Borrelia valaisiana in Cerebrospinal Fluid

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sive alternative to glycopeptides for              Borrelia valaisiana                      old man with a history of spastic para-
                                                    in Cerebrospinal
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.                                         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 • • 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:
                                            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

                        Emerging Infectious Diseases • • Vol. 10, No. 9, September 2004                                     1693

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