Cognitive functioning in late Lyme borreliosis

Language Fluency Deficits in Post-treatment Lyme Disease Syndrome

OBJECTIVE

Recent neurocognitive studies of patients with post-treatment Lyme disease syndrome (PTLDS) find consistent deficits in memory and processing speed. Language fluency deficits are observed as well but may be secondary to poor memory and slowing rather than an independent deficit.

METHOD

This study performed a secondary analysis of data presented previously, including individuals with PTLDS and comparison samples of healthy volunteers (HC) and patients with major depressive disorder (MDD), to determine if language fluency deficits could be accounted for by poor performance in these other neurocognitive domains.

RESULTS

Basic verbal abilities, memory, and processing speed were all significantly associated with fluency performance. MDD patients' fluency deficits relative to HC were accounted for by these covariates. However, PTLDS patients' poorer fluency performance relative to both other groups was not.

CONCLUSIONS

Language fluency appears to be an independent area of neurocognitive deficit within the constellation of PTLDS symptoms.

Neuropsychiatric Symptoms and Tick-Borne Diseases

In North America, Lyme disease (LD) is primarily caused by the spirochetal bacterium Borrelia burgdorferi, transmitted to humans by Ixodes species tick bites, at an estimated rate of 476,000 patients diagnosed per year. Acute LD often manifests with flu-like symptoms and an expanding rash known as erythema migrans (EM) and less often with neurologic, neuropsychiatric, arthritic, or cardiac features. Most acute cases of Lyme disease are effectively treated with antibiotics, but 10-20% of individuals may experience recurrent or persistent symptoms. This chapter focuses on the neuropsychiatric aspects of Lyme disease, as these are less widely recognized by physicians and often overlooked. Broader education about the potential complexity, severity, and diverse manifestations of tick-borne diseases is needed.

Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis

Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis.

This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults.

Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany).

The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.

Cognitive impairments in patients with persistent symptoms attributed to Lyme disease

Background

Persistent symptoms attributed to Lyme borreliosis often include self-reported cognitive impairment. However, it remains unclear whether these symptoms can be substantiated by objective cognitive testing.

Methods

For this observational study, cognitive performance was assessed in 280 adults with persistent symptoms attributed to Lyme borreliosis (as part of baseline data collected for the Dutch PLEASE study). Cognitive testing covered the five major domains: episodic memory, working memory / attention, verbal fluency, information-processing speed and executive function. Patients’ profiles of test scores were compared to a large age-, education- and sex-adjusted normative sample using multivariate normative comparison. Performance validity was assessed to detect suboptimal effort, and questionnaires were administered to measure self-reported cognitive complaints, fatigue, anxiety, depressive symptoms and several other psychological factors.

Results

Of 280 patients, one was excluded as the test battery could not be completed. Of the remaining 279 patients, 239 (85.4%) displayed sufficient performance validity. Patients with insufficient performance validity felt significantly more helpless and physically fatigued, and less orientated. Furthermore, they had a lower education level and less often paid work. Of the total study cohort 5.7% (n = 16) performed in the impaired range. Among the 239 patients who displayed sufficient performance validity, 2.9% (n = 7) were classified as cognitively impaired. No association between subjective cognitive symptoms and objective impairment was found.

Conclusions

Only a small percentage of patients with borreliosis-attributed persistent symptoms have objective cognitive impairment. Performance validity should be taken into account in neuropsychological examinations of these patients. Self-report questionnaires are insufficiently valid to diagnose cognitive impairment.

Trial registration

ClinicalTrials.gov NCT01207739. Registered 23 September 2010.

Cognitive Decline in Post-treatment Lyme Disease Syndrome

OBJECTIVE

Patient-reported cognitive complaints are common in those with post-treatment Lyme disease syndrome (PTLDS). Objective evidence of cognitive impairment in this population is variable in part due to methodological variability in existing studies. In this study, we sought to use a systematic approach to characterizing PTLDS based on the most current consensus diagnosis. We further examined PTLDS-related cognitive decline, operationalized as a significant decline in cognitive test performance relative to premorbid cognitive ability.

METHOD

We enrolled a case series of 124 patients with confirmed PTLDS defined by Infectious Diseases Society of America-proposed case definition. Cognitive functioning was evaluated using standardized neuropsychological measures.

RESULTS

The majority (92%) of participants endorsed some level of cognitive difficulty, yet 50% of the sample showed no statistically or clinically significant cognitive decline, 26% of the sample evidenced significant cognitive decline on measures of memory and variably on measures of processing speed, and 24% of the sample were excluded from analyses due to suboptimal test engagement.

CONCLUSIONS

The current findings are consistent with the literature showing that the most robust neurocognitive deficit associated with PTLDS is in verbal memory and with variable decline in processing speed. Compared to population normative comparison standards, PTLDS-related cognitive decline remains mild. Thus, further research is needed to better understand factors related to the magnitude of subjective cognitive complaints as well as objective evidence of mild cognitive decline.

Effect of prolonged antibiotic treatment on cognition in patients with Lyme borreliosis

Objective

To investigate whether longer-term antibiotic treatment improves cognitive performance in patients with persistent symptoms attributed to Lyme borreliosis.

Methods

Data were collected during the Persistent Lyme Empiric Antibiotic Study Europe (PLEASE) trial, a randomized, placebo-controlled study. Study participants passed performance-validity testing (measure for detecting suboptimal effort) and had persistent symptoms attributed to Lyme borreliosis. All patients received a 2-week open-label regimen of intravenous ceftriaxone before the 12-week blinded oral regimen (doxycycline, clarithromycin/hydroxychloroquine, or placebo). Cognitive performance was assessed at baseline and after 14, 26, and 40 weeks with neuropsychological tests covering the cognitive domains of episodic memory, attention/working memory, verbal fluency, speed of information processing, and executive function.

Results

Baseline characteristics of patients enrolled (n = 239) were comparable in all treatment groups. After 14 weeks, performance on none of the cognitive domains differed significantly between the treatment arms (p = 0.49–0.82). At follow-up, no additional treatment effect (p = 0.35–0.98) or difference between groups (p = 0.37–0.93) was found at any time point. Patients performed significantly better in several cognitive domains at weeks 14, 26, and 40 compared to baseline, but this was not specific to a treatment group.

Conclusions

A 2-week treatment with ceftriaxone followed by a 12-week regimen of doxycycline or clarithromycin/hydroxychloroquine did not lead to better cognitive performance compared to a 2-week regimen of ceftriaxone in patients with Lyme disease–attributed persistent symptoms.

ClinicalTrials.gov identifier

NCT01207739.

Classification of evidence

This study provides Class II evidence that longer-term antibiotics in patients with borreliosis-attributed persistent symptoms does not increase cognitive performance compared to shorter-term antibiotics.

Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist's Clinical Practice

There is increasing evidence and recognition that Lyme borreliosis (LB) causes mental symptoms. This article draws from databases, search engines and clinical experience to review current information on LB. LB causes immune and metabolic effects that result in a gradually developing spectrum of neuropsychiatric symptoms, usually presenting with significant comorbidity which may include developmental disorders, autism spectrum disorders, schizoaffective disorders, bipolar disorder, depression, anxiety disorders (panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, intrusive symptoms), eating disorders, decreased libido, sleep disorders, addiction, opioid addiction, cognitive impairments, dementia, seizure disorders, suicide, violence, anhedonia, depersonalization, dissociative episodes, derealization and other impairments. Screening assessment followed by a thorough history, comprehensive psychiatric clinical exam, review of systems, mental status exam, neurological exam and physical exam relevant to the patient's complaints and findings with clinical judgment, pattern recognition and knowledgeable interpretation of laboratory findings facilitates diagnosis. Psychotropics and antibiotics may help improve functioning and prevent further disease progression. Awareness of the association between LB and neuropsychiatric impairments and studies of their prevalence in neuropsychiatric conditions can improve understanding of the causes of mental illness and violence and result in more effective prevention, diagnosis and treatment.

Lyme and Dopaminergic Function: Hypothesizing Reduced Reward Deficiency Symptomatology by Regulating Dopamine Transmission

The principal vector of Lyme disease in the United States is Ixodes scapularis: black legged or deer ticks. There is increased evidence that those infected may be plagued by anxiety or depression as well. Researchers have identified transcripts coding for two putative cytosolic sulfotransferases in these ticks, which recognized phenolic monoamines as their substrates. It is hypothesized that protracted Lyme disease sequelae may be due to impairment of dopaminergic function of the brain reward circuitry. The subsequent recombinant proteins exhibited sulfotransferase function against two neurotransmitters: dopamine and octopamine. This, in itself, can reduce dopamine function leading to many Reward Deficiency Syndrome behaviors, including depression and possibly, anxiety. In fact, it was shown that activity of Ixosc Sult 1 and Sult 2 in the Ixodid tick salivary glands might contain inactivation of the salivation signal through sulfonation of either dopamine or octopamine. This infraction results in a number of clinically observed mood changes, such as anxiety and depression. In fact, there are common symptoms observed for both Parkinson and Lyme diseases. The importance of understanding the mechanistic and neurobiological effects of Lyme on the central nervous system (CNS) provides the basis for pro-dopamine regulation as a treatment. WC 195

Nervous System Lyme Disease

Nervous system involvement occurs in 10% to 15% of patients infected with the tick-borne spirochetes Borrelia burgdorferi, B afzelii, and B garinii. Peripheral nervous system involvement is common. Central nervous system (CNS) involvement, most commonly presenting with lymphocytic meningitis, causes modest cerebrospinal fluid (CSF) pleocytosis. Parenchymal CNS infection is rare. If the CNS is invaded, however, measuring local production of anti-B burgdorferi antibodies in the CSF provides a useful marker of infection. Most cases of neuroborreliosis can be cured with oral doxycycline; parenteral regimens should be reserved for patients with particularly severe disease.

Neurocognitive functions and brain atrophy after proven neuroborreliosis: a case-control study

Background

Patients often report neurocognitive difficulties after neuroborreliosis (NB). The frequency and extent of cognitive problems in European patients have been studied incompletely.

Methods

Sixty patients received a neurological and neuropsychological work-up 6 months or longer after treatment for proven NB. Quality of life, psychiatric symptom load, and brain atrophy were measured. All results were compared with a group of 30 healthy control persons adapted for age, gender and education being serologically negative for Borrelia burgdorferi senso latu. A cognitive sum score and a global sum score including cognitive, psychological results and quality of life data was calculated for both groups.

Results

Patients after NB showed a lower (i.e. more impaired) score on the Scripps Neurological rating scale (SNRS), but the observed neurological deficits were generally mild (mean ± SD: 97.1 ± 4.7 vs. 99.1 ± 2.4, p = 0.02). The mean neuropsychological domain results of the NB group were all within the normal range. However, a lower performance was found for the frontal executive function z-values (mean ± SD –0.29 ± 0.60 vs. 0.09 ± 0.60; p = 0.0059) of NB patients. Comparing the global sum score (mean ± SD 11.3 ± 4.2 _NB vs. 14.3 ± 2.9 _control, p = 0.001) and the cognitive sum score of the NB group with those of the control group (mean ± SD -0.15 ± 0.42 _NB vs. 0.08 ± 0.31 _control, p = 0.0079), both differences were statistically different. The frequencies of impaired global sum scores and those of the pathological cognitive sum scores (p = 0.07) did not differ statistically. No significant differences were found for health-related quality of life (hrQoL), sleep, psychiatric symptom load, or brain atrophy.

Conclusion

The mean cognitive functions of patients after proven NB were in the normal range. However, we were able to demonstrate a lower performance for the domain of frontal executive functions, for the mean cognitive sum score and the global sum score as a sign of subtle but measurable sequelae of neuroborreliosis. Brain atrophy is not a common consequence of neuroborreliosis.

Nervous system lyme disease

Lyme disease, a multisystem spirochetal infection, continues to be the subject of considerable debate, but not controversy. Recent years have seen improvements in diagnostic tools, better understanding of pathophysiology, and increasing evidence of efficacy of standard treatment regimens. Nervous system involvement is particularly confusing to patients and many physicians. A rational approach based on objective findings can clarify the cause and dictate the best treatment of patients' difficulties. Diagnosis for all but the earliest cases rests on the combination of likely contact with infected Ixodes ticks and laboratory confirmation of exposure to the causative organism, Borrelia burgdorferi (two-tier serology, combining ELISA with a confirmatory Western blot). Treatment is generally with oral antimicrobials such as doxycycline. Parenteral regimens are usually necessary only for the most severe cases.

Nervous system Lyme disease

Lyme disease, the multisystem infectious disease caused by the tick-borne spirochete Borrelia burgdorferi involves the nervous system in 10-15% of affected individuals. Manifestations include lymphocytic meningitis, cranial neuritis, radiculoneuritis, and mononeuropathy multiplex. Encephalopathy, identical to that seen in many systemic inflammatory diseases, can occur during active systemic infection. It is not specific to Lyme disease and only rarely is evidence of nervous system infection. Diagnosis of systemic disease is based on demonstration of specific antibodies in peripheral blood by means of two-tier testing with an ELISA and Western blot. Central nervous system infection often results in specific antibody production in the CSF, demonstrable by comparing spinal fluid to blood serologies. Treatment is straightforward and curative in most instances. Many patients can be treated effectively with oral antibiotics such as doxycycline; in severe CNS infection parenteral treatment with ceftriaxone or other similar agents is highly effective. Treatment should usually be for 2 to at most 4 weeks. Longer treatment adds no therapeutic benefit but does add substantial risk.

Correlates of perceived health-related quality of life in post-treatment Lyme encephalopathy

BACKGROUND

Marked functional impairment has been reported by patients with post-treatment Lyme disease syndrome (PTLDS).

OBJECTIVE

We sought to identify the clinical features that contribute most strongly to the impaired health status associated with PTLDS.

METHODS

Enrolled patients had a well-documented history of Lyme disease, prior treatment with at least 3 weeks with intravenous ceftriaxone, a positive IgG Western blot, and objective problems with memory. An index score to capture aggregate cognitive functioning, Short-Form 36 physical and mental component summary scores, and scores on other clinical and demographic measures were examined. Multiple linear regressions were performed to determine significant predictors of perceptions of impaired life functioning as delineated by the Short-Form 36.

RESULTS

Fatigue was the most important contributor to perceived impairments in overall physical functioning, and fatigue and depression significantly predicted perceived impairments in overall mental functioning.

CONCLUSIONS

Because fatigue and depression contribute prominently to reports of impaired physical functioning and mental functioning among patients with PTLDS, clinicians should assess patients for these symptoms and consider targeting these symptoms in the selection of treatment interventions. Future controlled studies should examine the effectiveness of such agents for patients with PTLDS.

Neurologic manifestations of lyme disease

Borrelia burgdorferi infection, the tick-borne spirochetosis known as Lyme disease or Lyme borreliosis, involves the nervous system (neuroborreliosis) in 10% to 15% of patients. Common manifestations include lymphocytic meningitis, cranial neuritis, mononeuropathy multiplex, and painful radiculoneuritis. Rare patients develop inflammation in the brain or spinal cord. Regardless of the form of involvement, neuroborreliosis can be microbiologically cured in virtually all patients using standard 2- to 4-week antimicrobial regimens. Oral regimens appear to be as effective as parenteral ones in most instances. Although patients ill with Lyme disease may have concomitant cognitive or memory difficulty, these symptoms are not specific to neuroborreliosis and, when present in isolation, should not be viewed as suggestive of this diagnosis. When present as part of Lyme disease, they do not require additional or different treatment.

European neuroborreliosis: neuropsychological findings 30 months post-treatment

BACKGROUND

The aim of this study was to compare neuropsychological (NP) functioning in patients with Lyme neuroborreliosis (LNB) 30months after treatment to matched controls.

METHODS

We tested 50 patients with LNB and 50 controls with the trail-making test (TMT), Stroop test, digit symbol test, and California Verbal Learning test (CVLT). A global NP sumscore was calculated to express the number of low scores on 23 NP subtasks.

RESULTS

Mean scores were lower amongst LNB-treated patients than amongst controls on tasks assessing attention/executive functions: (Stroop test 4: 77.6 vs. 67.0, P=0.015), response/processing speed (TMT 5: 23.4 vs. 19.2, P=0.004), visual memory (digit symbol recall: 6.6 vs. 7.2, P=0.038), and verbal memory (CVLT list B: 4.68 vs. 5.50, P=0.003). The proportion of patients and controls with NP sumscores within one SD from the mean in the control group (defined as normal) and between one and two SD (defined as deficit) were similar, but more LNB-treated patients than controls had a sumscore more than two SD from the mean (defined as impairment) (8 vs. 1, P=0.014).

CONCLUSIONS

As a group, LNB-treated patients scored lower on four NP subtasks assessing processing speed, visual and verbal memory, and executive/attention functions, as compared to matched controls. The distribution of NP dysfunctions indicates that most LNB-treated patients perform comparable to controls, whilst a small subgroup have a debilitating long-term course with cognitive problems.

[Neuroborreliosis]

Neuroborreliosis is easily diagnosed by means of clinical symptoms and laboratory findings. Guiding symptoms are radicular pain and pareses of the extremities and the facial nerve. There is a great number of further less frequently occurring neurological symptoms, which can be attributed to a borrelial infection only by appropriate investigations of the CSF. Radiculitis is cured adequately by oral doxycycline while symptoms of the central nervous system are probably better treated intravenously by ceftriaxone, cefotaxime or penicillin G. Post-Lyme syndrome is a diffuse description of non-specific complaints, which are not the explicit result of a former infection with B. burgdorferi. As further antibiotics do not help and the CSF is unremarkable in most patients, a persistent infection with B. burgdorferi s.l. in all probability can be excluded.

Lyme disease--current state of knowledge

BACKGROUND

Lyme disease is the most frequent tick-borne infectious disease in Europe. The discovery of the causative pathogen Borrelia burgdorferi in 1982 opened the way for the firm diagnosis of diseases in several clinical disciplines and for causal antibiotic therapy. At the same time, speculation regarding links between Borrelia infection and a variety of nonspecific symptoms and disorders resulted in overdiagnosis and overtreatment of suspected Lyme disease.

METHOD

The authors conducted a selective review of the literature, including various national and international guidelines.

RESULTS

The spirochete Borrelia burgdorferi sensu lato is present in approximately 5% to 35% of sheep ticks (Ixodes ricinus) in Germany, depending on the region. In contrast to North America, different genospecies are found in Europe. The most frequent clinical manifestation of Borrelia infection is erythema migrans, followed by neuroborreliosis, arthritis, acrodermatitis chronica atrophicans, and lymphocytosis benigna cutis. Diagnosis is made on the basis of the clinical symptoms, and in stages II and III by detection of Borrelia-specific antibodies. In adults erythema migrans is treated with doxycycline, in children with amoxicillin. The standard treatment of neuroborreliosis is third-generation cephalosporins.

CONCLUSIONS

After appropriate antibiotic therapy, the outcome is favorable. In approximately 95% of cases neuroborreliosis is cured without long-term sequelae. When chronic borreliosis is suspected, other potential causes of the clinical syndrome must be painstakingly excluded.

Memory and executive functions in adolescents with posttreatment Lyme disease

Although adults with late stage posttreatment Lyme disease often experience difficulties in memory, little is known about the relationship between cognition and Lyme disease in children and adolescents. Twenty-five adolescents with late stage posttreatment Lyme disease (symptoms > 6 months) and 25 participants without Lyme disease (matched on gender, IQ, age, socioeconomic status) were assessed for neuropsychological functioning, depression, school functioning, and predisease academic achievement. The Lyme group had significant deficits in cognition (short-term visual memory, short-term and delayed verbal memory, all forms of recognition memory), as well as worse attendance, grades, and subjective reports of memory problems, without differing in predisease achievement or depression. Deficits in visual memory exceeded deficits in verbal memory-a striking difference from what is reported in adults. These results reveal that adolescents with a history of treated Lyme disease are at risk for long-term problems in cognition and school functioning.

Certains symptômes cliniques aspécifiques ont-ils une origine borrélienne?

Chronic manifestations (knee arthritis, encephalomyelitis, axonal polyneuropathy) may occur in the late phase of Lyme disease. Contrasting with such well-defined manifestations, the "post-Lyme syndrome" includes symptoms such as fatigue, algia, malaise, cognitive disorders, after treatment of a documented Lyme disease. The analysis of clinical, neuropsychological, bacteriological, immunological, epidemiological, quality of life, and treatment data does not support the reality of such a syndrome. Moreover, no physiopathological data can relate Borrelia infection to such symptoms in patients without previously documented Lyme disease symptoms but who are seropositive (or even sometimes without serodiagnosis as for instance in the Munchausen by proxy, or Gulf war syndromes).

Aspects neurologiques et psychiatriques au cours de la maladie de Lyme

The neurological and psychiatric manifestations of Borrelia burgdorferi sensu lato are so numerous that Borrelia is also called the "new great imitator". Thus knowing about the multiple clinical aspects of neuroborreliosis is necessary for the clinician. We reviewed literature for "classical" neuroborreliosis such as acute meningoradiculitis or chronicle encephalomyelitis, but also for encephalitis, myelitis, polyneuritis, radiculitis and more controversial disorders such as chronic neurological disorders, ischemic and hemorrhagic stroke, and motor neuron disease. We specified every time on which basis each disorder was attributed to Lyme disease, particularly if European or American criteria were met. Every part of the nervous system can be involved: from central to peripheral nervous system, and even muscles. In endemic areas, Lyme serology must be assessed in case of unexplained neurological or psychiatric disorder. In case of positive serology, CSF assessment with intrathecal anti-Borrelia antibody index will be more efficient to prove the diagnosis.

Long-term neuropsychological deficits after central nervous system infections despite adequate therapy

Neuropsychological deficits are common consequences of central nervous system infections despite adequate treatment. The frequency and severity depends on the causative pathogen and the site(s) of injured brain parenchyma. The severity ranges from mild cognitive abnormalities not interfering with everyday life performance to fully developed Wernicke-Korsakow syndrome with complete inability to incorporate new information into long-term memory and to persistent vegetative state. In several conditions, rapid initiation of adequate therapy is crucial to minimise neuropsychological impairment.

The relationship between subjective fatigue and cognitive fatigue in advanced multiple sclerosis

The present study examined the cognitive performance and ratings of subjective fatigue in people with advanced MS and matched healthy control participants. A continuous n-back task, involving attention (0-back), was performed at the beginning and end of one testing session; a task involving working memory (1-back) was performed at the beginning and end of another testing session. Subjective fatigue was rated at regular intervals during each session. Overall, there was limited evidence of objective cognitive fatigue in the MS group, as assessed by the change in n-back performance during the sessions. The MS group did report a greater increase, than the control group, in the level of subjective fatigue during the 1-back testing session, but change in subjective fatigue did not correlate significantly with change in cognitive performance. The implications of these findings for our understanding of cognitive fatigue in MS are discussed.

WAIS-III and WMS-III performance in chronic Lyme disease

There is controversy regarding the nature and degree of intellectual and memory deficits in chronic Lyme disease. In this study, 81 participants with rigorously diagnosed chronic Lyme disease were administered the newest revisions of the Wechsler Adult Intelligence Scale (WAIS-III) and Wechsler Memory Scale (WMS-III), and compared to 39 nonpatients. On the WAIS-III, Lyme disease participants had poorer Full Scale and Performance IQ's. At the subtest level, differences were restricted to Information and the Processing Speed subtests. On the WMS-III, Lyme disease participants performed more poorly on Auditory Immediate, Immediate, Auditory Delayed, Auditory Recognition Delayed, and General Memory indices. Among WMS-III subtests, however, differences were restricted to Logical Memory (immediate and delayed) and Family Pictures (delayed only), a Visual Memory subtest. Discriminant analyses suggest deficits in chronic Lyme are best characterized as a combination of memory difficulty and diminished processing speed. Deficits were modest, between one-third and two-thirds of a standard deviation, consistent with earlier studies. Depression severity had a weak relationship to processing speed, but little other association to test performance. Deficits in chronic Lyme disease are consistent with a subtle neuropathological process affecting multiple performance tasks, although further work is needed to definitively rule out nonspecific illness effects.

Post-Lyme borreliosis syndrome: a meta-analysis of reported symptoms

BACKGROUND

This meta-analysis compares the prevalence of fatigue, musculoskeletal pain, and neurocognitive difficulties in patients who have had Lyme borreliosis (LB) and control subjects without LB.

METHODS

Titles and abstracts in PubMed were reviewed for studies with data on the symptoms listed above that compared patients who had had LB with controls from the general population. Five studies with 504 patients and 530 controls were included in the meta-analysis.

RESULTS

The prevalence of symptoms was significantly higher in the LB patients, with P-values between <0.00001 and 0.007 for 8 of the 10 symptoms in the three categories listed above. The higher prevalence of certain neurocognitive symptoms but not others, in the same pattern as reported in the literature, is further confirmation of this syndrome. The pattern of symptoms appears to be different from that seen in fibromyalgia, depression, and chronic fatigue syndrome.

CONCLUSIONS

This meta-analysis provides strong evidence that some patients with LB have fatigue, musculoskeletal pain, and neurocognitive difficulties that may last for years despite antibiotic treatment.

Is Gulf War Syndrome actually chronic Lyme disease?

Symptoms of Gulf War Syndrome and chronic Lyme disease are very similar. Lyme disease is a condition which can be difficult to diagnose since one of the main features of the condition, the erythema migrans rash, may be absent or overlooked and serological testing for Lyme disease may be falsely negative. Symptoms of Lyme disease may not became apparent until years after exposure to the causative organism. Military personnel during training in the field are at risk of tick bites and it may be that those who developed Gulf War Syndrome entered the conflict with latent Lyme disease. There has been no systematic examination of Gulf War Syndrome sufferers for chronic Lyme disease and it is hypothesized that chronic Lyme disease has been overlooked as a cause of Gulf War Syndrome. To address this it is suggested that sufferers of Gulf War Syndrome or similar illnesses should be examined by physicians who have experience diagnosing and treating large numbers of patients with Lyme disease.

Antibodies against OspA epitopes of Borrelia burgdorferi cross-react with neural tissue

Neurological sequela of chronic Lyme disease include encephalopathy, myelopathy and peripheral neuropathy. These have generally been attributed to either persistent infection or pathogen-induced autoimmunity. In this study, we investigated the presence of cross-reactive human neural epitopes that share amino acid sequences with Borrelia burgdorferi OspA protein. Sequence similarity analysis was carried out by searching known cDNA sequences from brain tissue. The cDNA database search yielded three sequences that were identical to sequences in OspA. Corresponding peptides were synthesized and antibodies were generated against them in rabbits. Antibodies against two of the homologous OspA peptides were found to react with neurons in human brain, spinal cord and dorsal root ganglia by immunohistochemistry.

Treatment of Lyme disease: a medicolegal assessment

Lyme disease is the most common tick-borne disease in the world today. Despite extensive research into the complex nature of Borrelia burgdorferi, the spirochetal agent of Lyme disease, controversy continues over the diagnosis and treatment of this protean illness. This report will focus on two aspects of the treatment of Lyme disease. First, the medical basis for diagnostic and therapeutic uncertainty in Lyme disease, including variability in clinical presentation, shortcomings in laboratory testing procedures, and design defects in therapeutic trials. Second, the standard of care and legal issues that have resulted from the clinical uncertainty of Lyme disease diagnosis and treatment. Specifically, the divergent therapeutic standards for Lyme disease are addressed, and the difficult process of creating treatment guidelines for this complex infection is explored. Consideration by healthcare providers of the medicolegal issues outlined in this review will support a more rational approach to the diagnosis and treatment of Lyme disease and related tick-borne illnesses.

Long-term neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease

BACKGROUND

There is little information about the long-term outcomes of children with facial nerve palsy attributable to Lyme disease, a group putatively at high risk for poor neurologic outcomes.

OBJECTIVE

The purpose of this study is to assess the long-term neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease.

METHODS

We conducted a matched cross-sectional study of children with facial nerve palsy in Connecticut who met the Centers for Disease Control and Prevention national surveillance case definition for Lyme disease. We identified children with facial nerve palsy attributable to Lyme disease from population-based data for the state of Connecticut from 1984 to 1991 as well as from selected clinical practices from 1984 to 1998. For each case, 2 controls without Lyme disease, matched by age, were selected by sequential digit dialing technique. Both patients and controls (or their parents) were interviewed using structured questionnaires. Outcomes included self/parents' reports both of symptoms and of abilities to perform normal daily activities since the diagnosis was made (or for an equivalent period of time for controls). In addition, the patients with facial nerve palsy attributable to Lyme disease were evaluated with a battery of neuropsychologic tests.

RESULTS

Of the 43 patients, 30% were female and 93% were white. Median age at diagnosis was 8 years (range: 2-18 years). Mean time to follow-up was 49 months (range: 7-161 months). Of the patients, 16% had been treated parenterally with ceftriaxone and 84% had been treated orally with either doxycycline or amoxicillin. Overall, 79% believed they were cured of Lyme disease, 9% believed they were not cured, and 12% did not know. The proportions of patients and of matched controls that reported increased problems with normal daily activities (eg, exercise, academic performance, word recall, sleeping) were similar. Patients with facial nerve palsy attributable to Lyme disease were more likely than matched controls to report symptoms of neck pain, changes in behavior, pains in joints or muscles, numbness or funny sensations in nerves, and problems with memory, but three quarters of them did not attribute these problems to Lyme disease. Twenty patients agreed to undergo neuropsychologic testing; all had average to above average scores on tests of IQ (eg, mean IQ was 110.2), memory, learning, attention, concentration, math, reading and spelling performance, executive functioning, abstract thinking, sequential processing, visuospatial scanning, and motor speed. There were no apparent differences in outcomes between children who received oral versus parenteral treatment.

CONCLUSIONS

The neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease 7 to 161 months earlier are comparable to those who did not have Lyme disease.

Neuropsychological functioning in chronic Lyme disease

Lyme disease is currently the most common vector-borne illness in the United States. The disease is multisystemic, and chronic disease, in particular, may be associated with neuropsychological deficits. However, to date, only a few empirical studies exist, which examine the neuropsychological sequelae associated with chronic Lyme disease. A review of the literature shows that the deficits observed in adults with chronic Lyme disease are generally consistent with the deficits that can be seen in processes with primarily frontal systems involvement. These observations are generally consistent with neuroradiologic findings. The clinical presentation in chronic Lyme disease and the nature of the neuropsychological deficits are discussed, as are several central issues in understanding neuropsychological functioning in chronic Lyme disease, such as the impact of chronic illness, response to treatment, and the relationship between neuropsychological performance and depression, fatigue, and neurological indicators of disease.

Relations among indexes of memory disturbance and depression in patients with Lyme borreliosis

This study examined the relation between complaints of memory disturbance and measures of mood and memory functioning in 55 patients with serological evidence of late-stage Lyme Borreliosis (LB). Patients completed the Self-Ratings of Memory Questionnaire (SRMQ) and the Beck Depression Inventory. Memory functioning was assessed with the California Verbal Learning Test. Depressed patients exhibited more frequent complaints of memory disturbance on the SRMQ, although their pattern of responses did not differ from nondepressed patients. There was a significant correlation between subjective memory ratings and self-reported depression (Spearman rho = -.57, p < .001). No relation was observed between subjective memory ratings and objective memory performance. The results indicate subjective complaints of more severe memory disturbance in patients with LB and depression. Particular attention should be paid to the assessment of depression and subjective symptoms of memory disturbance when administering neuropsychological tests of memory functioning in patients with LB.

Neuropsychological deficits in Lyme disease patients with and without other evidence of central nervous system pathology

A small percentage of Lyme patients develop mild to moderate encephalopathic symptoms months to years after diagnosis and treatment. Their symptoms typically include fatigue, memory loss, sleep disturbance, and depression. However, the etiology of this syndrome remains controversial. It is generally thought that Lyme patients with abnormal cerebral spinal fluid (CSF) have a neurological basis to their illness. To further examine this question, we compared Lyme patients with evidence of abnormal CSF, intrathecal antibody to Borrelia burgdorferi, elevated protein, or a positive polymerase chain reaction for B. burgdorferi DNA (n = 14); Lyme patients with normal CSF (n = 18); and healthy controls (n = 15) on a battery of neuropsychological and personality tests. Although both Lyme groups reported memory problems, only the Lyme group with abnormal CSF had measurable memory deficits. Both Lyme groups had higher depression scores than the normal control group, although depression was not correlated with memory scores. It appears that Lyme patients with abnormal CSF may have a neurological basis to their illness, whereas affective symptoms, common to many chronic disorders, may predispose other Lyme patients to the perception of cognitive dysfunction.

The neuropsychological examination of naming in Lyme borreliosis

Although subjective complaints of word finding and naming deficits are commonly reported by patients with Lyme Borreliosis (LB), the existence of these disturbances has not been thoroughly investigated. Forty-four patients with LB and 43 healthy controls were administered a symptom questionnaire, the Boston Naming Test (BNT), the Controlled Oral Word Association Test (COWAT), and a series of category naming tasks. LB patients had a higher rate of complaints of word-finding disturbance (55% vs. 14%). Lower mean scores were observed on the BNT, but not on the COWAT, nor on category naming tasks. Thirty-six percent of the LB sample exhibited BNT scores in the impaired range. BNT scores in this group were correlated with a measure of memory retrieval, but not with verbal fluency indexes. There was no relation between naming scores and depression. LB patients exhibit impairments in word finding that appear to be secondary to a generalized retrieval deficit.

Long-term cognitive effects of Lyme disease in children

Most studies of adults infected with Lyme disease (LD) have found adverse cognitive effects from the disease. In contrast, the only controlled study investigating cognitive effects of LD in a pediatric population found no effects after a 2-year follow-up. However, it was questioned whether the negative effects might take longer than 2 years to emerge. Therefore, this investigation reports a 4-year follow-up of the original sample. Twenty-five children with strictly defined LD were compared with 17 sibling control children. A neuropsychological battery was utilized, including assessment of the cognitive areas of IQ, information processing speed, fine-motor dexterity, novel problem solving and executive functioning, short-term and intermediate memory, and acquisition of new learning. In addition, parents' subjective ratings were obtained on the disease's impact on their child's participation in everyday activities. No between-group differences were found for 17 of the 18 neuropsychological test measures, nor were there differences in parents' subjective ratings. Therefore, in contrast with studies of adults with LD, the results of long-term follow-up of the pediatric population continue to strongly support the finding that children treated appropriately for LD have an excellent prognosis for normal cognitive functioning.

Spirochetal infection of the nervous system

Neurologic infection is a characteristic feature of spirochetes. The neurologic manifestations of spirochetal infection are a source of continuing public concern: Lyme neuroborreliosis in endemic areas, neurosyphilis in HIV infected patients, and neuroborreliosis during outbreaks of relapsing fever. These are reviewed in this article. The techniques for diagnosis and recommendations in the management of these infections are also discussed.

Does Process-Specific Slowing Account for Cognitive Deficits in Lyme Disease?

Although several studies have suggested that cognitive slowing is a symptom in Lyme disease, it is not clear whether this slowing is general or relates to specific cognitive tasks. This study examined cognitive speed in 25 Lyme disease patients using a mental arithmetic task. These patients showed significant impairments when initiating the cognitive processes involved in counting, but performed as well as healthy participants (n = 23) when the number of counting increments increased. Lyme patients also performed a speeded perceptual-motor matching task as well as healthy participants. Lyme-related initiation speed deficits were significantly correlated with performance on standardized neuropsychological tests, including the Trail Making Test and the Digit Symbol Test, but not with self-reported depression. These results suggest that the cognitive deficits seen on speeded tasks are process specific in the Lyme patient group, and are not the result of generalized slowing.

Psychological States and Neuropsychological Performances in Chronic Lyme Disease

The neuropsychiatric sequelae of chronic Lyme disease remains unclear. This study sought to characterize the psychological status of a group of participants who met criteria for post-Lyme syndrome (PLS). These measures were then used to examine the influence of psychological status on neuropsychological performances. Thirty PLS participants completed a structured psychiatric interview, the Positive and Negative Affect Schedule, the Lyme Symptom Checklist, and a battery of neuropsychological tests. As a group, the PLS participants did not appear to have an elevated incidence of psychiatric disorders, and psychiatric history was not useful for understanding neuropsychological performances or symptom reports. The mood of the PLS participants was characterized by lowered levels of positive affect (PA) and typical levels of negative affect. This combination can be distinguished from depression and is consistent with previous findings of affect patterns in individuals with chronic fatigue syndrome. PA was also linked to both total symptom severity and severity of cognitive complaints, but not to duration of illness, neurological manifestations at initial diagnosis, or treatment history. Relative to published normative data, neuropsychological performances were not in the impaired range on any measure. Neither psychological status nor symptom report were useful for understanding any aspect of cognitive functioning. It is concluded that decreased PA is the most useful marker of psychological functioning in PLS.

A proposal for the reliable culture of Borrelia burgdorferi from patients with chronic Lyme disease, even from those previously aggressively treated

Since culture of Borrelia burgdorferi from patients with chronic Lyme disease has been an extraordinarily rare event, clarification of the nature of the illness and proving its etiology as infectious have been difficult. A method for reliably and reproducibly culturing B. burgdorferi from the blood of patients with chronic Lyme disease was therefore sought by making a controlled blood culture trial studying 47 patients with chronic Lyme disease. All had relapsed after long-term oral and intravenous antibiotics. 23 patients with other chronic illness formed the control group. Positive cultures were confirmed by fluorescent antibody immuno-electron microscopy using monoclonal antibody directed against Osp A, and Osp A PCR. 43/47 patients (91%) cultured positive. 23/23 controls (100%) cultured negative. Although persistent infection has been, to date, strongly suggested in chronic Lyme disease by positive PCR and antigen capture, there are major problems with these tests. This new method for culturing B. burgdorferi from patients with chronic Lyme disease certainly defines the nature of the illness and establishes that it is of chronic infectious etiology. This discovery should help to reestablish the gold standard in laboratory diagnosis of Lyme disease.

Chorea as a symptom of neuroborreliosis: a case study

Borrelia burgdorferi (Bb) can cause a large number of neurological symptoms. Although extrapyramidal disturbances are rare (representing less than 2% of all neurological complications), diffuse choreic dyskinesias have been described during the course of mild encephalitis. The data published in the literature suggest that there are clinical and neurological analogies between neuroborreliosis and multiple sclerosis (MS). The presence of specific anti-Bb antibodies in cerebrospinal fluid is a discriminating factor that allows a diagnosis of neuroborreliosis to be made. We describe the case of a patient with Lyme disease, characterised by widespread chorea and behavioural disturbances. Emphasis is placed on the atypical onset and evolution, the difficulties encountered in formulating a diagnosis, and the uncertainties concerning the pathophysiology and clinical/neuroradiological correlations of the disease.

Neurocognitive abnormalities in children after classic manifestations of Lyme disease

BACKGROUND

In adults a subtle encephalopathy characterized primarily by memory impairment, irritability and somnolence may occur months to years after classic manifestations of Lyme disease. However, only limited information is available about whether there is an equivalent disorder in children.

METHODS

Case series of five children seen in a Lyme disease clinic in a university referral center for evaluation of neurocognitive symptoms that developed near the onset of infection or months after classic manifestations of Lyme disease. The diagnosis was based on clinical symptoms, serologic reactivity to Borrelia burgdorferi and intrathecal antibody production to the spirochete. Evaluation included detailed neuropsychologic testing. After evaluation the children were treated with intravenous ceftriaxone for 2 or 4 weeks. Follow-up was done in the clinic and a final assessment was made by telephone 2 to 7 years after treatment.

RESULTS

Along with or months after erythema migrans, cranial neuropathy or Lyme arthritis, the five children developed behavioral changes, forgetfulness, declining school performance, headache or fatigue and in two cases a partial complex seizure disorder. All five patients had IgG antibody responses to B. burgdorferi in serum as well as intrathecal IgG antibody production to the spirochete. Two patients had CSF pleocytoses and three did not. Despite normal intellectual functioning the five children had mild to moderate deficits in auditory or visual sequential processing. After ceftriaxone therapy, the four children in whom follow-up information was available experienced gradual improvement in symptoms.

CONCLUSIONS

Children may develop neurocognitive symptoms along with or after classic manifestations of Lyme disease. This may represent an infectious or postinfectious encephalopathy related to B. burgdorferi infection.

Nervous system Lyme disease

Lyme disease is a multisystem infectious disease caused by tick-borne spirochetes of the Borrelia burgdorferi group. The disease occurs primarily in specific areas of North America, Europe and Asia, reflecting the distribution of the hard-shelled Ixodes ticks that are required for disease transmission. Diagnosis of this infection can be somewhat problematic, although in clinically appropriate settings, serologic testing can be highly useful, particularly if Western blots are used to confirm borderline or positive results. The organism has several specific organotropisms-involvement of the heart, joints and nervous system being particularly common. The nervous system can be involved in one or more ways. Early in infection, patients tend to get a lymphocytic meningitis, cranial neuritis (particularly the facial nerves) or a painful radiculitis. Rarely, an encephalomyelitis can occur. In patients with more protracted and indolent involvement, a more disseminated mononeuropathy multiplex may occur, or a mild, non-focal alteration of cognitive function and memory, i.e. an encephalopathy. In patients with central nervous system involvement, the most sensitive diagnostic test is the demonstration of intrathecal production of anti-Borrelia burgdorferi antibody. Culture, polymerase chain reaction and other techniques appear to be less specific. In most instances, the disease is quite responsive to antimicrobial therapy. Oral treatment with doxycycline has been shown to be effective in meningitis. In more serious cases two to four week courses of parenteral ceffriaxone or cefotaxime are effective in the vast majority of patients.

Simultaneous expression of Borrelia OspA and OspC and IgM response in cerebrospinal fluid in early neurologic Lyme disease

Lyme disease is the major tick-borne disease, caused by Borrelia burgdorferi (Bb). Neurological involvement is common in all stages. In vivo expression of Bb antigens (Ags) and the immune response to them has not been well investigated in the cerebrospinal fluid (CSF). Upregulation of outer surface protein (Osp) C and concomitant downregulation of OspA before tick inoculation of the spirochete has been reported in skin and blood in animals. CSF OspA Ag in early disease suggests otherwise in CSF. Early Ag expression and IgM response in human CSF was investigated here. Paired CSF and serum was collected from 16 early, predominantly erythema migrans Lyme disease patients with neurologic problems, 13 late Lyme disease patients, and 19 other neurologic disease (OND) controls. Samples were examined for IgM reactivity to recombinant Bb-specific Osps using ELISA and immunoblot. Of 12 early Lyme disease patients with neurologic involvement with both CSF and serum IgM against OspC, 7 (58%) had IgM to OspA (n = 5) or OspB (n = 2) that was restricted to the CSF, not serum. Overall, 12 of 16 (75%) of these early Lyme disease patients with neurologic involvement had CSF and serum IgM against OspC. Only 3 of 13 (23%) late Lyme disease patients and none of 19 OND controls had CSF IgM directed against OspC. In conclusion, in CSF, OspC and OspA can be coexpressed, and IgM response to them occurs in early Lyme disease patients with neurologic involvement. This biologic finding may also provide a discriminating marker for CNS infection in Lyme disease.

Cognitive impairment after acute encephalitis: comparison of herpes simplex and other aetiologies

OBJECTIVE

To compare the cognitive defects after acute acyclovir treated herpes simplex encephalitis with those after other types of acute encephalitis.

METHODS

Seventy seven consecutive patients between 1985 and 1995 and 29 normal controls were studied. Of the 77 patients without concomitant neurological conditions, 17 had herpes simplex, one virus encephalitis (HSVE group), 27 had some other identified aetiology (non-HSVE group), and in 33 patients the cause was unknown. Acyclovir treatment was started less than four days after the first mental symptoms in 12 of 17 patients with HSVE. A thorough neuropsychological assessment was carried out about one month after the onset.

RESULTS

The HSVE group had deficits in verbal memory, verbal-semantic functions, and visuoperceptual functions more often than the non-HSVE group. The risk for cognitive defects was twofold to four-fold in the patients with HSVE compared with the non-HSVE patients. Two (12%) of the patients with HSVE and 12 (44%) of the non-HSVE patients were cognitively intact. Six patients with HSVE (46%) and 17 (89%) non-HSVE patients later returned to work. The lesions on CT or MRI were bilateral only in one patient with HSVE. The defects in the three patients with adenovirus infection were severe and resembled the amnesia after HSVE. Cognitive impairment, not previously reported, was found in encephalitis after rotavirus infection and epidemic nephropathy.

CONCLUSION

The recovery in the HSVE group was better than expected based on the medical literature. On the other hand there were surprisingly severe cognitive defects in encephalitis after other viruses. With early acyclovir treatment patients with the least severe HSVE were equivalent to those with non-HSV encephalitis with good outcome whereas those with the most severe non-HSV encephalitis were equivalent to those with HSVE with poor outcome.

Experimental immunization against Lyme borreliosis with recombinant Osp proteins: an overview

Interest in human and veterinary vaccines against Lyme borreliosis is growing. Both whole cell immunization and subunit vaccines can protect against infection with Borrelia burgdorferi. For development of a human vaccine the focus has been on a subunit vaccine. The most promising candidate is OspA, a major outer membrane lipoprotein of B. burgdorferi sensu lato. Of Osp proteins A through D, OspA shows the least variability between strains in its sequence and in the level of its expression. Borreliae in ticks express OspA. Antibodies to OspA kill borreliae in vitro and provide passive protection in mice. Active immunization of mice with OspA provides protection against challenge by syringe inoculation or tick bite. The lipid moiety of the OspA is necessary for immunogenicity in the absence of a potent adjuvant. A recombinant OspA-based vaccine is already in clinical trials. Although there is compelling evidence that immunization with OspA will provide protection, questions remain regarding the duration of protection from such immunization, the necessity to have a minimum level of neutralizing antibodies at all times for protection, and the relationship of an immune response to OspA and autoimmune features of Lyme borreliosis. The experimental aspects of immunization with Osp-A based constructs and other Lyme vaccine candidates are reviewed and discussed.