Abstract

Background: Lyme disease is an anthropozoonosis that has been increasingly diagnosed during the last twenty years. In this article, we presented the case of a 13-year-old boy, a student of an elementary school, who developed arthritis of the ankle joints following strenuous training. Although the epidemiological anamnesis was negative for a tick bite, a comprehensive infectious anamnesis by organs indicated polymorphic symptomatology, and a careful clinical examination of the skin of the whole body revealed a pale but typical Erythema chr. migrans on the skin of the right shoulder. Borrelia serology performed using the ELISA technique was negative, but the Immunoblot revealed positive antibodies to p41 protein sequences in both IgM and IgG phases. Objective: The aim of this article was to draw attention to the necessity of taking a detailed medical history by organs, as well as to the importance of a careful clinical examination of the skin of the entire body, when Lyme disease is suspected. Case presentation: Thirteen-year-old patient M.P. from Sarajevo, came to the office of an infectious disease specialist on May 20, 2019, due to suspicion of juvenile arthritis/polyarthritis reactiva, which was established two months earlier at the Pediatric Clinic. The disease started in June 2018 after a few days of intensive training. In the month of March 2019, the patient was hospitalized at the Pediatric Clinic, Clinical Center of the Sarajevo University for 7 days for clinical examination, as all the symptoms persisted. He received ibuprofen 3x400 mg due to suspected juvenile arthritis. A month later, during an examination by an infectious disease specialist in the doctor's office, he complains about pain in the ankle joints and weakness, as well as occasional poor sleep, frequent awakenings and infrequent heart palpitations. Findings: CBC, DBC, results of liver and kidney tests were normal. In accompanying discharge letter from the Pediatric Clinic, Dg. Polyarthralgiae, Tinea superficialis susp. All biochemical tests performed were normal, Ultrasonography of ankle joints and feet: no echo signs of pathological effusion. A hyperechoic edematous fascia is noticeable with a minimal effusion in this area. Due to the suspicion of chronic borreliosis with involvement of the skin, joints, ANS, eye, ear, and cardiovascular system, it was recommended to repeat the borreliosis serology ELISA + Immunioblot (not WB). The control results confirmed that the ELISA: IgM/IgG-At for Borrelia was negative, however, the advanced test for Borrelia Immunoblot showed positive antibodies to the p41+ IgM phase protein sequence and borderline positive antibodies to the p41 +/- IgG-phase protein sequence. Conclusion: Lyme disease is a disease that an experienced physician can diagnose based on a comprehensive history and clinical examination, despite negative serological tests. The ELISA technique in the diagnosis of Lyme disease should not be a criterion for diagnosing the disease because the specific antibodies it detects does not last for long time period.

Key words: Lyme disease, clinical diagnosis, serological diagnostics