Ackermann

Bettina Wilske

GianDomenico Borasio

Hans-Walter Pfister

Hollström

KarlMax Einhäupl

Pachner

Pfister

Sköldenberg

Steere

Uwe Neubert

Vera Preac-Mursic

Weber

Wilske

English

Crossref

REINFECTION WITH BORRELIA BURGDORFERI

Pfister, Hans-Walter

Neubert, Uwe

Wilske, Bettina

Preac-Mursic, Vera

Einhäupl, Karl Max

Borasio, Gian Domenico

Open Access LMU ( Ludwig-Maximilians-Univ. München)

RElNFECTION WITH BORRELlA BURGDORFERI SIH,- Lyme borreliosis, a tick-bome multisystcm disorder caused by the spirochaete Borrtlia burgdor/tri, typicaJly begins with crythema chronicwn migrans and is somctimcs foUowcd by involvctnent of the hcan, joints, and nervous system.' Neuro-Iogical manifcstations include mcningomdiculitis (ßannwanh's syndrome), meningitis, and enccphalitis.z-.t Thc clinical diagnosis can bc confirmcd by fmding antibodies tO B burgdor/t ri by indircct immunofluoresccnceor ELISA.$I> We desaibc hen.: a scro1ogically and baClCriologica11y confinncd case of possible reinfc:ction. In September, 1983,2 wecks after a tick bite on the right ann , a 59-ycar-<lld woman bad erythema migrans around the bite site. She prescntcdon Nov 15 with a painful meningoradiculitis and bilateral papilloedema. CSF analysis showed a Iymphocytic p lcocytosis (330 cells!lll) and an incrcase in total protcin (82 mgfdl). Her scrorn IgG antibody ti tre against B burgdorferi rosc from lcss than 16 to 256 within 4 wecks (figure). IgM antibodics were nOI dctcCted, and borreliae could not be isolated from thc CSF. The patient was treatcd with intravenous penicillin (20 mcgaunits daily for 5 days, then 10 megaunits daily for 5 days) and oral methylprednisolonc (70 mg daily over 2 wecks with dccreasing dosage). On dischargc (Oe<: 12) she was free of pain, with a slightly improvcd vision. Follow-up examinations showed residual bilateral papillauophy. In Octobcr, 1984, the CSF was no nnal ( I ccllflll, total protein 37 mg!dl). On Oct 2, 1985, the patient visited a fOIest. She did not rttaI.l any arthropod bites but on Oel 5 a painful redncss dcvclopcd on the right side of her ehcst. Shc presClucd on Oct 7 with an erythema cbronicum migrans, about 20 x 14 an. Spirochaetcs wercisolatedat biopsy of the skin acound the Icsion aftcr 4 wecks' incubation in modificd Kclly's mcdiwn. Her serum IgG antibcdy titrC ag.ainst B Imrgdorferi bad bet:n 16 on June 1:1, 1985 but bad risen to64 on Oct 17 v.;thout a corresponding IgM incrcasc. Treattnent with minocycline 200 rng daily by mouth for 14 days was succcssful. In 1958 HolIsuiim reponed a case of recurrcnt erythema migrans 5 years after primary infcction? Sköldcnbcrg el al in 1983 describcd a p:u:it:nt with tv.uepisoclcs, 20 ycars apan,ofcrythcma migransand meningitis after a tick b ite.· Scrological tcsts werc not done on these patients. In Weber and colleagucs' two patients with erythcma migrans and reinfcction after 5 and 7 ycars antibody titrcS agaimt R m'rPrI"r(.-ri o1id n,,' inr ...... _ 9 In 1983 our patient had Lyme borreliosis with Bannwanh's syndrome. Her senun IgG ritte against B Imrgdor/ni bceamc negative within 10 months. Erythema chronicum migrans rccurrcd 2 years later. The absence oflgM antibodics in aeute manifcstations of Lyme borrcliosis has been describcd beforc.1.6 The 1985 epi!iQde prcscmed after the patient had stayed for a long time in a roteSt in an area known to bc endemie for B burgdorferi infcction. D cspite the absence of a known tidt bitc wc think that thc secemd anack was a rcinfection and nOt a recuITttlcc. The skin sites involvcd wcrc different in the [WO cpisodes. PatialtS with Bannwanh's syndrome usually rctain a signiflcant IgG titrC against B burgdorfui for several ycars.' Our patient's antibcdy titrC was insignificant by 10 months. Tbe antibiotic aitd/o r oorticosteroid treatment given for thaI first attack may cxplain the short-Iived inununity, permitting rcinfection after only 2 ycars. [)tporTmoon1l <MNeumIoo """""'_. ~<MMwUdI, KlInikum GmIshadnn. 8000 M..udI70, west~; .-.d M .... ...,., 1>nunI:of ... Instituu iw H~ lfId M ediooJ M>c:robK>IosY, u.tiwnity <M Murudl HANS-WALTEH Pt'1S"rnR UwaNEUBERT B Ii1TINA WILSKE Vt;AA PREAC-M URSIC KAKL MAx Elloo"HÄUPL GI ..... '! Do,\1ENICO HoRASIO I. s.-.: AC. Grodzi,cSi RL, KQ<nblan AN, C< 11. ,.,.., opirod>eul C<ioIotD' oe Lymc dncase.. N hwl] Md 1983;:1(18,1))-12. 2 Pachner AR , Stccn: AC. "Thc triad <M ~ mMlifatrioni oe Lymoe dJHooH: Mcr""aillS, cronia! neuritis and nd>culonnuitis. N~ 1\18'; )S,47-51. 1. Pli" ... H.W, EinhJiupl KM, ~M"rlic V, W,b!u B, Schien G .• '"he optrod>eul eboIogy of Iymphocytic monin&<>ndkuUti. 0( fJann.W"ll"th (Bannwatth·, .ynd_). ] Nft60J 1984; BI: 141-44. 4. l'tir.ICr H . W. EnhOupl KM , Pruc-Munoc V, Wiloke ß . Simill>ritY<M~ ....... fel.Ultions of 8Drr<1u> ~fm inf"",iono in Ameri<;:a ond E"fOIl<". N .. m,l,.y I~; JS: 1)11}-44. ,. A<:I<crmol>n H, KJobo>l7Jti J, Bo6tcn HP. C< 11 . Sp1nxha\m-ÄIioIo"" <Itt Iirythtrna ctuon.cum migrans. K,~, Dudt Mtd WIdI, 1984; 109': 92-97. 6. Wjl$k. 13 , Scho= G, ~M"r$ic V, Webe, K, PR ..... HW, [l",hiI"pl KM. Strolojpcal d.q:nosit 0( eryth ....... mlglWt' diOCllX ond ",llo.cd diot>nkr9. l'lfw;"., 1984; 12: 111-37. 7. HoIl"rOm I!. Pmic:iUin <reonnc:n, 0( erydIanI chronicum migraru. Ahcliw.. AC/tl Drmt-V ....... 1958; 38: 285-89. 8. Sk6Idcnbn; B, Stiem. ud!: G, Garde ... . KoImodm G. Carl.uom .... Nord Cll. O..,.,ic meningitis causod by • peme;l1in-smamY(' ~"") t..mu. l\18l; .: 1S-78. 9. Weber K . Schien G , W ibkc 13, C< 11. Rcinl"«Iion in ~ nu ...... ~. Io{",';"" IIJ86; 14: )2.--1~ 

Reinfection with Borrelia Burgdorferi

Universität München: Elektronischen Publikationen

RElNFECTION WITH BORRELlA BURGDORFERI 
SIH,- Lyme borreliosis, a tick-bome multisystcm disorder 
caused by the spirochaete Borrtlia burgdor/tri, typicaJly begins with 
crythema chronicwn migrans and is somctimcs foUowcd by 
involvctnent of the hcan, joints, and nervous system.' Neuro-
Iogical manifcstations include mcningomdiculitis (ßannwanh's 
syndrome), meningitis, and enccphalitis.z-.t Thc clinical diagnosis 
can bc confirmcd by fmding antibodies tO B burgdor/t ri by indircct 
immunofluoresccnceor ELISA.$I> We desaibc hen.: a scro1ogically 
and baClCriologica11y confinncd case of possible reinfc:ction. 
In September, 1983,2 wecks after a tick bite on the right ann , a 
59-ycar-<lld woman bad erythema migrans around the bite site. She 
prescntcdon Nov 15 with a painful meningoradiculitis and bilateral 
papilloedema. CSF analysis showed a Iymphocytic p lcocytosis (330 
cells!lll) and an incrcase in total protcin (82 mgfdl). Her scrorn IgG 
antibody ti tre against B burgdorferi rosc from lcss than 16 to 256 
within 4 wecks (figure). IgM antibodics were nOI dctcCted, and 
borreliae could not be isolated from thc CSF. The patient was 
treatcd with intravenous penicillin (20 mcgaunits daily for 5 days, 
then 10 megaunits daily for 5 days) and oral methylprednisolonc 
(70 mg daily over 2 wecks with dccreasing dosage). On dischargc 
(Oe<: 12) she was free of pain, with a slightly improvcd vision. 
Follow-up examinations showed residual bilateral papillauophy. In 
Octobcr, 1984, the CSF was no nnal ( I ccllflll, total protein 
37 mg!dl). 
On Oct 2, 1985, the patient visited a fOIest. She did not rttaI.l any 
arthropod bites but on Oel 5 a painful redncss dcvclopcd on the 
right side of her ehcst. Shc presClucd on Oct 7 with an erythema 
cbronicum migrans, about 20 x 14 an. Spirochaetcs wercisolatedat 
biopsy of the skin acound the Icsion aftcr 4 wecks' incubation in 
modificd Kclly's mcdiwn. Her serum IgG antibcdy titrC ag.ainst 
B Imrgdorferi bad bet:n 16 on June 1:1, 1985 but bad risen to64 on 
Oct 17 v.;thout a corresponding IgM incrcasc. Treattnent with 
minocycline 200 rng daily by mouth for 14 days was succcssful. 
In 1958 HolIsuiim reponed a case of recurrcnt erythema migrans 
5 years after primary infcction? Sköldcnbcrg el al in 1983 describcd 
a p:u:it:nt with tv.uepisoclcs, 20 ycars apan,ofcrythcma migransand 
meningitis after a tick b ite.· Scrological tcsts werc not done on these 
patients. In Weber and colleagucs' two patients with erythcma 
migrans and reinfcction after 5 and 7 ycars antibody titrcS agaimt 
R m'rPrI"r(.-ri o1id n,,' inr ...... _ 9 
In 1983 our patient had Lyme borreliosis with Bannwanh's 
syndrome. Her senun IgG ritte against B Imrgdor/ni bceamc 
negative within 10 months. Erythema chronicum migrans rccurrcd 
2 years later. The absence oflgM antibodics in aeute manifcstations 
of Lyme borrcliosis has been describcd beforc.1.6 The 1985 epi!iQde 
prcscmed after the patient had stayed for a long time in a roteSt in an 
area known to bc endemie for B burgdorferi infcction. D cspite the 
absence of a known tidt bitc wc think that thc secemd anack was a 
rcinfection and nOt a recuITttlcc. The skin sites involvcd wcrc 
different in the [WO cpisodes. 
PatialtS with Bannwanh's syndrome usually rctain a signiflcant 
IgG titrC against B burgdorfui for several ycars.' Our patient's 
antibcdy titrC was insignificant by 10 months. Tbe antibiotic aitd/o r 
oorticosteroid treatment given for thaI first attack may cxplain the 
short-Iived inununity, permitting rcinfection after only 2 ycars. 
[)tporTmoon1l <MNeumIoo 
"""""'_. ~<MMwUdI, 
KlInikum GmIshadnn. 
8000 M..udI70, west~; 
.-.d M .... ...,., 1>nunI:of ... Instituu 
iw H~ lfId M ediooJ M>c:robK>IosY, 
u.tiwnity <M Murudl 
HANS-WALTEH Pt'1S"rnR 
UwaNEUBERT 
B Ii1TINA WILSKE 
Vt;AA PREAC-M URSIC 
KAKL MAx Elloo"HÄUPL 
GI ..... '! Do,\1ENICO HoRASIO 
I. s.-.: AC. Grodzi,cSi RL, KQ<nblan AN, C< 11. ,.,.., opirod>eul C<ioIotD' oe Lymc 
dncase.. N hwl] Md 1983;:1(18,1))-12. 
2 Pachner AR , Stccn: AC. "Thc triad <M ~ mMlifatrioni oe Lymoe dJHooH: 
Mcr""aillS, cronia! neuritis and nd>culonnuitis. N~ 1\18'; )S,47-51. 
1. Pli" ... H.W, EinhJiupl KM, ~M"rlic V, W,b!u B, Schien G .• '"he optrod>eul 
eboIogy of Iymphocytic monin&<>ndkuUti. 0( fJann.W"ll"th (Bannwatth·, 
.ynd_). ] Nft60J 1984; BI: 141-44. 
4. l'tir.ICr H . W. EnhOupl KM , Pruc-Munoc V, Wiloke ß . Simill>ritY<M~ 
....... fel.Ultions of 8Drr<1u> ~fm inf"",iono in Ameri<;:a ond E"fOIl<". N .. m,l,.y 
I~; JS: 1)11}-44. 
,. A<:I<crmol>n H, KJobo>l7Jti J, Bo6tcn HP. C< 11 . Sp1nxha\m-ÄIioIo"" <Itt Iirythtrna 
ctuon.cum migrans. K,~, Dudt Mtd WIdI, 1984; 109': 92-97. 
6. Wjl$k. 13 , Scho= G, ~M"r$ic V, Webe, K, PR ..... HW, [l",hiI"pl KM. 
Strolojpcal d.q:nosit 0( eryth ....... mlglWt' diOCllX ond ",llo.cd diot>nkr9. l'lfw;"., 
1984; 12: 111-37. 
7. HoIl"rOm I!. Pmic:iUin <reonnc:n, 0( erydIanI chronicum migraru. Ahcliw.. AC/tl 
Drmt-V ....... 1958; 38: 285-89. 
8. Sk6Idcnbn; B, Stiem. ud!: G, Garde ... . KoImodm G. Carl.uom .... Nord Cll. 
O..,.,ic meningitis causod by • peme;l1in-smamY(' ~"") t..mu. l\18l; 
.: 1S-78. 
9. Weber K . Schien G , W ibkc 13, C< 11. Rcinl"«Iion in ~ nu ...... ~. 
Io{",';"" IIJ86; 14: )2.--1~ 


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Reinfection with Borrelia Burgdorferi

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Universität München: Elektronischen Publikationen