference Center (TBD-RC) was started in 2017. The aim of our study was to compare the clinical features of patients according to their final diagnoses, and to determine the factors associated with recovery in the context of multidisciplinary management for suspected LB. Methods. We included all adult patients who were seen at the TBD-RC (2017\textendash 2020). Four groups were defined: (i) confirmed LB, (ii) possible LB, (iii) Post-Treatment Lyme Disease Syndrome (PTLDS) or sequelae, and (iv) other diagnoses. Their clinical evolution at 3, 6, and 9\textendash 12 months after care was compared. Factors associated with recovery at 3 and at 9\textendash 12 months were identified using logistic regression models. Results. Among the 569 patients who consulted, 72 (12.6%) had confirmed LB, 43 (7.6%) possible LB, 58 (10.2%) PTLDS/sequelae, and 396 (69.2%) another diagnosis. A favorable evolution was observed in 389/569 (68.4%) at three months and in 459/569 (80.7%) at 12 months, independent of the final diagnosis. A longer delay between the first symptoms and the first consultation at the TBD-RC (p = 0.001), the multiplicity of the diagnoses (p = 0.004), and the inappropriate prescription of long-term antibiotic therapy (p = 0.023) were negatively associated with recovery, reflecting serial misdiagnoses. Conclusions. A multidisciplinary team dedicated to suspicion of LB may achieve a more precise diagnosis and better patient-centered medical support in the adapted clinical sector with a shorter delay, enabling clinical improvement and avoiding inappropriate antimicrobial prescription