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Differentiating Lyme arthritis: a case-based review

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Abstract

The incidence or prevalence of Lyme arthritis (LA) in Denmark is unknown and assumed very low. No published cases of polymerase chain reaction (PCR)-confirmed LA from Denmark exist. Clinically, LA does not differ from other rheumatic oligoarthritic disorders posing a differential diagnostic challenge. To review the incidence and prevalence of LA to our knowledge and to present a case series of PCR-confirmed LA cases from Denmark. We conducted a systematic literature review via MEDLINE and EMBASE to explore incidence and prevalence rates of LA. Additionally, we present six cases of patients diagnosed with LA in Denmark. Our literature review identified 23 studies reporting prevalence or incidence, yet only ten studies provided estimates ranging from 1.1 to 280/100.000 in the general population. Our case series identified six patients with LA from a localized region in Southern Denmark; all confirmed by Borrelia-specific real-time PCR from synovial fluid. The diagnostic delay was up to 38 months. All patients except one had a history of previous tick bites; none had erythema migrans lesions. All presented with recurrent arthritis in the knee joint, and two had arthritis in the wrist. The literature review showed an incidence of LA ranging from 1.1 to 15.8 per 100.000 in Europe. Our case series suggests a potentially higher prevalence of LA in Denmark than previously believed. Lack of tick exposure history, antibody assessments and test of Borrelia burgdorferi sensu lato DNA in synovial fluid might lead to misdiagnosed cases potentially explaining the assumed low incidence of LA in Denmark.

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Acknowledgements

The authors would like to thank the patients for participating in this case series and the clinicians and technicians at Department of Rheumatology, Microbiology, and Infectious Disease for their involvement in diagnostics and treatment.

Funding

The study was conducted without any funding.

Author information

Authors and Affiliations

  1. Department of Rheumatology, University Hospital of Southern Denmark, Esbjerg, DK-6700, Denmark

    Ayse Mine Unlu, Stavros Chrysidis & Philip Rask Lage-Hansen

  2. Clinical Center for Emerging and Vectorborne Infections, Odense University Hospital, Odense, DK-5000, Denmark

    Nanna Skaarup Andersen, Sanne Løkkegaard Larsen & Fredrikke Christie Knudtzen

  3. Department of Clinical Microbiology, Odense University Hospital, Odense, DK-5000, Denmark

    Nanna Skaarup Andersen & Sanne Løkkegaard Larsen

  4. Clinical Microbiology research unit, University of Southern Denmark, Odense, Denmark

    Nanna Skaarup Andersen, Sanne Løkkegaard Larsen & Sigurdur Skarphedinsson

  5. Department of Infectious Diseases Q, Odense University Hospital, Odense, DK-5000, Denmark

    Sigurdur Skarphedinsson & Fredrikke Christie Knudtzen

  6. Department of Rheumatology, Hospital South West Jutland, Esbjerg, DK-6700, Denmark

    Ayse Mine Unlu

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  1. Ayse Mine Unlu
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Contributions

Ayse Mine Unlu and Philip Rask Lage-Hansen contributed to the study’s conception and design. Ayse Mine Unlu conducted the systematic literature search, screened the retrieved records, and created the flowchart and table. Ayse Mine Unlu and Philip Rask Lage-Hansen drafted the initial manuscript. Clinicians (Nanna Skaarup Andersen and Sanne Løkkegaard Larsen) from the Department of Clinical Microbiology described and conducted the B.b.s.l. specific PCR analyses. Philip Rask Lage-Hansen and Stavros Chrysidis diagnosed the patients in this case series, with Sigurdur Skarphedinsson consulted regarding antibiotic treatment in all cases. All authors critically reviewed and contributed substantially to the manuscript’s refinement. All authors take full responsibility for the integrity and accuracy of all aspects of the work.

Corresponding author

Correspondence to Ayse Mine Unlu.

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In accordance with Danish national regulations, case reports are not subject to approval by any ethics committee. Written informed consent was obtained from all patients for publication of data pertaining to their medical history and laboratory test results.

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Unlu, A.M., Andersen, N.S., Larsen, S.L. et al. Differentiating Lyme arthritis: a case-based review. Rheumatol Int (2024). https://doi.org/10.1007/s00296-024-05618-0

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