Brazilian Lyme-like syndrome (BYS) is a tick-borne illness that closely resembles Lyme disease. Recent polymerase chain reaction (PCR) testing has confirmed the presence of Borrelia burgdorferi sensu stricto in Brazil, strengthening evidence that this condition represents a true borrelial infection rather than a distinct or unrelated syndrome.

The existence of Borrelia burgdorferi s.s. in Brazil was recently confirmed by polymerase chain reaction (PCR) testing, writes Miziara in the journal Clinics (São Paulo). The Amblyomma and Rhipicephalus genera ticks can transmit the bacteria to humans through the bite of an infected tick. In the United States, Borrelia burgdorferi s.s. is transmitted by Ixodes scapularis, while in Europe transmission occurs through the Ixodes ricinus complex.

While there are differences between Brazilian Lyme-like syndrome and Lyme disease as described in North America and Europe, the two conditions share striking similarities across clinical, microbiologic, diagnostic, and therapeutic domains.

Clinical manifestations

• An erythema migrans (bull’s-eye) rash occurs at the tick bite site in approximately 50% of cases.
• Neurologic involvement commonly includes meningitis, cranial neuritis, and peripheral neuropathy.
• Psychiatric complaints are reported in approximately 20% of patients.
• Ocular manifestations include diplopia, eyelid ptosis, optic nerve damage, papilledema, uveitis, and chorioretinitis.
• Some patients develop encephalitis, either alone or in association with meningitis.
• Arthritis of large joints, particularly the knee, occurs in 30–35% of patients.
• Various degrees of atrioventricular block have been described, though pacemaker placement is generally unnecessary.

Microbiologic findings

• Multiple morphologic forms of Borrelia burgdorferi s.s. have been identified in culture. “When cultured under adverse conditions of pH or temperature, or in the presence of antibiotics, Borrelia bacteria develop morphological alterations similar to elongated bacteria (bacteroids), dense bodies suggestive of Chlamydia bacteria, or cell-wall–deficient forms resembling Mycoplasma,” writes Miziara.
• Blood analysis from BYS patients has demonstrated non-motile structures consistent with cystic or spirochetal forms.
• PCR testing has detected B. burgdorferi DNA in the skin or blood months to years after disease onset, even following antibiotic treatment, suggesting persistent or active infection.
• Evidence supports activation of the neuro-immune-endocrine axis, possibly driven by “hidden” Borrelia or spirochetal outer membrane surface proteins.

Diagnostic issues

• Diagnosis is challenging in the absence of an erythema migrans rash.
• Most cases are diagnosed on epidemiologic and clinical grounds after exclusion of other diseases. Serologic testing may assist but is insufficient alone for diagnosis.
• Symptoms frequently mimic other chronic illnesses, including chronic fatigue syndrome (CFS).
• Manifestations may include physical and mental fatigue lasting longer than six months, myalgia, arthralgia, lymphadenopathy, neurocognitive symptoms, headache, sore throat, and sleep disturbance.
• Symptoms often wax and wane and may recur.

The authors question “the frequency of patients treated as presenting idiopathic chronic fatigue syndrome or autoimmune disease when they in fact represent undiagnosed cases of Borrelia burgdorferi infection.”

Treatment approach

• Patients in the acute stage of BYS with localized erythema migrans and no dissemination are typically treated with antibiotics for less than one month.
• Early treatment is emphasized. Delays longer than three months after symptom onset result in recurrence or reactive symptoms in approximately 75% of cases.
• Longer antibiotic treatment may be required when dissemination is present, including flu-like symptoms.
• Delayed diagnosis may lead to serious and sometimes irreversible complications, including chronic neuroborreliosis and erosive arthritis.
• Neuroborreliosis is generally treated initially with intravenous ceftriaxone or penicillin G for 15–30 days, followed by oral antibiotics to complete a three-month course.

Autoimmune concerns

• The authors discuss the possibility that Borrelia burgdorferi infection may trigger autoimmune responses in some patients, necessitating different treatment strategies.
• BYS patients may exhibit features resembling autoimmune disease, including arthritis, Raynaud’s phenomenon, lupus-like skin lesions, scleroderma, sicca symptoms, myositis, thrombosis, and vasculitis.
• Allergic manifestations related to food, medications, or insect bites have also been reported.

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