Etiology. Lyme's illness (tick-borne borreliosis, Laymborrelioz, an illness Lima) - the disease transferred by mites, which is characterized by a peculiar skin syndrome (erythema chronicum migrans), a carditis, meningitis and arthritis. As a disease-producing factor serve Borrelia burgdorferi spirochete, more rare as other carrier (Amelyomma americanum).
Epidemiology. In spite of the fact that the migrating annulyarny rashes (erythema chronicum migrans) were for the first time described at the Swedish patient bitten by an ixodic tick of Iricinus in 1909. In 1975 it was reported about several patients in Lyme (the State of Connecticut, the USA) with a wide range of clinical displays of an illness, including and such as carditis, arthritis, meningitis. From this description the term "Lyme's illness" is accepted. The disease was described also in Europe where proceeds less hard, than in the USA. The same microorganisms are allocated from mites of Iricinus, from skin rashes, blood, synovial and cerebrospinal fluid of the infected patients.
Clinical manifestations. Early skin changes (erythema chronicum migrans) are provided by makulopapulezny eritema. About 30% of patients have in the anamnesis of the instruction on a sting of a tick in the area where there was an erythema. During various span (3 — 32 days), and on average about 1 week there is an extending erythematic annulyarny rash with an enlightenment in the center reaching on diameter of 6 — 38 cm (on average 16 cm).
At certain patients the erythema has consolidation in the center where in the subsequent the vesicle or a necrosis is formed. Localization of rashes can be the most various, however the arrangement on hips, in inguinal and axillary areas is the most typical. In several days after emergence of primary rash there is secondary rash. Its elements usually smaller, have no the central condensed zone and do not correspond to sting zones a tick. At the patients living in Europe, secondary rash was not observed. Other skin symptoms of an illness of Lyme can include rashes in the field of zygomas, conjunctivitis and quickly taking place small annulyarny rashes or acneform elements.
Weakness and drowsiness can be constant symptoms, other signs are changeable and include a headache, a fever, the migrating muscle and joints pains. It is reported about a lymphadenopathy, the phenomena of a meningism, encephalopathy, a gepatosplenomegaliya, hypostasis of testicles.
During the early period of an illness of Lyme nonspecific laboratory changes are noted: considerable acceleration of sedimentation of erythrocytes (50% of patients), increase in the IgM level in serum (33% of patients), increase of activity of glutaminic oxalacetic transaminase (19% of patients), a microhematuria and a moderate proteinuria. All these symptoms and signs independently and irrespective of treatment are leveled during 3 — 4 weeks. Skin rashes can recur.
Late clinical manifestations can be expressed in defeat of TsNS (10%), cardiovascular system (8%), the musculoskeletal device (80%). The symptomatology is more expressed and has especially steady character at patients with HLA and DR-2 antigens. Neurologic manifestations arise within 4 weeks from the moment of the first manifestations and can last till 3 months.
The triad is most typical: meningitis, a peripheral radiculoneuritis, a cranial neuropathy with paralysis Bella. With a smaller frequency the chorea, a cerebellar ataxy, Julian's syndrome — Barret, a brain pseudoneoplasm, demyelinating encephalopathy are observed. In cerebrospinal fluid — a mononuclear pleocytosis at the normal level of glucose and moderate increase of level of protein. The neurologic symptomatology is described for a long time by the European clinical physicians as tick-borne meningopolinevrit, a syndrome of Bannwarth or a lymphocytic meningoradiculitis. At patients high antiserum capacities to Borrelia come to light.
Changes in heart come to light in terms about 5 weeks from an onset of the illness and include various degrees of an atrioventricular block (from the I degree across Venkebakh to the full heart block), mioperikardit, dysfunctions of a left ventricle quite often with a cardiomegaly. Changes from heart usually last of 3 days to 6 weeks and seldom recur.
The joint syndrome comes to light in terms from one week to 2 flyings. At first there are migrating arthralgias, in several months large joints are involved in process, knee are more often. However not only large, but also small joints can be affected, and at small part of patients also symmetric polyarthritis forms. Arthritis duration from several weeks to several months also recurs within several years. In synovial fluid the number of leykouzl reaches 500 — 100 000 in 1 ml with dominance of polymorphonuclear leukocytes, protein content is increased and the maintenance of C3, C4 and hemolitic complement in general is a little reduced. Approximately at 10% of patients arthritis of large joints accepts a chronic current and leads to erosive changes of a cartilaginous and bone tissue. The risk of chronic arthritis is connected with existence of the V-cellular antigen of DR-2. The possibility of transplacental transfer of V. of burgdorferi is shown. Congenital anomalies of development, pre-natal death of a fruit, the premature birth and arrest of development of children are a consequence of such transfer.
Diagnosis and treatment. The diagnosis of an illness of Lyme is made on the basis of identification of clinical signs at the child living in a local zone as in the presence, and in lack of data on a sting a tick. The diagnosis is confirmed by serological methods. False positive results of serological research are possible at other infections from group of treponematoz or in the presence of some autoantibodies.
False-negative results receive in early terms of an illness of Lyme or at an early initiation of treatment antibacterial agents. The raised antiserum capacities can remain for many years.
The symptomatology disappears in earlier terms at the patients receiving doxycycline or amoksitsiklin, and more slowly at treated erythromycin.
At an early stage of an illness of Lyme appoint doxycycline (100 mg 2 times in days) inside or amoksitsiklin (500 mg 4 times in days) inside. Patients with an allergy to penicillin are treated tsefuroksimy (500 mg 2 times in days). Erythromycin use (250 mg 4 times in days) is inside not so effective, but can be applied at an allergy to other medicines. Treatment duration — 10 days for an illness with skin manifestations and 20 — 30 days at the disseminated infection.
Within the first days from an initiation of treatment at about 1/7 patients the reaction reminding Yarish's reaction — Gerksgeymera is noted. The patient with the expressed AV blockade or an interval of PR> 0,3 with recommends intravenous administration of benzylpenicillin of 20 million. Piece/days (introduction of doses in 4 — 6 h) or a tseftriaksona of 2 g a day intravenously within 10 days.