gastrointestinal manifestations of Lyme disease
Gastrointestinal manifestations of Lyme disease and co-infections to be observed - a literature review.
By Steere et al (1) in 1983 were reported gastrointestinal symptoms associated with Lyme disease.
Fried et al., published in 1996 an article of pathological changes of the gastrointestinal tract in children who suffered from Lyme disease (5).
Further scientific publications of the same group of authors on the same subject was followed in 1999 and 2002 (6) and (7)
In 2002, Fried and colleagues also published a work of, in which Bartonella henselae has been associated with gastrointestinal symptoms such as heartburn, abdominal pain, mesenteric lymphadenitis, gastritis and duodenitis as well as skin redness (8). Bartonella henselae is otherwise known as the causative agent of cat scratch disease.
The latest work on this subject were published in Nov. 2004 (9), published by Fried, Adelson and Eli Mordechai (microbiology and molecular genetics). It is dasVorkommen on the frequency and four in this context investigated by agents reported saying:
Were examined 81 patients aged 8-21 years. They had been by your treating physicians or pediatricians admitted for inpatient evaluation. The spectrum of complaints and diagnostic spectrum at admission ranged from chronic abdominal pain, blood in stool, gastroesophageal reflux with heartburn, Crohn's disease, celiac disease on to failure to thrive or weight loss. All patients were examined clinically and laboratory findings, including determination of antibodies to known pathogens. They were also either ösophagogastroduodenoskopiert or kolonoskopiert, derived from mucosal biopsies were PCR tests performed on the above agents, only the detection of Helicobacter light microscopy was carried out biopsies of the upper gastrointestinal tract. In the DNA analysis for Borrelia burgdorferi-primers were for the OSP-A gene and chromosomal LY1 specifically used. For the determination of Bartonella and Mycoplasma fermentans were studied ribosomal RNA genes. In case of suspected gallbladder or bile duct involvement were abdominal sonographic studies of the supplement also carried out. In case of suspected mesenteric lymphadenitis or Apendizitis led to investigations of the abdomen by computed tomography, and stool tests for blood ocultes, Chlostridium difficile toxin, Salmonella, Shigella, Yersinia, Campylobacter, E. Coli, worm eggs and Elisa antigen tests against lamblia. Mucosal biopsies were taken from inflamed mucosal areas, either at the esophago-gastro-duodenoscopy or colonoscopy.
Results:
On the basis of this study appears that Bartonella henselae as the most commonly pathogenic agent in the patient population studied.
In patient with chronic gastrointestinal and possibly multisystemic complaints is therefore necessary to think of these pathogens.
In the evaluation of chronic gastrointestinal complaints endoscopy with biopsy sampling and DNA analysis from the above mentioned organisms (by PCR method) to confirm the diagnosis is recommended.
This is especially important if there are additional neurological symptoms or e.g. arthralgia.
In the interpretation of results should be taken into account that the PCR method is not perfectly sensitive, negative results should not therefore be used clinically and serologically or perhaps even a history-exclude suspected diagnosis.
Order, and quasi-rounded patients who do justice to the subject, the same joint pain complain, I want the "Research Report 2001" of the Department of Rheumatology, Hannover Medical School indicate (Director: Prof. Henning Zeidler) (10).
Here was a group of patients, namely patients with so-called "early undifferentiated oligoarthritis", also by PCR method
To clarify: only 40-50% of patients oligoarthritis (inflammation of 1-4 joints) can develop, disease, years of a defined rheumatic disease are associated with the first. The rest are known as "undifferentiated arthritis" classified. In this population there are many characteristics that infektreaktive arthritis and spondylarthritides remember, such as a cluster of hereditary characteristics HL AB 27, a preferred attack of the lower extremity or a contribution from the axial skeleton.
In the period 1994-97 were 52 patients recruited. The inclusion criteria were in accordance in all patients, the Lyme disease serology and also certain chlamydial DNA negative in morning urine, because the disease usually already as Lyme arthritis and Chlamydia-induced arthritis would have been classified.
These results show that approximately one third of patients with undifferentiated arthritis using modern molecular methods, a triggering infection with either Chlamydia trachomatis or Borrelia burgdorferi can be detected.
They prove the existence of seronegative Lyme disease cases.
Literature:
Meanwhile, however, we have learned that ticks can transmit a whole range of other pathogens, too.
An overview of these pathogens can be found in Zaidi and Singer (2).
Pathogens in detail:
In (2) contained tabular representation can be seen easily that not only Borrelia but also all listed tick-borne pathogens can cause gastrointestinal symptoms.The clinical symptoms are often very similar and can overlap.
Symptoms in detail:
Weight loss, nausea, vomiting, abdominal pain, diarrhea, liver enlargement, enlargement of the spleen, jaundice (rare), increased liver enzymes enzymes.
Regarding the frequency of individual symptoms in each disease may I refer to Table 1 (2).
Ehrlichiosis (E): - clinical cases were reported in Europe since then only very occasionally; Ehrlichia, the actual pathogens, are related to rickettsiae, it differs in humans and a granulöcytäre moncytäre form d. E.; as well as fever, headache, muscle pain and transaminase are very characteristic, besides leukopenia and thrombocytopenia.
Tularemia (T) is called in German "rabbit fever," agent: Francisella tularensis; Main reservoir are wild rabbits and other rodents, there are several means of transmission:
The causative agent of Q fever Coxiella burnetti is, diagnosis is usually serological protection possible and the acute form usually runs a high fever as a disease with head and limbs and pain, sometimes referred to as atypical. Pneumonia, granulomatous hepatitis as a complication can occur even see references in (4) and (3)
All of these pathogens can therefore be transmitted by ticks and can cause symptoms gastroitestinale. Depending on the clinical picture should be drawn og infection whereas in the differential diagnosis.
Literature:
(1): Steere AC, Bartenhagen NH, Craft JE, et al. The early clinical manifestations of Lyme disease. Ann Intern Med 1983; 99: 76-82
(2) :) Zaidi SA, Singer C. Gastrointestinal and hepatic manifestations of tickborne diseases in the United States.
Clin Infect Dis. 2002 May 1;34(9):1206-12. Epub 2002 Apr 2. Review.
(3) Kimmig P., Hassler D., Braun R.: Zecken, Kleiner Stich mit bösen Folgen, Verlag Ehrenwirth Ratgeber, 2000 ISBN 3-431-04018-7
(4) Dupont HT, Raoult D Brouqui P et al: Epidemiologic features and clinical presentations of acute Q fever in hositalized patients: 323 French cases, Am J Med 1992; 93: 427-34.
(5) Fried MD. Duray P, Pietrucha D. Gastrointestinal Pathology in children with Lyme Disease. J Spirochetal and Tick-Borne Diseases, 1996; 3: 101-104.
(6) Fried MD, Abel M, Pietrucha D, Yen-Hong K, Ball A. The spectrum of gastrointestinal manifestations in children aund adolescents with Lyme disease. J Spirochetal and Tick-Borne Diseases, 1999; 6: 89-93
(7) Martin D. Fried, MD; Dorothy Pietrucha, MD; Gaye Madigan, RN; and Aswine Bal, MD. Borrelia burgdorferi Persists in the Gastrointestinal tract of Children and Adolescents with Lyme Disease. Journal of Spirochetal and Tick- Borne Diseases. Vol. 9, No. 1, 2002. pp. 11-15.
(8) Fried MD, Schairer J, Madigan G, Ball A. Bartonella henselae is associated with heartburn, abdominal pain, skin rash, mesenteric adenitis, gastritis and duodenitis. J Pediatr. Gastroenterol. Nutr. 2002; 35:3 Abstract 158
(9) Fried MD, Adelson ME, Mordechai E: Simultaneous Gastrointestinal Infections in Children and Adolescnts, Practical Gastroenterology, November 2004 87-80.
(10) „Forschungsbericht 2001“ der Abteilung Rheumatologie der medizinischen Hochschule Hannover hinweisen (Direktor: Prof. Henning Zeidler)
By Steere et al (1) in 1983 were reported gastrointestinal symptoms associated with Lyme disease.
Fried et al., published in 1996 an article of pathological changes of the gastrointestinal tract in children who suffered from Lyme disease (5).
- In this study, symptoms were 10 children 8-19 years with Lyme disease and chronic gastrointestinal investigated.
- Showed a histological inflammation of the stomach, duodenum, but also of the colon
- Histologically to evidence of spirochetes in five of the 10 cases in later works, these are identified as Borrelia burgdorferi.
Further scientific publications of the same group of authors on the same subject was followed in 1999 and 2002 (6) and (7)
In 2002, Fried and colleagues also published a work of, in which Bartonella henselae has been associated with gastrointestinal symptoms such as heartburn, abdominal pain, mesenteric lymphadenitis, gastritis and duodenitis as well as skin redness (8). Bartonella henselae is otherwise known as the causative agent of cat scratch disease.
The latest work on this subject were published in Nov. 2004 (9), published by Fried, Adelson and Eli Mordechai (microbiology and molecular genetics). It is dasVorkommen on the frequency and four in this context investigated by agents reported saying:
- Helicobacter pylori,
- Borrelia burgdorferi
- Mycoplasma fermentans and
- Bartonella henselae
Were examined 81 patients aged 8-21 years. They had been by your treating physicians or pediatricians admitted for inpatient evaluation. The spectrum of complaints and diagnostic spectrum at admission ranged from chronic abdominal pain, blood in stool, gastroesophageal reflux with heartburn, Crohn's disease, celiac disease on to failure to thrive or weight loss. All patients were examined clinically and laboratory findings, including determination of antibodies to known pathogens. They were also either ösophagogastroduodenoskopiert or kolonoskopiert, derived from mucosal biopsies were PCR tests performed on the above agents, only the detection of Helicobacter light microscopy was carried out biopsies of the upper gastrointestinal tract. In the DNA analysis for Borrelia burgdorferi-primers were for the OSP-A gene and chromosomal LY1 specifically used. For the determination of Bartonella and Mycoplasma fermentans were studied ribosomal RNA genes. In case of suspected gallbladder or bile duct involvement were abdominal sonographic studies of the supplement also carried out. In case of suspected mesenteric lymphadenitis or Apendizitis led to investigations of the abdomen by computed tomography, and stool tests for blood ocultes, Chlostridium difficile toxin, Salmonella, Shigella, Yersinia, Campylobacter, E. Coli, worm eggs and Elisa antigen tests against lamblia. Mucosal biopsies were taken from inflamed mucosal areas, either at the esophago-gastro-duodenoscopy or colonoscopy.
Results:
- In 30 of the 81 patients (or 37%) were found PCR-positive for a single infection.
- 19 of 81 (24%) and in 6 of 81 (8%) with ppositive biopsy (PCR) for two or three gastrointestinal infections.
- in 30 patients with only a single infection Bartonella henselae were in twelve cases represented the most common, followed by
- Helicobacter-pylori followed in nine cases
- Mycoplasma fermentans in 6 cases
- Borrelia burgdorferi in 3 cases.
- co-infections found by the Bartonella, and Mycoplasma fermentans in 10 cases
- Bartonella and Borellia burgdorferi in 6 cases
- Borellia-burgdorferi and Mycoplasma fermentans-cases were also found in 2 and were each associated with localized inflammatory mucosal changes.
- In the gastro-intestinal biopsies with triple infections were 4 cases in the same Bartonella, mycoplasma fermentans and Helicobacter detected during Bartonella henselae, Mycoplasma and Borrelia burgdorferi- two cases were detected at the same time.
- From the 81 patients which were examined: 35 Bartonella henselae infections, 24 Mycoplasma fermentans infections, 14 Helicobacter-pylori infections and a total of 13 patients with a Borrelia burgdorferi-infection either monoinfection or as multiple infections, such as described.
- In 33% of the patients, let no infectious cause of disease to demonstrate at the stool analysis, no further infections are detected. Abdominal ultrasonography in the supplementary notes were neither gallstones nor pancreatitis or other gall-associated dieseases.
On the basis of this study appears that Bartonella henselae as the most commonly pathogenic agent in the patient population studied.
In patient with chronic gastrointestinal and possibly multisystemic complaints is therefore necessary to think of these pathogens.
In the evaluation of chronic gastrointestinal complaints endoscopy with biopsy sampling and DNA analysis from the above mentioned organisms (by PCR method) to confirm the diagnosis is recommended.
This is especially important if there are additional neurological symptoms or e.g. arthralgia.
In the interpretation of results should be taken into account that the PCR method is not perfectly sensitive, negative results should not therefore be used clinically and serologically or perhaps even a history-exclude suspected diagnosis.
Order, and quasi-rounded patients who do justice to the subject, the same joint pain complain, I want the "Research Report 2001" of the Department of Rheumatology, Hannover Medical School indicate (Director: Prof. Henning Zeidler) (10).
Here was a group of patients, namely patients with so-called "early undifferentiated oligoarthritis", also by PCR method
- Chlamydia trachomatis - DNA tested and
- Borrelia burgdorferi - DNA tested.
To clarify: only 40-50% of patients oligoarthritis (inflammation of 1-4 joints) can develop, disease, years of a defined rheumatic disease are associated with the first. The rest are known as "undifferentiated arthritis" classified. In this population there are many characteristics that infektreaktive arthritis and spondylarthritides remember, such as a cluster of hereditary characteristics HL AB 27, a preferred attack of the lower extremity or a contribution from the axial skeleton.
In the period 1994-97 were 52 patients recruited. The inclusion criteria were in accordance in all patients, the Lyme disease serology and also certain chlamydial DNA negative in morning urine, because the disease usually already as Lyme arthritis and Chlamydia-induced arthritis would have been classified.
- Fifteen of the 52 patients had a positive PCR in the synovial fluid results in 9 patients (17%) could Chlamydia trachomatis DNA in 6 patients (12%), Borrelia burgdorferi DNA was detected.
- In a control group of 31 patients with rheumatoid arthritis found no intra-articular contrast, DNA evidence, while the PCR detection control groups with confirmed chlamydia-induced arthritis in 50%, in Lyme arthritis in 69% succeeded in.
These results show that approximately one third of patients with undifferentiated arthritis using modern molecular methods, a triggering infection with either Chlamydia trachomatis or Borrelia burgdorferi can be detected.
They prove the existence of seronegative Lyme disease cases.
Literature:
Meanwhile, however, we have learned that ticks can transmit a whole range of other pathogens, too.
An overview of these pathogens can be found in Zaidi and Singer (2).
Pathogens in detail:
- Borrelia burgdorferi
- Ehrlichia chaffeensis and Ehrlichia phagocytophilia
- Rickettsia rickettsii (Rocky Mountain spotted fever), European counterparts: Rickettsia conori, the cause of the Mitel sea typhus (vector: "Brown tick"), but also Rickettsia prowazekii, the cause of typhus (vector: body louse), literature on this, see also (3)
- Francisella tularensis: the cause of tularemia (rabbit fever), literature see also (3)
- Colorado tick fever: high fever a disease caused by a "Colti" virus; The listed Colorado tick fever corresponds i. Eyach Europe the virus, which is also in the group of Reo-virus probably belongs. Clinical course similar to the TBE with bimodal febrile period. Literature on this, see also (3)
- Tick-borne relapsing fever caused by Borrelia (B.) of the genus B. turricatae, B. hermsii and B. parkeri, carrier: ticks from the genus Ornithodorus, "Worldwide occurrence. Already in 1905 could be detected in ticks by Dutton and Todd responsible pathogen as spirochetes, which determines which consisted Borrelia; Borrelia relapsing fever actually differ a little bit from the pathogens d. Lyme disease, but make violent fevers usually in 7 - day cycles. Other names: Borrelia hispanica, Crocidura, microti, etc., depending on the geographical occurrence, literature on this, see also (3)
- Q fever: caused by Coxiella burnetti, an obligate intracellular pathogen that is among the rickettsiae, the pathogen is by ticks of the genus Dermacentor to domestic animals-sheep, goats, cattle, transmitted, transmission to humans is often secondary to aerosols and also by consumption of raw milk or fresh goat cheese, which can lead to hepatitis (4)
- Babesiosis; pathogens: Babesia microti (United States), Babesia divergens (Europe), among others, include Babesia as the causative agent of malaria, the single-celled protozoa and are found in erythrocytes, can therefore be detected in the blood smear also.
In (2) contained tabular representation can be seen easily that not only Borrelia but also all listed tick-borne pathogens can cause gastrointestinal symptoms.The clinical symptoms are often very similar and can overlap.
Symptoms in detail:
Weight loss, nausea, vomiting, abdominal pain, diarrhea, liver enlargement, enlargement of the spleen, jaundice (rare), increased liver enzymes enzymes.
Regarding the frequency of individual symptoms in each disease may I refer to Table 1 (2).
Ehrlichiosis (E): - clinical cases were reported in Europe since then only very occasionally; Ehrlichia, the actual pathogens, are related to rickettsiae, it differs in humans and a granulöcytäre moncytäre form d. E.; as well as fever, headache, muscle pain and transaminase are very characteristic, besides leukopenia and thrombocytopenia.
Tularemia (T) is called in German "rabbit fever," agent: Francisella tularensis; Main reservoir are wild rabbits and other rodents, there are several means of transmission:
- First direct contact with blood of infected animals,
- 2nd Tick bites (by ticks of the genus Dermacentor and Ixodes);
- 3rd Inhalation of infectious aerosols: dead rodents were in the hay, the loading of highly infectious inhalation aerosol, which usually progress to a pneumonic form of the Baptist leads in; SA to Lit (3).
The causative agent of Q fever Coxiella burnetti is, diagnosis is usually serological protection possible and the acute form usually runs a high fever as a disease with head and limbs and pain, sometimes referred to as atypical. Pneumonia, granulomatous hepatitis as a complication can occur even see references in (4) and (3)
All of these pathogens can therefore be transmitted by ticks and can cause symptoms gastroitestinale. Depending on the clinical picture should be drawn og infection whereas in the differential diagnosis.
Literature:
(1): Steere AC, Bartenhagen NH, Craft JE, et al. The early clinical manifestations of Lyme disease. Ann Intern Med 1983; 99: 76-82
(2) :) Zaidi SA, Singer C. Gastrointestinal and hepatic manifestations of tickborne diseases in the United States.
Clin Infect Dis. 2002 May 1;34(9):1206-12. Epub 2002 Apr 2. Review.
(3) Kimmig P., Hassler D., Braun R.: Zecken, Kleiner Stich mit bösen Folgen, Verlag Ehrenwirth Ratgeber, 2000 ISBN 3-431-04018-7
(4) Dupont HT, Raoult D Brouqui P et al: Epidemiologic features and clinical presentations of acute Q fever in hositalized patients: 323 French cases, Am J Med 1992; 93: 427-34.
(5) Fried MD. Duray P, Pietrucha D. Gastrointestinal Pathology in children with Lyme Disease. J Spirochetal and Tick-Borne Diseases, 1996; 3: 101-104.
(6) Fried MD, Abel M, Pietrucha D, Yen-Hong K, Ball A. The spectrum of gastrointestinal manifestations in children aund adolescents with Lyme disease. J Spirochetal and Tick-Borne Diseases, 1999; 6: 89-93
(7) Martin D. Fried, MD; Dorothy Pietrucha, MD; Gaye Madigan, RN; and Aswine Bal, MD. Borrelia burgdorferi Persists in the Gastrointestinal tract of Children and Adolescents with Lyme Disease. Journal of Spirochetal and Tick- Borne Diseases. Vol. 9, No. 1, 2002. pp. 11-15.
(8) Fried MD, Schairer J, Madigan G, Ball A. Bartonella henselae is associated with heartburn, abdominal pain, skin rash, mesenteric adenitis, gastritis and duodenitis. J Pediatr. Gastroenterol. Nutr. 2002; 35:3 Abstract 158
(9) Fried MD, Adelson ME, Mordechai E: Simultaneous Gastrointestinal Infections in Children and Adolescnts, Practical Gastroenterology, November 2004 87-80.
(10) „Forschungsbericht 2001“ der Abteilung Rheumatologie der medizinischen Hochschule Hannover hinweisen (Direktor: Prof. Henning Zeidler)