Borrelia

Presenter : Dr Raihana Ali

Moderator: Dr Nayeem
Date: 09-04-2018
 Borrelia

Introduction
1. Flagellated Spirochete
2. Causative agents
– B.burgdorferi-Lyme disease
– B.recurrentis –Relapsing fever
– B.vincentii –Vincents angina
3. Requires obligate blood feeding arthropods for their transmission and
maintenance in vertebrate host populations.
4. Transmitted by Insect Vectors
1. Lice or
2. Ticks
 TAXONOMY
Kingdom K BACTERIA
Phylum P Spirochetes
Class C Spirochetia
Order O Spirochetales

Family F:I Spirochetaceae FII:Brachyspiraceae FIV :Leptospiraceae

F III :Brevinmataceae

Genus G 1. GI:Spirochete G: Leptospira

2. GII: Borrelia G:Leptonema.
3. GIII: Cristispira G: Turneriella
4. GIV:
Treponema
Total Species: 37 in No:
Lyme Borrelia Agents of Lyme 12
Complex Borreliosis

Relapsing Fever 1. New World 23

[RF] Tick Born RF

2: Old World Louse 1

Born RF
 Borrelia Species
• Causing “Lyme Borreliosis”
“Borrelia Burgdoferi sensu • B. carolinensis • B. americana
lato” • B.calforinesis • B. andersoni
- Includes Borrelia species • B.finlandenesis • B. bavariensis
1. B. Burgdoferi sensu • B. Japonica • B.bissetti
stricto • B. lusitaniae
2. B .afzelii • B. tanukii
3. B. garinii • Borrelia turdi
• Borrelia sinica
• Borrelia
spielmani
• Borrelia
valaisiana
 Borrelia Species
• Causing “Relapsing Fever”
1. B.recurrentis 1. B. persica
2. B. coriaceae 2. B. parkari
3. B.crocidurae 3. B. tillae
4. B.caucasica 4. B. turicate
5. B.brasilinensis 5. B. turcica
6. B .miyamotoi 6. B.venezulenesis
7. B. hispanica 7. B.graingeri
8. B. hermsii
9. B.harveyi
10.B. duttoni
11.B.dugesii
 Borrelia: Properties of the Bacteria
Size Dimensions :
1. Length:10-30 micrometer
2. Breadth :0.2-0.3 micrometer

Shape 1. Helical, spiral-shaped cells

2. Wavy with wide-opened coils
3. Flat-wave cell morphology.
4. End Shape Profile:
1. Blunt to Pointed
Motility 1. Endoflagella present
2. Motility Pattern
• Cork-screw like motility
• forward and backward waves
3. Highly flexible
4. Move both by rotation and twisting
Spirals
1. Number- 3- 10 [Less in number]
2. Irregular/loose spiral
3. Spaced at an interval of ----1- 1.5 µm
4. Wavelength= 2.83 µm
5. Amplitude = 2µm [longer]

Irregular/loose spiral
 Cell Wall Components

Peptidoglycan 1. Rich in diaminoacid Ornithine & Muramic

Layer acid
1. Presence of Osp A,Osp B ,Osp C
Outer 2. Few transmembrane Proteins
Membrane 3. No Lipopolysacharide
Layer

S Layer
Outer slime-like 1. Characteristic layer
layer 2. 4-30nm in thickness
3. Chemical Composition : Not Known
4. Easily lost in aqueous solutions
5. prevents the bacterium to be digested once
inside the host's body.
Cell Wall Structure
Variants of Borrelia
3 polymorphic forms of Borrelia
Burgdorferi
1. Cell-wall-deficient form (CWD) or
L-form
2. Cyst Forms
3. Granular Forms
4. Bleb Forms –Contain Plasmid
DNA
Bio-Film Formation
 Borrelia Axofilament
Basic Structure  Similar to architecture of other eubacteria
Consisting of
1. Neck
2. Hook
3. Filament Portion
4. Basic Disc-----------------at the apical end of the flagella that become integral
part of periplasmic cylinder
Location 1. Endocellular
2. beneath the outer membrane in Periplasmic Space
Number 7 to 20 per terminus

Protoplasmic Consists of
cylinder 1. a peptidoglycan layer
2. an inner membrane -------which encloses the internal components of the cell
3. Flagella wraps -----around the periplasmic cylinder in a Right Hand sense
Point of Insertion  Insert sub-terminally at one end or the other of the protoplasmic cylinder

Function 1. Maintains Cell shape

2. Motility
3. infectivity of the disease es
4. offer the bacterium protection against its host’s immune system
5. Crucial ----For Surviving in Ticks as well as in mammalian Host
 Electron micrograph

Drawing of a cross-section
through Borrelia burgdorferi
 Borrelia GENOME

1. Unique among prokaryote-----mainly linear DNA

2. genome content one-quarter that of Escherichia coli.

3. Consists of

1. linear chromosome ---------- ~1000kb

1. 6% of the chromosomal genome encodes proteins involved in motility

and chemotaxis

2. Plasmids =21 [ 9-Circular, 12-Linear]

1. 40% of total genome

1. 9-62kb—LB Borrelia Species

2. 5-220-kb —RF Borrelia Species

3. G+ C Content= ~30%
4.
 Borrelia Physiology & Biochemistry

• Limited denovo biosynthetic & metabolic capacities

• Primary Carbon Energy Source--- glucose

– Glycolysis-------main end product Lactic Acid

– Can also use Glycerol, Glucosamine, Fructose & Maltose

• Baceria [B.burgdorferi ]doesnot contain genes for

– TCA enzyme or

– For components of the electron transport system

• ATP production : accompalished at substrate level

• B.burgdorferi--- Catalase Negative

 Direct Microscopic Examination:
Conventional Light Microscopy
Dark Ground Microscopy
(DGM)
Gram Staining
Silver Impregnation Staining
Aniline Dyes
Electron micrographs
Fluorochrome reactions
Or Immunofluroresence
Cannot be Visualized
 Visualized Light objects against
Dark background
Dark Field Illumination
American Society of Microbiology
Poorly Gram-stained
Warthin –Starry Silver Stain-
Stains Spirochetes Black
Giemsa Staining ---Stains
Spirochetes --blue-pink color
Using Negative Stain with
Ammonium Molybdate
Giemsa Staining
Details of spirochete morphology
could not be evaluated adequately---
-because of the phenomenon of
rapidly extinguishing fluorescence
Electron micrograph
 Growth Requirements
Optimal conditions 1. Temperature: 30–37ºC B. Burgdorferri
2. Microaerophilic or anaerobes Optimum temperature :30-34°C

Generation time under Mean Generation Time:

optimal conditions 7–20 h. B. Burgdorferi= 8-12 hrs
B.hermsii= approx:7 hrs
B.recurrentis: 8-9 hrs

Nutritional -Complex nutritional requirements--- a. N-acetylglucosamine (GlcNAc)

Requirements Difficult to grow on artificial media constituent of Peptidoglycan
1. specific addition of-- free N-
acetylglucosamine (GlcNAc)
2. Long chain saturated and
unsaturated fatty acids
3. don’t require iron in its diet
Artifical Media 1. Can grow in chorioallantoic 1. -Barbour-Stoenner –Kelly II (BSK II)
membrane of chick embryo. Medium
2. Currently Used Culture Media
1. Barbour-Stoenner –Kelly I 2. Introduced in 1980
(BSK ) Medium 3. Can be made Selective by adding
2. Modified Kelly–Pettenkofer
(MKP) medium
Antibiotics
Composition
• Glass-distilled water 900 mL
Before use, add unheated rabbit
• CMRL 1066 medium 100ml of10×
serum (“trace hemolyzed) to a final
concentrate without
glutamine
concentration of 6%.
• neopeptone 5g
• bovine serum albumin, 60 g

• fraction V
• N-2 6g
hydroxyethylpiperazine-
N-2-ethanesulfonic
acid[(HEPES[
• Glucose 5g
• Sodium Citrate 0.7 g
• Sodium Pyruvate 0.8 g
• N-acetylglucosamine 0.4 g
(Sigma
• Sodium Bicarbonate 2.2 g
• 7% Gelatin--dissolved in 200ml
boiling water.
 Growth Conditions & Dynamics in Vivo

Dynamics of Growth & Dissemination & Localization in

Dissemination in Ticks Animals
Assessed by Feeding I.scapularis on
Infected Mice MC used Animal Models Mouse
Mutated Mouse ---C3H/ HeN Mice

Critical Step in Infection of Tick is

dissemination & Infection of
Salivary Glands
1. Takes place 36-48 hrs after
attachment
Morphological differences between Treponema, Borrelia and leptospira
Treponema Borrelia leptospira
Size 6-14 µm x 10-30 µm 6-20 µm x 0.1 µm
0.2 µm 0.2-0.5 µm
Spirals (in number) 6- 12 3-10 Numerous and
[less in number] tightly coiled with
Irregular & Loose hooked ends
Wavelength 1 µm 3 µm 0.5 µm
Amplitude of Spirals 1- 1.5µm Upto 2 µm 0.1 µm
Endo flagella at 3- 4 7-11 1
each pole
Staining Do not take up ordinary stains;
can be stained only by sliver impregnation stains, except
Borrelia which is poorly Gram-stained.
 Unique Features of Bacteria –

1 Adaptation---in .
different hosts. Capable of adjusting to different immune systems in different hosts
DNA rearrangement in linear plasmid appears to be responsible
Primary Host: Massive changes in gene expression resulting in concomitant shifts in
Ticks, the proteins required for survival and growth in the arthropod or
Second Host : Deer, warm-blooded animal environments.
Humans ◦

2 Antigenic Antigenic variation

variation  is a unique property exhibited by Borrelia in humans.
 Capable of adjusting to different immune systems of different
hosts.
 Humans Ticks, Deer
3 Unique Growth They donot require Iron for their growth
Requirements specific addition of-- free N-acetylglucosamine (GlcNAc)
 l

LYME BORRELIOSIS
Definition :
• Lyme disease is a multisystem vector-borne zoonosis caused by the
spirochete
– Borrelia burgdorferi------------ In United States
– Borrelia afzelli and B.gerinii ---------- In Europe & Asia

• Transmitted to humans through the bite of infected blacklegged ticks-------

---Ixodes Ricinus Complex Deer Tick

• Clinical Manifestations can be complex but affect primarily the skin, joint
, nervous system & Heart
 Lyme Disease
Agent Vector • Geographical Primary
Distribution Reservior

Borrelia burgdorferi--- Ixodes Ricinus Complex In United States White –footed

--senso stricto lato Deer Tick mouse
Ixodes scapularis 1. Northeastern
1. Deer Tick 2. Mid Atlantic
3. Northern –Mid West
4. north-central

Borrelia burgdorferi-- Ixodes pacificus United States

=Western Black Legged Tick Pacific Coast
north-west---

Borrelia burgdorferi- Ixodes ricinus-sheep tick Europe Black-striped

Borrelia afzelli and mice
B.gerinii
burgdorferi-Borrelia Ixodes Persulcatus Asia , Japan Russia , Rodents
afzelli and B.gerinii China
Reservoir:
– Small rodents (mice, voles, rats)
– insectivores (shrews,
hedgehogs) _ MC animal
reservoirs of Borrelia,
– Hares and birds may also serve
as reservoirs.
– larger animals (deer, livestock) White –footed mouse
serve as hosts for the tick
vectors---- maintain tick
populations.
Vector:
• Vector: Hard ticks,
• Family: Ixodeidae
– they need to ingest a blood meal to
transform to their next stage of
development
• Most transmission to humans is by the
nymphal tick stage.
Transmission of B. burgdorferi

Natural Reservoir of B. burgdorferi

Wild rodents
1. White footed mouse- Peromyscus
leucopus
 Epidemiology
Global Distribution • Distributed in Temperate Regions of Northern
Hemisphere with patients residing in North America,
Europe , Asia
• In North America & Europe , it is the most common
Vector Borne disease

In United States • Most frequently reported from

– Northeast : from Maine to North California
– Upper – Midwest : mostly in Wisconsin and Minnesota
midwestern West Coast & Michigan
US---- – West : particularly northern California
– Eastern U.S

In Europe 1. Highest Reported Frequencies are in

1. Germany
2. Austria
3. Slovenia
4. Sweden
Lyme disease

• Most commonly reported

vector born illness in the US

• 6th Mc ----Nationally
Notifiable Disease [In 2015]

• No. Of Cases Reported in US=

38468
 History
1902 Chronic atrophic skin Lessions described by Herxheimer
Later was recognized as part of erythema chronicum migrans

1907 Genus Borrelia was named after French bacteriologist

Amedée Borrel (1867–1936)

1921–1923 Afzelius in Sweden and Lipschütz in Austria described

erythema chronicum migrans Willy Burgdorfer
1970  Erythema Migrans was first described in the USA
1971  Development of Artificial culture medium by Kelly
1977  First description of “Lyme arthritis”
 Described by ALLEN C. STEERE
1982  B. Burgdoferi -etiological agent of Lyme Disease
recognised by Willy Burgdorfer
1984 Alan Barboure & Stonner ----who modified the media for
Growth of B. Burgdoferi and nemed it as BSK medium

1997 B. Burgdoferi senso stricto was sequenced

 History: How it All Began
• October 1975: Two mothers contacted
health officials about arthritis cases in their
communities [Lyme and Old Lyme,
Connecticut (CT) ].
• January 1977: First description of “Lyme
arthritis”
– Patients had an arthropod-transmitted
illness
– 1/4 of the children or their parents Polly Murray
recalled an expanding skin lesion
before the onset of arthritis
Dr David Syndham
 Antigenic Structure & Antigenic variation
1. antigenic variation--------a unique property
2. Organism must adapt markedly to different environments
a. Tick &
b. Mammalian Host
3. DNA rearrangement in linear plasmid appears to be responsible
4. Antigens as ---Virulence Factors of Borelia bacteria
5. Antigenic composition is also different between different B. burgdorferi sensu
lato species
6. The organism differentially expresses
a. various genes in different Host
a. Tick &
b. Mammalian Host
b. Different antigens are expressed also at different LB disease stages.

Antigens Detected in Ticks
1. Outer-surface protein A (OspA)
2. Outer-surface protein C(OspC):
Early Stages Antigens in Lyme Borreliosis
1. Flagellar Protein Flagellin (41-kDa), or
FlaB,
2. The Flagellar outer sheath protein FlaA
3. OspC protein (21- to 25-kDa)[ plasmid-
encoded]
4. BmpA protein(39-kDa)
5. Vmp-like sequence expressed protein (VlsE)
(34- to 35-kDa)
6. P35/BBK32 (47-kDa), P37, and P66
antigens

Antigens that help the bacterial attachment

1. 66-kDa spirochetal protein
2. 26-kDa glycosaminoglycan binding protein
3. Decorin-binding proteins A and B (DbpA and DbpB)
 Clinical Manifestations of Lyme
Disease
I. Stage 1: Localized infection
II. Stage 2: Early disseminated infection
III. Stage 3: Late persistent infection
Early Infection: Stage 1 (Localized Infection)

1. Incubation period – 3–32 days

2. Begins in summer
3. Presentation :
1. erythema migrans (EM)--- 70-)---80% of
Patients
2. Lymphadenopathy
3. Flu -like symptoms
4. Characteristic Lession –
1. Erythema migrans (EM
2. Bulls Eye or Target Lession
5. Location : At the site of Bite
6.
 Early infection: Disseminated Stage 2
CNS Manifestations:
1. Onset : Several Days to weeks
(About 15% of untreated patients )
2. During this
Neuroborreliosis :
period hematogenous Dissemination of
bacteria occurs 1. Meningitis [ MC]

3. Associated Syndromes----------- 2. Cranial neuropathy / Facial Palsy[

1. Skin Lesions :Multiple EM Lesions
2. Lyme Arthritis
3. CVS : Lyme Carditis (5% of
untreated patients)
1. Atrio-ventricular (AV) nodal
block
2. Myopericarditis
MC]
3. Motor or sensory
radiculoneuropathy
4. Subtle cognitive difficulties
5. pseudotumor cerebri (all rare)
Additional Manifestations
1. Conjunctivitis, keratitis, uveitis
2. Malar rash
3. Mild hepatitis
4. Splenomegaly
 Late infection : persistent Stage 3
Months after the onset
Musculoskeltal System
1. Arthritis – 60% of untreated patients[ mc]
a. Large Joint with Inflammatory effusions
2. Intermittent attacks in one or a few joints, especially the knee,
sometimes becoming chronic
Nervous System Manifestations-----5%
PNS Manifestations
1. Polyneuropathy[ EMG]
2. Mononeuritis Complex
3. Chronic axonal polyradiculopathy
CNS Manifestations
1. Late subtle encephalopathy
2. Chronic encephalomyelitis
1. accompanied by abnormal cerebrospinal fluid (CSF) or
electromyogram (EMG)
3. Rare Neuropsychiatric Sequelae

Eyes:Keratitis
Late Skin Manifestaions: Acrodermatitis Chronica Atrophicans
1. Reddish –voilaceous discoloration
 Post –Lyme Disease Syndrome

Post–Lyme Syndrome (Chronic Lyme Disease)

1. Persistance of some symptoms
2. Like malaise, joint pain fatigue
3. Disbling joints pain, neurocognitive difficulties , or Sleep
disorders
4. Incapciating fatigue symptoms for months or years
afterwards.
D.DX
1. chronic fatigue syndrome
2. fibromyalgia
• Co- Infection associated with Lyme Disease
1. ~ 10 % of Cases Babesia or Anaplasma
2. Anaplasma phagocytophilum (formerly referred to as “the
agent of human granulocytic ehrlichiosis”
DIAGNOSIS

Clinical Diagnosis  For Typical Lessions : Erythema Migrans

 Characteristics of Typical Lessions
a. History of tick bite
b. Size: >5cm
c. Expanding Lesions at the site of bite
d. Onset of rash after 2 days

Lab Diagnosis I. Direct Methods: Detection of Causative Organism

1. Direct Microscopic Examination
2. Culture
3. PCR
4. Detection of Specific Antigens
5. Animal Inoculation
I. Indirect Methods: Detection of Immune Response to the
Causative Organism
I. Serologic assays: Detecting antibodies
 Direct Methods: Detection of Causative Organism

Direct Methods: Detection of Causative Organism

a. By culture B. burgdorferi is more easily detected
b. By PCR By culture and/or PCR:
a. Skin Samples
Specimen: b. Blood samples
c. Synovial fluid-------- patients with Lyme
arthritis
 during the early stages of the disease (erythema
migrans, when the diagnosis is mostly clinical)
For other presentations, it is very difficult to confirm the presence of the
bacteria
Methods Used
Culture  Permits definitive diagnosis
Barbour-Stoenner-  Direct Method---Detection of
Kelly (BSK) medium Causative Organism
 Positive ---mainly early in
the illness
 Currently method has been
used primarily in research
studies.
Specimen Used
Specimen Used
 Cutaneous Tissue--- primarily
from biopsies of EM lesions,
 Plasma Samples :less often
 Blood
 CSF: occasionally
 Molecular Dx :Direct Methods: Detection of Causative Organism
PCR Targets Genes in PCR (B. burgdorferi )
1. Conventional PCR, 1. chromosome genes such as
2. Nested PCR, 1. rrs,
3. Quantitative PCR, 2. fla B,
4. Competitive PCR, or 3. rec A, and
5. Real-time PCR 4. p66, and
5. plasmid-derived osp A
2. RFLP—of Integennic rrf-rrl
region
Validated amplification PCR is greatly superior to culture in
tests for B. burgdorferi a. late stages of infection
b. For Specimens
a. joint fluid -detection of 2. CSF: [from patients with
DNA
1. Real-time PCR---quantify the
number of spirochetes in clinical
specimens.
1. Target Gene: recA DNA
Validated amplification tests -----Real-
time PCR-
-- for Specimens
1. Synovial Fluid And
2. Synovial Membrane Biopsies
Specimens
1. Joint Fluid—the major use for PCR
testing in Lyme disease.
neuroborreliosis ] PCR sensitivity --
-much lower.
3. Blood & Urine : PCR little role if
any
 Indirect Methods: Detection of Immune
Response to the Causative Organism

• Serologic assays: Detecting antibodies to B. burgdorferi

• Current CDC recommendations: 2-tier algorithm
1. Tier 1 :ELISA or IFA [Very sensitive ]
2. Tier 2:Western blot
Sensitivity =100%
Specificity=90%
Western IgM Consider positive 1. 23, 39, and 41 kDa.
Blot western Blot if two of the 2. combination of the
Criteria following three 23- and 41-kDa
bands are present: bands may still
represent a false-
41 kDa-(flagellin) positive result

IgG 1. 18, 23, 28, 30, 39,

western blot Consider positive 41, 45, 58, 66, and
Criteria • if 5 of the following 10 93 kDa.
bands are present:
 VlsE: A New Diagnostic Marker
1. Two peptides are Include
Peptide-based immunoassays 1. pepC10 (OspC region) and
2nd generation Serological Tests 2. C6 (VlsE invariable region or IR6)

Characteristic Features of these 1. Highly conserved among different B. burgdorferi

Peptides 2. Immunodominant protein antigens

Addition of VlsE to both 1st and 2nd tier tests has improved their performance
1. C6 –IgG ELISA
a. more sensitive for patients with erythema migrans than standard 2-tiered testing,
b. more specific than whole cell sonicate ELISA
c. FDA-approved as a 1st tier test;
Post Exposure Prophylaxis
• Not Routinely Indicated

However if tick found is engored

with blood
• Doxycycline: 200mg
– Within 72 hrs after tick bite
 PREVENTION

• No human vaccines
• Prevention strategies include
1. Personal protection
1. Avoidance of Tick Infested Areas
2. Uses of Tick Repellants----DEET
3. Wear permethrin-treated
clothing
2. Constant Tick Check

3. Environmental modification
4. Tick suppression

Find and remove ticks from your body

 Bathe or shower as soon as possible
after coming indoors
 Every day check for and remove ticks
on body, pets and outdoor gear
 Prevention Through Environmental Modification and
Tick Suppression
Host reduction or exclusion
● Install deer-proof fencing
Reduce the numbers of
host-seeking ticks Reduce the numbers of ticks
● Landscape management on hosts
 Acaricide treatment of rodents or deer
● Kill host-seeking ticks with acaricides
or biological agents
Relapsing Fever
Relapsing Fever

Definition

1. Relapsing fever is a acute bacterial infection ,

characterized by recurring episodes of fever, headache,
muscle and joint aches & nausea.

2. It is also known as “recurrent fever” or “tick fever”

There are two forms:
1. Louse born Relapsing Fever (LBRF )(Epidemic )
2. Tick born Relapsing Fever (TBRF) (Endemic)
 Tick-borne relapsing fever (TBRF)
B .Species Vector -Ticks---Soft Geographic Regions Primary
ticks--- Reservoir
Species Ornithodoros hermsi Western United States Rodents
B. hermsii [MC] and Canada
B. parkerii, O.parkeri Western United States and Rodents
Baja California
B. turicatae O. turicata, Southwestern United States Rodents

B. duttoni O.moubata Africa Humans

B. crocidurae -- O. Sonrai Africa Rodents

O.erraticus
B. miyamota Ixodes scapularis US, Japan Deer
[Hard Tick
Reservoir of Ticks

• Ground squirrels
• Tree squirrels
• Chipmunks
• Rabbits , Rats
• Mice,
• Lizards
• Owls
• Pigs Chipmunks

Tree squirrels
Ornithodorus Tick
1. Family Argasidae (Ornithodoros species)
2. prefers coniferous forests
3. at altitudes of 1500 to 8000 feet
4. All stages are obligate feeders
5. They Feed on ground squirrels, tree squirrels
and chipmunks.
6. They quickly obtain a blood meal within 15 to
90 minutes of attachment-
7. after each blood meal lay clutches of eggs---
8. feed at night when their natural or incidental
hosts are sleeping.
9. Once Infected They remain infectious for the
rest of its life
10. Transovarian or vertical transmission
1. Ticks live in the nests of squirrels,
chipmunks, and other small animals-
nests usually located inside the walls or
in the attic or crawl space
2. Forested areas at various elevations in
mountainous regions
3. Cabins and Rustic buildings----where
rodents have built nests.
4. Living near freshwater lakes, which
often carry rustic tourist cabins.
5. Ticks Inhabit rodent Burrows, Decaying
Woods, cabins, animals shelters & Caves
TBRF: Epidemiology
Found in discrete areas throughout the
TBRF is reported worldwide, except
world
Antarctica, Australia, New zealand
1. North America, and the Pacific Southwest.
2. South America
Rare in tropical, low-desert, arctic, or
3. Central America,
alpine environments
4. Canada (southern portion of British
Columbia)
5. Plateau regions of Mexico
6. The Mediterranean Region
7. Central Asia
8. Africa
9. Russia
 Louse-borne relapsing fever (LBRF)

B .Species Vector -Louse Geographic Regions Primary Reservoir

B. recurrentis Pediculus humanus 1. Ethiopia 1. Humans

2. Sudan
1. Previously World
wide
• In 2015, ----LBRF were reported among asylum seekers from Eritrea in the
Netherlands, Switzerland, and Germany.

• In 2016, more cases of LBRF were reported in refugees from East Africa who were
residing in Germany
Pathophysiology

Virulence Factors
Main Virulence Factors

1. antigenic shift or antigenic variations 1. Extracellular Bacteria

2. escape from immune clearance of the host 2. No Exotoxins
. 3. No LPS Endotoxins
Pathogenesis of relapsing fever

Tick Born Relapsing fever Louse Born Relapsing fever

Mode of
Transmission Louse Crushing, Rubbing,
Tick Bite Squeezing
Salivary Secretions • Inoculation of Feces, &
Hemolymph into
1. the open wound,
2. conjunctiva,
3. bite sites

Reaches The blood circulation

Dissemination of Bacteria
1. Proliferation of Bacteria
2. ---doubling time: every 6 hrs
3. Reaching 10 6-107 or more
Host immunity

Host specific humoral immunity development against Borrelia.

immunity contributes to recovery in a patient after a number of
relapses.

IgM IgM antibodies

antibodies 1. specific for the serotype-defining surface lipoprotein
2. appear after a few days of infection and
3. reaching a concentration that causes lysis of bacteria in the
blood through either
a. direct bactericidal action or
b. opsonization.
 Clinical Manifestations
Both epidemic and endemic RF have similar manifestations although not identical
Incubation period TBRF LBRF
 7 days  8 days
Mean IP  (range, 4 to >18 days)  (range, 5–15 days;
Recurrent febrile episodes 1. Lasting 3- 5 days  Unremitting Fever
Characteristic of Diseases 2. Intervening with afebrile  3-6 days
1. Sudden onset periods of 7- 9 days.
1. Temp: >39C- 43C a. Subsequent episodes
are shorter.
TBRF
• First Fever Episode is f/b sequence of Events
1. Crisis Phase---
1. Chill Phase
2. “Flush Phase”,

Chill Phase--- “Flush Phase”

1. Lasting for 15-30m minutes persist for several hours
1. Rigors, 1. drenching sweats a
2. Further elevation in temperature
2. rapid decrease in body
3. Pulse
4. Blood pressure temperature
3. Hypotension
Course of Disease
Recurrent febrile episodes 1. Non-specific symptoms like
a. Head ache
Along with Non specific b. Neck stiffness, a
Symptoms c. Arthralgia,
d. Myalgia,
e. alteration of sensorium,
f. abdominal pain,
g. nausea ,vomiting and Diarrhea.
Respiratory Symptoms 1. Acute Respiratory Distress Syndrome---- TBRF in
US
2. Non-Productive Cough
1. MC in LBRF
2. DDX – Influenza
1. Non-Productive Cough + Fever +
Myalgia

1. Lymphadenopathy
2. Hepatosplenomegaly
3. Abdominal Pain
Hemorrhages: more likely in 1. Petechiae,
epidemic RF. 2. Epistaxis and
3. Blood-tinged sputum
Neurologic MC in epidemic RF • Lymphocytic meningitis,
Complications [10- 30% of cases ] • seizure,
• Altered Mental Status
neurologic • Focal deficits, paraplegia and psychosis
complications (B. may occur in and
duttonii and B. CRANIAL NEURITIS
turicatae) • Bells Palsy [ unilateral/ bilateral]
• 7th & 8th Cranial Nerve palsy [ deafness ]
.
Visual 1. Pan- Opthalmitis [ unilateral/ bilateral]
Impairment 2. Iridocyclitis
3. Uveitis
Cardiovascular 1. Myocarditis---arrythmias
Manifestations
COMPLICATIONS
Acute TBRF Moderate to severe thrombocytopenia, although
not associated with a fatal outcome, is a typical
finding in acute TBRF.
LBRF—Mc Bleeding complications, such as
asscoiated 1. epistaxis, purpura,
2. hemoptysis, hematemesis, bloody diarrhea,
hematuria,
3. subarachnoid and cerebral hemorrhages,
4. splenic rupture, and
5. retinal hemorrhage,
During pregnancy, 1. spontaneous abortion,
2. premature birth, or
3. neonatal death.
 DIAGNOSIS

1. Direct Methods: Objectives Confirmation of Dx by

1. Microscopy 1. Direct Detection of 1. Direct Detection of
2. Culture Spirochete Spirochete
3. Animal 2. Isolation of Spirochete 2. Culture
inoculation 3. Mouse Inoculation

II: Molecular Methods 1. PCR Amplification

II :Indirect Methods: Detection of Immune Response

to the Causative Organism
Specimen 1. Blood
2. CSF

Microscopy 1. Fixed Smear

2. Wet Mount

Wet Mount 1. Wet mount of anticoagulated Blood mixed with saline

2. Observe under Dark ground microscope or Phase
Contrast Microscopy
1. may show red cells colliding with spirochetes.
2. most visible when they are located between red
blood cells

Peripheral Blood Smear Staining 1. Sensitive

Fixed Smear 1. Giemsa Staining, 1. 70% TBRF
1. Thick Smear 2. Wrights Staining,
2. Thin Smear 3. Acridine Orange
4. Gram Staining
Microscopy :
1. Giemsa Staining,
2. Wrights Staining,
3. Acridine Orange
4. Gram Staining
Quantitative buffy coat(QBC)
analysis
Microhematocrit centrifugation Concentrates the
technique
Direct fluorescent antibody
Test
Sensitivity
1. Febrile Illness=70% TBRF
2. A Febrile Illness= Lower
Gram Staining-------------Poor method
Buffy CoatTechnique
 Staining using Higher Sensitivity than thick Film
Acridine Orange =100X
Especially for LBRF
 Low Spirochete number
 Spirochete concentrated in Red
Blood Cell Layer
1. used the fluorescent acridine
borreliae in and above orange technique to demonstrate
the buffy coat. borreliae in peripheral smears
using monoclonal antibody to
identify the species
Culture :
Culture Used : Barbour- Stonner Kelly’s Broth medium

1. Relapsing fever borreliae is Cultivable

2. Is not used routinely for isolation from clinical specimens as Borrelia
organisms
1. have complex nutritional requirements for their growth and
2. they grow very slowly on these media.
Animal pathogenicity
1. Animal Used : Immunodeficient white mice
1. a more sensitive method
Procedure 1. inoculating a mouse intraperitoneally with 1–2 mL of
blood from the infected patient.
2. After 1-10 days--- The blood is collected from the tail
vein of the mice
3. Blood is examined for the presence of Borrelia daily
for 2 weeks.
Molecular methods

1. Multiplex Real- time PCR

2. Nucleic Acid Sequencing Analysis

Multiplex Target Genes

Real- time PCR 1. 16S rRNA
2. glpQ genes
3. flagellar B Protein (flaB)
4. gyrase B Protein(gyr B)
5. Variable tick protein( vtp)

Uses: 1. Used to Dx B.hermsii Blood stream Infections

2. Tick analysis – for identification & Characterization
1. amplification techniques for borrelial nucleic acid &
2. Subsequent Nucleic Acid Sequencing Analysis
Serology
1. ELISA
2. IFA (indirect fluorescence assay)
3. GlpQ assay
Interpretations
1. fourfold rise in antibody titer between an acute and convalescent serum samples is considered
to be significant
or
1. with a single convalescent serum sample that is reactive
ELISA
1. should be confirmed with immunoblot
1. An IFA titer of 1:128 to 1:256 or higher is considered positive.
GlpQ assay
1. GlpQ -----glycerophosphoryl diester phosphodiesterase (GlpQ)
2. an immunoreactive protein,
3. It is an immunoblot assay detecting antibodies against recombinant GlpQ protein
4. Not widely available
5. In future---- improve sensitivity and specificity of serology tests
Treatment
TBRF LBRF
7-day (or 10-day) Single-dose therapy
course
Age >9 yrs First Choice Doxycycline=100bd 1. Doxycycline=200mg BD
Therapy oral
2. Tetracycline =500 mg
3. Tetracycline =250-500 mg
i/v
Second choice Tetracycline =500 mg Penicillin G procaine IM
qid 800,000 U
Third choice Erythromycin= Erythromycin=
500 mg qid 500 mg oral

Age <9 yrs First Choice Erythromycin= Erythromycin=

Therapy 12.5mg/kg day 12.5mg/kg day
Second choice Penicillin G procaine IM
200,000–400,000 U children
Third choice
 TBRF LBRF
7-day (or 10-day) Single-dose therapy
course
Pregnancy Erythromycin= Erythromycin=
500 mg qid 500 mg qid

CNS Involvement Ceftriaxone 2 g –I/V

1. Meningitis/ or
2. Encephalitis Na penicillin G, 5 million U qid –I/V
10-14 days
Prevention
1. No Vaccine is
available
Key Strategy for Prevention
 Avoidance of Arthropod vectors
 Elimination of the arthropod vectors.
For TBRF 1. avoidance of cabins and woodpiles with rodents,
2. elimination of rodent nests, and
3. use of insect repellents containing DEET (N,N-
diethyl-m-toluamide
1. Postexposure prophylaxis with
a. Day 1: Doxycycline, 200 mg
b. Day 2-4: Doxycycline, 100 mg daily
LBRF 1. Good personal hygiene
2. Delousing procedures
3. For Infested Clothing :Laundry and soaking
in hot water
4. Iinsecticides such as
1. dimethyl dithiophosphate (malathion)
2. Fumigation with pyrethrin or permethrin
TABLE : Differences between and endemic relapsing fever
Tick Born Relapsing fever Louse Born Relapsing fever
Endemic relapsing fever Epidemic relapsing fever

Distribution Endemic in United States, East Africa

Canada 1. Ethiopia
2. Sudan
Agent B.duttoni B.hermsii B. recurrentis
Vector Soft Tick Louse
-Transmission via Salivary -Transmission via Rubbing ,
Secretion Crushing &squeezing of louse
Natural Host Rodents Humans
Relapsing fever Repeated relapses are Single relapse
Characteristics common –30
Mortality low mortality < 5%.[ 4-10%] high mortality---10–70%.
- associated with
Vincent’s angina
DEFINITION

Necrotizing ulcerative gingivitis (NUG) is a non-contagious anaerobic

inflammatory destructive disease of the gingiva which is associated with
overwhelming proliferation of Borrelia vincenti and fusiform bacteria
presenting characteristic signs and symptoms
 CLINICAL MANIFESTATIONS
1. Vincent's angina is Tonsillitis and
pharyngitis,
2. NUG involves the gum
3. primarily involving the free gingival
margin and the interdental papilla
Symptoms • Severe gingival pain
• Spontaenous bleeding on slightest
stimulation.
Other • Fetid odor
Symptoms • Increased pasty saliva.
• Metallic foul taste.
• Extreme sensitive to touch.
Oral Signs • Punched out crater like depressions at the
crest of interdental papillae,extending to the
marginal gingiva.
• Grayish pseudo-membrane slough
covering the craters.
Complications • Cancrum oris (noma)
Borrelia Vincentii 1. a spirochaete
2. Gram Negative
3. motile spirochete,
4. 3-8 coils of variable size.
5. obligate anaerobe
Fusobacterium 1. Gram Negative
fusiforme--- 2. spindle-shaped or fusiform
Fusobacterium rod-shaped bacterium
nucleatum 3. Anaerobe
4. parallel walls wuth
rounded or tapered ends

Staining It is easily stained with

1. dilute carbol fuschin
2. methyl violet,
3. giemsa and
4. leishman stains
– Plaut in 1894 and Vincent in 1896 first proposed this bacterial
etiology.
Predisposing Risk Factors
Age Group 1. MC 18-30 years
1. Young adults -------Developed Countries
2. Children ---------Developing Countries
1. low socio-economic groups
2. Malnutrition-
Vincents Angina as Opportunistic Infection
Local Conditions Systemic Conditions
Local & Systemic • Trauma • Blood dyscrasias
Immunosuppression---- • Poor oral hygiene • Debilitating diseases
• HIV/AIDS
• Severe gastrointestinal
disorders (ulcerative colitis)
• Smoking
• Nutritional deficiencies
• Inadequate Sleep
• Insufficient rest
• Physical or emotional stress
• It rarely occurs in nonsmokers.
 Diagnosis
Specimen : Swab from Gingival Ulcers,
Tonsillar areas

Diagnosis

Microscopy : For
Clinical Dx Laboratory Diagnosis Presumptive Dx
 Usually Clinical  Microscopy Staining:
 Isolation of Organism 1. Giemsa Staining,
 Culture----Swabs 2. Gram Staining
 Blood Cultures

Culture
1. Not very helpful
2. Cannot be interpreted
3. Difficult to culture
Blood Cultures--- if
associated with Sepsis &
Metastatic Infections
TREATMENT
Oral Hygiene  Area cleansed with warm saline
water,
 Dilute Hydrogen Peroxide
 Chlorhexidine
Debridement of  superficial calculus is removed.  Topical anesthesia applied
Necrotic Tissue  Subgingival scaling and curettage and area gently swabbed
with a cotton pellet to
remove the pseudo
membrane and non-
attached surface debris.
Oral Antibiotic & 1. Penicillin (500mg 6th hourly); Indications
Systemic Antibitics 2. Metronidazole 500mg bid 7 days 1. moderate or severe NUG
3. Clindamycin and
2. local lymphadenopathy or
3. other systemic symptoms
THANK YOU !!