Erythema migrans, Lymphozytoma, ACA and Obligation to Report

Obligation to Report.

In just about half of Germany, an obligation to report has been established.  This means that every colleague has the obligation to report migrant reddening, erythema migrans and elevated IgG-titers combined with clinical symptoms of Lyme disease to the appropriate agency (Health Services).  This development can be seen as positive.

 

Bureaucratic issues

Unfortunately, not all colleagues know that and the registration forms and indications that have to be reported vary from one federal state to another.  Moreover, it is not always clear who has to report: the attending clinical doctor or the laboratory?  Besides, this recording and reporting represents an additional bureaucratic burden for our colleagues.  Therefore, we cannot rely on the reported cases to give us a real idea of the spreading. Also, it is possible that the cases do not correspond to typical case definitions of the corresponding health service.

 

As a hint:  An infection with ehrlichia (or another tick-borne disease like babesia etc.) will not show an erythema migrans or lymphocytoma after the ticke bite !

 

Difficult to discover

There are not only bureaucratic issues, but also practical ones that have contributed to such low rates of reporting. Not all patients develop an erythema migrans or they do not discover it on themselves (area of the body that is hard to reach, increasing single households with no partner).  Some do not feel the need to see a doctor. Further, other patients and/or doctors do not recognise it as such.  Instead, they believe it to be an allergic reaction to an insect sting, a haematoma or genital mycosis (fungal infection on the genitals).  Furthermore, it is very difficult to recognise an erythema migrans on sun tanned (or solarium tanned) skin, or generally dark skin and sun burns. There are simply many practical situations that hinder us from recognising an erythema migrans.

All these undiscovered cases, though, are Lyme-borreliosis in stage I (early stage). Even the influenza-like stage (stage II) is cured by the patient at home or is diagnosed by the doctor as being a viral infection. Do all strains of borrelia cause an erythema migrans?

Again, this is not about assigning guilt. It should merely be pointed out how difficult this situation can be in practice. There is no argument that all infections of Lyme disease that were not diagnosed or treated accordingly in stage 1 or 2 (f.e. with fenistil gel, fungicide oinments, cooling, zinc oinments, waiting for improvement) at least have the potential (or the opportunity) to develop into a chronic form (late stage). We do not wish to participate in any speculations of how many cases there are.

It is obvious that the corresponding agencies can only register and present the cases that are reported to them. All colleagues should help and support the process. The question for the private practices is: do we recognise all the cases and variations of erythema migrans, lymphozytoma and acrodermatitis chronic atrophicans (ACA)?

 

Pictures in the pracice

In the following part, there are some images to show what an erythema migrans , a lymphocytoma and the acrodermatitis chronica atrophicans (ACA) look like in practice and where they can be found on the body (also multilocular – in different places). The images were kindly provided by the dermatological practice of Dr. med. R. Schulte-Beerbühl from Dortmund. Additionally, there are images by colleagues from the ILADS to show the possible appearance of the EM (also multilocular – in different places simultaneously) on dark skin. We think that out of practical reasons, there could be a larger undetected group of patients with dark skin in this case!

 

Examples:   Erythema migrans

 

Em24

EmP1300830 - Kopie

EmBORRELIOSE3

EmBORRELIOSE

Em216330_4_Datum_08.10.2013

Em212341_2_Datum_05.10.2012

Em211682_2_Datum_13.08.2012

Em197058_04.05.2009_2 (2)

Em190009_2_Datum_04.10.2010

Em182805_29.06.2009_2

Em14781_2_Datum_23.10.2008

Em12967_03.06.2009_5

Em12047_2_Datum_04.10.2010

Em2992_6_Datum_30.08.2011

Em456_2_Datum_09.11.2012

Em31

 

 

Examples:   Lymphozytom

 

L042

L209525_2_Datum_30.01.2012

L203894_2_Datum_27.08.2010

L48

 

 

Examples:   Acrodermatitis chronica atrophicans

 

 

ACA047

ACA046

ACA044

ACA039