Childhood Lyme borreliosis in Europe

Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis in children: a systematic review

BACKGROUND

Many aspects of pharmacological treatment of Lyme neuroborreliosis in children, such as choice of drug, dosage, and duration are subject to intense debates, leading to uncertainties in patients' parents and healthcare providers alike. To assess the available evidence for pharmacological treatment for children with Lyme neuroborreliosis we conducted a systematic review.

METHODS

The comprehensive systematic literature search included randomized-controlled trials (RCTs) and non-randomized studies (NRS) on treatment of Lyme neuroborreliosis in children (age <18 years). Our primary outcome was neurological symptoms after treatment. Risk of bias was assessed with the Cochrane risk of bias tools for RCTs and NRS. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Two RCTs and four NRS were eligible for inclusion. Risk of bias in RCTs and NRS was generally high. Reporting of studies was generally poor. Regarding the primary outcome neurological symptoms at 1-3 months, no statistically significant difference could be found in cohort studies between doxycycline and beta-lactam antibiotics. In two RCTs comparing penicillin G and ceftriaxone, no patient experienced residual neurological symptoms at the last reported time points. Quality of evidence according to GRADE was judged very low.

CONCLUSIONS

Data is scarce and with limited quality. Several issues could not be addressed due to scarcity of information. No eligible study compared different treatment durations. According to the available evidence, there seems to be no difference between different antibiotic agents for the treatment of Lyme neuroborreliosis in children regarding neurological symptoms. We found no evidence that supports extended antibiotic regimes.

REVIEW REGISTRATION

Systematic review registration: CRD42014008839 .

[Acute transverse myelitis and Lyme borreliosis: a case report]

Lyme disease is an infectious disease caused by a spirochete of the Borrelia sensu lato group. Its incidence has greatly increased in recent years. The main vector is a tick of the Ixodes family. Clinical manifestations are multiple and show the multi-organ character of the disease. In terms of frequency, joint and neurological presentations, respectively more frequent in North America and Europe, are the main manifestations after cutaneous symptoms, of which erythema migrans is the most common, followed by cardiac and ocular signs. Other signs exist but are anecdotal. Neuroborreliosis manifests itself most often with peripheral facial palsy, but there are other clinical forms, which include acute myelitis (4-5% of neuroborreliosis). We present here the case of a 16-year-old teenager with acute myelitis and meningeal involvement due to Lyme disease, who presented with atypical symptoms (massive and rapid weight loss, vomiting). MRI showed localized marrow edema as well as leptomeningeal and root enhancement. Lumbar puncture showed lymphocytic pleocytosis. Lyme serology was positive both in blood and cerebrospinal fluid. Even if acute myelitis remains exceptional among neuroborreliosis manifestations, this diagnosis has to be thought of when a child presents with unexplained neurological symptoms.

Enhanced levels of leukotriene B(4) in synovial fluid in Lyme disease

The purpose of this study was to evaluate the potential role of LTB(4) and cysteinyl leukotrienes in Lyme disease (LD). Therefore, a total number of 34 patients divided into four groups was studied. The patients were classified as having Lyme arthritis (n = 7) or Lyme meningitis (n = 10), and as control groups patients with a noninflammatory arthropathy (NIA) (n = 7) and healthy subjects (n = 10). LTB(4) as well as LTC(4) secretion from stimulated polymorphonuclear leukocytes (PMNL) from all groups of patients showed no statistical differences. LTB(4) levels in synovial fluid were significantly increased in patients with Lyme arthritis (median 142 ng/ml, range 88-296) when compared to the control subjects with NIA (median 46 ng/ml, range 28-72) (p < 0.05). No statistical difference of urinary LTE(4) levels between all the different groups of patients was observed. These results show that cysteinyl leukotrienes do not play an important role in the pathogenesis of LD. In contrast to previous findings in rheumatoid arthritis, LTB(4) production from stimulated PMNL was not found to be increased in LD. However, the significantly elevated levels of LTB(4) in synovial fluid of patients with Lyme arthritis underline the involvement of LTB(4) in the pathogenesis of this disease.

Rational diagnostic strategies for Lyme borreliosis in children and adolescents: recommendations by the Committee for Infectious Diseases and Vaccinations of the German Academy for Pediatrics and Adolescent Health

The varying clinical manifestations of Lyme borreliosis, transmitted by Ixodes ricinus and caused by Borrelia burgdorferi, frequently pose diagnostic problems. Diagnostic strategies vary between early and late disease manifestations and usually include serological methods. Erythema migrans is pathognomonic and does not require any further laboratory investigations. In contrast, the diagnosis of neuroborreliosis requires the assessment of serum and cerebrospinal fluid. Lyme arthritis is diagnosed in the presence of newly recognized arthritis and high-titer serum IgG antibodies against B. burgdorferi. The committee concludes the following recommendations: Borrelial serology should only be ordered in case of well-founded clinical suspicion for Lyme borreliosis, i.e., manifestations compatible with the diagnosis. Tests for borrelial genomic sequences in ticks or lymphocyte proliferation assays should not be ordered. When results of such tests or of serological investigations that were not indicated are available, they should not influence therapeutic decisions. Laboratories should be cautious when interpreting results of serological tests and abstain from giving therapeutic recommendations and from proposing retesting after some time without intimate knowledge of patient's history and disease manifestations.

[Juvenile arthritides]

Arthritis in children represents a diagnostic and therapeutic challenge. The diagnostic spectrum is broad and a very precise indication for diagnostic and therapeutic procedures, especially in small children, is important. In addition to acute arthritides - viral arthritis, reactive arthritis, Lyme arthritis and septic arthritis - secondary chronic arthritis related to an underlying disease as well as juvenile idiopathic arthritis (JIA), the most common chronic inflammatory systemic disease in children, need to be considered. This overview is a guide to the diagnosis of arthritis in childhood and to evidence-based therapy of JIA in particular. This consists of a combination of nonsteroidal anti-inflammatory drugs, systemic and intraarticular corticosteroids, traditional DMARDs such as sulfasalazine, methotrexate and leflunomide, the TNF inhibitors etanercept, adalimumab and, with restrictions, infliximab, other biopharmaceuticals such as anakinra, canakinumab and rilonacept, and tocilizumab and finally, abatacept.

[Lyme arthritis in children and adolescents]

Lyme arthritis is one of the manifestations of Lyme disease and is caused by infection with Borrelia burgdorferi sensu lato. This article reviews the current knowledge regarding the epidemiology, etiology and pathogenesis as well as the clinical manifestations, the diagnosis, treatment and prognosis with special emphasis on children and adolescents.

The spectrum of paediatric and adolescent rheumatology

A wide range of conditions comes under the umbrella of paediatric rheumatology. These problems are common in childhood and cover a wide variety of presentations and outcomes. Many conditions are benign and self-limiting, others run a chronic relapsing and remitting course; some are fatal. Broadly, rheumatological problems can be subdivided into inflammatory, mechanical, and behaviourally or psychologically driven aetiologies, although these are not mutually exclusive. The majority of patients with rheumatological conditions will present with symptoms that are easily localized to the musculoskeletal system. Sometimes, however, a child with a rheumatological condition may present less specifically: for example with fatigue, deterioration in school performance or growth retardation. In this case a rheumatological aetiology may be overlooked unless it is specifically suspected and a careful assessment for musculoskeletal symptoms and signs is undertaken. In order to arrive at the correct diagnosis and plan appropriate further management, it is therefore important for the clinician both to have an effective system to ensure that musculoskeletal symptoms are appropriately determined and assessed, and to be aware of the wide range of conditions, which can cause such symptoms in childhood and adolescence. The keys to this lie in acquiring the clinical skills necessary to accurately assess such patients and awareness of the changing differential diagnosis with the age of the child. In this chapter, we aim to address these issues, initially by discussing the prevalence of musculoskeletal symptoms in children and adolescents and the various conditions which cause them, and subsequently by looking at common presentations of rheumatic disease in childhood and suggesting an approach to diagnosis in each case.

Successful treatment of neuroborreliosis with ten day regimens

BACKGROUND

There have been few large reports of the treatment and outcome of neuroborreliosis in children.

METHODS

All 203 children with symptoms, cerebrospinal fluid and serologic findings compatible with neuroborreliosis and treated at one of the four pediatric hospitals in Stockholm from 1994 through 1996 were included. Children were treated with intravenous beta-lactam antibiotics or oral doxycycline for 10 days and followed until the resolution of symptoms.

RESULTS

At the end of treatment 58% and after 2 months 92% of the children had no symptoms. Cerebrospinal fluid findings had no statistically significant influence on the outcome. Facial paralysis persisted longer than other symptoms.

CONCLUSIONS

The prognosis of neuroborreliosis in children 2 months after treatment seems to be excellent with 10-day treatment regimens.

Lyme disease in children

Lyme borreliosis is a multisystem disorder caused by Borrelia burgdorferi and transmitted by ticks in the northern hemisphere. The disease is common in children. In addition to frequently recognized manifestations such as erythema migrans, neuroborreliosis, and Lyme arthritis, rarer manifestations, including eye and ear disease, are increasingly understood. Clinical diagnosis is supported by serologic confirmation. Improvement of laboratory methodology, especially polymerase chain reaction-based tests, is continuing. Actual treatment recommendations based on controlled studies reflect expanding scientific knowledge. In the United States, license of a vaccine to prevent infection in children is awaited. Lyme borreliosis is an intriguing human example of bacterial persistence in the presence of the host immune system. Chronic Lyme arthritis is a model of chronic arthritis resembling forms of arthritis of unknown cause, such as rheumatoid arthritis and juvenile idiopathic arthritis.

Tick-borne diseases

Tick-transmitted infectious agents have assumed increased importance as causes of human disease in the United States. During the past two decades, Lyme borreliosis, ehrlichiosis, and babesiosis have emerged as newly described tick-borne infectious diseases of significance for pediatricians and pediatric neurologists. In fact, the highest rates of infection for Lyme disease and Rocky Mountain spotted fever (RMSF), by decade of age, are in childhood. As such, tick-borne infectious disease are of considerable public health concern, particularly for children residing in endemic regions. RMSF and human ehrlichioses can be life-threatening but are also eminently treatable when recognized early. Delays in diagnosis and treatment can lead to adverse outcomes. This article reviews the clinical and epidemiological features of Lyme borreliosis, RMSF, and ehrlichiosis, important causes of neurological illness among children, and summarizes current therapeutic and preventive strategies.

Lyme neuroborreliosis in children

Children are more likely than adults to be bitten by ticks and thus more likely to be infected by Borrelia burgdorferi. In a serosurvey the infection rate measured by immunoglobulin G (IgG) antibodies was 2.6%. In a prospective hospital-based multicentre study 169 children with Lyme neuroborreliosis were examined; the infection was diagnosed by detection of specific immunoglobulin M (IgM) antibodies in the cerebrospinal fluid (CSF) using an IgM capture ELISA. The yearly incidence of Lyme neuroborreliosis was 5.8 cases per 100,000 children aged 1-13. Facial palsy and lymphocytic meningitis account for nearly 90% of all cases with neuroborreliosis indicating striking differences in the clinical spectrum between children and adults. Lyme borreliosis proves to be the most frequently verifiable cause of acute peripheral facial palsy in children, causing every second case of this disorder in the summer and autumn. In cases of facial palsy, nearly all patients with a positive history of tick bite or erythema migrans in the head and neck region show ipsilateral subsequent facial nerve palsy, suggesting a direct invasion via the affected nerve by Borrelia burgdorferi. Lyme borreliosis is the third most frequent cause of lymphocytic meningitis in childhood. Inflammatory changes of the cerebrospinal fluid along with the presence of specific antibodies are mandatory for the diagnosis of Lyme neuroborreliosis. High-dose intravenous penicillin G as well as third-generation cephalosporins prove to be effective in paediatric Lyme neuroborreliosis.

Diagnostic value of synovial fluid analysis in children with reactive arthritis

We report on three children with pauciarticular arthritis in whom the clinical picture and serology were compatible with both arthritis reactive to infection with Yersinia or Salmonella and with Lyme arthritis. Results of analysis of synovial fluid by polymerase chain reaction for enterobacterial or borrelial sequences were negative. Immunofluorescence with specific antibodies revealed the presence of amorphous enterobacterial antigens in synovial fluid cells. Since this staining did not reveal enterobacterial morphology, we infected synovial fluid cells of two children with juvenile rheumatoid arthritis in vitro with Yersinia or Salmonella. After 24 h typical rods were observed, but after about 1 week amorphous antigen similar to what had been found in the three patients was seen. In cases of reactive arthritis with ambiguous results of serological testing the diagnosis may be confirmed by demonstration of enterobacterial antigens in synovial fluid.

Lyme arthritis in European children and adolescents. The Pediatric Rheumatology Collaborative Group

OBJECTIVE

To evaluate and describe Lyme arthritis in European children and adolescents.

METHODS

This was a prospective multicenter study. The diagnosis of Lyme arthritis required the exclusion of other diseases and positive findings on serology for IgG antibodies to Borrelia burgdorferi. Enzyme-linked immunosorbent assay, immunoblotting, and polymerase chain reaction techniques to identify infection by B burgdorferi were used.

RESULTS

Among 62 children and adolescents with Lyme arthritis, only 1 had a preceding erythema migrans. Arthritis was episodic in 62% and was chronic at onset in 18%. The most common manifestation was monarthritis of the knee. Joint involvement in patients with oligoarthritis was predominantly unilateral or symmetric. Arthralgia was very rare. Treatment with 1 or 2 courses of different antibiotics resulted in disappearance of the arthritis in 77% of the patients.

CONCLUSION

The clinical presentation of Lyme arthritis in children is different from that in adults. The calculated incidence of Lyme arthritis in persons under the age of 17 years (4/100,000) exceeds previous estimations.

Acute childhood neuroborreliosis with a selective immune response to a low molecular weight protein expressed by Borrelia garinii

In patients with Lyme borreliosis the early immune response to Borrelia burgdorferi is usually directed against the flagellin (41 kD) antigen. However, the sera of 4 out of 12 children with typical early neuroborreliosis contained antibodies to two low molecular weight proteins of 19 and 23 kD. These antibodies were demonstrated in serological tests using Borrelia garinii as antigen source. B. garinii is the species of B. burgdorferi sensu lato associated with neuroborreliosis. In contrast serological tests using B. burgdorferi sensu stricto, associated with arthritis, or using VS461 strains (B. afzelii), associated with chronic skin disease, were false-negative. Monospecific rabbit sera raised against the 23 kD protein of B. garinii strain W1 detected the 23 kD epitope in B. garinii isolates only. Results of serological tests for Lyme borreliosis may depend on the infecting strain and on the choice of the strain used as antigen source for diagnostic tests. The attending physician should interpret serological test results with care and rely on astute clinical judgement.

Persisting complaints attributed to chronic Lyme disease: possible mechanisms and implications for management

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.

Demonstration of Borrelia burgdorferi infection in a child with Guillain-Barré syndrome

A 4.5-year-old child suffered from rapidly evolving motor weakness with paresthesia and radicular pain in both legs, accompanied by an isolated elevation of protein levels in CSF. Isoelectric focusing revealed oligoclonal IgG produced in the cerebrospinal compartment only. The diagnosis of Guillain-Barré syndrome was confirmed by electrophysiological studies. High antibody titres against Borrelia burgdorferi in the serum and specific antibodies in the CSF were demonstrable by ELISA and immunoblotting. B. burgdorferi specific DNA fragments were demonstrated in urine and CSF by means of a nested polymerase chain reaction (PCR), thus providing the borrelial aetiology and indicating B. burgdorferi infection. Complete recovery was observed after treatment with high dose immunoglobulin and ceftriaxone and control urine specimens were PCR negative.

2nd European Symposium on Lyme Borreliosis. A NATO advanced research workshop. United Kingdom, 19-20 May 1993. Abstracts

Images

Detection of Borrelia burgdorferi by nested polymerase chain reaction in cerebrospinal fluid and urine of children with neuroborreliosis

Diagnosis of neuroborreliosis is often difficult since history and clinical presentation may be non-specific and serological tests may initially be negative. We therefore tested the polymerase chain reaction (PCR) for the detection of borrelial sequences in CSF and urine samples of consecutive children with neuroborreliosis seen in a single summer season. Four of eight children were negative in serum for antibodies to Borrelia burgdorferi. Two of eight children were PCR-positive in CSF and one other child was positive in urine. In two out of four children PCR was the only laboratory test confirming the clinical diagnosis. All children recovered after treatment with third generation cephalosporins. When seven of eight children were re-examined 6 months later all were healthy and antibodies to B. burgdorferi were detected in their serum. PCR may assist the paediatrician in establishing a diagnosis of neuroborreliosis; however, a negative result does not rule out neuroborreliosis. PCR is an adjunct, but no substitute for clinical judgement and serology.

Penicillin G sodium and ceftriaxone in the treatment of neuroborreliosis in children--a prospective study

A controlled clinical study was set up to examine whether penicillin G sodium (PG) or ceftriaxone (C) is superior in the treatment of acute neuroborreliosis in childhood. Within a time period of 18 months 77 children with symptoms indicative of Lyme borreliosis of the central nervous system (CNS) were seen. In 23 of these children Borrelia burgdorferi specific cerebrospinal fluid (CSF) parameters confirmed the diagnosis of a neuroborreliosis. These children were treated at random with intravenous (i.v.) PG 400,000-500,000 I.U./kg/day for 14 days (group I) or with i.v. ceftriaxone 75-93 mg/kg/day for 14 days (group II), respectively. Clinical examination and a set of diagnostic laboratory parameters were done at admission, right after therapy, three, six and partly 12 months after therapy. The general condition of all children in both groups improved dramatically during antibiotic therapy, and no relapse occurred within the observation period. Considering the clear and comparable decrease of B. burgdorferi serum titres and the clinical outcome (duration of disease and follow-up for at least six months) in children of both groups no difference between both antibiotic drugs can be demonstrated.