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Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
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2
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MacLellan AD, Easton AS, Alubankudi R, Pickett GE. Documented growth of an intracranial capillary hemangioma: A case report. Neuropathology 2024; 44:76-82. [PMID: 37403213 DOI: 10.1111/neup.12933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 06/10/2023] [Accepted: 06/14/2023] [Indexed: 07/06/2023]
Abstract
Intracranial capillary hemangiomas in adults are rare, and diagnosis can be challenging. Hemangiomas, in general (and particularly in the skin), are more often noted in the pediatric population. Due to the lack of imaging undertaken in the presymptomatic phase, the literature provides few clues on the rate of growth of these unusual tumors. Therefore, we report a case of a 64-year-old man with a medical history of Lyme disease who presented with exhaustion and confusion. Imaging demonstrated an intra-axial lesion with vascularity in the posterior right temporal lobe, raising the possibility of a glioma. Imaging two years prior revealed a very small lesion in the same location. The patient underwent a craniectomy, total resection of the lesion was completed, and his symptoms of confusion resolved. Biopsy revealed a capillary hemangioma composed of small vascular channels lined by endothelial cells and pericytes without smooth muscle. Features of glioma, vascular neoplasms or neuroborreliosis (cerebral Lyme disease) were not identified. Our case documents the growth over two years of a rare intracranial capillary hemangioma in an older adult male.
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Affiliation(s)
| | - Alexander S Easton
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Rufus Alubankudi
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gwynedd E Pickett
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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Philipps J, Erdlenbruch B, Kuschnerow M, Jagoda S, Salihaj B, Glahn J, Schellinger PD. Hyperacute treatment of childhood stroke in Lyme neuroborreliosis: report of two cases and systematic review of the literature. Ther Adv Neurol Disord 2022; 15:17562864221102842. [PMID: 36061261 PMCID: PMC9437258 DOI: 10.1177/17562864221102842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
The safety and efficacy of hyperacute reperfusion therapies in childhood stroke
due to focal cerebral arteriopathy (FCA) with an infectious and inflammatory
component is unknown. Lyme neuroborreliosis (LNB) is reported as a rare cause of
childhood stroke. Intravenous thrombolysis (IVT) and endovascular therapy (EVT)
have not been reported in LNB-associated stroke in children. We report two
children with acute stroke associated with LNB who underwent hyperacute stroke
treatment. A systematic review of the literature was performed to identify case
reports of LNB-associated childhood stroke over the last 20 years. Patient 1
received IVT within 73 min after onset of acute hemiparesis and dysarthria;
medulla oblongata infarctions were diagnosed on magnetic resonance imaging
(MRI). Patient 2 received successful EVT 6.5 hr after onset of progressive
tetraparesis, coma, and decerebrate posturing caused by basilar artery occlusion
with bilateral pontomesencephalic infarctions. Both patients exhibited a
lymphocytic cerebrospinal fluid (CSF) pleocytosis and elevated antibody index
(AI) to Borrelia burgdorferi. Antibiotic treatment, steroids,
and platelet inhibitors including tirofiban infusion in patient 2 were
administered. No side effects were observed. On follow-up, patient 1 showed good
recovery and patient 2 was asymptomatic. In the literature, 12 cases of
LNB-associated childhood stroke were reported. LNB-associated infectious and
inflammatory FCA is not a medical contraindication for reperfusion therapies in
acute childhood stroke. Steroids are discussed controversially in inflammatory
FCA due to LNB. Intensified antiplatelet regimes may be considered; secondary
prophylaxis with acetyl-salicylic acid (ASA) is recommended because of a high
risk of early stroke recurrence.
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Affiliation(s)
- Joerg Philipps
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Hans-Nolte-Str. 1, D-32429 Minden, Germany
| | - Bernhard Erdlenbruch
- Department of Pediatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Michael Kuschnerow
- Department of Diagnostic and Interventional Radiology, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Sunil Jagoda
- Department of Anesthesiology and Intensive Care, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Blerta Salihaj
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Joerg Glahn
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Peter Dieter Schellinger
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
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Chhajed M, Jain A, Gunasekaran PK, Dhaliwal N, Saini L. Lyme Neuroborreliosis with Intracranial Hypertension and Erythema Multiforme: A Rare Presentation. J Trop Pediatr 2022; 68:6648460. [PMID: 35867049 DOI: 10.1093/tropej/fmac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A 9-year-old previously healthy boy presented with high-grade intermittent fever, severe headache associated with neck stiffness for 5 days, rash over trunk and extremities for 4 days, vomiting for 3 days and diplopia for 2 days. There was no history of seizures, abnormal body movements, altered sensorium or focal deficits. On examination, he had maculopapular erythematous rashes over the trunk and extremities and erythema multiforme. He had bilateral abducens nerve palsy and the rest of the cranial nerve, sensory and motor examination was normal. He had neck stiffness and positive Kernig's sign. Fundus examination showed grade 4 papilledema. Cerebrospinal fluid workup revealed elevated opening pressure, lymphocytic pleocytosis, normal protein and glucose levels. Neuroimaging showed features suggestive of intracranial hypertension. Borrelia IgM and IgG antibodies came positive. The uniqueness of our case lies with two rare presenting manifestations of Lyme neuroborreliosis in the same child.
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Affiliation(s)
- Monika Chhajed
- Department of Pediatrics, Chaitanya Hospital, Chandigarh 160047, India
| | - Amit Jain
- Department of Radiodiagnosis, MM Institute of Medical Sciences and Research, Ambala, Haryana 133207, India
| | | | - Navdeep Dhaliwal
- Department of Pediatrics, Chaitanya Hospital, Chandigarh 160047, India
| | - Lokesh Saini
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342005, India
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6
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Cervantes-Arslanian AM, Anand P. Infectious Vasculitides of the Central Nervous System. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00815-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Sapi E, Kasliwala RS, Ismail H, Torres JP, Oldakowski M, Markland S, Gaur G, Melillo A, Eisendle K, Liegner KB, Libien J, Goldman JE. The Long-Term Persistence of Borrelia burgdorferi Antigens and DNA in the Tissues of a Patient with Lyme Disease. Antibiotics (Basel) 2019; 8:antibiotics8040183. [PMID: 31614557 PMCID: PMC6963883 DOI: 10.3390/antibiotics8040183] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 01/29/2023] Open
Abstract
Whether Borrelia burgdorferi, the causative agent of Lyme disease, can persist for long periods in the human body has been a controversial question. The objective of this study was to see if we could find B. burgdorferi in a Lyme disease patient after a long clinical course and after long-term antibiotic treatment. Therefore, we investigated the potential presence of B. burgdorferi antigens and DNA in human autopsy tissues from a well-documented serum-, PCR-, and culture-positive Lyme disease patient, a 53-year-old female from northern Westchester County in the lower Hudson Valley Region of New York State, who had received extensive antibiotic treatments during extensive antibiotic treatments over the course of her 16-year-long illness. We also asked what form the organism might take, with special interest in the recently found antibiotic-resistant aggregate form, biofilm. We also examined the host tissues for the presence of inflammatory markers such as CD3+ T lymphocytes. Autopsy tissue sections of the brain, heart, kidney, and liver were analyzed by histological and immunohistochemical methods (IHC), confocal microscopy, fluorescent in situ hybridization (FISH), polymerase chain reaction (PCR), and whole-genome sequencing (WGS)/metagenomics. We found significant pathological changes, including borrelial spirochetal clusters, in all of the organs using IHC combined with confocal microscopy. The aggregates contained a well-established biofilm marker, alginate, on their surfaces, suggesting they are true biofilm. We found B. burgdorferi DNA by FISH, polymerase chain reaction (PCR), and an independent verification by WGS/metagenomics, which resulted in the detection of B. burgdorferi sensu stricto specific DNA sequences. IHC analyses showed significant numbers of infiltrating CD3+ T lymphocytes present next to B. burgdorferi biofilms. In summary, we provide several lines of evidence that suggest that B. burgdorferi can persist in the human body, not only in the spirochetal but also in the antibiotic-resistant biofilm form, even after long-term antibiotic treatment. The presence of infiltrating lymphocytes in the vicinity of B. burgdorferi biofilms suggests that the organism in biofilm form might trigger chronic inflammation.
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Affiliation(s)
- Eva Sapi
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Rumanah S Kasliwala
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Hebo Ismail
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Jason P Torres
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Michael Oldakowski
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Sarah Markland
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Gauri Gaur
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Anthony Melillo
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Klaus Eisendle
- Central Teaching Hospital Bolzano L Böhlerstr, 539100 Bolzano, Italy.
| | - Kenneth B Liegner
- Private practice, 592 Route 22, Suite 1B, Pawling, NY 12564, USA.
- Northwell System, Northern Westchester Hospital, Mount Kisco, NY 10549, USA.
- Health Quest System, Sharon Hospital, Sharon, CT 06069, USA.
| | - Jenny Libien
- Department of Pathology, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA.
| | - James E Goldman
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10031, USA.
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9
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Monteventi O, Steinlin M, Regényi M, Roulet-Perez E, Weber P, Fluss J. Pediatric stroke related to Lyme neuroborreliosis: Data from the Swiss NeuroPaediatric Stroke Registry and literature review. Eur J Paediatr Neurol 2018; 22:113-121. [PMID: 29208342 DOI: 10.1016/j.ejpn.2017.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 10/09/2017] [Accepted: 10/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cerebrovascular complications of Lyme neuroborreliosis (LNB) are poorly documented in the paediatric population. METHODS We performed a retrospective analysis from prospectively registered cases of acute ischemic stroke (AIS) from the Swiss NeuroPaediatric Stroke Registry (SNPSR) from 2000 to 2015. Only cases with serologically confirmed LNB were included. In addition, a literature review on paediatric stroke cases secondary to Lyme neuroborreliosis in the same time frame was performed. RESULTS 4 children out of 229 children with arterial ischemic childhood stroke and serologically confirmed LNB were identified in the SNPSR giving a global incidence of 1.7%. Median age was 9.9 years. A prior history of tick bites or erythema migrans (EM) was reported in two cases. Clinical presenting signs were suggestive of acute cerebellar/brainstem dysfunction. On imaging, three children demonstrated a stroke in the distribution of the posterior inferior cerebellar artery. The remaining fourth child had a "stroke-like" picture with scattered white matter lesions and a multifocal vasculitis with prominent basilar artery involvement. Lymphocytic pleocytosis as well as intrathecal synthesis of Borrelia burgdorferi antibodies were typical biological features. Acute intravenous third generation cephalosporins proved to be effective with rapid improvement in all patients. No child had recurrent stroke. Data from the literature concerning eight patients gave similar results, with prominent posterior circulation stroke, multifocal vasculitis and abnormal CSF as distinctive features. CONCLUSIONS Lyme Neuroborreliosis accounts for a small proportion of paediatric stroke even in an endemic country. The strong predilection towards posterior cerebral circulation with clinical occurrence of brainstem signs associated with meningeal symptoms and CSF lymphocytosis are suggestive features that should rapidly point to the diagnosis. This can be confirmed by appropriate serological testing in the serum and CSF. Clinicians must be aware of this rare neurological complication of Lyme disease that demands specific antibiotic treatment.
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Affiliation(s)
- O Monteventi
- Pediatric Neurology Unit, Pediatrics Subspecialities Service, Geneva Children's Hospital, Switzerland
| | - M Steinlin
- Department of Neuropediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital Bern, Switzerland
| | - M Regényi
- Department of Neuropediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital Bern, Switzerland
| | - E Roulet-Perez
- Pediatric Neurology and Neurorehabilitation Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - P Weber
- University Children's Hospital Basel, Division of Neuropediatrics and Developmental Medicine, Basel, Switzerland
| | - J Fluss
- Pediatric Neurology Unit, Pediatrics Subspecialities Service, Geneva Children's Hospital, Switzerland.
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10
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Garkowski A, Zajkowska J, Zajkowska A, Kułakowska A, Zajkowska O, Kubas B, Jurgilewicz D, Hładuński M, Łebkowska U. Cerebrovascular Manifestations of Lyme Neuroborreliosis-A Systematic Review of Published Cases. Front Neurol 2017; 8:146. [PMID: 28473801 PMCID: PMC5397664 DOI: 10.3389/fneur.2017.00146] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/31/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) is a disease caused by spirochete Borrelia burgdorferi, involving the nervous system. It usually manifests as lymphocytic meningoradiculitis, but in rare cases, it can also lead to cerebrovascular complications. We aimed to perform a systematic review of all reported cases of LNB complicated by central nervous system vasculitis and stroke or transient ischemic attack (TIA). MATERIALS AND METHODS We conducted a systematic review of literature between May 1987 and December 2016 with patients who presented with cerebrovascular course of LNB. RESULTS This study included 88 patients with a median age of 46 years. The median interval from onset of symptoms suggesting Lyme disease to first symptoms of cerebrovascular manifestations of LNB was 3.5 months. The most common cerebrovascular manifestation of LNB was ischemic stroke (76.1%), followed by TIA (11.4%). The posterior circulation was affected alone in 37.8% of patients, the anterior circulation in 24.4% of patients, and in 37.8% of cases, posterior and anterior circulations were affected simultaneously. The most common affected vessels were middle cerebral artery-in 19 cases, basilar artery-in 17 cases, and anterior cerebral artery-in 16 cases. A good response to antibiotic treatment was achieved in the vast number of patients (75.3%). The overall mortality rate was 4.7%. CONCLUSION Cerebral vasculitis and stroke due to LNB should be considered, especially in patients who live in or have come from areas with high prevalence of tick-borne diseases, as well as in those without cardiovascular risk factors, but with stroke-like symptoms of unknown cause.
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Affiliation(s)
- Adam Garkowski
- Department of Radiology, Medical University of Białystok, Białystok, Poland
| | - Joanna Zajkowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Agata Zajkowska
- Department of Neurology, Medical University of Białystok, Białystok, Poland
| | - Alina Kułakowska
- Department of Neurology, Medical University of Białystok, Białystok, Poland
| | - Olga Zajkowska
- Faculty of Applied Informatics and Mathematics, Warsaw University of Life Sciences SGGW, Warsaw, Poland
| | - Bożena Kubas
- Independent Department, Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Dorota Jurgilewicz
- Independent Department, Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Marcin Hładuński
- Independent Department, Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Urszula Łebkowska
- Department of Radiology, Medical University of Białystok, Białystok, Poland
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Muehlenbachs A, Bollweg BC, Schulz TJ, Forrester JD, DeLeon Carnes M, Molins C, Ray GS, Cummings PM, Ritter JM, Blau DM, Andrew TA, Prial M, Ng DL, Prahlow JA, Sanders JH, Shieh WJ, Paddock CD, Schriefer ME, Mead P, Zaki SR. Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:1195-205. [PMID: 26968341 DOI: 10.1016/j.ajpath.2015.12.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/23/2015] [Accepted: 12/15/2015] [Indexed: 12/17/2022]
Abstract
Fatal Lyme carditis caused by the spirochete Borrelia burgdorferi rarely is identified. Here, we describe the pathologic, immunohistochemical, and molecular findings of five case patients. These sudden cardiac deaths associated with Lyme carditis occurred from late summer to fall, ages ranged from young adult to late 40s, and four patients were men. Autopsy tissue samples were evaluated by light microscopy, Warthin-Starry stain, immunohistochemistry, and PCR for B. burgdorferi, and immunohistochemistry for complement components C4d and C9, CD3, CD79a, and decorin. Post-mortem blood was tested by serology. Interstitial lymphocytic pancarditis in a relatively characteristic road map distribution was present in all cases. Cardiomyocyte necrosis was minimal, T cells outnumbered B cells, plasma cells were prominent, and mild fibrosis was present. Spirochetes in the cardiac interstitium associated with collagen fibers and co-localized with decorin. Rare spirochetes were seen in the leptomeninges of two cases by immunohistochemistry. Spirochetes were not seen in other organs examined, and joint tissue was not available for evaluation. Although rare, sudden cardiac death caused by Lyme disease might be an under-recognized entity and is characterized by pancarditis and marked tropism of spirochetes for cardiac tissues.
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Affiliation(s)
- Atis Muehlenbachs
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Brigid C Bollweg
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joseph D Forrester
- Bacterial Diseases Branch, Division of Vector Borne Infectious Diseases, Centers for Disease Control and Prevention, Ft. Collins, Colorado
| | - Marlene DeLeon Carnes
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Claudia Molins
- Bacterial Diseases Branch, Division of Vector Borne Infectious Diseases, Centers for Disease Control and Prevention, Ft. Collins, Colorado
| | | | | | - Jana M Ritter
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dianna M Blau
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Thomas A Andrew
- Office of the Chief Medical Examiner, Concord, New Hampshire
| | | | - Dianna L Ng
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph A Prahlow
- The Medical Foundation, South Bend, Indiana; Indiana University School of Medicine-South Bend, South Bend, Indiana
| | - Jeanine H Sanders
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wun Ju Shieh
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christopher D Paddock
- Rickettsial Zoonotic Diseases Branch, Division of Vector Borne Infectious Diseases, Atlanta, Georgia
| | - Martin E Schriefer
- Bacterial Diseases Branch, Division of Vector Borne Infectious Diseases, Centers for Disease Control and Prevention, Ft. Collins, Colorado
| | - Paul Mead
- Bacterial Diseases Branch, Division of Vector Borne Infectious Diseases, Centers for Disease Control and Prevention, Ft. Collins, Colorado
| | - Sherif R Zaki
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
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Ramgopal S, Obeid R, Zuccoli G, Cleves-Bayon C, Nowalk A. Lyme disease-related intracranial hypertension in children: clinical and imaging findings. J Neurol 2016; 263:500-7. [PMID: 26739381 DOI: 10.1007/s00415-015-8007-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 12/16/2022]
Abstract
Lyme disease (LD) is a tick-borne infection that is endemic to multiple areas of the United States. Patients with LD may present with sign and symptoms of intracranial hypertension (IH). The objective of this study is to evaluate the history, clinical findings, CSF analysis, and brain imaging results in pediatric patients with increased intracranial pressure secondary to LD. A retrospective database search was performed using the International Classification of Diseases (ICD) 9/10 codes to identify patients diagnosed with LD and IH between 2004 and 2014 at a tertiary referral pediatric hospital. Clinical, laboratory and neuroimaging data for each patient were reviewed. Seven patients met inclusion criteria; mean age was 9.6 years (standard deviation 4.0 years); 4/7 patients were male. Average body mass index was 18.8 kg/m(2) (standard deviation 3.0 kg/m(2)). Fever was present in four patients. Four had a history of LD related erythema migrans. All had elevated CSF opening pressure with leukocytosis and lymphocytic predominance. MRI obtained in six patients showed contrast enhancement of various cranial nerves. Tentorial enhancement was noted in all patients. In addition, patients had widening of the optic nerve sheath (ONS), optic nerve protrusion, and flattening of the posterior globe consistent with increased intracranial pressure. All patients had resolution of their symptoms after initiation of antibiotic therapy. In endemic areas, LD should be included in the differential of IH. MRI can help distinguish IH due to LD from its idiopathic form due to the presence of tentorial and cranial nerve enhancement in the former in addition to abnormal CSF showing leukocytosis with lymphocyte predominance.
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Affiliation(s)
- Sriram Ramgopal
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, AOB 5400, Pittsburgh, PA, 15224, USA.
| | - Rawad Obeid
- Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Giulio Zuccoli
- Section of Neuroradiology, Department of Radiology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catalina Cleves-Bayon
- Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrew Nowalk
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kurian M, Pereira VM, Vargas MI, Fluss J. Stroke-like Phenomena Revealing Multifocal Cerebral Vasculitis in Pediatric Lyme Neuroborreliosis. J Child Neurol 2015; 30:1226-9. [PMID: 25316727 DOI: 10.1177/0883073814552104] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 08/20/2014] [Indexed: 12/19/2022]
Abstract
Stroke-like presentation in Lyme neuroborreliosis is rare in the pediatric age group. We report a previously healthy 12-year-old boy who presented with acute left hemiparesis and meningeal signs. Neuroimaging failed to reveal any cerebral infarction but demonstrated a multifocal cerebral vasculitis involving small, medium and large-sized vessels affecting both the anterior and posterior circulation. Concentric contrast enhancement of the basilar artery was also observed. Further investigations and laboratory findings were consistent with Lyme neuroborreliosis. A rapidly favorable clinical outcome was obtained with appropriate antibiotic treatment along with antiaggregants and steroids. Lyme neuroborreliosis should be considered in the diagnostic differential, not only in adults but also among children, especially in the context of an unexplained cerebral vasculitis.
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Affiliation(s)
- Mary Kurian
- Pediatric Neurology, Pediatric Subspecialties Service, Children's Hospital, Geneva, Switzerland
| | | | | | - Joel Fluss
- Pediatric Neurology, Pediatric Subspecialties Service, Children's Hospital, Geneva, Switzerland
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14
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Garkowski A, Zajkowska J, Moniuszko A, Czupryna P, Pancewicz S. Infectious causes of stroke. THE LANCET. INFECTIOUS DISEASES 2015; 15:632. [PMID: 26008834 DOI: 10.1016/s1473-3099(15)00020-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Adam Garkowski
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, 14 E Żurawia Street, 15-540 Białystok, Poland.
| | - Joanna Zajkowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, 14 E Żurawia Street, 15-540 Białystok, Poland
| | - Anna Moniuszko
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, 14 E Żurawia Street, 15-540 Białystok, Poland
| | - Piotr Czupryna
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, 14 E Żurawia Street, 15-540 Białystok, Poland
| | - Sławomir Pancewicz
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, 14 E Żurawia Street, 15-540 Białystok, Poland
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15
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Zajkowska J, Garkowski A, Moniuszko A, Czupryna P, Ptaszyńska-Sarosiek I, Tarasów E, Ustymowicz A, Łebkowski W, Pancewicz S. Vasculitis and stroke due to Lyme neuroborreliosis - a review. Infect Dis (Lond) 2014; 47:1-6. [PMID: 25342573 DOI: 10.3109/00365548.2014.961544] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract Lyme neuroborreliosis (LNB) is a rare cause of vasculitis and stroke. It may manifest as subarachnoid hemorrhage, intracerebral hemorrhage, and most often ischemic stroke due to cerebral vasculitis. The vast majority of reported cases have been described by European authors. A high index of suspicion is required in patients who live or have traveled to areas with high prevalence of tick-borne diseases, and in the case of stroke-like symptoms of unknown cause in patients without cardiovascular risk factors. In this review, we also present four illustrative cases of vasculitis and stroke-like manifestations of LNB.
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Affiliation(s)
- Joanna Zajkowska
- From the 1 Department of Infectious Diseases and Neuroinfections
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16
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Headaches and vasculitis. Neurol Clin 2014; 32:321-62. [PMID: 24703534 DOI: 10.1016/j.ncl.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Vasculitis is a spectrum of clinicopathologic disorders defined by inflammation of arteries of veins of varying caliber with variable tissue injury. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. A suspicion of vasculitis based on the history, clinical examination, or laboratory studies warrants prompt evaluation and treatment to forestall progression and avert cerebral ischemia or infarction.
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17
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Lantos PM, Auwaerter PG, Wormser GP. A systematic review of Borrelia burgdorferi morphologic variants does not support a role in chronic Lyme disease. Clin Infect Dis 2013; 58:663-71. [PMID: 24336823 DOI: 10.1093/cid/cit810] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Much of the controversy that surrounds Lyme disease pertains to whether it produces prolonged, treatment-refractory infection, usually referred to as chronic Lyme disease. Some have proposed that round morphologic variants of Borrelia burgdorferi, known variably as "cyst forms" and "L-forms," are responsible for the pathogenesis of chronic Lyme disease. We have undertaken a systematic review of the literature to determine if there is a documented role of these variants in Lyme disease pathogenesis or in syndromes compatible with chronic Lyme disease. METHODS Two systematic literature searches were performed to identify studies in which round morphologic variants of B. burgdorferi have been described in situ in human specimens. RESULTS Our primary literature search identified 6 studies that reported round morphologic variants of B. burgdorferi in specimens obtained from 32 total patients. No study described these forms in patients who had purely subjective symptom complexes (eg, fatigue or pain). No study investigated a causal relationship between morphologic variants and clinical disease or evaluated treatment of morphologic variants in vivo. Of 29 additional studies that described the morphology of B. burgdorferi from patients with Lyme disease, the organism was invariably described as having spirochetal morphology. CONCLUSIONS In the context of the broader medical literature, it is not currently possible to ascribe a pathogenic role to morphologic variants of B. burgdorferi in either typical manifestations of Lyme disease or in other chronic disease states that are often labeled chronic Lyme disease. There is no clinical literature to justify specific treatment of B. burgdorferi morphologic variants.
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Affiliation(s)
- Paul M Lantos
- Departments of Internal Medicine and Pediatrics, Duke University School of Medicine, Durham, North Carolina
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18
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Miklossy J. Chronic or late lyme neuroborreliosis: analysis of evidence compared to chronic or late neurosyphilis. Open Neurol J 2012; 6:146-57. [PMID: 23346260 PMCID: PMC3551238 DOI: 10.2174/1874205x01206010146] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 06/22/2012] [Accepted: 07/02/2012] [Indexed: 12/24/2022] Open
Abstract
Whether spirochetes persist in affected host tissues and cause the late/chronic manifestations of neurosyphilis was the subject of long-lasting debate. Detection of Treponema pallidum in the brains of patients with general paresis established a direct link between persisting infection and tertiary manifestations of neurosyphilis. Today, the same question is in the center of debate with respect to Lyme disease. The goal of this review was to compare the established pathological features of neurosyphilis with those available for Lyme neuroborreliosis. If the main tertiary forms of neurosyphilis also occur in Lyme neuroborreliosis and Borrelia burgdorferi can be detected in brain lesions would indicate that the spirochete is responsible for the neuropsychiatric manifestations of late/chronic Lyme neuroborreliosis. The substantial amounts of data available in the literature show that the major forms of late/chronic Lyme neuroborreliosis (meningovascular and meningoencephalitis) are clinically and pathologically confirmed. Borrelia burgdorferi was detected in association with tertiary brain lesions and cultivated from the affected brain or cerebrospinal fluid. The accumulated data also indicate that Borrelia burgdorferi is able to evade from destruction by the host immune reactions, persist in host tissues and sustain chronic infection and inflammation. These observations represent evidences that Borrelia burgdorferi in an analogous way to Treponema pallidum is responsible for the chronic/late manifestations of Lyme neuroborreliosis.Late Lyme neuroborreliosis is accepted by all existing guidelines in Europe, US and Canada. The terms chronic and late are synonymous and both define tertiary neurosyphilis or tertiary Lyme neuroborreliosis. The use of chronic and late Lyme neuroborreliosis as different entities is inaccurate and can be confusing. Further pathological investigations and the detection of spirochetes in infected tissues and body fluids are strongly needed.
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Affiliation(s)
- Judith Miklossy
- International Alzheimer Research Center, Alzheimer Prevention Foundation, 1921 Martigny-Croix, Switzerland
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19
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Miklossy J. Alzheimer's disease - a neurospirochetosis. Analysis of the evidence following Koch's and Hill's criteria. J Neuroinflammation 2011; 8:90. [PMID: 21816039 PMCID: PMC3171359 DOI: 10.1186/1742-2094-8-90] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 08/04/2011] [Indexed: 12/14/2022] Open
Abstract
It is established that chronic spirochetal infection can cause slowly progressive dementia, brain atrophy and amyloid deposition in late neurosyphilis. Recently it has been suggested that various types of spirochetes, in an analogous way to Treponema pallidum, could cause dementia and may be involved in the pathogenesis of Alzheimer's disease (AD). Here, we review all data available in the literature on the detection of spirochetes in AD and critically analyze the association and causal relationship between spirochetes and AD following established criteria of Koch and Hill. The results show a statistically significant association between spirochetes and AD (P = 1.5 × 10-17, OR = 20, 95% CI = 8-60, N = 247). When neutral techniques recognizing all types of spirochetes were used, or the highly prevalent periodontal pathogen Treponemas were analyzed, spirochetes were observed in the brain in more than 90% of AD cases. Borrelia burgdorferi was detected in the brain in 25.3% of AD cases analyzed and was 13 times more frequent in AD compared to controls. Periodontal pathogen Treponemas (T. pectinovorum, T. amylovorum, T. lecithinolyticum, T. maltophilum, T. medium, T. socranskii) and Borrelia burgdorferi were detected using species specific PCR and antibodies. Importantly, co-infection with several spirochetes occurs in AD. The pathological and biological hallmarks of AD were reproduced in vitro by exposure of mammalian cells to spirochetes. The analysis of reviewed data following Koch's and Hill's postulates shows a probable causal relationship between neurospirochetosis and AD. Persisting inflammation and amyloid deposition initiated and sustained by chronic spirochetal infection form together with the various hypotheses suggested to play a role in the pathogenesis of AD a comprehensive entity. As suggested by Hill, once the probability of a causal relationship is established prompt action is needed. Support and attention should be given to this field of AD research. Spirochetal infection occurs years or decades before the manifestation of dementia. As adequate antibiotic and anti-inflammatory therapies are available, as in syphilis, one might prevent and eradicate dementia.
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Affiliation(s)
- Judith Miklossy
- International Alzheimer Research Center, Prevention Alzheimer Foundation, Martigny-Combe, Switzerland.
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20
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Imai DM, Barr BC, Daft B, Bertone JJ, Feng S, Hodzic E, Johnston JM, Olsen KJ, Barthold SW. Lyme Neuroborreliosis in 2 Horses. Vet Pathol 2011; 48:1151-7. [DOI: 10.1177/0300985811398246] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lyme neuroborreliosis—characterized as chronic, necrosuppurative to nonsuppurative, perivascular to diffuse meningoradiculoneuritis—was diagnosed in 2 horses with progressive neurologic disease. In 1 horse, Borrelia burgdorferi sensu stricto was identified by polymerase chain reaction amplification of B burgdorferi sensu stricto–specific gene targets ( ospA, ospC, flaB, dbpA, arp). Highest spirochetal burdens were in tissues with inflammation, including spinal cord, muscle, and joint capsule. Sequence analysis of ospA, ospC, and flaB revealed 99.9% sequence identity to the respective genes in B burgdorferi strain 297, an isolate from a human case of neuroborreliosis. In both horses, spirochetes were visualized in affected tissues with Steiner silver impregnation and by immunohistochemistry, predominantly within the dense collagenous tissue of the dura mater and leptomeninges.
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Affiliation(s)
- D. M. Imai
- Center of Comparative Medicine, Davis, California
- School of Veterinary Medicine, University of California, Davis, California
| | - B. C. Barr
- California Animal Health and Food Safety Laboratory System, Davis and San Bernardino, California
- Western University of Health Science, College of Veterinary Medicine, Pomona, California
| | - B. Daft
- California Animal Health and Food Safety Laboratory System, Davis and San Bernardino, California
| | - J. J. Bertone
- Western University of Health Science, College of Veterinary Medicine, Pomona, California
| | - S. Feng
- Center of Comparative Medicine, Davis, California
| | - E. Hodzic
- Center of Comparative Medicine, Davis, California
| | - J. M. Johnston
- School of Veterinary Medicine, University of California, Davis, California
| | - K. J. Olsen
- Center of Comparative Medicine, Davis, California
| | - S. W. Barthold
- Center of Comparative Medicine, Davis, California
- School of Veterinary Medicine, University of California, Davis, California
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21
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Cros D, Gonzalez RG, Mark EJ. Case records of the Massachusetts General Hospital. Case 6-2009. A 37-year-old woman with vertigo, facial weakness, and a generalized seizure. N Engl J Med 2009; 360:802-9. [PMID: 19228624 DOI: 10.1056/nejmcpc0807823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Didier Cros
- Department of Neurology, Harvard Medical School, USA
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22
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Nau R, Christen HJ, Eiffert H. Lyme disease--current state of knowledge. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:72-81; quiz 82, I. [PMID: 19562015 PMCID: PMC2695290 DOI: 10.3238/arztebl.2009.0072] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 09/01/2008] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Roland Nau
- Geriatrisches Zentrum, Evangelisches Krankenhaus Göttingen-Weende, Abteilung für Neurologie, Universitätsklinikum Göttingen, Göttingen, Germany.
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23
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Miklossy J. Biology and neuropathology of dementia in syphilis and Lyme disease. HANDBOOK OF CLINICAL NEUROLOGY 2008; 89:825-44. [PMID: 18631798 DOI: 10.1016/s0072-9752(07)01272-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Judith Miklossy
- University of British Columbia, Kinsmen Laboratory of Neurological Research, Vancouver, BC, Canada.
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24
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Borreliosi di Lyme e neuroborreliosi. Neurologia 2007. [DOI: 10.1016/s1634-7072(07)70543-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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25
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Jacobi C, Schwark C, Kress B, Hug A, Storch-Hagenlocher B, Schwaninger M. Subarachnoid hemorrhage due to Borrelia burgdorferi-associated vasculitis. Eur J Neurol 2006; 13:536-8. [PMID: 16722982 DOI: 10.1111/j.1468-1331.2006.01335.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
We report the case history of a patient who suffered a subarachnoid hemorrhage (SAH) in association with early Lyme neuroborreliosis. After a tick bite, this patient developed erythema chronicum migrans and complained of stinging radicular pain in both legs. A computed tomography (CT) scan was performed because of acute headache and nuchal rigidity, which revealed an occipital SAH. Cerebrospinal fluid analysis provided further evidence of acute neuroborreliosis. Digital substraction angiography showed irregularities in the right posterior cerebral artery, which might be due to vasculitis, but no aneurysms.
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Affiliation(s)
- C Jacobi
- Department of Neurology, Ruprecht-Karl University, Heidelberg, Germany.
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26
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Hajj-Ali RA, Ghamande S, Calabrese LH, Arroliga AC. Central nervous system vasculitis in the intensive care unit. Crit Care Clin 2002; 18:897-914. [PMID: 12418446 DOI: 10.1016/s0749-0704(02)00027-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intensivists are sometimes faced with unexplained neurologic defects in ICU patients. A subacute presentation over weeks or months characterized by headache and mental status change with focal deficits in the absence of evidence of secondary vasculitis or other diseases mentioned in the differential diagnosis should arouse suspicion of PACNS. Delay in diagnosis of this rare condition may lead to additional morbidity and prolong ICU stay. There is also a risk of permanent cognitive dysfunction with untreated PACNS. A reactive CSF picture, ischemic changes on MR imaging, and alterations in vessel caliber on cerebral angiography are not diagnostic but strengthen the evidence for PACNS. A brain biopsy may be required to confirm the diagnosis. High-dose steroid therapy with a prolonged course and gradual taper controls the disease in most cases. Additional immunosuppressive therapy is needed in some patients.
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Affiliation(s)
- Rula A Hajj-Ali
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue-G62, Cleveland, OH 44195, USA
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27
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Abstract
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.
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Affiliation(s)
- Holly James Westervelt
- Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island, USA
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28
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Cadavid D, O'Neill T, Schaefer H, Pachner AR. Localization of Borrelia burgdorferi in the nervous system and other organs in a nonhuman primate model of lyme disease. J Transl Med 2000; 80:1043-54. [PMID: 10908149 DOI: 10.1038/labinvest.3780109] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Lyme borreliosis is caused by infection with the spirochete Borrelia burgdorferi. Nonhuman primates inoculated with the N40 strain of B. burgdorferi develop infection of multiple tissues, including the central (CNS) and peripheral nervous system. In immunocompetent nonhuman primates, spirochetes are present in low numbers in tissues. For this reason, it has been difficult to study their localization and changes in expression of surface proteins. To further investigate this, we inoculated four immunosuppressed adult Macaca mulatta with 1 million spirochetes of the N40 strain of B. burgdorferi, and compared them with three infected immunocompetent animals and two uninfected controls. The brain, spinal cord, peripheral nerves, skeletal muscle, heart, and bladder were obtained at necropsy 4 months later. The spirochetal tissue load was first studied by polymerase chain reaction (PCR)-ELISA of the outer surface protein A (ospA) gene. Immunohistochemistry was used to study the localization and numbers of spirochetes in tissues and the expression of spirochetal proteins and to characterize the inflammatory response. Hematoxylin and eosin and trichrome stains were used to study inflammation and tissue injury. The results showed that the number of spirochetes was significantly higher in immunosuppressed animals. B. burgdorferi in the CNS localized to the leptomeninges, nerve roots, and dorsal root ganglia, but not to the parenchyma. Outside of the CNS, B. burgdorferi localized to endoneurium and to connective tissues of peripheral nerves, skeletal muscle, heart, aorta, and bladder. Although ospA, ospB, ospC, and flagellin were present at the time of inoculation, only flagellin was expressed by spirochetes in tissues 4 months later. Significant inflammation occurred only in the heart, and only immunosuppressed animals had cardiac fiber degeneration and necrosis. Plasma cells were abundant in inflammatory foci of steroid-treated animals. We concluded that B. burgdorferi has a tropism for the meninges in the CNS and for connective tissues elsewhere in the body.
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Affiliation(s)
- D Cadavid
- Department of Neuroscience, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark 07103, USA
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29
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Dotevall L, Hagberg L, Karlsson JE, Rosengren LE. Astroglial and neuronal proteins in cerebrospinal fluid as markers of CNS involvement in Lyme neuroborreliosis. Eur J Neurol 1999; 6:169-78. [PMID: 10053229 DOI: 10.1111/j.1468-1331.1999.tb00010.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Is Lyme neuroborreliosis, even in its early phase, a parenchymatous disorder in the central nervous system (CNS), and not merely a meningitic process? We quantified cerebrospinal fluid (CSF) levels of four nerve and glial cell marker proteins in Lyme neuroborreliosis patients with pretreatment durations of 7-240 days. All 23 patients had meningoradiculitis, and six had objective signs of encephalopathy. Glial fibrillary acidic protein (GFAp) pretreatment levels in CSF, and the light subunit of neurofilament protein (NFL) levels were related to clinical outcome and declined significantly after treatment (P < 0.001 and P < 0.01, respectively). NFL was detectable in 11 out of 22 patients, and pre- and post-treatment NFL levels were associated with the duration of neurological symptoms within 100 days prior to treatment. Neuron-specific enolase (NSE) concentrations also decreased after therapy (P < 0.001), while CSF levels of glial S-100 protein remained unchanged. The pretreatment duration of disease was related to postinfectious sequelae. GFAp, NSE and NFL levels in CSF are unspecific indicators of astroglial and neuronal involvement in CNS disease. The findings in the present study are in agreement with the hypothesis that early and late stages of Lyme neuroborreliosis damage the CNS parenchyma.
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Affiliation(s)
- L Dotevall
- Department of Infectious Diseases, Goteborg University, Goteborg, Sweden.
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30
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Hahn CN, Mayhew IG, Whitwell KE, Smith KC, Carey D, Carter SD, Read RA. A possible case of Lyme borreliosis in a horse in the UK. Equine Vet J 1996; 28:84-8. [PMID: 8565961 DOI: 10.1111/j.2042-3306.1996.tb01595.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- C N Hahn
- Animal Health Trust, Newmarket, Suffolk, UK
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31
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Silva MT, Sophar M, Howard RS, Spencer GT. Neuroborreliosis as a cause of respiratory failure. J Neurol 1995; 242:604-7. [PMID: 8551324 DOI: 10.1007/bf00868815] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We report three cases of neuroborreliosis presenting with acute respiratory impairment. All the patients had encephalopathy and focal neurological signs with brain stem abnormalities in two. All three patients had respiratory arrest associated with progressive nocturnal hypoventilation or prolonged central apnoea. Tracheostomy and prolonged periods of ventilatory support were necessary in all cases and weaning was complicated by residual central respiratory disturbances. These cases emphasise that Borrelia infection should be considered in the differential diagnosis of unexplained respiratory failure.
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Affiliation(s)
- M T Silva
- Lane Fox Respiratory Unit, St. Thomas' Hospital, London, UK
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Abstract
Neuroborreliosis, an infection of the nervous system caused by spirochetes of the genus Borrelia, has achieved worldwide attention in the last decade as part of the clinical spectrum of Lyme disease. This disorder, caused by Borrelia burgdorferi, has increased in incidence to become the most frequent arthropod-borne infection in North America and Europe. As a result of this rapid rise in incidence and of its protean neurological manifestations, this disease has created an important challenge to modern neurology. The diverse manifestations of neuroborreliosis require that it be included in the differential diagnosis of many neurological disorders. This review takes a chronological approach to clinical neuroborreliosis to summarize its most important aspects. The limitations as well as the benefits of laboratory diagnosis are also considered, with the aim of providing assistance in this area. Recent advances in neuroimmunology regarding the pathogenesis of neuroborreliosis that may elucidate its protean clinical spectrum are summarized.
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Sigal LH. Persisting complaints attributed to chronic Lyme disease: possible mechanisms and implications for management. Am J Med 1994; 96:365-74. [PMID: 8166157 DOI: 10.1016/0002-9343(94)90068-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A better understanding of the natural history of Lyme disease and of possible causes for persisting symptoms other than active infection is needed to optimize management of patients with persistent symptoms. Review of patients seen at a Lyme disease referral center and of the immunologic and clinical literature on Lyme disease suggests most symptoms that persist after therapy can be explained by one or more of seven proposed pathogenetic mechanisms, only one of which includes active ongoing infection. Individualization of care and reanalysis of patients problems are crucial if misdiagnosis and overtreatment of Lyme disease are to be avoided.
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Affiliation(s)
- L H Sigal
- Department of Medicine, University of Medicine and Dentistry, Robert Wood Johnson Medical School, New Brunswick, NJ
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García Moncó JC, Wheeler CM, Benach JL, Furie RA, Lukehart SA, Stanek G, Steere AC. Reactivity of neuroborreliosis patients (Lyme disease) to cardiolipin and gangliosides. J Neurol Sci 1993; 117:206-14. [PMID: 8410057 DOI: 10.1016/0022-510x(93)90175-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A subset of patients (50%) with neuroborreliosis (Lyme disease) showed IgG reactivity to cardiolipin in solid phase ELISA. In addition, a subset of patients with neuroborreliosis (29%) and syphilis (59%) had IgM reactivity to gangliosides with a Gal(beta 1-3) GalNac terminal sequence (GM1, GD1b, and asialo GM1). Anti-ganglioside IgM antibodies were significantly more frequent in these two groups of patients compared to patients with cutaneous and articular Lyme disease, primary antiphospholipid syndrome, systemic lupus erythematosus and normal controls. Correlative evidence and adsorption experiments indicated that antibodies to cardiolipin had separate specificities from those directed against the gangliosides. IgM antibodies to Gal(beta 1-3) GalNac gangliosides appeared to have similar specificities since these were positively correlated and inhibitable by cross adsorption assays. Given the clinical associations of patients with neuroborreliosis and syphilis with IgM reactivity to gangliosides sharing the Gal(beta 1-3) GalNac terminus, we suggest that these antibodies could represent a response to injury in neurological disease or a cross reactive event caused by spirochetes.
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Abstract
After the isolation of Borrelia burgdorferi, the previously unknown causative agent of Lyme disease, two neurological disorders, Bannwarth's syndrome and acrodermatitis chronica atrophicans-associated neuropathy, which have been known in Europe for decades, gained new interest. With the availability of serodiagnostic tests, a chronic debilitating disorder--progressive borrelia encephalomyelitis--was found to be caused by chronic infection with B. burgdorferi. Beside these typical manifestations, a growing number of publications about various neurological phenomena appeared, which were thought to be caused by B. burgdorferi. This assumption was based in many cases on the results of serodiagnostic tests only. Considerations for causal connections were frequently lacking. While prior to the availability of serodiagnostic tests neurological manifestations of Lyme borreliosis frequently remained undiagnosed, we now face a tendency for overdiagnosis. The great variety of neurological manifestations in Lyme borreliosis--most of them can also be attributed to other conditions--and the high rate of seropositivity for B. burgdorferi amongst the population living in endemic areas require strict criteria for the correct diagnosis of new and typical neurological manifestations.
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Affiliation(s)
- W Kristoferitsch
- Neurologische Abteilung, Wilhelminenspital der Stadt Wien, Austria
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