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An immunocompetent male in his 70s was diagnosed with psoriatic arthritis based on dactylitis, onycholysis of the nails and scalp psoriasis. He was treated with corticosteroids, methotrexate and local corticosteroid injections without improvements in his symptoms. When tumor necrosis factor-alpha inhibitor treatment was introduced, the symptoms worsened and dactylitis of all digits and a bluish-red rash were observed on the extensor side of the left hand and arm. At this point, a skin biopsy was performed showing histopathological changes compatible with Lyme borreliosis and serum contained IgG antibodies against Borrelia burgdorferi. It was concluded that he was suffering from acrodermatitis chronica atrophicans (ACA) and Lyme dactylitis. Ten days of phenoxymethylpenicillin treatment was initiated, and after 2 weeks, the dactylitis and ACA had regressed substantially. After 6 months, both had resolved. This case emphasises the need for clinical reassessment, when treatment is not effective. [ABSTRACT FROM AUTHOR]

Background Our objectives were to improve the following outcomes in patients with Lyme borreliosis (LB) through an educational intervention in general practice: (i) increase the number of hospital referrals on suspicion of LB, (ii) increase the number of cerebrospinal fluid (CSF) tests examined for Borrelia burgdorferi antibody index, (iii) decrease the number of serum- B. burgdorferi antibody tests ordered, (iv) shorten delay from symptom onset to hospital in Lyme neuroborreliosis (LNB) patients, (v) increase LB knowledge among general practitioners. Methods A prospective non-blinded non-randomized intervention trial on the island of Funen, Denmark. The intervention included oral and written education about LB and was carried out in areas with an LNB incidence ≥4.7/100.000 between 22 January 2019 and 7 May 2019. Results were compared between the intervention group (49 general practices) and the remaining general practices in Funen (71 practices) 2 years before and after the intervention. Results In the study period, 196 patients were referred on suspicion of LB, a 28.9% increase in the intervention group post-intervention, 59.5% increase in the control group (P  = 0.47). The number of CSF- Borrelia -antibody index tests increased 20.8% in the intervention group, 18.0% in the control group (P  = 0.68), while ordered serum- B. burgdorferi antibody tests declined 43.1% in the intervention group, 34.5% in the control group (P  = 0.30). 25.1% had the presence of serum- B. burgdorferi antibodies. We found no difference in LNB pre-hospital delay before and after intervention or between groups (P  = 0.21). The intervention group performed significantly better on a follow-up questionnaire (P  = 0.02). Conclusion We found an overall improvement in LB awareness and referrals among general practitioners but could not show any effect of the intervention on clinical outcomes of LNB. [ABSTRACT FROM AUTHOR]

Background: Large health care databases are a valuable source of infectious disease epidemiology if diagnoses are valid. The aim of this study was to investigate the accuracy of the recorded diagnosis coding of herpes simplex encephalitis (HSE) in the Danish National Patient Registry (DNPR). Methods: The DNPR was used to identify all hospitalized patients, aged =15 years, with a firsttime diagnosis of HSE according to the International Classification of Diseases, tenth revision (ICD-10), from 2004 to 2014. To validate the coding of HSE, we collected data from the Danish Microbiology Database, from departments of clinical microbiology, and from patient medical records. Cases were classified as confirmed, probable, or no evidence of HSE. We estimated the positive predictive value (PPV) of the HSE diagnosis coding stratified by diagnosis type, study period, and department type. Furthermore, we estimated the proportion of HSE cases coded with nonspecific ICD-10 codes of viral encephalitis and also the sensitivity of the HSE diagnosis coding. Results: We were able to validate 398 (94.3%) of the 422 HSE diagnoses identified via the DNPR. Hereof, 202 (50.8%) were classified as confirmed cases and 29 (7.3%) as probable cases providing an overall PPV of 58.0% (95% confidence interval [CI]: 53.0-62.9). For "Encephalitis due to herpes simplex virus" (ICD-10 code B00.4), the PPV was 56.6% (95% CI: 51.1-62.0). Similarly, the PPV for "Meningoencephalitis due to herpes simplex virus" (ICD-10 code B00.4A) was 56.8% (95% CI: 39.5-72.9). "Herpes viral encephalitis" (ICD-10 code G05.1E) had a PPV of 75.9% (95% CI: 56.5-89.7), thereby representing the highest PPV. The estimated sensitivity was 95.5%. Conclusion: The PPVs of the ICD-10 diagnosis coding for adult HSE in the DNPR were relatively low. Hence, the DNPR should be used with caution when studying patients with encephalitis caused by herpes simplex virus. [ABSTRACT FROM AUTHOR]

Tick-borne encephalitis (TBE) is a viral tick-borne infection occurring in many parts of Europe and Asia as described in this review. Increasing TBE case numbers have been reported over recent decades. In Denmark the infection is rare (1-14 annual cases). The rise in TBE in Denmark is mainly driven by microfoci outside of Bornholm, primarily North Zealand. Clinical illness has a bi-phasic presentation: "summer-flu" which may be followed by a neuroinfection. No specific treatment exists, and mortality is less-than 1%. A considerable percentage of patients may experience neurological sequelae. TBE is preventable through vaccination., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Tick-borne encephalitis virus (TBEV) is spreading geographically, and new risk areas are expected throughout Denmark. In this case report, we describe the first Danish case of vaccine breakthrough tick-borne encephalitis (TBE) in a 76-year old female suffering from severe symptoms with need of intensive-care therapy. We want to draw attention to TBE as a differential diagnosis in all undiagnosed patients with symptoms of viral encephalitis, regardless of travel history and vaccine status. TBEV can cause severe disease, especially in the elderly. Patients with vaccine breakthrough infection may develop a more severe disease than non-vaccinated.

The castor bean tick, Ixodes ricinus, is common in woodlands in most of Denmark. Besides Borrelia burgdorferi, it can harbour a number of pathogenic microorganisms such as tick-borne encephalitis virus, Anaplasma phagocytophilum, Rickettsia helvetica, Francisella tularensis, Candidatus Neoehrlichia mikurensis, Bartonella spp., Borrelia miyamotoi and Babesia spp. These tick-borne infections should be a differential diagnostic consideration during the tick season in Denmark. We review the distribution, clinical manifestations, diagnosis and treatment of these microorganisms.