Ocular manifestations of Lyme disease

Optic nerve involvement in patients with Lyme neuroborreliosis: an electrophysiological study

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.

Multimodal imaging for the management of Lyme-associated uveitis: A case report from an Italian tertiary center

INTRODUCTION

Lyme borreliosis may present with different systemic manifestations and also the ocular involvement may be difficult to diagnose because of its multifaceted presentation. Considering the growing incidence of Lyme disease in European countries, ophthalmologist should be trained to distinguish ocular borreliosis.

CASE REPORT

Several clinical presentations have been previously described, including uveitis, unilateral or bilateral chorioretinitis, keratitis, episcleritis, papillitis and ischemic optic neuropathy, retinal vasculitis and acute posterior multifocal placoid pigment epitheliopathy (APMPPE); however our case report showed a rare presentation with the presence of unilateral uveitis with vitreitis and multiple, patchy, yellowish lesions, in association with retinal vasculitis. This clinical picture was to be considered in differential diagnosis with ocular Toxoplasmosis.

CONCLUSIONS

The appropriate management of this patient was made possible by the combination of multimodal imaging and appropriate laboratory tests, representing the optimal process in the diagnostic and therapeutic pathway in high-risk patients for ocular Lyme disease.

Characteristics of Lyme optic neuritis: a case report of Lyme associated bilateral optic neuritis and systematic review of the literature

Optic Neuritis is rare in Lyme borreliosis. The current knowledge of optic nerve involvement in Lyme borreliosis relies solely on case reports. The aim of this systematic review was to characterize and investigate the associated factors of optic neuritis in Lyme borreliosis. We further presented a very rare case of isolated bilateral optic neuritis in a Lyme seropositive patient.

Case Report: An Isolated Abducens Palsy Secondary to Lyme Disease

SIGNIFICANCE

Lyme disease can have widespread and long-lasting systemic implications, and ocular manifestations of Lyme disease may be the only presenting symptoms of infection. As such, eye care providers can play a critical role in facilitating diagnosis and treatment of this disease.

PURPOSE

This case report describes an isolated sixth nerve palsy secondary to Lyme disease, which is a rare neuro-ophthalmic presentation. This report emphasizes the importance of considering Lyme disease in the setting of atypical nerve palsies to allow for appropriate treatment and prevent long-term complications of untreated disease.

CASE REPORT

A 63-year-old man presented with new onset, painful diplopia for one day and was diagnosed with a right sixth nerve palsy. His medical history was significant for relapsing polychondritis with associated ocular complications, so his nerve palsy was presumed secondary to a flare of his systemic disease. However, secondary to complaints of new night sweats, infectious etiologies were also considered. The patient was initially treated with oral steroids with no improvement in his diplopia after being admitted to the hospital for further work-up. Approximately one week after presentation, Lyme titers returned positive and the diagnosis was revised to abducens palsy secondary to Lyme disease. The patient's nerve palsy rapidly resolved after oral therapy with doxycycline.

CONCLUSIONS

Lyme disease is a systemic illness that can have widely varying manifestations, including ocular findings. Eye involvement may be the only presenting symptom, allowing eye care providers to serve an important role in disease recognition and management.

Internuclear Ophthalmoplegia as the First Manifestation of Pediatric-Onset Multiple Sclerosis and Concurrent Lyme Disease

BACKGROUND Internuclear ophthalmoplegia (INO) presents as a disruption of horizontal conjugate ocular movement and is an uncommon finding in the pediatric population. Its presence warrants a thorough evaluation to search for demyelinating, mass effect, inflammatory, or infectious etiologies. CASE REPORT A 15-year-old African American girl presented to the Emergency Department with acute horizontal binocular diplopia in left gaze. An ophthalmic examination revealed a right INO. She denied any fever, chills, or neck stiffness. Complete blood counts and a metabolic panel were unremarkable. Magnetic resonance imaging (MRI) of the brain and orbits revealed scattered pontine, periventricular, and subcortical white matter signal abnormalities within the left frontal lobe suggestive of active demyelination. MRI of the spinal column also demonstrated multiple areas of increased signal intensity from the C3 to C7-T1 region. Inflammatory and autoimmune studies were negative. However, her serum IgM and IgG studies were positive for Borrelia burgdorferi with negative CSF titers. Cerebrospinal fluid (CSF) analysis demonstrated mildly elevated glucose (82 mg/dL) and oligoclonal bands, but was otherwise unremarkable. She was started on intravenous methylprednisolone and ceftriaxone. She was subsequently diagnosed with pediatric-onset multiple sclerosis and started on disease-modifying therapy, with full resolution of diplopia and INO 2 weeks later. CONCLUSIONS We present a case of INO presenting as the first manifestation of multiple sclerosis in a pediatric patient with a concurrent infectious etiology. A thorough evaluation can lead to earlier identification and treatment of underlying diseases.

Ocular disease in horses with confirmed ocular or central nervous system Borrelia infection: Case series and review of literature

OBJECTIVE

To describe the clinical presentation, treatment, and clinical outcome of horses with ocular disease and evidence of systemic or ocular Lyme disease.

ANIMALS STUDIED

Five horses met the inclusion criteria of ocular disease with evidence of B burgdorferi present in ocular or CNS tissues.

PROCEDURE

The goal of this study was to describe the clinical presentation and progression of ocular disease when associated with ocular or CNS B burgdorferi infection in horses. A retrospective review of medical records was performed on horses admitted for ocular disease with evidence of B burgdorferi infection between 1998 and 2015. The diagnosis of B burgdorferi-associated uveitis was based on histopathologic lesions of lymphohistiocytic and suppurative uveitis/endophthalmitis and intralesional argyrophilic spirochetes in either ocular or CNS tissue consistent with Borrelia. Leptospiral uveitis was ruled out by PCR.

RESULTS

All five horses in the current study had intraocular inflammation at the time of presentation. Medical management with anti-inflammatories was successful in controlling uveitis in the two horses in which treatment of uveitis was attempted. Systemic treatment with oral tetracyclines was unsuccessful in a single case in which treatment of Borrelia was attempted. Four horses were euthanized due to progression of neurologic disease. The surviving horse had an enucleation performed and did not show systemic signs.

CONCLUSIONS

Infection with Borrelia burgdorferi should be considered in endemic areas as a differential for horses with ocular disease, in particular, uveitis. The prognosis for uveitis and neurologic disease associated with Lyme disease was poor in the current study.

Lyme Disease: What the Neuroradiologist Needs to Know

Lyme disease is the most common tick-borne disease in Canada and the United States, caused by Borrelia burgdorferi, which affects multiple organ systems. Epidemiology, clinical presentation, and neuroimaging findings are reviewed.

Simultaneous involvement of optic and abducens nerves by Lyme disease: Case report with review of the literature

Ocular manifestations of Lyme disease (LD) remain a rare feature of the disease, but it may present a wide range of clinical presentations with different combinations. LD related optic neuritis or cranial nerve (CN) six palsy have been reported in the literature. However, this is the first case report of simultaneous involvement of CN 2 and CN 6 in a patient with LD. The diagnosis of LD can be challenging and initial laboratory tests can be a false negative. It is paramount important to repeat the diagnostic test if clinical suspicious is ongoing. With this case, we aim to increase awareness of clinicians for possible ocular manifestations of LD and its complex diagnostic process.

The development and spontaneous resolution of a full-thickness macular hole in bartonella henselae neuroretinitis in a 12-year-old boy

Purpose

To describe an unusual case of Bartonella henselae neuroretinitis complicated by macular hole (MH) development.

Observations

A full-thickness macular hole developed in a 12-year-old boy in association with serology-confirmed Bartonella henselae neuroretinitis. Following a period of observation, the MH closed without intervention.

Conclusion and importance

MH may occur as a complication of neuroretinitis secondary to Cat-Scratch Disease.

Ocular Manifestations of Systemic Disease in the Horse

Many systemic diseases have ocular manifestations. In some cases, ocular abnormalities are the most obvious or first recognized sign of disease that prompts veterinary evaluation. In other cases, the systemic disease leads to secondary ocular changes that might lead to loss of vision or globe if not addressed. Therefore, recognition of ocular abnormalities that might result from systemic diseases is an essential skill for the equine practitioner. This article provides practitioners with information regarding the most common systemic diseases of horses in North America that have ocular manifestations, organized by ocular signs.

Contact dermatitis on the lower eyelid related to tick infestation: A case report in Taiwan

Tick bite on the lower eyelid is a rare condition. We reported a case of contact dermatitis on the lower eyelid related to the tick infestation. Ticks are vectors for disease transmission. Symptoms and treatments for tick-borne diseases were reviewed.

Bilateral optic neuropathy following bite from brown recluse spider (Loxosceles reclusa)

A 63-year-old female with history of a resected frontal lobe meningioma presented with bilaterally decreased vision after a bite from a brown recluse spider. The exam was significant for a left relative afferent pupillary defect, bilateral optic nerve pallor, decreased foveal sensitivity in the left eye and new bilateral visual field defects, despite stability of her meningioma. The findings remained stable at 1-year follow-up. To our knowledge, this is the first reported case of optic neuropathy secondary to a brown recluse spider bite. Visual field tests performed prior to the bite allowed us to compare and localize changes related to the bite.

[A Japanese case of neuroborreliosis with papillitis]

A 53-year-old Japanese female developed a fever about two months after a tick bite. She also exhibited blurred vision, central scotoma in the left eye, left facial paresis and mild ataxia. A fundus examination revealed left disc swelling in the left eye. An ophthalmological examination showed decreased visual acuity with central scotoma in the left eye. We suspected neuroborreliosis because of the presence of pleocytosis and an elevated level of IL-6 in the cerebrospinal fluid (CSF), in addition to the characteristic neurological findings. She was positive for serum IgG antibodies against Borrelia by a Western blot of her serum. Therefore, we diagnosed her to have neuroborreliosis with papillitis. After the combined administration of antibiotics and steroids, her symptoms gradually improved, but not all of her eye manifestations resolved. Although ocular involvement is rare in neuroborreliosis, this case highlights the fact that neuroborreliosis shoud be considered as a differential diagnosis for patients presenting with papillitis. The diagnosis of neuroborreliosis is important since improvement of the visual acuity is possible with specific antibiotheraphy. In cases with papillitis of unknown etiology, it might be better to consider the possibility of neuroborreliosis should be considered when there are signs of Lyme borreliosis, such as facial nerve palsy, arthritis or radiculoneuritis.

Pattern and motion-related visual-evoked potentials in neuroborreliosis: follow-up study

Visual-evoked potentials (VEPs) were used for objective testing of visual functions during treatment courses of Lyme neuroborreliosis (LNB) in adult patients in the Czech Republic. In 30 LNB patients with originally delayed VEP latencies, pattern-reversal (R-VEP) and motion onset (M-VEP) VEPs were repeatedly examined within 1 to 8 years. Six patients had Lyme optic neuritis (ON), five of them displayed prolonged latencies in both R-VEPs and M-VEPs, and one had only abnormal R-VEPs. The VEP recovery to normal latency values was in three of them. In the group of 24 LNB patients without ON, 14 patients displayed prolonged latencies only to motion stimuli, and 10 patients had abnormal latencies in both R-VEPs and M-VEPs. During the follow-up period, 7 patients displayed shortening to normal latencies. In 5 patients, VEPs latencies improved only partially, and in the remaining 12 patients, VEPs did not improve at all. This study provides objective evidence that in LNB, most of the patients without clinically manifesting ON display optic pathway involvement-predominantly magnocellular system/dorsal stream function changes. In patients with ON, however, mainly the parvocellular system is affected. About half of the patients without ON improved with a relatively long-time course of latency shortening.

Understanding the role of aldose reductase in ocular inflammation

Aldose reductase, although identified initially as a glucose-reducing enzyme via polyol pathway, is believed to be an important component of antioxidant defense system as well as a key mediator of oxidative stress-induced molecular signaling. The dual role played by AR has made it a very important enzyme for the regulation of not only the cellular redox state by detoxifying the reactive lipid-aldehydes generated by lipid peroxidation which is crucial in the cellular homeostasis, but also in the regulation of molecular signaling cascade that may regulate oxidative stress-induced cytotoxic events. Search for the new molecular targets to restrain the oxidative stress-induced inflammation has resulted in the identification of AR as an unanticipated mediator of oxidative stress-induced signaling. Although, in last one decade or so AR has been implicated in various inflammation-related diseases conditions ranging from diabetes, sepsis, cancer, cardiovascular and ocular inflammation, however, a critical evaluation of the clinical efficacy of AR inhibitors awaits a better understanding of the role of AR in regulating inflammation, especially in ocular inflammation.

Lyme optic neuritis

Lyme optic neuritis (ON) is a rare disease and only a few cases have been reported. We describe two cases of isolated Lyme ON, one with recurrence 9 months after the appearance of initial symptoms. Diagnosis criteria for multiple sclerosis and neuromyelitis optica were not met. The etiological diagnosis was based on European case definition criteria for neuroborreliosis. Both patients had positive serum and cerebrospinal fluid serology, a positive intrathecal anti-Borrelia antibody index, and a good outcome on ceftriaxone. Specific diagnosis of Lyme ON is important since improvement of visual acuity is possible with specific antibiotherapy, even after many months.

Tick infestation on the lower eyelid: a case report

Background

The tick infestation of the lower lid is a quite rare condition.

Case Presentation

We report a case of a 40 years old caucasian female who presented with the above condition after camping in the Norfolk area, UK.

Conclusion

Tick bite can be responsible for many diseases the most common being Lyme disease which can affect the eyes in several ways. It is still debatable whether or not prophylactic treatment is needed after tick bite.

Lyme neuroborreliosis: manifestations of a rapidly emerging zoonosis

Lyme disease has a worldwide distribution and is the most common vector-borne disease in the United States. Incidence, clinical manifestations, and presentations vary by geography, season, and recreational habits. Lyme neuroborreliosis (LNB) is neurologic involvement secondary to systemic infection by the spirochete Borrelia burgdorferi in the United States and by Borrelia garinii or Borrelia afzelii species in Europe. Enhanced awareness of the clinical presentation of Lyme disease allows inclusion of LNB in the imaging differential diagnosis of facial neuritis, multiple enhancing cranial nerves, enhancing noncompressive radiculitis, and pediatric leptomeningitis with white matter hyperintensities on MR imaging. The MR imaging white matter appearance of successfully treated LNB and multiple sclerosis display sufficient similarity to suggest a common autoimmune pathogenesis for both. This review highlights differences in the epidemiology, clinical manifestations, diagnosis, and management of Lyme disease in the United States, Europe, and Asia, with an emphasis on neurologic manifestations and neuroimaging.

[Ocular manifestations of Lyme disease]

Despite the wide spectrum of clinical entities, eye involvement remains a rare event in patients with Lyme borreliosis. Most of ocular manifestations occur during the late phase of the disease. The infection needs to be considered along with more conventional causes of ocular inflammation, particularly in regions where Lyme disease is common. The pathogenesis of this condition remains controversial. Direct ocular infection and a delayed hypersensitivity mechanism may be involved at different disease stages. Uveitis and optic neuritis are the most common ocular complications. Serological testing lacks sensitivity and specificity. In atypical cases, ocular fluids sampling and analysis may be proposed. PCR seems to be an interesting diagnostic tool, allowing genotypic analysis. In the majority of cases, therapeutic strategy should be based on the association of antibiotics and corticosteroids. A new course of antibiotics may be prescribed to patients with chronic or relapsing inflammation due to bacterial persistence in ocular tissues.

A rat model of radiofrequency ablation of trigeminal innervation via a ventral approach with stereotaxic surgery

Neurotrophic keratopathy (NK), a consequence of sensory denervation of the cornea, must be better understood in order to develop new approaches to therapy. The purpose of this study was to create a rat model for neurotrophic keratopathy by denervating the trigeminal nerve through a ventral approach with stereotaxic surgery. Stereotaxic coordinates were measured in 46 male Sprague Dawley rat cadavers for localization of V1. After further refining the coordinates in nine live animals, radiofrequency ablation was chosen as an effective method of disrupting the innervation to the cornea. Fifty-two live rats were treated with radiofrequency ablation to define the anatomical localization of the lesion by utilizing gross and histopathological studies. A gross lesion of the trigeminal nerve and/or ganglion was observed in 47 (90%) of the 52 animals. Histopathological studies revealed that all 52 animals had anatomical damage of the trigeminal innervation to the eye. Low mortality and little morbidity were observed in these animals. We have developed a rat model for neurotrophic keratopathy that is simple to produce, accurate in creating a lesion by utilizing stereotaxic techniques combined with radiofrequency ablation, and successful in decreasing morbidity and mortality.

Ophthalmologic manifestations of rheumatic diseases

OBJECTIVES

Detailed review of the manifestations of eye involvement in the context of rheumatic diseases.

METHODS

An OVID Medline search of the rheumatology and ophthalmology English literature related to the eye manifestations of human rheumatic diseases from 1966 to the present was conducted by the authors.

RESULTS

Analysis of 300 recent and consecutive rheumatology consultations from a large Veterans Administration Healthcare System shows that 4% are referred for eye manifestations of suspected rheumatic diseases, most commonly, anterior uveitis and keratoconjunctivitis sicca (KCS). Ocular involvement is common in the rheumatic diseases but varies among the different disorders. A literature review indicated that the most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, anterior uveitis, and scleritis. The most serious eye complications of the inherited connective tissue disorders are lens involvement with cataract formation or subluxation. The most significant side effects of the drugs used to treat rheumatic diseases are the maculopathy associated with anti-malarial agents and cataracts and glaucoma associated with corticosteroid use. Although many of the eye manifestations are easily recognizable, consultation with an ophthalmologist is usually necessary for optimal treatment and prevention of complications.

CONCLUSIONS

The rheumatologist, in coordination with the ophthalmologist, can play a major role in detecting and managing the eye involvement in his patients to save this important sense. Understanding the varied manifestations of eye disease will permit the rheumatologist to better evaluate the activity of the rheumatic disease.

Management of Lyme arthritis

Musculoskeletal complaints and findings can be features of Lyme disease and can occur following treatment. Only with a good understanding of the pathogenesis of these problems can further evaluation and a proper therapeutic scheme be developed.

Hypertensive retinopathy mimicking neuroretinitis in a twelve-year-old girl

Bilateral disk swelling and marked peripapillary and macular exudates were found on routine ophthalmologic examination in a 12 1/2-year-old girl. Eleven months later, with persistent findings, her blood pressure was found to be extremely elevated. She had an Ask-Upmark kidney, a rare form of segmental renal hypoplasia. The Ask-Upmark kidney abnormality occurs primarily in young women and is associated with hypertension. The disk edema and retinopathy resolved after the hypertension was controlled. Hypertensive retinopathy can sometimes resemble neuroretinitis.

Current aspects of Lyme disease and other Borrelia burgdorferi infections

Lyme disease, acrodermatitis chronica atrophicans, and borrelial lymphocytoma are caused by species of the spirochete Borrelia burgdorferi. Lyme disease has emerged as the leading vector-borne infectious disease in the United States. This article presents a current review of these entities.

PCR in laboratory diagnosis of human Borrelia burgdorferi infections

The laboratory diagnosis of Lyme borreliosis, the most prevalent vector-borne disease in the United States and endemic in parts of Europe and Asia, is currently based on serology with known limitations. Direct demonstration of Borrelia burgdorferi by culture may require weeks, while enzyme-linked immunosorbent assays for antigen detection often lack sensitivity. The development of the PCR has offered a new dimension in the diagnosis. Capable of amplifying minute amounts of DNA into billions of copies in just a few hours, PCR facilitates the sensitive and specific detection of DNA or RNA of pathogenic organisms. This review is restricted to applications of PCR methods in the diagnosis of human B. burgdorferi infections. In the first section, methodological aspects, e.g., sample preparation, target selection, primers and PCR methods, and detection and control of inhibition and contamination, are highlighted. In the second part, emphasis is placed on diagnostic aspects, where PCR results in patients with dermatological, neurological, joint, and ocular manifestations of the disease are discussed. Here, special attention is given to monitoring treatment efficacy by PCR tests. Last, specific guidelines on how to interpret PCR results, together with the advantages and limitations of these new techniques, are presented.