Lyme disease, skin manifestations in Croatia 1988-1990 Short report L YME DISEASE IS SPREADING TO THE SOUTH-EAST Skin manifestations in Croatia 1988-90 A. Kansky ABSTRACT An evaluation of the characteristic skin lesion caused by Borrelia burgdorferi in Croatia was attempted. Informations on erythema chronicum migrans (ECM), lymphocytoma cutis (LCC) and acrodermatitis chronica atrophicans (ACA) were evaluated. During the years 1988, 1989 and the firsthalf of 1990, 965 cases were reported: 907 ofECM (94 %), 42 ofLCC (4,3 %) and 16 of ACA (1, 7 %). The regi ona! distribution showed that skin manifestations ofLyme disease are not rare in the woody areas of Westem and Central Croatia, but the disease is rare in Istria and Dalmatia. KEYWORDS: Lyme disease, skin manifestations, Croatia, 1988-1990 period INTRODUCTION Lyme disease (Lyme borreliosis) is spread over large parts ofthe world. Ithas beendescribed inNorth America, Europe, China, J apan, Australia and in the former Soviet Union. Howeveritisnotevenly distributed but occursmorefrequently in certain areas. In the U.S.A. Lyme disease is often diagnosed in three districts: in the Northeast from Massachussets to Maryland, in Midwest in Wisconsin and Minnesota and in the West in Califomia and Oregon (1). A number of cases has been reported also from Texas (2). There is a little doubt that ali European states are involved in the transmission of Borrelia burgdorferi. N atural foci seem to be in certain woody areas ofWest Germany, Switzerland, France, Austria, Scandinavian countries, Slovenia and others acta dermatovenerologica A.P.A. Vol 1, 92, No 3 (3, 4). Lyme disease occuring in Europe may be milder and more likely to be characterized by erythema chronicum migrans (multiple lesions included) but less likely to have arthritic complications as compared to the cases observed in the U.S.A. (5), butan elevated number of arthritis cases was reported from Switzerland (4). Tick bites are not rarely observed in the Zagreb and other Croatian areas. For this reason an attempt to obtain informations onL yme disease in Croatia was made. Erythema chronicum migrans (ECM), lymphocytoma cutis (LCC) and acrodermatitis chronica atrophicans (ACA) are well known dermatological entities and if typical they are easy to diagnose. As these dermatological entities are usually caused by Borrelia burgdorferi (Bb ), ECM, LCC and ACA were chosen 93 Lyme disease, ski11 ma11ifesrario11s in Croaria 1988-1990 as parameters to be used in order to assess the occurence of the Lyme disease in Croatia. The years 1988, 1989 and the first half of 1990 were covered. The unfavorable political situation later on did not allow to carry on this study. Dermatologists from ali dermatological departments and dermatological outpatient services in Croatiahave cooperated. It was agreed before the study started that reports would be sent in for each year separately. RESULTS During the two and a half years 965 cases of ECM, LCC and ACA were registered. Details are presented in table l. ECM cases are representative of the first and LCC usually of the second stage of the early phase of the Lyme disease, OGULIN ~ ZAGREB 187 o SISAK 103 o whereas ACA is typical manifestation of the late phase. The regional distribution of788 cases observed during the years 1988 and 1989 is presented in figure 1. As it can be seen skin manifestations characteristic of the Lyme disease were observed in elevated numbers in cities situated near larger woody areas like Zagreb, Zabok, Koprivnica, Virovitica, Sisak, Karl ovac and Ogulin. The above mentioned cities are in the Central and Northem Croatia. In contrast to this there were few cases ofECM, LCC and ACA observed in Istria and Dalmatia, which are known tourist areas. An exception are the surroundings of Šibenik including the Krka river where such clinical manifestation were not rare. The data presented include only skin symptoms and may NOVA GRADIŠKA :!5 o SLAVONSKI BROD 39 o OSIJEK 19 o Figure]. Frequency of skin manifestations ofLyme-disease in Croatia in the years 1988 and 1989 94 acta dermatovenerologica A.P A. Vol 1, 92 , No 3 Lyme disease, skin manifestations in Croatia 1988-1990 be considered as a rather rough estimate of Lyme disease manifestations in Croatia. The observation of so many ECM. LCC and ACA cases shows however inequivocally thatin the woody areas ofZagorje. Kalnik. Westem Slavonija, Banija and Gorski Kotar skin manifestations caused by Bb are rather frequent. The conclusion is justified that the Lyme disease is not only limited to Central and Northem Europe, as it has been assumed. The general physicians, rheumatologists and doctors of other specialties should be aware ot these characteristic skin manifestations in order to recognize and successfully treat patients with Lyme disease. Table 1 Skin manifestations ofLyme disease in Croatia Year 1988 1989 1990 total number ECM - LCC - ACA - Diagnosis Tota! number % ECM LCC ACA 377 20 10 407 365 13 3 381 165 9 3 178 907 42 16 965 Erythema chronicum migrans Lymphocytoma cutis Acrodem1atitis chronica atrophicans 94,0 4,3 1,7 100,0 REFERENCES l. Steere AC. Borrelia burgdorferi (Lyme disease). In Mandell GL, Douglas RG, BenettJE. Principles and Practice of Infectious Diseases. Churchill - Livingston. New York 1990, 1819-27 2. Teltow GJ, Foumier PV, Rawlings JA. Isolation of Borrelia burgdorferi from arthropods collected in Texas. Amer J Trop Med Hyg 1991; 44: 469-74 3. WHO Reg Office Europe. Lyme borreliosis. Report on WHO seminar Prague. 14-17 November 1989 4. Stanek G, Pletschette M, Flarnm H et al. European Lyme Borreliosis. Ann New York Acad Sci 274-282 5. Schmid GP. The globa! distribution ofLyme disease. Rev InfectDis 1985; 7: 41-50 AUTHOR'S ADDRESS Aleksej Kansky M.O., Ph.D., professor of dermatology. Štihova 26. 61000 Ljubljana. Slovenia acta dermatovenerologica A.P A. Vol 1, 92, No 3 95