High levels of serum hepatitis B virus DNA in patients with 'anti-HBc alone': role of HBsAg mutants.

It remains unclear how the detection of hepatitis B core antibody (anti-HBc) in the absence of hepatitis B surface antigen (HBsAg) and antibody (anti-HBs) should be interpreted and whether all patients with this pattern need to be tested for hepatitis B virus (HBV)-DNA. This study aimed at reassessing the significance of 'anti-HBc alone' in unselected sera referred to the clinical laboratory and determining whether significant HBV viraemia can be found in this setting. Of the 6431 patients tested for HBsAg, total anti-HBc and anti-HBs in a Paris hospital over a 1-year period, 362 (5.6%) had 'anti-HBc alone' (24.8% of anti-HBc-positive patients). Only 11 of the 362 sera (3.0%) were found to be false positive. One patient was in the resolving phase of acute hepatitis B. HBV-DNA was detected in 10 of 362 (2.8%) patients, using a commercial standardized assay (threshold: 350 IU/mL). Viral loads exceeded 10(4) copies/mL in 6 of 10 patients. Mutations in the HBsAg immunodominant region were identified in seven of the viraemic patients. HBsAg was detected in only two cases when retested by one of the latest, multivalent assays. Neither human immunodeficiency virus nor hepatitis C virus serostatus distinguished between patients with and without HBV-DNA. In conclusion, 'anti-HBc alone' should be considered a risk marker for a so-called 'false occult' HBV infection with significant viraemia. Indeed, results in this hospital population indicate that a small proportion of patients with 'anti-HBc alone' have high viral loads, revealing the occurrence of infection with HBV mutants that escape detection even by multivalent HBsAg assays.

Full spectrum of clinical, serological, and epidemiological features of complicated forms of Lyme borreliosis in the Paris, France, area.

The aim of this study was to report the clinical, serological and epidemiological features of a homogeneous cohort of patients with various forms of Lyme borreliosis, based on recent European case-definition guidelines. Complete clinical and epidemiological reports were requested from the patients' physicians for case definition. Enzyme immunoassay IgG and IgM screening tests were performed. A total of 170 patients (141 adults and 29 children) with the following forms of Lyme borreliosis were included between 1989 and 1997: erythema migrans alone (n = 38), early neuroborreliosis (n = 76), arthritis (n = 34), acrodermatitis chronica atrophicans (n = 12), carditis (n = 2), lymphocytoma (n = 3), chronic neuroborreliosis (n = 2), and miscellaneous disorders (n = 3). On the basis of the occurrence and course of the full spectrum of complicated forms of Lyme borreliosis, the specificity of the clinical and biological presentation of the complicated forms (age, ratio of children/adults, sex ratio, incubation period, time to diagnosis, and serological profiles) was demonstrated, as was the absence of overlap between the clinical presentations. Using these data, an alternative scheme for the natural history of Lyme borreliosis is suggested.

Differentiation between early and late complicated Lyme borreliosis by specific IgG avidity.

Patients with early complicated forms of Lyme borreliosis had a low specific IgG avidity index and patients with late forms had a high avidity index. Naturally exposed individuals had intermediate values.

[Lyme borreliosis: therapeutic aspects]. / Borrélioses de Lyme: aspects thérapeutiques.

CAUSAL AGENTS: Several Borrelia burgdorferi sensu lato species have been recently described which cause different clinical forms of Lyme disease. B. garinii is implicated in neurological forms, B. burgdorferi sensu stricto in articular forms and B. afzelii in late cutaneous forms. As such disease diversity is seen only in Europe and Asia, clinical management in Europe is somewhat different than in North America. NUMEROUS CLINICAL TRIALS: A recently proposed classification of the European forms of Lyme disease is based on clinical presentation: contagious conditions or erythema migrans, early neurologic or cardiologic complications, late articular, neurologic or cutaneous complications. Therapeutic proposals should be guided by the results of European trials, taking into account this classification. ADAPTED MANAGEMENT: For contagious conditions or erythema migrans, amoxicillin and doxycycline are the first intention antibiotics and should be given for 14 to 21 days. Other antibiotic classes (macrolides, oral cephalosporins) have not been found be more effective and should be reserved for second line treatment. Early neurological involvement requires penicillin, a third generation cephalosporin or doxycycline for one month. Oral antibiotics are preferred in case of joint involvement using amoxicillin or doxycycline as first line therapy. A second regimen could be proposed in case of failure. Parenteral administration should be reserved for second line treatment. There is little data available on chronic atrophic acrodermatitis and protocols are based on ceftriaxone, doxycycline or penicillin.