sive alternative to glycopeptides for Borrelia valaisiana old man with a history of spastic para-
the treatment of MRSA infections. paresis, which is strong clinical evi-
Data from the United States and dence of advanced neuroborreliosis.
Europe have shown that vancomycin- Fluid Symptoms, mainly difficulty in walk-
intermediate S. aureus isolates also ing, began approximately 10 years
remain susceptible to some of the con- To the Editor: Lyme borreliosis is earlier, with a slow progressive course
ventional antimicrobial drugs, includ- the most common tickborne human of neuroborreliosis. His medical his-
ing co-trimoxazole (5). If their effica- disease in the Northern Hemisphere. tory showed an unidentified sexually
cy in vivo is validated by clinical tri- The incidence of the disease is not the transmitted disease in 1982, an unde-
als, use of these conventional drugs same throughout Europe; in southern fined episode of arthritis in the lower
would not only reduce the load on Europe, the incidence ranges from limbs in 1990, and a nonspecific rash
overstretched health care budgets but 43% in Croatia to 1.1% in Greece. in the genitals in 1995. The patient
reduce the use of vancomycin, there- Suspected borreliosis cases have been lived in South Africa from 1961 to
fore decreasing the risk of isolates reported in Greece, none were con- 1997 and visited Thassos Island in
continuing to develop vancomycin firmed. Ixodes ricinus, the principal northern Greece every year. The neu-
resistance. tick vector of Borrelia burgdorferi in rologic examination demonstrated an
Europe, is found in northern Greece. intense pyramidal spasticity in the
Tariq Butt,* Rifat Nadeem Ahmad,* A low prevalence of B. burgdorferi lower limbs and moderate weakness
Muhammad Usman,* antibodies was found in healthy per- (Medical Research Council grade 3)
and Abid Mahmood* sons in Greece (1,2); a frequency of of the proximal muscles. Serial mag-
*Armed Forces Institute of Pathology, 7.3% was found in arthritis patients netic resonance imaging (MRI) of the
Rawalpindi, Pakistan (1), while a frequency of 16.9% was brain showed small hyperintensities
found in patients with neurologic dis- in the periventricular area on T2-
References orders (E. Diza, unpub. data). weighted images; MRI of the spinal
Polymerase chain reaction (PCR) cord showed no abnormalities.
1. Bishara J, Pitlik S, Samra Z, Levy I, Paul
M, Leibovici L. Co-trimoxazole–sensitive, has been used to detect B. burgdorferi Multiple sclerosis, B12 deficiency,
methicillin-resistant Staphylococcus DNA in humans and to determine human T-cell lymphotrophic virus-1
aureus, Israel, 1988–1997. Emerg Infect genospecies (3). Isolates found in the infection, structural inflammatory
Dis. 2003;9:1168–9. United States have constituted a
2. Hafiz S, Hafiz AN, Ali L, Chughtai AS, lesions of the spinal cord, motor neu-
Memon B, Ahmed A, et al. Methicillin homogeneous group. In Europe, five ron disease, and hereditary spastic
resistant Staphylococcus aureus: a multi- different genospecies from the origi- paraplegia have been excluded. The
centre study. J Pak Med Assoc. nal B. burgdorferi, now called patient was treated occasionally with
2002;52:312–4. burgdorferi sensu lato complex, have
3. National Committee for Clinical intravenous penicillin G, as well as
Laboratory Standards. Performance stan- been described: B. burgdorferi sensu with corticosteroids, but no clinical
dards for antimicrobial disk susceptibility stricto, B. garinii, B. afzelii, B. improvement was achieved. Venereal
tests. 7th ed. Approved standard M2-A7. valaisiana, and B. lusitaniae. Patho- disease reaction level was negative
Wayne (PA): The Committee; 2000. genicity for humans remains
4. World Health Organization Collaborating and all tests for syphilis in CSF were
Centre for Drug Statistics Methodology. uncertain for B. valaisiana and B. negative.
Guidelines for ATC classification and DDD lusitaniae (4). DNA was extracted from CSF, and
assignment. Oslo: The Centres; 1996. Neuroborreliosis, the most serious a region of the chromosomal flagellin
5. Tenover FC, Biddle JW, Lancaster MV. manifestation of disseminated Lyme
Increasing resistance to vancomycin and gene of B. burgdorferi was amplified
other glycopeptides in Staphylococcus disease, has become the most fre- by nested PCR (3). B. afzelii (VS461)
aureus. Emerg Infect Dis. 2001;7:327–32. quently recognized arthropodborne DNA was used as a positive control.
infection of the nervous system in the All precautions were taken to avoid
Address for correspondence: Tariq Butt, United States and Europe. B. garinii, contamination. The amplified PCR
Department of Microbiology, Armed Forces B. afzelii, and B. burgdorferi sensu product was sequenced, and the
Institute of Pathology, Rawalpindi, Pakistan; stricto are confirmed causes of neu- sequence (Th1) was deposited in
fax: 92-51-9271247; email: tariqbutt24@ roborreliosis (5); however, B. GenBank with the accession no.
yahoo.com valaisiana has not been isolated from AY270021. Phylogenetic analysis
cerebrspinal fluid (CSF) until this showed that strain Th1 was clustering
report. with strains belonging to B.
We report the genetic detection of valaisiana genomic group.
B. valaisiana in the CSF of a 61-year- Specifically, a nucleotide difference
1692 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 9, September 2004
of 0.38% was observed among Th1 and respective B. valaisiana se- 5. Ornstein K, Berglund J, Bergstrom S,
and isolates Ku10 and To76 (acces- quences from other European coun- Norrby R, Barbour AG. Three major Lyme
Borrelia genospecies (Borrelia burgdorferi
sion no. AYO83505 and AYO83504, tries suggests that he likely was infect- sensu stricto, B. afzelii, and B. garinii)
respectively), which belong to B. ed in Greece. The status of Lyme dis- indentified by PCR in cerebrospinal fluid
valaisiana genomic group and were ease in southern Africa is unknown, from patients with neuroborreliosis in
isolated from ricinus in Sweden (6). A but Ixodes spp. ticks have been found Sweden. Scand J Infect Dis.
genetic difference of 0.77% was there, and preliminary evidence indi- 6. Fraenkel CJ, Garpmo U, Berglund J.
observed between Th1 and B. cates that the disease may occur in Determination of novel Borrelia
valaisiana strain Tr29 (accession no. humans in South Africa (10). genospecies in Swedish Ixodes ricinus
ABO91805) isolated from I. ricinus in We detected B. valaisiana DNA in ticks. J Clin Microbiol. 2002;40:3308–12.
7. Guner ES, Hashimoto N, Takada N,
Turkey (7), while the genetic differ- CSF of a patient with slow progres- Kaneda K, Imai Y, Masuzawa T. First isola-
ence between Th1 and B. burgdorferi sive spastic paraparesis, which sug- tion and characterization of Borrelia
(X15661) was much greater, 6.83%. gests that this microorganism might burgdorferi sensu lato strains from Ixodes
This report is the first of genetic be the causative agent of the disease. ricinus ticks in Turkey. J Med Microbiol.
detection of B. valaisiana in CSF, Nucleotide sequence information of 8. Ryffel K, Peter O, Rutti B, Suard A, Dayer
which indicates a probable associa- Borrelia strains from clinical cases E. Scored antibody reactivity determined
tion of this genospecies with disease and ticks from different countries will by immunoblotting shows an association
in humans. B. valaisiana has been iso- elucidate the molecular epidemiology between clinical manifestations and pres-
ence of Borrelia burgdorferi sensu stricto,
lated from I. ricinus ticks collected of the disease. B. garinii, B. afzelii and B. valaisiana in
from vegetation and from ticks humans. J Clin Microbiol. 1999;37;
engorged on birds, in several Acknowledgment 4086–92.
European countries, including Turkey We thank O. Peter for providing 9. Kaiser R. False negative serology in
patients with neuroborreliosis and the value
(7). The pathogenic capabilities of B. DNA control samples. of employing of different borrelial strains in
valaisiana are still uncertain; it has serological assays. J Med Microbiol.
been detected by PCR and restriction 2000;49:911–5.
Eudoxia Diza,* Anna Papa,* 10. Fivaz BH, Petney TN. Lyme disease—a
fragment length polymorphism analy- Eleni Vezyri,* Stefanos Tsounis,* new disease in southern Africa? J S Afr Vet
sis in skin biopsy specimens from two Ioannis Milonas,* Assoc. 1989;60:155–8.
erythema migrans patients and from and Antonis Antoniadis*
patients with mixed infection (erythe- *Aristotle University of Thessaloniki, Address for correspondence: Anna Papa, First
ma migrans and acrodermatitis chron- Thessaloniki, Greece Department of Microbiology, School of
ica atrophicans) (4). Indirect evidence Medicine, Aristotle University of Thessaloniki,
suggests that B. valaisiana is involved References 54124, Thessaloniki, Greece; fax: 2310-
in some chronic clinical manifesta- 999149; email: firstname.lastname@example.org
1. Settas L, Diza E, Kyriazopoulou V,
tions (8). Dimitriadis G, Souliou E, Sfetsios T.
Borreliosis is difficult to diagnose Detection of anti-Borrelia burgdorferi anti-
by serologic evaluation and Western bodies in patients with arthritis from
blot interpretation. In our patient, no Northern Greece (Macedonia and Thrace).
Helliniki Rheumatologia. 1996;7:11–20.
intrathecal antibodies were produced 2. Stamouli M, Totos G, Braun HB, Michel G,
to support clinical suspicion of dis- Gizaris V. Very low seroprevalence of
ease. The low antibody titers could be Lyme borreliosis in young Greek males.
attributed to antigenic variation Eur J Epidemiol. 2000;16:495–6.
3. Schmidt B, Muelleger RR, Stockenhuber C,
between B. valaisiana and B. burgdor- Soyer PH, Hoedl S, Luger A, et al.
feri sensu stricto, which was used as Detection of Borrelia burgdorferi-specific
antigen because no commercial kit is DNA in urine specimens from patients with
specific for B. valaisiana. Differences erythema migrans before and after antibiot- in California
ic therapy. J Clin Microbiol. 1996;34:
between the strain causing infection 1359–63.
and the antigen may play a role in the To the Editor: We read with inter-
4. Rijpkema SG, Tazelear DJ, Molkeboer HJ,
false-negative results (9). The low Noordhoek GT, Plantinga G, Schouls LM,
est the article of Roussere et al. on the
antibody response in our patient could et al. Detection of Borrelia afzelii, Borrelia distribution of Baylisascaris procyo-
be caused by antimicrobial drugs and burgdorferi sensu stricto, Borrelia garinii nis eggs in northern California com-
and group VS116 by PCR in skin biopsies munities (1). The widespread dissem-
corticosteroid medication. of patients with erythema migrans and
The high homology of the acrodermatitis chronica atrophicans. Clin
ination and high density of raccoon
nucleotide sequence from our patient Microbiol Infect. 1997;3:109–16. latrines in residential areas clearly
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