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McEntire CRS, Chwalisz BK. Cranial nerve involvement, visual complications and headache syndromes in Lyme disease. Curr Opin Ophthalmol 2024; 35:265-271. [PMID: 38518069 DOI: 10.1097/icu.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW To provide a summary of the visual manifestations and cranial neuropathies seen in Lyme disease. RECENT FINDINGS Lyme facial palsy remains the most common manifestation of Lyme neuroborreliosis. Recent investigations show likely evidence of vagal involvement in Lyme disease. SUMMARY The literature on Lyme neuroborreliosis continues to evolve. Lyme disease can affect nearly any cranial nerve in addition to causing various headache syndromes. The most common manifestation is Lyme disease facial palsy, occurring in up to 5-10% of patients with documented Lyme disease. Headache syndromes are common in the context of facial palsy but can occur in isolation, and more specific headache syndromes including trigeminal and geniculate neuralgias can occur rarely. Signs and symptoms indicative of vestibulocochlear nerve involvement are relatively common, although it could be that these represent other vestibular involvement rather than a specific cranial neuropathy. Optic neuritis is a controversial entity within Lyme disease and is likely overdiagnosed, but convincing cases do exist. Physicians who see any cranial neuropathy, including optic neuritis, in an endemic area can consider Lyme disease as a possible cause.
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Affiliation(s)
- Caleb R S McEntire
- Massachusetts General Hospital-Harvard Medical School
- Brigham and Women's Hospital-Harvard Medical School, Department of Neurology
| | - Bart K Chwalisz
- Massachusetts General Hospital-Harvard Medical School
- Massachusetts Eye and Ear-Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts, USA
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Biniaz-Harris N, Kuvaldina M, Fallon BA. Neuropsychiatric Lyme Disease and Vagus Nerve Stimulation. Antibiotics (Basel) 2023; 12:1347. [PMID: 37760644 PMCID: PMC10525519 DOI: 10.3390/antibiotics12091347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/29/2023] Open
Abstract
Lyme disease, the most common tick-borne disease in the United States, is caused by infection with the spirochete Borrelia burgdorferi. While most patients with acute Lyme disease recover completely if treated with antibiotics shortly after the onset of infection, approximately 10-30% experience post-treatment symptoms and 5-10% have residual symptoms with functional impairment (post-treatment Lyme disease syndrome or PTLDS). These patients typically experience pain, cognitive problems, and/or fatigue. This narrative review provides a broad overview of Lyme disease, focusing on neuropsychiatric manifestations and persistent symptoms. While the etiology of persistent symptoms remains incompletely understood, potential explanations include persistent infection, altered neural activation, and immune dysregulation. Widely recognized is that new treatment options are needed for people who have symptoms that persist despite prior antibiotic therapy. After a brief discussion of treatment approaches, the article focuses on vagus nerve stimulation (VNS), a neuromodulation approach that is FDA-approved for depression, epilepsy, and headache syndromes and has been reported to be helpful for other diseases characterized by inflammation and neural dysregulation. Transcutaneous VNS stimulates the external branch of the vagus nerve, is minimally invasive, and is well-tolerated in other conditions with few side effects. If well-controlled double-blinded studies demonstrate that transcutaneous auricular VNS helps patients with chronic syndromes such as persistent symptoms after Lyme disease, taVNS will be a welcome addition to the treatment options for these patients.
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Affiliation(s)
- Nicholas Biniaz-Harris
- Lyme & Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, USA; (N.B.-H.); (M.K.)
| | - Mara Kuvaldina
- Lyme & Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, USA; (N.B.-H.); (M.K.)
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Brian A. Fallon
- Lyme & Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, USA; (N.B.-H.); (M.K.)
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA
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Affiliation(s)
- Christine S. Kim
- Division of Otolaryngology, Albany Medical Center, Albany, New York
| | - Alexander G. Bien
- Division of Otolaryngology, Albany Medical Center, Albany, New York
- Albany ENT & Allergy Services, PC, Albany, New York
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Abstract
Magnetic resonance imaging findings of meningitis are usually nonspecific with respect to the causative pathogen because the brain response to these insults is similar in most cases. In this article, we will use a few representative cases to describe the characteristic magnetic resonance findings of meningitis and its complications, including ventriculitis.
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Ewers EC, Dennison DH, Stagliano DR. A unique case of adolescent neuroborreliosis presenting with multiple cranial neuritis and cochlear inflammation on magnetic resonance imaging. Pediatr Neurol 2015; 52:107-9. [PMID: 25459362 DOI: 10.1016/j.pediatrneurol.2014.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/08/2014] [Accepted: 10/09/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND Lyme disease is the most common vector-borne disease in the United States and is caused by infection with the spirochete Borrelia burgdorferi. In children, neuroborreliosis usually presents as peripheral facial nerve palsy and lymphocytic meningitis and only rarely is associated with cranial polyneuritis. PATIENT DESCRIPTION We present a 15-year-old with tinnitus, hearing loss, and facial nerve palsy in the setting of acute, severe right arm pain and a several week history of malaise and headache. Lumbar puncture was notable for lymphocytic pleocytosis. Serologic testing demonstrated positive Lyme antibody and a positive immunoglobulin M Western blot. Immunofluorescent assay of cerebrospinal fluid was also positive for anti-Lyme immunoglobulin M. Audiologic testing revealed mixed, right-sided hearing loss. Neuroimaging demonstrated cranial polyneuritis and right-sided cochlear inflammation. The patient was treated with parenteral ceftriaxone with resolution of his symptoms at close follow-up. DISCUSSION Neuroborreliosis with radiculopathy, lymphocytic meningitis, and cranial polyneuritis is a rare presentation of pediatric Lyme disease. Additionally, cochlear inflammation along with cranial nerve VIII inflammation may contribute to hearing loss in patients with neuroborreliosis.
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Affiliation(s)
- Evan C Ewers
- Department of Medicine, Tripler Army Medical Center, Honolulu, Hawaii.
| | - David H Dennison
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David R Stagliano
- Pediatric Infectious Diseases, Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland
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Mayne PJ. Clinical determinants of Lyme borreliosis, babesiosis, bartonellosis, anaplasmosis, and ehrlichiosis in an Australian cohort. Int J Gen Med 2014; 8:15-26. [PMID: 25565883 PMCID: PMC4278782 DOI: 10.2147/ijgm.s75825] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Borrelia burgdorferi is the causative agent of Lyme borreliosis. This spirochete, along with Babesia, Bartonella, Anaplasma, Ehrlichia, and the Rickettsia spp. are recognized tick-borne pathogens. In this study, the clinical manifestation of these zoonoses in Australia is described. Methods The clinical presentation of 500 patients over the course of 5 years was examined. Evidence of multisystem disease and cranial nerve neuropathy was sought. Supportive laboratory evidence of infection was examined. Results Patients from every state of Australia presented with a wide range of symptoms of disease covering multiple systems and a large range of time intervals from onset. Among these patients, 296 (59%) were considered to have a clinical diagnosis of Lyme borreliosis and 273 (54% of the 500) tested positive for the disease, the latter not being a subset of the former. In total, 450 (90%) had either clinical evidence for or laboratory proof of borrelial infection, and the great majority of cases featured neurological symptoms involving the cranial nerves, thus mimicking features of the disease found in Europe and Asia, as distinct from North America (where extracutaneous disease is principally an oligoarticular arthritis). Only 83 patients (17%; number [n]=492) reported never leaving Australia. Of the 500 patients, 317 (63%) had clinical or laboratory-supported evidence of coinfection with Babesia or Bartonella spp. Infection with A. phagocytophilum was detected in three individuals, and Ehrlichia chaffeensis was detected in one individual who had never traveled outside Australia. In the cohort, 30 (11%; n=279) had positive rickettsial serology. Conclusion The study suggests that there is a considerable presence of borreliosis in Australia, and a highly significant burden of coinfections accompanying borreliosis transmission. The concept sometimes advanced of a “Lyme-like illness” on the continent needs to be re-examined as the clinical interplay between all these infections. Evidence is presented for the first report of endemic anaplasmosis and ehrlichiosis on the continent.
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Farshad-Amacker NA, Scheffel H, Frauenfelder T, Alkadhi H. Brainstem abnormalities and vestibular nerve enhancement in acute neuroborreliosis. BMC Res Notes 2013; 6:551. [PMID: 24359885 PMCID: PMC3878100 DOI: 10.1186/1756-0500-6-551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 12/16/2013] [Indexed: 11/10/2022] Open
Abstract
Background Borreliosis is a widely distributed disease. Neuroborreliosis may present with unspecific symptoms and signs and often remains difficult to diagnose in patients with central nervous system symptoms, particularly if the pathognomonic erythema chronica migrans does not develop or is missed. Thus, vigilance is mandatory in cases with atypical presentation of the disease and with potentially severe consequences if not recognized early. We present a patient with neuroborreliosis demonstrating brain stem and vestibular nerve abnormalities on magnetic resonance imaging. Case presentation A 28-year-old Caucasian female presented with headaches, neck stiffness, weight loss, nausea, tremor, and gait disturbance. Magnetic resonance imaging showed T2-weighted hyperintense signal alterations in the pons and in the vestibular nerves as well as bilateral post-contrast enhancement of the vestibular nerves. Serologic testing of the cerebrospinal fluid revealed the diagnosis of neuroborreliosis. Conclusion Patients infected with neuroborreliosis may present with unspecific neurologic symptoms and magnetic resonance imaging as a noninvasive imaging tool showing signal abnormalities in the brain stem and nerve root enhancement may help in establishing the diagnosis.
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Affiliation(s)
- Nadja A Farshad-Amacker
- Diagnostic and Interventional Radiology Department, University Hospital of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
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A pattern approach to focal white matter hyperintensities on magnetic resonance imaging. Radiol Clin North Am 2013; 52:241-61. [PMID: 24582339 DOI: 10.1016/j.rcl.2013.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Evaluation of focal white matter hyperintensities on magnetic resonance imaging in any age group is always challenging because the cause of these hyperintensities varies extensively. Understanding the clinical presentation, pathophysiology, and associated imaging findings can allow the radiologist to limit the differential diagnosis. A specific imaging approach including age, pattern of distribution, signal characteristics on various sequences, enhancement pattern, and other ancillary findings helps to identify a correct cause for these hyperintensities. This article provides a pattern approach to differentiate various common and a few uncommon diseases presenting as focal white matter hyperintensities.
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Abstract
AIM Trigeminal neuropathies are a group of clinical disorders that involve injury to primary first-order neurons within the trigeminal nerve. We review the spectrum of etiologies underlying both painful and non-painful trigeminal neuropathies, with attention to particularly dangerous processes that may elude the clinician in the absence of a meticulous evaluation. Complications and management issues specific to patients with trigeminal neuropathy are discussed. METHODS Retrospective literature review. RESULTS Facial or intraoral numbness, the hallmark of trigeminal neuropathy, may represent the earliest symptomology of malignancy or autoimmune connective tissue disease as sensory neurons are destroyed. Such numbness, especially if progressive, necessitates periodic evaluation and vigilance even years after presentation if no diagnosis can be made. CONCLUSIONS In the routine evaluation of patients with facial pain, the clinician will inevitably be confronted with secondary pathology of the trigeminal nerves and nuclei. The appearance of numbness, even when pain continues to be the most pressing complaint, necessitates clinical assessment of the integrity of all aspects of the trigeminal pathways, which may also include neurophysiologic, radiographic, and laboratory evaluation.
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James FM, Engiles JB, Beech J. Meningitis, cranial neuritis, and radiculoneuritis associated with Borrelia burgdorferi infection in a horse. J Am Vet Med Assoc 2010; 237:1180-5. [PMID: 21073390 DOI: 10.2460/javma.237.10.1180] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 12-year-old Thoroughbred was examined because of signs of depression, neck stiffness, and poor performance. CLINICAL FINDINGS Physical examination revealed that the horse was dull, appeared depressed, was reluctant to raise its neck and head above a horizontal plane, and had a temperature of 38.5°C (101.3°F). No radiographic or scintigraphic abnormalities of the neck were found; however, high plasma fibrinogen concentration and relative lymphopenia were identified and the horse was seropositive for antibodies against Borrelia burgdorferi. Analysis of CSF revealed neutrophilic inflammation, and results of a PCR assay of CSF for B burgdorferi DNA were positive. Immunologic testing revealed severe B-cell lymphopenia and a low serum IgM concentration consistent with common variable immunodeficiency. TREATMENT AND OUTCOME The horse responded well to do×ycycline treatment (10 mg/kg [4.5 mg/lb], PO, q 12 h for 60 days) and returned to normal exercise. However, 60 days after treatment was discontinued, the horse again developed a stiff neck and rapidly progressive neurologic deficits, including severe ataxia and vestibular deficits. The horse's condition deteriorated rapidly despite IV oxytetracycline treatment, and the horse was euthanatized. Postmortem examination revealed leptomeningitis, lymphohistiocytic leptomeningeal vasculitis, cranial neuritis, and peripheral radiculoneuritis with Wallerian degeneration; findings were consistent with a diagnosis of neuroborreliosis. CLINICAL RELEVANCE Nervous system infection with B burgdorferi should be considered in horses with evidence of meningitis and high or equivocal serum anti-B burgdorferi antibody titers. Evaluation of immune function is recommended in adult horses evaluated because of primary bacterial meningitis.
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Affiliation(s)
- Frances M James
- Department of Clinical Studies, University of Pennsylvania, PA 19348, USA.
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Baumann M, Birnbacher R, Koch J, Strobl R, Rostásy K. Uncommon manifestations of neuroborreliosis in children. Eur J Paediatr Neurol 2010; 14:274-7. [PMID: 19748808 DOI: 10.1016/j.ejpn.2009.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 07/10/2009] [Accepted: 08/03/2009] [Indexed: 11/19/2022]
Abstract
Lyme borreliosis is a tick-borne spirochetal infection which affects the skin, joints, heart and nervous system. Children with a neuroborreliosis usually present with a facial nerve palsy or aseptic meningitis, but the spectrum also includes other rare manifestations. We report four unusual cases of childhood neuroborreliosis and show that seizures with regional leptomeningeal enhancement, acute transverse myelitis, meningoradiculitis with pain and paraesthesia and cranial nerve palsies other than facial nerve palsy can be the leading symptoms of children with neuroborreliosis. All children had serological evidence of an acute infection with Borrelia burgdorferi, a pleocytosis in the cerebrospinal fluid and a complete response to antibiotic treatment. An intrathecal synthesis of IgG antibodies was detected in three children. Thus, diagnostic work up in children with unusual neurological symptoms should include cerebrospinal fluid studies with determination of the white blood cell count and calculation of the antibody index against B. burgdorferi.
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Affiliation(s)
- Matthias Baumann
- Department of Pediatrics, Division of Pediatric Neurology and Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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