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Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 104-105

Commentary: Tick talk: A glimpse into the literature

Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Web Publication19-Dec-2019

Correspondence Address:
Dr. Parthopratim Dutta Majumder
Department of Uvea, Sankara Nethralaya, 18, College Road, Nungambakkam, Chennai - 600 006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1539_19

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How to cite this article:
Dutta Majumder P. Commentary: Tick talk: A glimpse into the literature. Indian J Ophthalmol 2020;68:104-5

How to cite this URL:
Dutta Majumder P. Commentary: Tick talk: A glimpse into the literature. Indian J Ophthalmol [serial online] 2020 [cited 2020 Dec 2];68:104-5. Available from: https://www.ijo.in/text.asp?2020/68/1/104/273206

Since its first report in 1977 in the town of Old Lyme, Connecticut, United States, there has been a consistent increase in the prevalence of Lyme disease worldwide. The seroprevalence of the disease remains remarkably variable worldwide—varying by country and region in the same country. Though relatively sparse and sporadic, there is an increase in reports of Lyme disease from various parts of India.[1],[2] There is a paucity of epidemiological data on infection due to Borrelia burgdorferi, and the risk factors for contracting the illness in India have remained largely unknown. There are two studies that estimated the prevalence of antibodies against Borrelia burgdorferi in the Indian population. Using commercial enzyme-linked immunosorbent assay (ELISA) kit to detect IgG antibody to Borrelia burgdorferi, Praharaj et al.[2] estimated seroprevalence of 13% in northeastern states of India. In this issue of the journal, Babu et al.,[3] estimated the seroprevalence of 15.6% Borrelia burgdorferi infection by a two-tier approach—using an ELISA initially, followed by specific Western blot as a confirmatory testin Nagarahole and Bandipur forest ranges in South India.

The diagnosis of Lyme disease remains elusive. In majority cases, a combination of pathognomonic erythema migrans rash, travel history to an endemic area, clinical findings, and supportive serological investigations have been described to clinch the diagnosis. In the first few weeks of the illness, the serological test may be negative as antibodies against Borrelia burgdorferi are slow to develop. IgM usually takes 1 to 2 weeks to appear in the blood and IgG may not be detectable up to 4 to 6 weeks of infection.[4] However, once produced in response to Borrelia burgdorferi, IgM and IgG persist for a long time, thereby, making serology difficult to differentiate between old and new infections. The Centers for Disease Control and Prevention (CDC, USA) and the Food and Drug Administration (FDA) in 1995 recommended a two-step algorithm—using an enzyme immunoassay initially and if reactive or equivocal, then a Western blot to run on the same sample to confirm the serodiagnosis.[4] A study from the United States estimated the huge economic burden involved with the serological tests for Lyme disease; the study concluded that these tests are being overused and only 12% out of 3 million tests yielded a positive result.[5] CDC recommends performing serological screening for Lyme disease only in symptomatic patients with a risk of exposure to ticks.[4] Recently CDC recommended a modified two-test method on July 29, 2019, which uses a second ELISA test rather than a western blot in Lyme disease serological test algorithm.[6]

The diagnosis of ophthalmic manifestation of Lyme disease in the absence of systemic symptoms and suggestive history is challenging. Usually, the ophthalmic manifestations are reported in later part of the illness and there are possibilities of negative serological tests.[7] There are only two available reports of ophthalmic involvement in Lyme disease from India and both had presented with neuroretinitis.[8],[9] One patient was an inhabitant of Nagarahole forest and had a history of a tick bite, although there was no history or presence of classic erythema migrans like skin rash.[8] The second patient had a history of a recent visit to hilly terrain in the Himalayas and had denied any of tick bite or any other systemic manifestation.[9] In both cases, a diagnosis of Lyme disease was achieved as a disease of exclusion—serological tests and from a suggestive history.[8],[9]

One needs to interpret data on seroprevalence with caution; higher seroprevalence does not necessarily mean the increased incidence of the disease.[10],[11] Many of these studies on the seroprevalence of Lyme disease had asymptomatic seropositive subjects. We do not know whether asymptomatic seropositive subjects are at risk of developing symptomatic disease or represent late sequelae of infection, and what are the chances of seroreversion in them. Fahrer et al.[10] found no increased risk for the development of symptomatic disease in asymptomatic seropositive subjects up to 6.5 years of follow-up. Chances of ocular involvement will be rather rare in such scenario. Ocular involvement is considered to be less than 1% in patients with Lyme disease and remains the cause of less than 1% of all uveitis cases in an endemic country.[7],[12] Because of the low prevalence of Lyme disease in uveitis, even the two-tier approach of serological testing is not considered sufficient to establish a diagnosis.[13]

In conclusion, though rare in India, one should consider a diagnosis of Lyme disease in uveitis patients based on systemic findings, history of a tick bite, especially if the patient hails from a forested area or gives a history of travel to an endemic area. Serological testing should be used accordingly, and the diagnosis of Lyme disease remains a diagnosis of exclusion.

  References Top

Sharma A, Guleria S, Sharma R, Sharma A. Lyme disease: A case report with typical and atypical lesions. Indian Dermatol Online J 2017;8:124-7.  Back to cited text no. 1
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Praharaj AK, Jetley S, Kalghatgi AT. Seroprevalence of Borrelia burgdorferi in North Eastern India. Med J Armed Forces India 2008;64:26-8.  Back to cited text no. 2
Babu K, Murthy KR, Bhagya M, Murthy PR, Puttamallesh VN, Ravi V. Seroprevalence of Lymes disease in the Nagarahole and Bandipur forest areas of South India. Indian J Ophthalmol 2020;68:100-3.  Back to cited text no. 3
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Lyme Disease. Lyme Disease. CDC [Internet]. 2019. Available from: https://www.cdc.gov/lyme/index.html. [Last cited on 2019 Aug 18].  Back to cited text no. 4
Hinckley AF, Connally NP, Meek JI, Johnson BJ, Kemperman MM, Feldman KA, et al. Lyme disease testing by large commercial laboratories in the United States. Clin Infect Dis Off Publ Infect Dis Soc Am 2014;59:676-81.  Back to cited text no. 5
Mead P, Petersen J, Hinckley A. Updated CDC recommendation for serologic diagnosis of Lyme disease. MMWR Morb Mortal Wkly Rep 2019;68:703.  Back to cited text no. 6
Rosenbaum JT, Rahn DW. Prevalence of Lyme disease among patients with uveitis. Am J Ophthalmol 1991;112:462-3.  Back to cited text no. 7
Babu K, Murthy PR. Neuroretinitis as a manifestation of Lyme disease in South India: A case report. Ocul Immunol Inflamm 2010;18:97-8.  Back to cited text no. 8
Guliani BP, Kumar S, Chawla N, Mehta A. Neuroretinitis as presenting and the only presentation of Lyme disease: Diagnosis and management. Indian J Ophthalmol 2017;65:250-2.  Back to cited text no. 9
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Fahrer H, Sauvain MJ, Zhioua E, Van Hoecke C, Gern LE. Longterm survey (7 years) in a population at risk for Lyme borreliosis: What happens to the seropositive individuals? Eur J Epidemiol 1998;14:117-23.  Back to cited text no. 10
Kuiper H, van Dam AP, Moll van Charante AW, Nauta NP, Dankert J. One year follow-up study to assess the prevalence and incidence of Lyme borreliosis among Dutch forestry workers. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol 1993;12:413-8.  Back to cited text no. 11
Ocular involvement in Lyme disease [Internet]. Am Acad Ophthalmol 2008. Available from: https://www.aao.org/current-insight/ocular-involvement-in-lyme-disease. [Last cited on 2019 Aug 21].  Back to cited text no. 12
Mackensen F, Zimmermann S, Alle W, Max R, Jakob E, Becker MD, et al. Difficulties of interpreting Borrelia serology in patients with uveitis. Ocul Immunol Inflamm 2011;19:227-31.  Back to cited text no. 13


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