Bilateral keratitis in Lyme disease

Lyme disease presenting as persistent severe photophobia

Long-term photophobia in children that has no obvious cause is uncommon and presents a diagnostic dilemma. It may produce significant discomfort and result in social isolation and school absence. We present the case of a 5-year-old boy who presented with chronic photophobia due to interstitial keratitis that was the result of Lyme disease.

[Ocular Lyme disease occurring during childhood: five case reports]

INTRODUCTION

Lyme borreliosis (LB) is the most common human tick-borne disease in the Northern hemisphere. The various ophthalmologic manifestations of Lyme borreliosis (LB) during childhood are discussed in this paper.

PATIENTS AND METHODS

Six children with LB-associated ocular manifestations were treated between 2000 and 2010 in the ophthalmology department of Strasbourg University Hospital (an endemic area). Medical history, ocular and systemic clinical findings, determinations of antibodies related to Borrelia, as well as exclusion of other causes were the diagnosis criteria.

RESULTS

Two cases of uveitis, two cases of abducens palsies, one case of optical neuropathy, and one case of orbital myositis associated with LB were diagnosed. Systemic findings, such as arthritis, rash, or erythema migrans were mentioned in all cases. Two children also complained of severe knee arthritis. Determination of antibodies was positive in all patients. They were all treated with antibiotics adjusted to individual circumstances and some of them (two cases of uveitis and one of optic neuropathy) also had anti-inflammatory treatment. Resolution of ocular signs, with no relapse, was observed in all patients within two to 12 weeks.

CONCLUSION

For any unexplained ocular symptom, even in children, LB should be taken into account, especially in endemic areas. Such patients should undergo serological testing. If the clinical presentation is suggestive of LB, a course of oral antibiotics should be used. All in all, permanent defects are extremely rare during the childhood period, even following long-term manifestation at an early age.

[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.

Orbital myositis associated with Borrelia burgdorferi (Lyme disease) infection

OBJECTIVE

To report on the clinical findings in a patient with isolated left inferior rectus myositis associated with serologically confirmed Borrelia burgdorferi infection.

DESIGN

Interventional case report.

TESTING

Comprehensive clinical, laboratory, and imaging evaluation.

RESULTS

Contrast-enhanced computed tomography showed a swollen inferior rectus muscle with infraorbital soft tissue swelling in a patient with diplopia and prior symptoms consistent with manifestations of Lyme disease. Positive serum and cerebrospinal fluid antibodies to B. burgdorferi by enzyme-linked immunoassay were confirmed by Western blot, and the cerebrospinal fluid/serum antibody ratio was elevated. No alternative cause for orbital myositis was found, and treatment with antibiotics resulted in a complete recovery.

CONCLUSIONS

Orbital myositis should be added to the expanding list of ophthalmic manifestations of Lyme disease. Correct diagnosis and appropriate antibiotic therapy may reduce the likelihood of further neurologic or ophthalmologic sequelae.

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.

Ocular manifestations of Lyme disease

Although ocular manifestations of Lyme disease have long been noted, they remain a rare feature of the disease. The spirochete invades the eye early and remains dormant, accounting for both early and late ocular manifestations. A nonspecific follicular conjunctivitis occurs in approximately 10% of patients with early Lyme disease. Keratitis occurs often within a few months of onset of disease and is characterized by nummular nonstaining opacities. Inflammatory syndromes, such as vitritis and uveitis, have been reported; in some cases, a vitreous tap is required for diagnosis. Neuro-ophthalmic manifestations include neuroretinitis, involvement of multiple cranial nerves, optic atrophy, and disc edema. Seventh nerve paresis can lead to neurotrophic keratitis. In endemic areas, Lyme disease may be responsible for approximately 25% of new-onset Bell's palsy. Criteria for establishing that eye findings can be attributed to Lyme disease include the lack of evidence of other disease, other clinical findings consistent with Lyme disease, occurrence in patients living in an endemic area, positive serology, and, in most cases, response to treatment. Management of ocular manifestations often requires intravenous therapy.

Diagnosis and clinical characteristics of ocular Lyme borreliosis

PURPOSE

To establish a diagnosis, in a group of patients we studied the characteristics of ocular Lyme borreliosis.

METHODS

During a two-year period, 236 patients with prolonged external ocular inflammation, uveitis, retinitis, optic neuritis, or unexplained neuro-ophthalmic symptoms were examined for Lyme borreliosis. Antibodies to Borrelia burgdorferi were measured by indirect ELISA and western blot. Cerebrospinal fluid was also analyzed by polymerase chain reaction.

RESULTS

Ocular Lyme borreliosis was diagnosed in ten patients on the basis of medical history, clinical findings, and serologic test results. Results of ELISA disclosed that five patients were seropositive, two patients showed borderline reactivity, and three patients were seronegative. Four of the five patients with borderline or negative results by ELISA had a positive result by western blot analysis. In one seropositive patient, polymerase chain reaction verified a gene of B. burgdorferi endoflagellin from the vitreous and cerebrospinal fluid specimen. In five of the six patients with known onset of the Borrelia infection, the ocular disorder appeared as a late manifestation. Abnormalities of the posterior segment of the eye, such as vitreitis, retinal vasculitis, neuroretinitis, choroiditis, and optic neuropathy were seen in six patients. Bilateral paralytic mydriasis, interstitial keratitis, episcleritis, and anterior uveitis were seen in one patient each.

CONCLUSIONS

Late-phase ocular Lyme borreliosis is probably underdiagnosed because of weak seropositivity or seronegativity in ELISA assays. Ocular borrelial manifestations show characteristics resembling those seen in syphilis.

Microbial keratitis in children

In a five-year review, we identified 29 cases of microbial infection in 28 patients who were 16 years old or younger. Herpes simplex infections were excluded. Predisposing factors included trauma (ten cases, 34%), severe systemic illness (eight cases, 27%), contact lens use (seven cases, 24%), exposure keratopathy (seven cases, 24%), and previous ocular surgery (six cases, 21%). A total of 24 microorganisms were identified in cultures of corneal scrapings from 22 of the 29 cases; two cases involved polymicrobial infections. Of the 24 identified pathogens, gram-positive cocci were the most common (12). Other microorganisms included gram-negative bacteria (five) and fungi (four). Isolated cases of Acanthamoeba species, Borrelia burgdorferi, and Bacillus species were also present. Therapy with intensive topical antibiotics was successful in this series. The rate of surgical intervention (6/29, 21%) was similar to that of previous reports.

Long-term effects of ceftriaxone treatment on intraocular Lyme borreliosis

Twelve patients with intraocular Lyme borreliosis suffering from vitreitis were treated with ceftriaxone intravenously. Eight patients had definitive Lyme borreliosis, and tentative diagnosis was made in four patients. After treatment with ceftriaxone, all 12 patients were followed up for more than one year. Vitreitis diminished in all patients and visual acuity improved in six patients. The best results were achieved in patients with definitive Lyme borreliosis.

The long-term course of Lyme arthritis in children

BACKGROUND AND METHODS

The natural history of Lyme disease is not completely known. We studied the long-term course of Lyme arthritis in 46 children in whom the onset of the disease occurred between 1976 and 1979 and who received no antibiotic therapy for at least the first four years of the illness.

RESULTS

Of the 46 children (age range, 2 to 15 years), 33 (72 percent) initially had erythema migrans, 7 (15 percent) had influenza-like symptoms, and 6 (13 percent) had migratory joint pain. These manifestations were followed by brief attacks of arthritis, particularly affecting the knee. The percentage of children with recurrent episodes of arthritis declined each year. By year 4, only 10 children still had a mean of two episodes of arthritis per year; the duration of arthritis was generally longer in older children (P less than 0.05). During the sixth year of illness, two children (4 percent) had keratitis, and more than 10 years after the onset of disease, a subtle encephalopathy developed in two other children. Of the 39 children whom we were able to contact in 1988-1989, 12 (31 percent) still had occasional brief episodes of joint pain and 1 (3 percent) had marked fatigue. All 46 children had positive IgG antibody responses to Borrelia burgdorferi throughout the illness and on long-term follow-up. As compared with those who became asymptomatic, the children with recurrent symptoms more often had IgM responses to the spirochete and had significantly higher IgG titers (P less than 0.05).

CONCLUSIONS

The course of initially untreated Lyme disease in children may include acute infection followed by attacks of arthritis and then by keratitis, subtle joint pain, or chronic encephalopathy.

Lyme disease: neurologic and ophthalmic manifestations

Lyme disease is tick-borne infection which produces early and late manifestations in many organ systems. Prominent symptoms and signs occur in skin, heart, joints and nervous system. Many ocular and neuro-ophthalmic abnormalities recently have been attributed to Lyme disease, but some cases have not been well established as direct sequelae. This review of the contemporary state of knowledge about Lyme disease was undertaken so that more rigorous criteria can be applied in future diagnosis.

Neuro-ophthalmologic manifestations of Lyme disease

Lyme disease is a tick-borne spirochetal infection characterized by skin rash, neurologic, cardiac, and arthritic findings. The authors report six patients with Lyme disease who had neuro-ophthalmologic manifestations. One patient had meningitis with papilledema, two had optic neuritis, and one had neuroretinitis. Three patients had sixth nerve paresis, two of whom cleared quickly, whereas multiple cranial nerve palsies and subsequent optic neuropathy developed in another. Early recognition of neuro-ophthalmologic findings can help in the diagnosis and treatment of Lyme disease.

Orbital myositis with Lyme disease

We examined, treated, and followed up for nine years a 5-year-old girl with active Lyme disease and orbital myositis. Clinically, the patient demonstrated typical symptoms for each of the major stages of Lyme disease, including fever, erythema chronicum migrans, aseptic meningitis, Bell's palsy, and arthritis. She subsequently developed clinical and computed tomographic evidence of orbital myositis. Although orbital myositis is generally considered to be an idiopathic inflammation, our findings suggest that in certain patients it may be a manifestation of Lyme disease.

Ocular Lyme borreliosis

In six patients with ocular Lyme borreliosis, bilateral granulomatous iridocyclitis and vitritis were present in five. One of these five also had bilateral optic neuritis. Another patient developed combined trochlear and facial nerve palsies. A syndrome resembling pars planitis with atypical features such as granulomatous keratic precipitates and posterior synechiae should prompt a search for Lyme borreliosis. Topical corticosteroid therapy is necessary to prevent complications of anterior segment inflammation caused by Lyme uveitis, but the benefit of systemic and periocular corticosteroids is uncertain. Oral antibiotics may be effective in treating early stages of ocular Lyme borreliosis. In later stages, intravenous antibiotic therapy is indicated.