1
|
Palmer KN, Sokola M, Uysal SP, Cooperrider J, Leung AK, Torres-Trejo A, Li Y, Abbatemarco JR. Diagnostic Challenges of Lyme Neuroborreliosis in Inpatient Neurology: A Case Series. Neurohospitalist 2024; 14:301-307. [PMID: 38895010 PMCID: PMC11181985 DOI: 10.1177/19418744241246308] [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: 06/21/2024] Open
Abstract
Lyme disease is a multisystem disorder transmitted through the Ixodes tick and is most commonly diagnosed in northeastern and mid-Atlantic states, Wisconsin, and Minnesota, though its disease borders are expanding in the setting of climate change. Approximately 10%-15% of untreated Lyme disease cases will develop neurologic manifestations of Lyme neuroborreliosis (LNB). Due to varying presentations, LNB presents diagnostic challenges and is associated with a delay to treatment. We discuss three cases of LNB admitted to our referral center in a traditionally low-incidence state to highlight clinical pearls in LNB diagnosis. Three patients from low-incidence areas with prior diagnostic evaluations presented in August with neurologic manifestations of radiculoneuritis, cranial neuropathies, and/or lymphocytic meningitis. MRI findings included cranial nerve, nerve root, and leptomeningeal enhancement leading to broad differential diagnoses. Lumbar puncture demonstrated lymphocytic pleocytosis (range 85-753 cells/uL) and elevated protein (87-318 mg/dL). Each patient tested positive for Lyme on two-tiered serum testing and was diagnosed with LNB. All three cases were associated with a delay to health care presentation (mean 20 days) and a delay to diagnosis and treatment (mean 54 days) due to under-recognition and ongoing evaluation. With the geographic expansion of Lyme disease, increasing awareness of LNB manifestations and acquiring detailed travel histories in low-incidence areas is crucial to prompt delivery of care. Clinicians should be aware of two-tiered serum diagnostic requirements and use adjunctive studies such as lumbar puncture and MRI to eliminate other diagnoses. Treatment with an appropriate course of antibiotics leads to robust improvement in neurological symptoms.
Collapse
Affiliation(s)
| | - Maria Sokola
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Sanem P. Uysal
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Anthony K. Leung
- Department of Infectious Disease, Cleveland Clinic Akron General, Akron, OH, USA
| | - Alejandro Torres-Trejo
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Yuebing Li
- Neuromuscular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Justin R. Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
2
|
Szanyi J, Kremlacek J, Kubova Z, Kuba M, Vit F, Langrova J, Gebousky P, Szanyi J. Optic nerve involvement in patients with Lyme neuroborreliosis: an electrophysiological study. Doc Ophthalmol 2024:10.1007/s10633-024-09975-w. [PMID: 38622306 DOI: 10.1007/s10633-024-09975-w] [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: 09/08/2023] [Accepted: 03/28/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE The aim of this neurophysiological study was to retrospectively analyze visual evoked potentials (VEPs) acquired during an examination for diagnosing optic nerve involvement in patients with Lyme neuroborreliosis (LNB). Attention was focused on LNB patients with peripheral facial palsy (PFP) and optic nerve involvement. METHODS A total of 241 Czech patients were classified as having probable/definite LNB (193/48); of these, 57 were younger than 40 years, with a median age of 26.3 years, and 184 were older than 40 years, with a median age of 58.8 years. All patients underwent pattern-reversal (PVEP) and motion-onset (MVEP) VEP examinations. RESULTS Abnormal VEP results were observed in 150/241 patients and were noted more often in patients over 40 years (p = 0.008). Muscle/joint problems and paresthesia were observed to be significantly more common in patients older than 40 years (p = 0.002, p = 0.030), in contrast to headache and decreased visual acuity, which were seen more often in patients younger than 40 years (p = 0.001, p = 0.033). Peripheral facial palsy was diagnosed in 26/241 LNB patients. Among patients with PFP, VEP peak times above the laboratory limit was observed in 22 (84.6%) individuals. Monitoring of patients with PFP and pathological VEP showed that the adjustment of visual system function occurred in half of the patients in one to more years, in contrast to faster recovery from peripheral facial palsy within months in most patients. CONCLUSION In LNB patients, VEP helps to increase sensitivity of an early diagnostic process.
Collapse
Affiliation(s)
- Jana Szanyi
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic.
| | - Jan Kremlacek
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Zuzana Kubova
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Miroslav Kuba
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Frantisek Vit
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Jana Langrova
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Pavel Gebousky
- Department of Infectious Diseases, Faculty Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Juraj Szanyi
- Department of Infectious Diseases, Faculty Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| |
Collapse
|
3
|
Jespersen FVB, Hansen SUB, Jensen SS, Omland LH, Helweg-Larsen J, Bjarnsholt T, Nielsen CH, Ziebell M, Bodilsen J, Markvart M. Cerebral abscesses with odontogenic origin: a population-based cohort study. Clin Oral Investig 2023:10.1007/s00784-023-04976-6. [DOI: 10.1007/s00784-023-04976-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
Abstract
Objectives
Recent studies have indicated that cerebral abscess (CA) patients with odontogenic origin are on the rise. However, CA patients are often poorly characterized and with an unknown etiologic background. The purpose of this study is to identify and characterize CA patients that may have an odontogenic origin based on microbiologic, radiographic, and/or clinical findings.
Materials and methods
This is a population-based cohort study analyzing retrospective and prospective data from CA patients. Radiographic examinations of panoramic radiographs (PRs) or computed tomography (CT) scans were conducted. CA patients characterized with odontogenic origin required the fulfilment of the following criteria on admission: (1) Oral pathologic conditions were the only bacterial infections present, (2) oral microorganisms were isolated in the purulent exudate from the brain, and (3) radiographically and/or clinical recordings of oral pathologic conditions.
Results
A total of 44 patients could be included in this study of which 25 (57%) were characterized as having CA with a likely odontogenic origin. Type two diabetes (T2D) (p = 0.014) and microorganisms of the Streptococcus anginosus group (SAG) (p < 0.01) were overrepresented in patients with CAs of odontogenic origin.
Conclusions
Odontogenic infections may cause CAs to a greater extent than previously assumed. T2D was overrepresented among patients with odontogenic CA. When microorganisms of the SAG were isolated from the brain pus, CA patients had a predisposing odontogenic or sinus infection.
Clinical relevance
The identification of patients with a likely odontogenic CA will contribute to understanding the etiology of the infectious disease and highlighting the importance of preserving oral health.
Collapse
|
4
|
Assessment of cognitive function, structural brain changes and fatigue 6 months after treatment of neuroborreliosis. J Neurol 2023; 270:1430-1438. [PMID: 36380166 PMCID: PMC9971095 DOI: 10.1007/s00415-022-11463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Complete recovery after adequately treated neuroborreliosis is common, but studies report that some patients experience persistent symptoms like self-reported cognitive problems and fatigue. Persisting symptoms are often termed post-Lyme disease syndrome, of which etiology is not clearly understood. The aim of this study was to investigate cognitive function, possible structural changes in brain regions and level of fatigue. We have not found previous studies on neuroborreliosis that use standardized neuropsychological tests and MRI with advanced image processing to investigate if there are subtle regional changes in cortical thickness and brain volumes after treatment. METHODS We examined 68 patients treated for neuroborreliosis 6 months earlier and 66 healthy controls, with a comprehensive neuropsychological test protocol, quantitative structural MRI analysis of the brain and Fatigue Severity Scale. RESULTS We found no differences between the groups in either cognitive function, cortical thickness or brain volumes. The patients had higher score on Fatigue Severity Scale 3.8 vs. 2.9 (p = 0.001), and more patients (25.4%) than controls (5%) had severe fatigue (p = 0.002), but neither mean score nor proportion of patients with severe fatigue differed from findings in the general Norwegian population. CONCLUSION The prognosis regarding cognitive function, brain MRI findings and fatigue after adequately treated neuroborreliosis is favorable.
Collapse
|
5
|
Halperin JJ, Eikeland R, Branda JA, Dersch R. Lyme neuroborreliosis: known knowns, known unknowns. Brain 2022; 145:2635-2647. [PMID: 35848861 DOI: 10.1093/brain/awac206] [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: 02/26/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Lyme borreliosis affects the nervous system in three principal ways-mononuclear cell meningitis, cranial neuropathies and radiculoneuropathies-the last a broad term encompassing painful radiculopathy, unifocal and multifocal peripheral nerve involvement. Diagnostic tools have been significantly refined-including improved peripheral blood and CSF serodiagnostics-and much has been learned about the interactions between the causative pathogen and the nervous system. Despite these advances in our understanding of this disease, a broad range of other disorders continue to be misattributed to nervous system Lyme borreliosis, supported by, at best, limited evidence. These misattributions often reflect limited understanding not only of Lyme neuroborreliosis but also of what constitutes nervous system disease generally. Fortunately, a large body of evidence now exists to clarify many of these issues, establishing a clear basis for diagnosing nervous system involvement in this infection and, based on well performed studies, clarifying which clinical disorders are associated with Lyme neuroborreliosis, which with non-neurologic Lyme borreliosis, and which with neither.
Collapse
Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, 99 Beauvoir Ave., Summit, NJ 07901, USA.,Department of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.,Department of Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Randi Eikeland
- National Advisory on Tick-borne Diseases, Sørlandet Hospital Trust, Egvsveien 100, 4615 Kristiansand, Norway.,Faculty of Health and Sport Sciences, University of Agder, 4879 Grimstad, Norway
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA.,Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| |
Collapse
|
6
|
Lindland ES, Solheim AM, Dareez MN, Eikeland R, Ljøstad U, Mygland Å, Reiso H, Lorentzen ÅR, Harbo HF, Beyer MK. Enhancement of cranial nerves in Lyme neuroborreliosis: incidence and correlation with clinical symptoms and prognosis. Neuroradiology 2022; 64:2323-2333. [PMID: 35608630 DOI: 10.1007/s00234-022-02957-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/08/2022] [Indexed: 01/17/2023]
Abstract
PURPOSE Symptoms of cranial neuritis are a common presentation of Lyme neuroborreliosis (LNB). Imaging studies are scarce and report contradictory low prevalence of enhancement compared to clinical studies of cranial neuropathy. We hypothesized that MRI enhancement of cranial nerves in LNB is underreported, and aimed to assess the prevalence and clinical impact of cranial nerve enhancement in early LNB. METHODS In this prospective, longitudinal cohort study, 69 patients with acute LNB were examined with MRI of the brain. Enhancement of cranial nerves III-XII was rated. MRI enhancement was correlated to clinical findings of neuropathy in the acute phase and after 6 months. RESULTS Thirty-nine of 69 patients (57%) had pathological cranial nerve enhancement. Facial and oculomotor nerves were most frequently affected. There was a strong correlation between enhancement in the distal internal auditory canal and parotid segments of the facial nerve and degree of facial palsy (gamma = 0.95, p < .01, and gamma = 0.93, p < .01), despite that 19/37 nerves with mild-moderate enhancement in the distal internal auditory canal segment showed no clinically evident palsy. Oculomotor and abducens nerve enhancement did not correlate with eye movement palsy (gamma = 1.00 and 0.97, p = .31 for both). Sixteen of 17 patients with oculomotor and/or abducens nerve enhancement had no evident eye movement palsy. CONCLUSIONS MRI cranial nerve enhancement is common in LNB patients, but it can be clinically occult. Facial and oculomotor nerves are most often affected. Enhancement of the facial nerve distal internal auditory canal and parotid segments correlate with degree of facial palsy.
Collapse
Affiliation(s)
- Elisabeth S Lindland
- Department of Radiology, Sorlandet Hospital, Sykehusveien 1, N-4809, Arendal, Norway.
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.
| | - Anne Marit Solheim
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Randi Eikeland
- The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital, Kristiansand, Norway
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Unn Ljøstad
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Habilitation, Sorlandet Hospital, Kristiansand, Norway
| | - Harald Reiso
- The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital, Kristiansand, Norway
| | - Åslaug R Lorentzen
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital, Kristiansand, Norway
| | - Hanne F Harbo
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mona K Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
7
|
Bodilsen J, Larsen L, Brandt CT, Wiese L, Hansen BR, Andersen CØ, Lüttichau HR, Helweg-Larsen J, Storgaard M, Nielsen H. Existing Data Sources for Clinical Epidemiology: The Danish Study Group of Infections of the Brain Database (DASGIB). Clin Epidemiol 2021; 13:921-933. [PMID: 34675681 PMCID: PMC8500496 DOI: 10.2147/clep.s326461] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022] Open
Abstract
Central nervous system (CNS) infections are rare diseases that are associated with considerable morbidity and mortality. Increased knowledge based on contemporary data is a prerequisite for improved management and prevention of these serious conditions. Yet, population-based databases of patients hospitalized with CNS infections remain scarce. The Danish Study Group of Infections of the Brain (DASGIB) has prospectively registered information on all adults ≥18 years of age admitted with CNS infections at departments of infectious diseases in Denmark since 2015. The main variables collected are baseline demographics, blood and cerebrospinal fluid tests, imaging results, and outcome using the Glasgow Outcome Scale score. To investigate important aspects for each type of CNS infections, additional variables are included specifically for bacterial meningitis, viral meningitis, encephalitis, brain abscess, neurosyphilis, and Lyme neuroborreliosis. From 2015 to 2020, a total of 3579 cases of CNS infections have been recorded in the DASGIB database. Using the unique civil registration number assigned to all Danish residents, the database can be unambiguously linked with nationwide healthcare registries at the individual level. This enables researchers to conduct detailed population-based and longitudinal observational studies of risk and prognosis of CNS infections and to compare them with matched population cohorts. The database is well-suited for epidemiological research and the DASGIB network forms a solid infrastructure for future national and international collaborations.
Collapse
Affiliation(s)
- Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, 9000, Denmark
| | - Lykke Larsen
- Department of Infectious Diseases, Odense University Hospital, Odense, 5000, Denmark
| | - Christian Thomas Brandt
- Department of Infectious Diseases, Nordsjællands Hospital, Hillerød, 3400, Denmark.,Department of Infectious Diseases, Sjælland University Hospital, Roskilde, 4000, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Sjælland University Hospital, Roskilde, 4000, Denmark
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, 2650, Denmark
| | | | - Hans Rudolf Lüttichau
- Department of Infectious Diseases, Herlev Gentofte Hospital, Copenhagen, 2730, Denmark
| | | | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, 8200, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, 9000, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, 9000, Denmark
| |
Collapse
|
8
|
Berg A, Syre H, Ophaug CH, Møller JH, Behzadi GIN. Neuroborreliosis with severe mental confusion and thickening of cranial nerves. IDCases 2021; 24:e01135. [PMID: 33996465 PMCID: PMC8102158 DOI: 10.1016/j.idcr.2021.e01135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Aase Berg
- Stavanger University Hospital, Department of Infectious Diseases, PO Box 8100, 4068, Stavanger, Norway
| | - Heidi Syre
- Stavanger University Hospital, Department of Microbiology, PO Box 8100, 4068, Stavanger, Norway
| | - Christine H Ophaug
- Stavanger University Hospital, Department of Infectious Diseases, PO Box 8100, 4068, Stavanger, Norway
| | - Jannicke H Møller
- Stavanger University Hospital, Department of Intensive Care, PO Box 8100, 4068, Stavanger, Norway
| | - Gry I N Behzadi
- Stavanger University Hospital, Department of Radiology, PO Box 8100, 4068, Stavanger, Norway
| |
Collapse
|