Treatment of Borrelia Pseudolymphoma
For Borrelia pseudolymphoma, oral antibiotic therapy for 14 days is the recommended treatment approach. 1, 2
Understanding Borrelia Pseudolymphoma
Borrelia pseudolymphoma (also called borrelial lymphocytoma) is a rare cutaneous manifestation of early localized European Lyme borreliosis that presents as:
- A solitary nodule or plaque with diameter up to a few centimeters
- More common in children than adults, with male predominance
- Predilection sites: breast in adults, ear lobe in children
- Often associated with a history of tick bite at or near the lesion site
- Frequently accompanied by erythema migrans
- Predominantly caused by Borrelia afzelii in European cases 2
Diagnostic Considerations
Before initiating treatment, confirm the diagnosis:
- Clinical appearance: solitary bluish-red swelling with mild localized discomfort 1
- Histology: dense polyclonal B lymphocytic infiltration of cutis and subcutis, often with germinal centers 1
- Serology: approximately half of patients have measurable serum borrelial antibodies at presentation 2
- Culture: spirochetes can be cultivated from the skin lesion in about one-third of cases 2
- Differential diagnosis: malignant lymphoma, Paget's disease (when on breast nipple), eczema 3
Treatment Recommendations
First-Line Treatment:
- Oral antibiotic therapy for 14 days (weak recommendation, low-quality evidence) 1, 2
- Options include:
- Doxycycline 100 mg twice daily
- Amoxicillin 500 mg three times daily
- Phenoxymethylpenicillin
- Azithromycin for 5 days 4
For Disseminated Infection:
- If signs of disseminated borrelial infection are present or clinically suspected:
- Intravenous ceftriaxone or penicillin G for 14 days 4
Treatment Response and Prognosis
- Lesions typically disappear within a few weeks after starting treatment 4
- Speed of regression depends on the duration of lymphocytoma before treatment initiation 4
- Posttreatment duration is positively associated with:
- Pretreatment duration of the lesion
- Patient age
- Treatment failure is associated with clinical signs of disseminated Lyme borreliosis at presentation 2
- Overall prognosis is good with appropriate treatment 2
Important Clinical Considerations
- While comparative studies are limited, evidence suggests doxycycline and azithromycin have comparable effectiveness 4
- Amoxicillin appears effective, while phenoxymethylpenicillin may be less effective than newer antibiotics 4
- In cases where the lesion is on the breast nipple, it can be mistaken for Paget's carcinoma; proper diagnosis is crucial to avoid unnecessary surgery 3
- Some patients may be cured by antibiotic therapy alone, avoiding the need for excision 3
Special Situations
- For patients with signs of disseminated infection (such as neurological symptoms), more aggressive treatment may be needed 4, 5
- In cases with clonal lymphoid populations, closer follow-up may be warranted 3
- For pregnant women, children under 8 years, and those with antibiotic intolerances, amoxicillin is preferred over doxycycline 6
The early recognition and appropriate antibiotic treatment of Borrelia pseudolymphoma has significantly improved outcomes in recent decades, making it a generally mild disease with good prognosis when properly managed 2.