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Medicina Universitaria

2007, Número 34

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Med Univer 2007; 9 (34)


Enfermedad de Lyme

Skinner TCM, Flores GMS, Colunga PIJ, Salinas PCK, Garza EMA

Idioma: Español
Referencias bibliográficas: 160
Paginas: 24-32
Archivo PDF: 134.93 Kb.


RESUMEN

La enfermedad de Lyme es un padecimiento infeccioso causado por la espiroqueta Borrelia burgdorferi, que se transmite por la mordedura de garrapatas del género Ixodes. En Europa y EU la seroprevalencia determinada por ELISA es de 1 a 27%. En México sólo hay reportes de casos aislados, pero recientemente se encontró prevalencia de 3 a 6% en un banco de sueros congelados del Distrito Federal y el Noreste del país.
El cuadro clínico es muy variable; el eritema migratorio es el síntoma inicial, que aparece en el sitio de la mordedura; semanas más tarde surgen diversas manifestaciones clínicas, entre las cuales se encuentran artritis, fibromialgia y fatiga crónica. En etapas tardías hay manifestaciones neurológicas y cardiovasculares. El diagnóstico se realiza por ELISA y se confirma mediante Western blot o PCR, debido a la dificultad para aislar Borrelia spp. en cultivos.


REFERENCIAS (EN ESTE ARTÍCULO)

  1. Steere AC. Lyme disease. N Engl J Med 2001;345:115-25.

  2. Ruddy S, Harris E Jr., Sledge CB, Kelly WN. Lyme disease. In: Kelly WN editor. Textbook of rheumatology. 5th Ed. Philadelphia: WB Saunders Company, 1997;pp:1462-72.

  3. Torok E, Lakos A, Dragodan K, Lanyi C. Erythema chronicum migrans Lipschutz. Orv Hetil 1987;128:1983-6.

  4. Keirans JE, Hutcheson HJ, Durden LA, Klompen JS. Ixodes scapularis (Acari: Ixodidae): redescription of all active stages, distribution, hosts, geographical variation, and medical and veterinary importance. J Med Entomol 1996;33:297-318.

  5. Steere AC, Coburn J, Glickstein L. The emergence of Lyme disease. J Clin Invest 2004;113:1093-101.

  6. Jouda F, Crippa M, Perret J, Gern L. Distribution and prevalence of Borrelia burgdorferi sensu lato in Ixodes ricinus ticks of canton Ticino (Switzerland). Eur J Epidem 2003;18:907.

  7. Centers for Disease Control and Prevention (CDC). Lyme disease—United States, 2001-2002. MMWR Morb Mortal Wkly Rep 2004;53:365-9.

  8. Masters E, Granter S, Duray P, Cordes P. Physician-diagnosed erythema migrans and erythema migrans-like rashes following Lone Star tick bites. Arch Dermatol 1998;134:955-60.

  9. Oteo Revuelta JA, Estrada Pena A. Ixodes ricinus, a demonstrated vector of Borrelia burgdorferi in Spain. Med Clin (Barc) 1991;96:599.

  10. Steere AC. Lyme disease: a growing threat to urban populations. Proc Natl Acad Sci USA 1994;91:2378-83.

  11. Singh-Behl D, La Rosa SP, Tomecki KJ. Tick-borne infections. Dermatol Clin 2003;21:237-44.

  12. Martinez A, Salinas A, Martinez F, Cantu A, et al. Serosurvey for selected disease agents in white-tailed deer from Mexico. J Wildl Dis 1999;35:799-803.

  13. Hamilton DR. Lyme disease. The hidden pandemic. Postgrad Med 1989;85:303-8, 313-4.

  14. Liang FT, Aberer E, Cinco M, Gern L, et al. Antigenic conservation of an immunodominant invariable region of the VlsE lipoprotein among european pathogenic genospecies of Borrelia burgdorferi SL. J Infect Dis 2000;182:1455-62.

  15. Treib J, Woessner R, Grauer MT, Mueller-Reiland D, et al. Prevalence of antibodies to tick-borne encephalitis virus and Borrelia burgdorferi sensu lato in samples from patients with abnormalities in the cerebrospinal fluid. Zentralbl Bakteriol 1998;288:253-66.

  16. Liang FT, Caimano MJ, Radolf JD, Fikrig E. Borrelia burgdorferi outer surface protein (OSP) B expression independent of OSP-A. Microb Pathog 2004;37:35-40.

  17. Weis JJ. Host-pathogen interactions and the pathogenesis of murine Lyme disease. Curr Opin Rheumatol 2002;14:399-403.

  18. Sigal LH. Lyme disease: a review of aspects of its immunology and immunopathogenesis. Annu Rev Immunol 1997;15:63-92.

  19. Donta ST. Late and chronic Lyme disease. Med Clin North Am 2002;86:341-9,vii.

  20. Smith RP, Schoen RT, Rahn DW, Sikand VK, et al. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med 2002;136:421-8.

  21. Steere AC, Dhar A, Hernandez J, Fischer PA, et al. Systemic 0symptoms without erythema migrans as the presenting picture of early Lyme disease. Am J Med 2003;114:58-62.

  22. Hengge UR, Tannapfel A, Tyring SK, Erbel R, et al. Lyme borreliosis. Lancet Infect Dis 2003;3:489-500.

  23. Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis 2000;31:533-42.

  24. Steere AC, Glickstein L. Elucidation of Lyme arthritis. Nat Rev Immunol 2004;4:143-52.

  25. Weinstein A, Britchkov M. Lyme arthritis and post-Lyme disease syndrome. Curr Opin Rheumatol 2002;14:383-7.

  26. Sigal LH. Lyme arthritis: lessons learned and to be learned. Arthritis Rheum 1999;42:1809-12.

  27. Coyle PK, Schutzer SE. Neurologic aspects of Lyme disease. Med Clin North Am 2002;86:261-84.

  28. Halperin JJ, Golightly M. Lyme borreliosis in Bell’s palsy. Long Island Neuroborreliosis Collaborative Study Group. Neurology 1992;42:1268-70.

  29. Rothermel H, Hedges TR, Steere AC. Optic neuropathy in children with Lyme disease. Pediatrics 2001;108:477-81.

  30. Kalish RA, Kaplan RF, Taylor E, Jones-Woodward L, et al. Evaluation of study patients with Lyme disease, 10-20-year follow-up. J Infect Dis 2001;183:453-60.

  31. Halperin JJ. Facial nerve palsy associated with Lyme disease. Muscle Nerve 2003;28:516-7.

  32. Halperin JJ. Neuroborreliosis (Nervous System Lyme Disease). Curr Treat Options Neurol 1999;1:139-46.

  33. Berglund J, Stjernberg L, Ornstein K, Tykesson-Joelsson K, et al. 5-y follow-up study of patients with neuroborreliosis. Scand J Infect Dis 2002;34:421-5.

  34. Treib J, Fernandez A, Haass A, Grauer MT, et al. Clinical and serologic follow-up in patients with neuroborreliosis. Neurology 1998;51:1489-91.

  35. Axford JS, Rees DH, Mageed RA, Wordsworth P, et al. Increased IgA rheumatoid factor and V(H)1 associated cross reactive idiotype expression in patients with Lyme arthritis and neuroborreliosis. Ann Rheum Dis 1999;58:757-61.

  36. Halperin JJ. Lyme disease and the peripheral nervous system. Muscle Nerve 2003;28:133-43.

  37. Halperin JJ. Nervous system Lyme disease. Vector Borne Zoonotic Dis 2002;2:241-7.

  38. Mullegger RR, McHugh G, Ruthazer R, Binder B, et al. Differential expression of cytokine mRNA in skin specimens from patients with erythema migrans or acrodermatitis chronica atrophicans. J Invest Dermatol 2000;115:1115-23.

  39. Donta ST. Long-term outcomes of Lyme disease. JAMA 2000;283:3068. Author reply 3069.

  40. Shotland LI, Mastrioanni MA, Choo DL, Szymko-Bennett YM, et al. Audiologic manifestations of patients with post-treatment Lyme disease syndrome. Ear Hear 2003;24:508-17.

  41. Kaplan RF, Jones-Woodward L, Workman K, Steere AC, et al. Neuropsychological deficits in Lyme disease patients with and without other evidence of central nervous system pathology. Appl Neuropsychol 1999;6:3-11.

  42. Perides G, Charness ME, Tanner LM, Peter O, et al. Matrix metalloproteinases in the cerebrospinal fluid of patients with Lyme neuroborreliosis. J Infect Dis 1998;177:401-8.

  43. Massarotti EM. Lyme arthritis. Med Clin North Am 2002;86:297-309.

  44. Guerau-de-Arellano M, Huber BT. Development of autoimmunity in Lyme arthritis. Curr Opin Rheumatol 2002;14:388-93.

  45. Akin E, Aversa J, Steere AC. Expression of adhesion molecules in synovia of patients with treatment-resistant Lyme arthritis. Infect Immun 2001;69:1774-80.

  46. Hu LT, Eskildsen MA, Masgala C, Steere AC, et al. Host metalloproteinases in Lyme arthritis. Arthritis Rheum 2001;44:1401-10.

  47. Lin B, Kidder JM, Noring R, Steere AC, et al. Differences in synovial fluid levels of matrix metalloproteinases suggest separate mechanisms of pathogenesis in Lyme arthritis before and after antibiotic treatment. J Infect Dis 2001;184:174-80.

  48. Steere AC, Gross D, Meyer AL, Huber BT. Autoimmune mechanisms in antibiotic treatment-resistant lyme arthritis. J Autoimmun 2001;16:263-8.

  49. Gross DM, Forsthuber T, Tary-Lehmann M, Etling C, et al. Identification of LFA-1 as a candidate autoantigen in treatmentresistant Lyme arthritis. Science 1998;281:703-6.

  50. Sigal LH. Musculoskeletal manifestations of Lyme arthritis. Rheum Dis Clin North Am 1998;24:323-51.

  51. Dinerman H, Steere AC. Lyme disease associated with fibromyalgia. Ann Intern Med 1992;117:281-5.

  52. Steere AC. A 58-year-old man with a diagnosis of chronic Lyme disease. JAMA 2002;288:1002-10.

  53. Pinto DS. Cardiac manifestations of Lyme disease. Med Clin North Am 2002;86:285-96.

  54. Bateman H, Sigal L. Update on Lyme carditis. Curr Infect Dis Rep 2000;2:299-301.

  55. Ntchobo H, Rothermel H, Chege W, Steere AC, et al. Recognition of multiple antibody epitopes throughout Borrelia burgdorferi p66, a candidate adhesin, in patients with early or late manifestations of Lyme disease. Infect Immun 2001;69:1953-6.

  56. Richardson RD, Engel CC. Evaluation and management of medically unexplained physical symptoms. Neurologist 2004;10:18-30.

  57. Goldenberg DL. Fibromyalgia, chronic fatigue syndrome, and myofascial pain syndrome. Curr Opin Rheumatol 1995;7:127-35.

  58. Bunikis J, Barbour AG. Laboratory testing for suspected Lyme disease. Med Clin North Am 2002;86:311-40.

  59. Tugwell P, Dennis DT, Weinstein A, Wells G, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med 1997;127:1109-23.

  60. Steere AC, Taylor E, McHugh GL, Logigian EL. The overdiagnosis of Lyme disease. JAMA 1993;269:1812-6.

  61. Blaauw AA, van Loon AM, Schellekens JF, Bijlsma JW. Clinical evaluation of guidelines and two-test approach for Lyme disease. Rheumatology (Oxford) 1999;38:1121-6.

  62. Steere AC. Diagnosis and treatment of Lyme arthritis. Med Clin North Am 1997;81:179-94.

  63. Bacon RM, Biggerstaff BJ, Schriefer ME, Gilmore RD, et al. Serodiagnosis of Lyme disease by kinetic enzyme-linked immunosorbent assay using recombinant VlsE1 or peptide antigens of Borrelia burgdorferi compared with 2-tiered testing using whole-cell lysates. J Infect Dis 2003;187:1187-99.

  64. Liang FT, Steere AC, Marques AR, Johnson BJ, et al. Sensitive and specific serodiagnosis of Lyme disease by enzyme-linked immunosorbent assay with a peptide based on an immunodominant conserved region of Borrelia burgdorferi VlsE. J Clin Microbiol 1999;37:3990-6.

  65. Lawrenz MB, Hardham JM, Owens RT, Nowakowski J, et al. Human antibody responses to VlsE antigenic variation protein of Borrelia burgdorferi. J Clin Microbiol 1999;37:3997-4004.

  66. Kowal K, Weinstein A. Western Blot band intensity analysis. Application to the diagnosis of Lyme arthritis. Arthritis Rheum 1994;37:1206-11.

  67. Ornstein K, Berglund J, Bergstrom S, Norrby R, et al. Three major Lyme Borrelia genospecies (Borrelia burgdorferi sensu stricto, B. afzelii and B. garinii) identified by PCR in cerebrospinal fluid from patients with neuroborreliosis in Sweden. Scand J Infect Dis 2002;34:341-6.

  68. Oliver JH, Chandler FW, Luttrell MP, James AM, et al. Isolation and transmission of the Lyme disease spirochete from the Southeastern United States. Proc Natl Acad Sci USA 1993;90:7371-5.

  69. Carlson D, Hernandez J, Bloom BJ, Coburn J, et al. Lack of Borrelia burgdorferi DNA in synovial samples from patients with antibiotic treatment-resistant Lyme arthritis. Arthritis Rheum 1999;42:2705-9.

  70. Pahl A, Kuhlbrandt U, Brune K, Rollinghoff M, et al. Quantitative detection of Borrelia burgdorferi by real-time PCR. J Clin Microbiol 1999;37:1958-63.

  71. Kohls GM, Clifford CM. Three new species of Ixodes from Mexico and description of the male of I. auritulus auritulus Neumann, I. conepati Cooley and Kohls, and I. lasallei Mendez and Ortiz (Acarina: Ixodidae). J Parasitol 1966;52:810-20.

  72. Salinas-Melendez JA, Avalos-Ramirez R, Riojas-Valdez VM, Martinez-Munoz A. Serological survey of canine borreliosis. Rev Latinoam Microbiol 1999;41:1-3.

  73. Vargas MH. Lyme disease in Mexico City. Salud Publica Mex 1993;35:435-6.

  74. Salinas-Melendez JA, Tamez-Gonzalez R, Welsh-Lozano O, Barrera-Saldana HA. Detection of Borrelia burgdorferi DNA in human skin biopsies and dog synovial fluid by the polymerase chain reaction. Rev Latinoam Microbiol 1995;37:7-10.

  75. Gordillo G, Torres J, Solorzano F, Cedillo-Rivera R, et al. Serologic evidences suggesting the presence of Borrelia burgdorferi infection in Mexico. Arch Med Res 1999;30:64-8.

  76. Gordillo-Perez G, Torres J, Solorzano-Santos F, Garduno-Bautista V, et al. Seroepidemiologic study of Lyme’s borreliosis in Mexico City and the Northeast of the Mexican Republic. Salud Publica Mex 2003;45:351-5.

  77. Harvey WT, Salvato P. Lyme disease: ancient engine of an unrecognized borreliosis pandemic? Med Hypotheses 2003;60:742-59.

  78. Sigal LH. Summary of the first 100 patients seen at a Lyme disease referral center. Am J Med 1990;88:577-81.

  79. Lightfoot RW, Luft BJ, Rahn DW, Steere AC, et al. Empiric parenteral antibiotic treatment of patients with fibromyalgia and fatigue and a positive serologic result for Lyme disease. A cost-effectiveness analysis. Ann Intern Med 1993;119:503-9.

  80. Sigal LH, Patella SJ. Lyme arthritis as the incorrect diagnosis in pediatric and adolescent fibromyalgia. Pediatrics 1992;90:523-8.

  81. Steere AC. Lyme disease. N Engl J Med 2001;345:115-25.

  82. Ruddy S, Harris E Jr., Sledge CB, Kelly WN. Lyme disease. In: Kelly WN editor. Textbook of rheumatology. 5th Ed. Philadelphia: WB Saunders Company, 1997;pp:1462-72.

  83. Torok E, Lakos A, Dragodan K, Lanyi C. Erythema chronicum migrans Lipschutz. Orv Hetil 1987;128:1983-6.

  84. Keirans JE, Hutcheson HJ, Durden LA, Klompen JS. Ixodes scapularis (Acari: Ixodidae): redescription of all active stages, distribution, hosts, geographical variation, and medical and veterinary importance. J Med Entomol 1996;33:297-318.

  85. Steere AC, Coburn J, Glickstein L. The emergence of Lyme disease. J Clin Invest 2004;113:1093-101.

  86. Jouda F, Crippa M, Perret J, Gern L. Distribution and prevalence of Borrelia burgdorferi sensu lato in Ixodes ricinus ticks of canton Ticino (Switzerland). Eur J Epidem 2003;18:907.

  87. Centers for Disease Control and Prevention (CDC). Lyme disease—United States, 2001-2002. MMWR Morb Mortal Wkly Rep 2004;53:365-9.

  88. Masters E, Granter S, Duray P, Cordes P. Physician-diagnosed erythema migrans and erythema migrans-like rashes following Lone Star tick bites. Arch Dermatol 1998;134:955-60.

  89. Oteo Revuelta JA, Estrada Pena A. Ixodes ricinus, a demonstrated vector of Borrelia burgdorferi in Spain. Med Clin (Barc) 1991;96:599.

  90. Steere AC. Lyme disease: a growing threat to urban populations. Proc Natl Acad Sci USA 1994;91:2378-83.

  91. Singh-Behl D, La Rosa SP, Tomecki KJ. Tick-borne infections. Dermatol Clin 2003;21:237-44.

  92. Martinez A, Salinas A, Martinez F, Cantu A, et al. Serosurvey for selected disease agents in white-tailed deer from Mexico. J Wildl Dis 1999;35:799-803.

  93. Hamilton DR. Lyme disease. The hidden pandemic. Postgrad Med 1989;85:303-8, 313-4.

  94. Liang FT, Aberer E, Cinco M, Gern L, et al. Antigenic conservation of an immunodominant invariable region of the VlsE lipoprotein among european pathogenic genospecies of Borrelia burgdorferi SL. J Infect Dis 2000;182:1455-62.

  95. Treib J, Woessner R, Grauer MT, Mueller-Reiland D, et al. Prevalence of antibodies to tick-borne encephalitis virus and Borrelia burgdorferi sensu lato in samples from patients with abnormalities in the cerebrospinal fluid. Zentralbl Bakteriol 1998;288:253-66.

  96. Liang FT, Caimano MJ, Radolf JD, Fikrig E. Borrelia burgdorferi outer surface protein (OSP) B expression independent of OSP-A. Microb Pathog 2004;37:35-40.

  97. Weis JJ. Host-pathogen interactions and the pathogenesis of murine Lyme disease. Curr Opin Rheumatol 2002;14:399-403.

  98. Sigal LH. Lyme disease: a review of aspects of its immunology and immunopathogenesis. Annu Rev Immunol 1997;15:63-92.

  99. Donta ST. Late and chronic Lyme disease. Med Clin North Am 2002;86:341-9,vii.

  100. Smith RP, Schoen RT, Rahn DW, Sikand VK, et al. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med 2002;136:421-8.

  101. Steere AC, Dhar A, Hernandez J, Fischer PA, et al. Systemic symptoms without erythema migrans as the presenting picture of early Lyme disease. Am J Med 2003;114:58-62.

  102. Hengge UR, Tannapfel A, Tyring SK, Erbel R, et al. Lyme borreliosis. Lancet Infect Dis 2003;3:489-500.

  103. Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis 2000;31:533-42.

  104. Steere AC, Glickstein L. Elucidation of Lyme arthritis. Nat Rev Immunol 2004;4:143-52.

  105. Weinstein A, Britchkov M. Lyme arthritis and post-Lyme disease syndrome. Curr Opin Rheumatol 2002;14:383-7.

  106. Sigal LH. Lyme arthritis: lessons learned and to be learned. Arthritis Rheum 1999;42:1809-12.

  107. Coyle PK, Schutzer SE. Neurologic aspects of Lyme disease. Med Clin North Am 2002;86:261-84.

  108. Halperin JJ, Golightly M. Lyme borreliosis in Bell’s palsy. Long Island Neuroborreliosis Collaborative Study Group. Neurology 1992;42:1268-70.

  109. Rothermel H, Hedges TR, Steere AC. Optic neuropathy in children with Lyme disease. Pediatrics 2001;108:477-81.

  110. Kalish RA, Kaplan RF, Taylor E, Jones-Woodward L, et al. Evaluation of study patients with Lyme disease, 10-20-year follow-up. J Infect Dis 2001;183:453-60.

  111. Halperin JJ. Facial nerve palsy associated with Lyme disease. Muscle Nerve 2003;28:516-7.

  112. Halperin JJ. Neuroborreliosis (Nervous System Lyme Disease). Curr Treat Options Neurol 1999;1:139-46.

  113. Berglund J, Stjernberg L, Ornstein K, Tykesson-Joelsson K, et al. 5-y follow-up study of patients with neuroborreliosis. Scand J Infect Dis 2002;34:421-5.

  114. Treib J, Fernandez A, Haass A, Grauer MT, et al. Clinical and serologic follow-up in patients with neuroborreliosis. Neurology 1998;51:1489-91.

  115. Axford JS, Rees DH, Mageed RA, Wordsworth P, et al. Increased IgA rheumatoid factor and V(H)1 associated cross reactive idiotype expression in patients with Lyme arthritis and neuroborreliosis. Ann Rheum Dis 1999;58:757-61.

  116. Halperin JJ. Lyme disease and the peripheral nervous system. Muscle Nerve 2003;28:133-43.

  117. Halperin JJ. Nervous system Lyme disease. Vector Borne Zoonotic Dis 2002;2:241-7.

  118. Mullegger RR, McHugh G, Ruthazer R, Binder B, et al. Differential expression of cytokine mRNA in skin specimens from patients with erythema migrans or acrodermatitis chronica atrophicans. J Invest Dermatol 2000;115:1115-23.

  119. Donta ST. Long-term outcomes of Lyme disease. JAMA 2000;283:3068. Author reply 3069.

  120. Shotland LI, Mastrioanni MA, Choo DL, Szymko-Bennett YM, et al. Audiologic manifestations of patients with post-treatment Lyme disease syndrome. Ear Hear 2003;24:508-17.

  121. Kaplan RF, Jones-Woodward L, Workman K, Steere AC, et al. Neuropsychological deficits in Lyme disease patients with and without other evidence of central nervous system pathology. Appl Neuropsychol 1999;6:3-11.

  122. Perides G, Charness ME, Tanner LM, Peter O, et al. Matrix metalloproteinases in the cerebrospinal fluid of patients with Lyme neuroborreliosis. J Infect Dis 1998;177:401-8.

  123. Massarotti EM. Lyme arthritis. Med Clin North Am 2002;86:297-309.

  124. Guerau-de-Arellano M, Huber BT. Development of autoimmunity in Lyme arthritis. Curr Opin Rheumatol 2002;14:388-93.

  125. Akin E, Aversa J, Steere AC. Expression of adhesion molecules in synovia of patients with treatment-resistant Lyme arthritis. Infect Immun 2001;69:1774-80.

  126. Hu LT, Eskildsen MA, Masgala C, Steere AC, et al. Host metalloproteinases in Lyme arthritis. Arthritis Rheum 2001;44:1401-10.

  127. Lin B, Kidder JM, Noring R, Steere AC, et al. Differences in synovial fluid levels of matrix metalloproteinases suggest separate mechanisms of pathogenesis in Lyme arthritis before and after antibiotic treatment. J Infect Dis 2001;184:174-80.

  128. Steere AC, Gross D, Meyer AL, Huber BT. Autoimmune mechanisms in antibiotic treatment-resistant lyme arthritis. J Autoimmun 2001;16:263-8.

  129. Gross DM, Forsthuber T, Tary-Lehmann M, Etling C, et al. Identification of LFA-1 as a candidate autoantigen in treatmentresistant Lyme arthritis. Science 1998;281:703-6.

  130. Sigal LH. Musculoskeletal manifestations of Lyme arthritis. Rheum Dis Clin North Am 1998;24:323-51.

  131. Dinerman H, Steere AC. Lyme disease associated with fibromyalgia. Ann Intern Med 1992;117:281-5.

  132. Steere AC. A 58-year-old man with a diagnosis of chronic Lyme disease. JAMA 2002;288:1002-10.

  133. Pinto DS. Cardiac manifestations of Lyme disease. Med Clin North Am 2002;86:285-96.

  134. Bateman H, Sigal L. Update on Lyme carditis. Curr Infect Dis Rep 2000;2:299-301.

  135. Ntchobo H, Rothermel H, Chege W, Steere AC, et al. Recognition of multiple antibody epitopes throughout Borrelia burgdorferi p66, a candidate adhesin, in patients with early or late manifestations of Lyme disease. Infect Immun 2001;69:1953-6.

  136. Richardson RD, Engel CC. Evaluation and management of medically unexplained physical symptoms. Neurologist 2004;10:18-30.

  137. Goldenberg DL. Fibromyalgia, chronic fatigue syndrome, and myofascial pain syndrome. Curr Opin Rheumatol 1995;7:127-35.

  138. Bunikis J, Barbour AG. Laboratory testing for suspected Lyme disease. Med Clin North Am 2002;86:311-40.

  139. Tugwell P, Dennis DT, Weinstein A, Wells G, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med 1997;127:1109-23.

  140. Steere AC, Taylor E, McHugh GL, Logigian EL. The overdiagnosis of Lyme disease. JAMA 1993;269:1812-6.

  141. Blaauw AA, van Loon AM, Schellekens JF, Bijlsma JW. Clinical evaluation of guidelines and two-test approach for Lyme disease. Rheumatology (Oxford) 1999;38:1121-6.

  142. Steere AC. Diagnosis and treatment of Lyme arthritis. Med Clin North Am 1997;81:179-94.

  143. Bacon RM, Biggerstaff BJ, Schriefer ME, Gilmore RD, et al. Serodiagnosis of Lyme disease by kinetic enzyme-linked immunosorbent assay using recombinant VlsE1 or peptide antigens of Borrelia burgdorferi compared with 2-tiered testing using whole-cell lysates. J Infect Dis 2003;187:1187-99

  144. Liang FT, Steere AC, Marques AR, Johnson BJ, et al. Sensitive and specific serodiagnosis of Lyme disease by enzyme-linked immunosorbent assay with a peptide based on an immunodominant conserved region of Borrelia burgdorferi VlsE. J Clin Microbiol 1999;37:3990-6.

  145. Lawrenz MB, Hardham JM, Owens RT, Nowakowski J, et al. Human antibody responses to VlsE antigenic variation protein of Borrelia burgdorferi. J Clin Microbiol 1999;37:3997-4004.

  146. Kowal K, Weinstein A. Western Blot band intensity analysis. Application to the diagnosis of Lyme arthritis. Arthritis Rheum 1994;37:1206-11.

  147. Ornstein K, Berglund J, Bergstrom S, Norrby R, et al. Three major Lyme Borrelia genospecies (Borrelia burgdorferi sensu stricto, B. afzelii and B. garinii) identified by PCR in cerebrospinal fluid from patients with neuroborreliosis in Sweden. Scand J Infect Dis 2002;34:341-6.

  148. Oliver JH, Chandler FW, Luttrell MP, James AM, et al. Isolation and transmission of the Lyme disease spirochete from the Southeastern United States. Proc Natl Acad Sci USA 1993;90:7371-5.

  149. Carlson D, Hernandez J, Bloom BJ, Coburn J, et al. Lack of Borrelia burgdorferi DNA in synovial samples from patients with antibiotic treatment-resistant Lyme arthritis. Arthritis Rheum 1999;42:2705-9.

  150. Pahl A, Kuhlbrandt U, Brune K, Rollinghoff M, et al. Quantitative detection of Borrelia burgdorferi by real-time PCR. J Clin Microbiol 1999;37:1958-63.

  151. Kohls GM, Clifford CM. Three new species of Ixodes from Mexico and description of the male of I. auritulus auritulus Neumann, I. conepati Cooley and Kohls, and I. lasallei Mendez and Ortiz (Acarina: Ixodidae). J Parasitol 1966;52:810-20.

  152. Salinas-Melendez JA, Avalos-Ramirez R, Riojas-Valdez VM, Martinez-Munoz A. Serological survey of canine borreliosis. Rev Latinoam Microbiol 1999;41:1-3.

  153. Vargas MH. Lyme disease in Mexico City. Salud Publica Mex 1993;35:435-6.

  154. Salinas-Melendez JA, Tamez-Gonzalez R, Welsh-Lozano O, Barrera-Saldana HA. Detection of Borrelia burgdorferi DNA in human skin biopsies and dog synovial fluid by the polymerase chain reaction. Rev Latinoam Microbiol 1995;37:7-10.

  155. Gordillo G, Torres J, Solorzano F, Cedillo-Rivera R, et al. Serologic evidences suggesting the presence of Borrelia burgdorferi infection in Mexico. Arch Med Res 1999;30:64-8.

  156. Gordillo-Perez G, Torres J, Solorzano-Santos F, Garduno-Bautista V, et al. Seroepidemiologic study of Lyme’s borreliosis in Mexico City and the Northeast of the Mexican Republic. Salud Publica Mex 2003;45:351-5.

  157. Harvey WT, Salvato P. Lyme disease: ancient engine of an unrecognized borreliosis pandemic? Med Hypotheses 2003;60:742-59.

  158. Sigal LH. Summary of the first 100 patients seen at a Lyme disease referral center. Am J Med 1990;88:577-81.

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