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Klinicne in epidemiološke znacilnosti bolnikov z erythema migrans
Avtor: Videcnik Jerneja, Zorman Peter
Mentor: prof.dr. Franc Strle, dr.med.
Lymska borelioza je v Sloveniji endemicna bolezen. Incidenca je v zadnjih desetih letih mocno narasla in je med najvišjimi v Evropi. Erythema migrans je v poteku bolezni dalec najbolj pogost klinicni znak. Ocenjujejo, da se pojavlja pri približno treh cetrtinah bolnikov z lymsko boreliozo v zgodnjem obdobju bolezni. Erythema migrans tipicnega izgleda je edini znak, ki v vsakdanji klinicni praksi omogoca dokaj zanesljivo postavitev diagnoze lymske borelioze. Kot tak je zadosten kriterij za pricetek antibioticnega zdravljenja, s katerim z veliko gotovostjo preprecimo nadaljnji razvoj bolezni in mocno zmanjšamo pojavnost kasnih zapletov bolezni.
NAMEN: Predstavili smo klinicne in epidemiološke znacilnosti odraslih bolnikov z diagnozo erythema migrans, ki so bili pregledani v Ambulanti za lymsko boreliozo na Kliniki za infekcijske bolezni in vrocinska stanja v Ljubljani v letu 2000. Dobljene podatke smo primerjali z rezultati podobne raziskave, ki je na isti kliniki potekala v letu 1993.
HIPOTEZA: Predpostavili smo, da se je poznavanje bolezni od leta 1993 do leta 2000 povecalo. Zato smo pricakovali, da bodo bolniki v letu 2000 prihajali na pregled bolj zgodaj v poteku bolezni in da bodo zaradi tega kožne spremembe ob pregledu manjše ter dodatni bolezenski znaki manj pogosto prisotni.
METODE: V prospektivno raziskavo, ki je potekala v letih 1993 in 2000, smo vkljucili vse bolnike starejše od 15 let z diagnozo erythema migrans. Znacilna kožna sprememba je morala ustrezati modificiranim kriterijem CDC (Centers for Disease Control). Epidemiološke in klinicne podatke smo beležili s pomocjo standardnega vprašalnika. Za primerjavo kvantitativnih podatkov smo uporabili Kruskall-Wallisov test, za primerjavo kvalitativnih pa test hi-kvadrat oziroma Fisherjev test.
REZULTATI: V letu 2000 je bilo v raziskavo vkljucenih 535 bolnikov, od tega 309 (57,8%) žensk in 226 (42,2%) moških, starih od 15-80 (mediana 47) let. Vboda klopa na mestu eritema se je spominjalo 311 (58,1%) bolnikov. Erythema migrans se je v 55,7% pojavil na spodnji okoncini, 14 (mediana) dni po vbodu klopa. Eritemi so bili ob pregledu v povprecju veliki 75 cm, in so merili 2-87 cm v najdaljšem premeru (mediana 12 cm). Bolniki so eriteme opazili 8,5 (mediana) dni pred pregledom. 36/535 (6,7%) pacientov je imelo vec kot eno kožno spremembo. 52,5% bolnikov je imelo na mestu erythema migrans prisotne lokalne simptome, 35,7% bolnikov je imelo pridružene splošne težave. V letu 1993 je bila diagnoza erythema migrans postavljena pri 889 bolnikih. Na pregled so prihajali mlajši bolniki kot v letu 2000 (44 proti 47 let, p=0,025), pogosteje so se spominjali vboda klopa (p=0,049), ob pregledu pa so imeli manjše eriteme (50,2 proti 75,0 cm?, p=0,025). Bolniki so v letu 1993 prihajali na pregled prej (8 proti 8,5 dni, p=0,352) in pogosteje navajali pridružene splošne težave (41,2% proti 35,7%, p=0,033).
ZAKLJUCEK.Epidemiološke in klinicne znacilnosti bolnikov v letu 2000 se niso bistveno razlikovale od tistih iz leta 1993. Naše hipoteze nismo potrdili, saj bolniki v letu 2000 niso prihajali na pregled bolj zgodaj in so imeli vecje eriteme. Splošne težave pa so bile kljub temu izražene pri manjšem številu bolnikov.
[Abstract / English version]
Clinical and epidemiological findings for patients with erythema migrans
Author: Videcnik Jerneja, Zorman Peter
Mentor: prof.dr. Franc Strle, dr.med.
BACKGROUND. Lyme borreliosis is endemic in Slovenia. The incidence has been increasing during the past ten years and is among highest in Europe. Erythema migrans is the clinical hallmark of Lyme borreliosis. It is estimated that this sign is present in approximately three fourths of patients in the early course of the disease. Typical erythema migrans is the only clinical finding that enables a reliable diagnosis of Lyme borreliosis. The presence of erythema migrans alone is a sufficient indicator for the institution of antibiotic therapy, which is especially efficient early in the course of the illness. AIM. In our study we presented clinical and epidemiological findings of adult patients with erythema migrans diagnosed at the Lyme boreliosis Outpatient's Clinic, Department of Infectious Diseases, University Medical Center, Ljubljana in the year 2000. These findings were compared with the data obtained by the same approach for an identical group of patients from 1993.
HYPOTHESIS. We expected that the knowledge on Lyme borreliosis has improved in 2000 comparing to 1993, and hypothesized that patients would visit the Clinic earlier in the course of the disease and consequently present with smaller skin lesions and had fewer systemic complaints.METHODS. The study was prospective. Patients who qualified for the inclusion in the study were adults aged 15 years and more, diagnosed with typical erythema migrans in 1993 and 2000 at the Lyme boreliosis Outpatient's Clinic in Ljubljana. Diagnosis of erythema was established clinically according to the modified criteria proposed by CDC (Centers for Disease Control). Epidemiological and clinical data were acquired by means of a questionnaire. Differences in the quantitative data were analyzed by the Kruskall-Wallis test while differences in the qualitative data by hi-square test or Fisher's exact test.RESULTS. 535 patients were included in the study in 2000, 309 (57.8%) were female and 226 (42.2%) were males, aged from 15-80 (median 47). 311 (58.1%) patients recalled a tick bite at the site of later erythema. 55.7% of patients presented with erythema on the lower extremity, median of 14 days after a tick bite. At the time of the diagnosis the average area of the skin involved was 75 cm? and measured from 2-87 (median 12) cm in largest diameter. Median duration of erythema prior to diagnosis was 8.5 days. 36/535 (6.7%) patients presented with multiple skin lesions. 52.2% of patients reported local symptoms and 35.7% had systemic complaints. In 1993, 889 patients with typical erythema migrans were diagnosed. Comparing to the cohort of patients with erythema migrans regis tered in 2000, patients from 1993 were younger (44 versus 47 years, p=0.025), recalled a tick bite more often (p=0.049) and presented with smaller erythema at the diagnosis (50.2 versus 75.0 cm?, p=0.025). Patients from 1993 visited the clinic earlier than in 2000 (8 versus 8.5 days, p=0.352) but had systemic symptoms more frequently (41.2% versus 35.7%, p=0.033).
CONCLUSIONS. The majority of findings for the cohorts of patients with erythema migrans seen in 1993 and in 2000 were comparable. Our hypothesis was not confirmed. Patients in 2000 did not visit the Clinic earlier and had larger diameters of erythema at the time of the visit. Nevertheless they reported systemic symptoms less frequently.