REPOST:
Update to Lyme Disease 1991 4/93
A new "telltale rash" of Lyme disease: " A blistering rash easily
mistaken for poison ivy, an allergic reaction, herpes simplex or a variety
of other conditions is also associated with Lyme" (from an article by Dr.
Neil CKKGoldberg et al., Nov. 1992 Archives of Dermatology.)

(Urticaria is another word for hives)

".....32.78% of them had
specks and urticaria (hives), 23.33% had muscle pain and 41.11%.."

Zhongguo Meijieshengwuxue ji Kongzhi Zazhi = Chinese Journal of Vector Biology and Control 1998, 261-264<Picture: rule>

Country: China,Guangdong
Abstract journal details: 2T09604
Language: Ch
Other info: 4 ref.
Authors affiliation: Medical College Shantou University, 515031, China. CABICODES: VV200

Abstract:

Using IEA and ELISA, the prevalence of Borrelia burgdorferi antibodies was examined in the eastern part of Guangdong province, China, in 1994-95. Of 2184 people investigated, 225 cases of infection were noted, a rate of infection of 10.3%. The highest infection rate was in school pupils, and the 2nd was amongst peasants. The infective rate appears to be lower amongst forestry workers and their administrative personnel. There were no obvious differences in populations between the forested and non-forested areas. Individual investigations of the 180 antibody positive cases found that 40% of them had been bitten by ticks, and although there was no ECM rash, 32.78% of them had specks and urticaria (hives), 23.33% had muscle pain and 41.11% had arthritis. Descriptors:

Lyme disease,Borrelia burgdorferi,antibodies,arthritis,children,infections,urticaria,Metastigmat a,forestry workers,tickborne diseases,symptoms,man,human diseases,epidemiology,disease prevalence

Abstract no: 990500354

Urticarial vasculitis and Lyme disease
source: Journal of the American Academy of Dermatology vol. 22 Number 6, Part 1, June 1990, page 1114-1116
author: Judyann Olson M.D., Nancy B. Esterly

"Erythema chronicum migrans (ECM) is the classic skin lesion of Lyme disease, a multisystem disease caused by the spirochete Borrelia burgdorferi. Other cutaneous manifestations of Lyme disease include localized and generalized urticaria, generalized macular eruptions, malar erythema in febrile patients, and septal panniculitis. We describe a child with urticarial vasculitis as the presenting feature of Lyme disease.........in endemic areas a diagnosis of Lyme disease should be considered in patients with a clinical or histologic urticarial vasculitis, because it is a potentially treatable condition."

source: Lyme Disease 1991
Patient/Physician Perspectives from the U.S. and Canada

Skin Manifestations of Lyme Disease by John Drulle M.D.

"Since Lyme disease is a widely disseminated, multi-organ system disease,
skin involvement is common, and occurs in about half of those infected.......

"The pathognomonic (diagnostic) rash of early Lyme is called EM(erythema migrans--in Latin LErythema means redness, and migrans means migratory or expanding). It usually appears at the site of the tick, flea, fly, or
mosquito bite several days to a year or more later. (It was recently
reported that 18% of the cases of Lyme in Austria are due to bites of
non-tick vectors such as flies and perhaps mosquitos. Borrelia
burgdorferi -Lyme spirochete- has been isolated from these insects.) The
fact that one half of people who develope Lyme do not recall a tick bite
may be partially explained by non-tick vectors. The EM rash is usually circular or oval, but irregularly shaped rashes are common. They may
spread or enlarge rapidly, but we have seen where pressure on the skin from
a tight garment impedes the progression of the rash causing irregularity of shape. There may or may not be central clearing, and concentric rings of different shades are often seen within the rash. There may be necrosis
(death of areas of tissue) or a blue violet shading at the site of the
bite. These rashes are rarely painful, as brown recluse spider bites
almost always are, and often itch. They are usually warm to the touch.
The rash may be completely flat, but occasionally the edges may be elevated
and be scaly or contain vesicular components. Ten variations of the EM
rash have been described by Dr Alan McDonald. Some of these are very recognizable or "classic" in their appearance, but others may be confused
with other common skin infections such as ringworm, cellulitis, erythema multiforme, eczema, or hives.

"......I feel that the best approach in an endemic area would be to assume
that the rash is Lyme and treat accordingly. It's better to err on the
side of overdiagnosis than to miss the diagnosis and have it haunt you
months or years later." (my own words-this Dr. obviously has a conscience)
" Waiting for other symptoms to develope may delay treatment and result in persistence of symptoms or even more serious problems in the future.

"........I must note that a treatment effective in one person may not work
in another. This is generally true for any particular symptom of Lyme.

"Another type of chronic Lyme rash we have seen, occurs in some small
children. These tend to be widely disseminated, blotchy plaques, pink in color. They do not spare the face. They have been seen in children born
with Lyme, especially if the mother was a bit late in pregnancy. These
rashes are usually misdiagnosed as eczema, and they do not respond to
topical or systemic steroids. They do respond quite well to oral or IV antibiotics ....

"In summary, I believe the current official description of Lyme skin manifestations is quite incomplete. We are anxiously awaiting the PCR test
to become more readily available, since I feel that we will find evidence
of active infection in many of these chronic skin rashes."

Update to Lyme Disease 1991 4/93
A new "telltale rash" of Lyme disease: " A blistering rash easily
mistaken for poison ivy, an allergic reaction, herpes simplex or a variety
of other conditions is also associated with Lyme" (from an article by Dr.
Neil CKKGoldberg et al., Nov. 1992 Archives of Dermatology.)

from: Clinical Manifestations of Lyme Disease in the United States
authors: Trock, et al
Source: Connecticut Medicine June 1989 Volume 53, No. 6
"....Although the bite (and subsequent erythema migrans) may occur anywhere, the tick has a predilection for the thigh, groin, or axilla. Facial erythema migrans is more common among children. Atypical forms of erythema migrans occur: ealy lesions may have indurated or vesicular centers , or MIMIC
STREPTOCOCCAL OR STAPHYLOCCAL CELLULITIS. Central necrosis also may occur and be misdiagnosed as a bite of the brown-recluse spider. Rarely, transient eruptions are seen in early Lyme disease and include, maculopapular rashes, urticaria, " (hives) "malar rash, septal panniculitis (erythema nodosum), and/or
localized granuloma annulare. Although B. burgdorferi has been isolated from the perimeter of erythema migrans, skin biopsy is a low-yeild procedure. Histologically, erythema migrans has a non-specific appearance with a perivascular infiltrate comprised of lymphocytes, plasma cells, eosinophils, and histiocytes.
" In addition to erythema migrans, many patients with early disease will have a flu-like syndrome characterized by fatigue, fever, malaise, headache, arthralgias, myalgias, regional or generalized lymphadenopathy, and/or conjunctivitis." My LLD said that conjunctivitis in both eyes is a as diagnostic of Lyme as a bull's eye rash. "One-third of patients will have such symptoms in the absence of erythema migrans. These symptoms are typically intermittent and changing, with the exception of fatigue, which is often persistent and may be debilitating. Right upper-quadrant tenderness and a mild hepatitis may occur (hepatitis has also been reported in later disease), as well as cases of rare myositis "- maybe rarely recognized- " and adult respiratory distress syndrome. During this early phase of disease, laboratory findings are nonspecific........."

from: Lyme Disease and Its Neurological Complications
author Michael F. Finkle, MD
source: Archives of Neurol--Vol. 45, Jan 1986

" Lyme disease is recognized as a cause of illness involving
multiple organ systems. The transmission of the B. burgdorferi
spirochete depends on a complicated vector life cycle, involving
multiple mammalian and avian hosts.
Although the illness is reported worldwide, variable clinical
presentations on different continents raise questions about
disease mechanisms. Multiple neurologic syndromes can
occur alone or in combination, producing peripheral neuropathies, radiculopathies," (disease of the spinal nerve roots) "myelopathies, encephalitides, meningitides, and pain syndromes. These may
be noted with dermatological, rheumatological and cardiological
syndromes. Several pathophysicologic mechanisms are reviewed. ............

"Lyme disease was not recognized in the United States until the
1970s. The first case of tick-induced ECM" (erythema chronica
migrans - bulls eye rash) "was reported from Wisconsin in 1970.(6)
"The illlness had a
seasonal prevalence......25% of the individuals had a skin lesion
four weeks before developing arthritis.(7,8)........21 % of the individuals remembered a preceding tick bite. Many of the individuals also
had tick infested pets, especially cats and dogs. The illness
was first referred to as Lyme arthritis. (7,8) By the late 1970s, it
was
recognized that the illness was a systemic disorder
with dermatologic, neurologic, rheumatologic, and
cardiac components. The name was broadened to Lyme disease."

"Three stages of the illness were recognized.

"The first stage begins with ECM and associated symptoms.
The ECM lesion is commonly found in the thigh, GROIN, or axilla,
where the tick bites characteristically occur. It is an annular
erythema that may enlarge from its site of origin to a size
of 10.0 cm or greater.....The patient may have fever , chills,
malaise, and fatigue as well as a headache and a regional
adenonpathy. Secondary lesions may develop within
several days of the intitial lesion, which are annular and multiple.
They are smaller, less migratory, not indurated (hardened),
and are not in the area of a tick bite. Conjunctivitis,
urticaria (hives), or a MALAR rash may also occur as a later
manifestation...."
____________________________-
ACA exists in the United States and Borrelia Afzeli is not the only strain that causes ACA.
"........hypo-and hyperpigmentation
may occur. Atrophy also may involve nasopharyngeal,......"

"ACA is an outstanding example of prolonged latency
and chronic
infection."

Acrodermatitis Chronica Atrophicans: a Late Manifestation of Lyme
Disease -Synopsis

synopsis by Dave Bartholomew

The following is provided for information and is
quoted from the
article "Acrodermatitis Chronica
Atrophicans: Historical and Clinical Overview," by Rudolph J.
Scrimenti, Associate Clinical Professor of
Dermatology, Medical College of Wisconsin, Milwaukee.
Remarks added
are in parenthesis.

Montgomery and Sullivan from the Mayo Clinic reviewed
45 cases of ACA in 1945, 39 of which occurred
in immigrants. (The other six were born in the U.S.A. (DB))

(ACA has two stages): early infiltration and/or inflammation
and,
later atrophy.

ACA is an outstanding example of prolonged latency
and chronic
infection.

Early ACA usually begins in a subtle fashion with infiltration,
inflammation, or doughy swelling of an
extremity. Ordinarily mildly symptomatic, on rare
occasions it may
weep.
Patients do not usually associate it with an earlier bite. In some
patients, it may be preceded by signs
and symptoms of early LB. However, such information is not
volunteered readily by patients
because a correlation is often not perceived between symptoms
separated by long time intervals.

Slow, but definite progression, over months to years, even decades,
is the usual course. Central
progression toward the torso ensues.

The face rarely is involved and may resemble
dermatomyositis, contact
dermatitis or collagen disease.
The palms and soles participate in this disease
process as they do in
syphilis, but the lesions are much more confluent.

Eventually, atrophy appears in the involved sites,
subcutaneous fat
is lost, and inflammation may
subside. Now the skin becomes wrinkled, thin, scaling, dry,
hypohidrotic and transparent The
underlying venous architecure is readily visible.
Alopecia,
hyperesthesia, hypo-and hyperpigmentation
may occur. Atrophy also may involve nasopharyngeal,
lingual, and
vaginal mucous membranes. Various
stages of inflammation and atrophy may coexist at the
same time. A
noteworthy feature of the atrophy is
that it may take many years to occur and it is not an absolute
requirement for the diagnosis. Also
atrophy may be diffuse or localized. Rarely, sac-like
formations
occur in areas of macular atrophy.
Superinfection of erythema migrans in patients with
reexisting ACA
has been reported in Europe.

Other special distinguishing features noted in European
patients are
fibrotic bands, fibrous juxta
articular nodules, a distinctive arthropathy and pseudosclerodermoid
skin changes.

Fibrous nodules appear painlessly over the elbows,
knees, hands,
fingers, and elsewhere. Ranging in
size from one to three centimeters, they may be solitary,
multiple
and frequently grouped. Their color
varies from yellow white to reddish blue.

European observers have reported a sclerosing process of connective
tissue as an integral part of the
syndrome of idiopathic atrophy. Such lesions vary from moderately
infiltrated, yellow, stretched plaques
of skin to firmly indurated marble white areas resembling scleroderma.


Deforming arthritis with bone atrophy associated with
ACA was first
reported in 1924 by Jesner.

Recent studies indicate subluxations, and luxations of
small bones of
the hands and feet are the most
characteristic arthritic features.

A mild, but chronic, motor and/or sensory axonal
polyneuropathy is
characteristic in a large percentage
of patients with chronic borreliosis on both sides of the Atlantic.

ASSOCIATED CONDITIONS . Enthesopathies, periostitis, myositis,
myalgias, fasciitis, localized and
generalized lymphadenopathy, weight loss fatigue,
personality
disorders usually with negative
cerebrospinal fluid laboratory findings have been
reported with ACA.

LABORATORY FINDINGS. Increased erythrocyte sedimentation rates are
noted regularly. The organism
can be cultured slowly on modified Barbour-Stoenner-Kelly medium from
skin lesions, even decade-old
lesions at temperatures of 32 to 33 C. Focal areas of plasma cells
may be present in the deeper dermis.
With progression, epidermal thinning, degeneration of
elastic fibers
and collagen occurs. Eventually
after many years, advanced atrophy of the dermis,
including all
appendages, follows the inflammation.
Later, the inflammation disappears, and a pronounced
thinning of the
entire dermis and subcutis
develops. A rich mixture of plasma cells, if present may be the only
feature ifferentiating sclerotic and
atrophic ACA from idiopathic scleroderma (morphea)
and lichen
sclerosus, except for the presence of
the spirochete. Immunohistologic staining shows a
predominance of
CD4 lymphocytes. Most, but not
all, studies show no association between the development
of ACA and
HLA class II alleles. (Newly
identiied species may not culture and other tests may be
negative -D.
B.).

DIFFERENTIAL DIAGNOSIS. The distinctive plasmacytic infiltrate (if
present), unique clinical features
and serologic findings differentiate ACA from arterial and
venous
insufficiency, acrocyanosis, livedo
reticularis, vasculitis, contact dermatitis and collagen diseases. Acrodermatitis Chronica Atrophicans: a Late Manifestation of Lyme
Disease -Synopsis

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