Lyme disease in a Brazilian traveler who returned from Germany*

Dear Editor, Lyme disease (LD) is a multisystem infectious disease with prominent cutaneous findings. It is caused by spirochetes belonging to the Borrelia burgdorferi sensu lato complex, mainly transmitted by the bite of infected Ixodes ticks.1,2 In Europe, it is endemic in Germany, Austria, Denmark, and Sweden; in the Americas, it is considered a public health problem in the United States.1 As a notifiable disease, cases of borreliosis have been reported in Brazil in the states of Amazonas, Tocantins, Espírito Santo, Mato Grosso do Sul, Rio de Janeiro, and São Paulo.2 The purpose of this article is to describe the occurrence of LD in a Brazilian tourist who returned from Germany, and to alert the importance of early detection of the disease. A 40-year old female patient, resident in Rio de Janeiro, sought our dermatology service after noticing an erythematous patch with centrifugal growth and three weeks of evolution on the left thigh. She denied previous treatment or comorbidities and had no systemic symptoms. Two months before the onset of the lesion, the patient had returned from a trip to Germany, where she was camping in a rural area and suffered a tick bite on the left thigh. She reported having noticed the tick attached to her thigh in the morning, but was unable to tell the length the tick had been feeding. She removed the tick by pinching it with her fingernails. Dermatological examination revealed an erythematous, infiltrated lesion on the inner side of the left thigh, with edge and center presenting a more intense red color (Figure 1). We suggested the hypothesis of LD, given the patient’s recent history of travel to a borreliosis-endemic country, which was confirmed with positive serology for B. burgdorferi (IgM). VDRL, FTA-Abs, and FAN research were negative. Histopathological examination after lesion biopsy revealed perivascular inflammatory infiltrate, predominantly lymphocytic, with plasma cells in the superficial and middle dermis (Figure 2). Warthin-Starry staining was negative. The patient was treated with tetracycline (250 mg) orally every six hours for 14 days with thigh lesion regression (Figure 3). LD’s clinical picture can be divided into three stages: the first stage is characterized by predominantly cutaneous lesions, and its main manifestation is the migratory erythema, reported in 60%83% of cases; the second stage can occur with articular, neurological, cardiac, and ophthalmologic manifestations; the third stage features chronic rheumatologic, neurological, ophthalmological, and cutaneous pictures.1,2 Diagnosis is based on epidemiological, clinical, and laboratorial aspects.1,2 Histological findings by hematoxylin-eosin staining of the present case are suggestive for borreliosis. Failure to demonstrate the presence of B. burgdorferi using silver staining is justified by the low sensitivity of this technique, which varies from 10%-40%.2 In Brazil, due to the impossibility to identify the etiologic agent of LD – because of the difference between etiologic agent and vectors, and the lack of standardization of laboratory methods – cases be-