Neurologische Komplikationen bei Akrodermatitis chronica atrophicans (Herxheimer) und ihre Beeinflussung durch die Penicillintherapie.
Kaiser M. Dissertation in German 1972, University of Göttingen.
Scanned with Imaging for Windows95/98.   72_01 Neurocompl ACA Penicillin.tif

[NOTE The following is not a full translation of all the German text just part of it]  

Out of a total of 242 in whom ACA was diagnosed in 1958-70, in the University Dermatology Clinic in Göttingen, Germany - 167 patients were invited by letter and 120 of these patients could be evaluated.
Patients older than 70 were not included, a few had other complicating diseases, some were lost due to insufficient address, and a few had died.   Material:
During years 1958-68, 78 of 128 women came (60,9%) and 29 of 39 men came (77,4%??, I get this to 74,4%), totalling 107 patients.
During 169-70, 12 patients, 4 men and 8 women were included and 1 woman couldn't be re-evaluated, but is included in the report.

All patients had a thorough neurological evaluation, especially regarding sensibility disturbances (pain, touch, temperature, 2-point discrimination, vibration, digit-discrimination test). Author discuss the difficulty of repeating these subjective findings.
11 patients, 2 men and 9 women were excluded due to atypical presentation at time of reevaluation or course of skin disease, leaving 109 patients, of whom 76 were women and 33 men..
sexratio female:male=2,3:1 (69,7%:30,7%) - compared to all patients diagnosed with ACA 1958-70: 188 women and 66 men, i.e. a sex-ratio of 3,5:1.
Mean age of the 109 patients for first treatment was 47 years (14-67). At time of neurological evaluation mean age: 53 years (16-70).

The anamnestic duration of skin problems was mean 3,6 years (2 mo - 25 years). Total duration of disease at time of study was mean 10 years.
Regarding the relation between penicillin treatment and re-evaluation, the patients were divided in 3 groups:

34% only one extremity involved
38% either both arms or both legs
28% legs as well as arms
Upper extremities: 24%, lower extremities: 48%, all four 28%.
Extreme atrophy: 8,5%
Medium atrophy: 11,5%
Slight atrophy: 27%
Other skin manifestations than atrophy: 53%  
The patients often (51) had other subjective complaints and a great number had neurological deficits (44). The authors problem was to determine if and how these symptoms and findings were related to the skin disease.
28 patients with neurological findings formed a separate group, among these 18 had another possible cause of the neurological problems - but many of these symptoms is now known to be part of the picture we today know as Lyme disease.
The remaining 81 patients:
- 44 had subjective symptoms and objective neurological deficits which could be attributed to ACA with a high degree of probablilty - most symptoms were of polyneuropathic nature, sensory disturbances
- objective findings:
reduced vibration sense (36)
reduced 2-punct discrimination (19)
hypestesia (10)
hypalgesia (8)
""hyperpathie"" (6)
motoric (3) muscle atrophy, palsy,
reduced or total lack of achilles tendon reflex (7)    
- 51 patients had only subjective symptoms - 80% improved after penicillin
13 had itch, hyperpathie, tenseness -> 11 asymptomatic, 1 relapse, 1 rest symptom
10 cold or warm sense -> 8 asymptomatic, 1 relapse, 1 rest symptom
5 numbness -> all asymptomatic
17 pain -> 11 improved, 2 unchanged
20 fatigue or weakness or fascicular movements -> 13 asymptomatic, 5 unchanged, 2 only seen before treatment
5 cramps -> 3 asymptomatic, 1 relapse (fasciculations), 1 unchanged   - 8 patient without relapse were examined both before and after penicillin treatment (not specified); 4/5 of the subjective symptoms and 4/5 of the objective findings improved or completely resolved (3/5). Sensory disturbances:
1 warm, 4 parestsias, 2 pain, 3 fatigue or weakness, 2 muscle cramps.
Objective findings: weak mm. Interossei 1, weak achilles tendon reflex, 1 digit discrimination, 2 vibration sense, 4 hypaestesia (2 glove or sock formed distal area), 1 hypalgesia (glove), 3 hyperpathia (local in the affected area), 2 hyperaesresia (red skin area).   - patients with extreme atrophy more often had neurological defecits than those with milder atrophy.
- there was a clear, but due to small number not significant, relation between duration and/or age of the patient and neurological symptoms.
- overweigth of women
- relapses were seen  

My comments:
The patients were ALL treated with penicillin one or more times, but dose, administration and duration was not specified at all - so it is impossible to evaluate the cause of relapses in more detail.
Despite describing clear effect of penicillin treatment on neurological symptoms as well as on ACA - the author doesn't discuss the possible etiology of the disease as being an infection especially he does not mention a spirochete as the possible culprit - this is remarkable as it was proposed much earlier by Lennhoff, Hollström and several others.
Looking at the reference list: of the Scandinavian's only Thyresson and Pirilä's work are mentioned, and  lot of German works, but it is quite surprising that Afzelius, Hollström, Hellerström and Lennhoff's work is not mentioned at all - Why not??