Acute facial palsy in children--a 2-year follow-up study with focus on Lyme neuroborreliosis

Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis

BACKGROUND

Information on the medium-term recovery of children with Bell palsy or acute idiopathic lower motor neuron facial paralysis is limited.

METHODS

We followed up children aged 6 months to <18 years with Bell palsy for 12 months after completion of a randomized trial on the use of prednisolone. We assessed facial function using the clinician-administered House-Brackmann scale and the modified parent-administered House-Brackmann scale.

RESULTS

One hundred eighty-seven children were randomized to prednisolone (n = 93) or placebo (n = 94). At six months, the proportion of patients who had recovered facial function based on the clinician-administered House-Brackmann scale was 98% (n = 78 of 80) in the prednisolone group and 93% (n = 76 of 82) in the placebo group. The proportion of patients who had recovered facial function based on the modified parent-administered House-Brackmann scale was 94% (n = 75 of 80) vs 89% (n = 72 of 81) at six months (OR 1.88; 95% CI 0.60, 5.86) and 96% (n = 75 of 78) vs 92% (n = 73 of 79) at 12 months (OR 3.12; 95% CI 0.61, 15.98).

CONCLUSIONS

Although the vast majority had complete recovery of facial function at six months, there were some children without full recovery of facial function at 12 months, regardless of prednisolone use.

Paretic complications of tick-borne encephalitis and Lyme neuroborreliosis in the Czech Republic: Characteristics and clinical outcome

Tick-borne encephalitis (TBE) and Lyme neuroborreliosis (LNB), the most common tick-borne diseases of the central nervous system in Central Europe, are frequently associated with pareses. The aim of this study was to characterise paretic complications in patients with TBE and LNB, including their severity, persistence and impact on the patients' quality of life. Our retrospective observational study included patients with aseptic CNS infection due to TBE virus or Borrelia burgdorferi sensu lato. Paretic complications were evaluated in the acute phase and the patients were followed up until complete regression or long-term stabilisation of any neurological deficit. The severity of the neurological deficit was graded according to the modified Rankin Scale (mRS). A total of 823 patients (582 with TBE, 241 with LNB) was included. Paretic complications were diagnosed in 63 TBE patients (10.8 %) and in 147 LNB patients (61.0 %). In TBE, the most common neurological deficit was brachial plexus paresis in 21 patients (33 %) and bulbar symptoms in 18 patients (29 %). In LNB patients, facial nerve palsy was the most frequent neurological deficit (117patients; 79.6 %), followed by lower limb paresis in 23 patients (15.6 %). Forty-nine TBE patients and 134 LNB paretic patients completed follow-up. Paresis resolved within 3 weeks in 16 TBE patients (33 %) and 53 LNB patients (39.5 %), but the proportion of patients with paresis persisting for more than 12 months was significantly higher in TBE (34.7 vs. 3.7 %, p < 0.001). The mean mRS was significantly higher in TBE paretic patients compared to LNB (p < 0.001). Paretic complications are significantly more common in LNB than in TBE but pareses associated with TBE last longer than in LNB and considerably reduce the quality of life of patients. Prevention remains the only way to influence the long-term motor deficits of TBE.

Lyme Neuroborreliosis in Children

Lyme neuroborreliosis (LNB) is an infectious disease, developing after a tick bite and the dissemination of Borrelia burgdorferi sensu lato spirochetes reach the nervous system. The infection occurs in children and adults but with different clinical courses. Adults complain of radicular pain and paresis, while among the pediatric population, the most common manifestations of LNB are facial nerve palsy and/or subacute meningitis. Moreover, atypical symptoms, such as fatigue, loss of appetite, or mood changes, may also occur. The awareness of the various clinical features existence presented by children with LNB suspicion remains to be of the greatest importance to diagnose and manage the disease.

Facial palsy in children: long-term outcome assessed face-to-face and follow-up revealing high recurrence rate

PURPOSE

To evaluate the long-term (minimum of 2 years from the palsy onset) outcome of pediatric facial palsy by patient questionnaire and face-to-face assessment by the Sunnybrook facial grading system, House-Brackmann grading system, and Facial Nerve Grading System 2.0. To compare the outcome results of self-assessment with the face-to-face assessment. To assess the applicability of the grading scales. To assess the palsy recurrence rate (minimum of a 10-year follow-up).

METHODS

46 consecutive pediatric facial palsy patients: 38 (83%) answered the questionnaire and 25 (54%) attended a follow-up visit. Chart review of 43 (93%) after a minimum of 10 years for the facial palsy recurrence rate assessment.

RESULTS

Of the 25 patients assessed face-to-face, 68% had totally recovered but 35% of them additionally stated subjective sequelae in a self-assessment questionnaire. Good recovery was experienced by 80% of the patients. In a 10-year follow-up, 14% had experienced palsy recurrence, only one with a known cause. Sunnybrook was easy and logical to use, whereas House-Brackmann and the Facial Nerve Grading System 2.0 were incoherent.

CONCLUSIONS

Facial palsy in children does not heal as well as traditionally claimed if meticulously assessed face-to-face. Patients widely suffer from subjective sequelae affecting their quality of life. Palsy recurrence was high, much higher than previously reported even considering the whole lifetime. Of these three grading systems, Sunnybrook was the most applicable.

Peripheral facial nerve palsy in children in a Borrelia high-endemic area, a retrospective follow-up study

AIM

To identify the incidence, aetiology and prognosis of acute peripheral facial nerve palsy (FNP) in children in the Borrelia high-endemic region of Stockholm.

METHODS

The present study identified children from 0 to 18 years of age who visited a paediatric emergency department for acute peripheral FNP during a 1-year period from 2014 to 2015. Data were collected retrospectively. The Sunnybrook and House-Brackmann facial grading systems were used to measure clinical outcome.

RESULTS

A total of 77 children were identified with FNP, an estimated incidence of 30 per 100 000 children/year. Forty-five children (58%) were diagnosed with neuroborreliosis, 28 (36%) with idiopathic FNP and four (6%) with other rarer causes. Neuroborreliosis was common from June to November and mainly seen in children below 10 years of age. Six patients (8%) had remaining symptoms at least 3 months after onset; three had idiopathic facial palsy (IFP) and were all older than 10 years, one had neuroborreliosis and two had other causes.

CONCLUSION

Neuroborreliosis and IFP were the major causes of FNP during the study period. Neuroborreliosis-associated facial palsy had a seasonal variation and dominated in younger ages.

Infectious causes of peripheral facial nerve palsy in children-a retrospective cohort study with long-term follow-up

The aim of this study was to analyze the clinical and laboratory characteristics of children with peripheral facial nerve palsy (pFP) with a focus on identifying infectious etiology and long-term outcome. We conducted an ICD-10-based retrospective chart review on children hospitalized with pFP between January 1, 2006, and December 31, 2016. Furthermore, a telephone-based follow-up survey was performed. A total of 158 patients were identified, with a median age of 10.9 years (interquartile range 6.4-13.7). An infectious disease was associated with pFP in 82 patients (51.9%); 73 cases were classified as idiopathic pFP (46.2%). Three cases occurred postoperatively or due to a peripheral tumor. Among the infectious diseases, we identified 33 cases of neuroborreliosis and 12 viral infections of the central nervous system (CNS), caused by the varicella-zoster virus, human herpesvirus 6, herpes simplex virus, enterovirus, and Epstein-Barr virus. Other infections were mainly respiratory tract infections (RTIs; 37 cases). Children with an associated CNS infection had more often headache and nuchal rigidity, a higher cerebrospinal fluid cell count, and a longer length of hospital stay. Long-term follow-up revealed an associated lower risk of relapse in CNS infection-associated pFP. Among all groups, permanent sequelae were associated with female sex, a shorter length of hospitalization, and a lower white blood cell count at presentation. pFP is frequently caused by an CNS infection or is associated with concurrent RTIs, with a potential impact on the short- and long-term clinical course.

Lyme borreliosis-from tick bite to diagnosis and treatment

Lyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixodes. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves even without antibiotic treatment. The infecting pathogens can spread to other tissues and organs, resulting in manifestations that can involve the nervous system, joints, heart and skin. Fatal outcome is extremely rare and is due to severe heart involvement; fetal involvement is not reliably ascertained. Laboratory support-mainly by serology-is essential for diagnosis, except in the case of typical erythema migrans. Treatment is usually with antibiotics for 2 to 4 weeks; most patients recover uneventfully. There is no convincing evidence for antibiotic treatment longer than 4 weeks and there is no reliable evidence for survival of borreliae in adequately treated patients. European Lyme borreliosis is a frequent disease with increasing incidence. However, numerous scientifically questionable ideas on its clinical presentation, diagnosis and treatment may confuse physicians and lay people. Since diagnosis of Lyme borreliosis should be based on appropriate clinical signs, solid knowledge of clinical manifestations is essential.

Nervous System Lyme Disease

Nervous system involvement occurs in 10% to 15% of patients infected with the tick-borne spirochetes Borrelia burgdorferi, B afzelii, and B garinii. Peripheral nervous system involvement is common. Central nervous system (CNS) involvement, most commonly presenting with lymphocytic meningitis, causes modest cerebrospinal fluid (CSF) pleocytosis. Parenchymal CNS infection is rare. If the CNS is invaded, however, measuring local production of anti-B burgdorferi antibodies in the CSF provides a useful marker of infection. Most cases of neuroborreliosis can be cured with oral doxycycline; parenteral regimens should be reserved for patients with particularly severe disease.

[Should a lumbar puncture be performed in any child with acute peripheral facial palsy and clinical suspicion of Lyme borreliosis?]

Lyme borreliosis should be considered in any child affected with acute peripheral facial palsy without obvious cause in endemic areas, especially if it happens from May to November, with a history of erythema migrans, tick bite, or possible exposure during the previous weeks. The clinical appearance of Lyme borreliosis differs between adults and children and according to the geographical origin of the infection: therefore it is difficult to interpret and follow the recommendations for the management and treatment of this disease. Neuroborreliosis is more frequent in Europe than in the United States, and meningitis associated to facial palsy occurs earlier and is more frequent among the European pediatric population, too. When peripheral facial palsy occurs and there is suspicion of Lyme borreliosis, it seems necessary to perform a lumbar puncture in order to support the diagnosis with detection of intrathecal synthesis of specific antibodies, sometimes more abundant than in the serum, and thus to adapt the antibiotic therapy modalities. Parenteral antibiotherapy is recommended if any involvement is detected in the cerebrospinal fluid, while oral antibiotherapy should be prescribed for isolated facial palsies. Follow-up should be made according to clinical symptoms with a close collaboration between pediatricians, infection disease specialists, and ENT specialists.

Long-term clinical outcome after Lyme neuroborreliosis in childhood

OBJECTIVES

To determine long-term clinical outcome in children with confirmed Lyme neuroborreliosis (LNB) and to evaluate persistent subjective symptoms compared with a control group.

METHODS

After a median of 5 years, 84 children with confirmed LNB underwent a neurologic re-examination, including a questionnaire. Medical records were analyzed, and a control group (n = 84) was included.

RESULTS

The total recovery rate was 73% (n = 61). Objective neurologic findings, defined as "definite sequelae," were found in 16 patients (19%). The majority of these children had persistent facial nerve palsy (n = 11), but other motor or sensory deficits occurred (n = 5). Neurologic signs and/or symptoms defined as "possible sequelae" were found in another 7 patients (8%), mainly of sensory character. Nonspecific subjective symptoms were reported by 35 patients (42%) and 32 controls (38%) (nonsignificant). Affected daily activities or school performance were reported to the same extent in both groups (23% vs 20%, nonsignificant).

CONCLUSIONS

The long-term clinical recovery rate was 73% in children with confirmed LNB. Persistent facial nerve palsy occurred in 13%, whereas other motor or sensory deficits were found in another 14%. Neurologic deficits did not affect daily activities or school performance more often among patients than controls and should be considered as mild. Furthermore, nonspecific subjective symptoms such as headache, fatigue, or memory or concentration problems were reported as often among patients as controls and should not be considered as sequelae after LNB.

Entzündliche Erkrankungen

Unter einer Meningitis versteht man eine Entzündung von Pia mater und Arachnoidea. Das Erregerspektrum ist weit und reicht von Bakterien, die hämatogen-metastatisch, fortgeleitet oder durch offene Hirnverletzung zur eitrigen Meningitis führen, über Viren zu Pilzen und Parasiten. Insbesondere bei den unbehandelt häufig letal verlaufenden eitrigen Meningitiden ist eine rasche Diagnose mit Erregernachweis notwendig. Unverzüglich ist daraufhin eine spezifische, der regionalen Resistenzentwicklung angepasste Therapie einzuleiten. Die meningeale Affektion im Rahmen einer Listeriose oder Tuberkulose verdient aufgrund des klinischen Bildes, des Verlaufs und der spezifischen Therapie besondere Beachtung. Die fungalen Infektionen werden, da klinisch häufig als Meningoenzephalitis imponierend, in Abschn. 33.3 abgehandelt.

Facial nerve palsy: etiology and approach to diagnosis and treatment

Facial nerve palsy has a broad differential diagnosis and possible psychological and anatomical consequences. A thorough investigation must be performed to determine the cause of the palsy and to direct treatment. If no cause can be found, therapy with prednisone with or without an antiviral medication can be considered and begun as early as possible after onset of symptoms. Resolution and time to recovery vary with etiology, but overall prognosis is good.

Lyme neuroborreliosis in children

Lyme neuroborreliosis (LNB) represents the second most frequent manifestation of Lyme disease (LD) in Europe after cutaneous involvement. In the USA, LNB represents the third most frequent manifestation of LD after cutaneous involvement and arthritis. The scope of this article is, in the light of recent publications, to review the specific manifestations of LNB in children including predictive models, and to discuss diagnosis criteria, new diagnostic tools and new therapeutic options. Differences in disease patterns between the USA and Europe are also highlighted.

Lyme neuroborreliosis in children: a prospective study of clinical features, prognosis, and outcome

BACKGROUND

Evaluation of children with clinically suspected neuroborreliosis (NB) is difficult. With a prospective study design we wanted to characterize children with signs and symptoms indicative for NB, investigate clinical outcome and, if possible, identify factors of importance for recovery.

MATERIAL/METHODS

Children being evaluated for NB (n = 177) in southeast Sweden were categorized into 3 groups: "confirmed neuroborreliosis" (41%) with Borrelia antibodies in the cerebrospinal fluid, "possible neuroborreliosis" (26%) with pleocytosis but no Borrelia antibodies in the cerebrospinal fluid, and "not determined" (33%) with no pleocytosis and no Borrelia antibodies in the cerebrospinal fluid. Antibiotic treatment was given to 69% of children. Patients were followed during 6 months and compared with a matched control group (n = 174).

RESULTS

Clinical recovery at the 6-month follow-up (n = 177) was generally good and no patient was found to have recurrent or progressive neurologic symptoms. However, persistent facial nerve palsy caused dysfunctional and cosmetic problems in 11% of patients. Persistent nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls. Influence on daily life was reported to the same extent in patients and controls. Consequently, persistent headache and fatigue at follow-up should not be considered as attributable to NB. No prognostic factors could be identified.

CONCLUSIONS

Clinical recovery was satisfactory in children being evaluated for NB although persistent symptoms from facial nerve palsy occurred. Persistent nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls.

Diagnosis and treatment of the neuromuscular manifestations of Lyme disease

Although estimates vary, the nervous system appears to be involved in 10% to 15% of patients infected with Borrelia burgdorferi. The resulting disorders, known collectively as neuroborreliosis or nervous system Lyme disease, generally respond well to antimicrobial therapy. Definitive treatment of nervous system infection typically consists of 2 to 4 weeks of parenteral ceftriaxone, cefotaxime, or high-dose penicillin (Class III). However, numerous European studies have shown that oral doxycycline is equally effective in patients with Lyme meningitis and cranial neuritis (Class II and III). This may be equally valid in patients infected with the strains prevalent in the United States, but this remains to be established.

What we have learned about Lyme borreliosis from studies in children

Although pediatric Lyme borreliosis (LB) need not be a separate nosological entity, there are clinically important differences in presentation, antibiotic regimens and outcomes in children, which provide lessons that can be extrapolated to the disease as it affects adults. A large proportion of the worldwide data is obtained from children. The aim of this presentation is not to present an exhaustive review of the pediatric literature, but to review a selection of pediatric studies that have made a significant contribution to our body of knowledge in Lyme borreliosis.

Central nervous system Lyme disease

Nervous system infection with Borrelia burgdorferi frequently causes meningitis and rarely causes encephalomyelitis. Altered cognitive function also can occur in the absence of central nervous system infection. Recently developed serodiagnostic tools, such as the C6 assay, and appropriate use of Western blotting promise to improve diagnostic accuracy. Treatment trials have demonstrated the efficacy of relatively brief courses of oral antimicrobial agents, even in peripheral nervous system infection and meningitis. Several well-performed studies have clearly shown that prolonged antimicrobial treatment of "post-Lyme disease" is ineffective. Diagnosis and treatment of Lyme disease continue to improve.

Central nervous system lyme disease

Nervous system infection with Borrelia burgdorferi frequently causes meningitis and rarely causes encephalomyelitis. Altered cognitive function also can occur in the absence of central nervous system infection. Recently developed serodiagnostic tools, such as the C6 assay, and appropriate use of Western blotting, promise to improve diagnostic accuracy. Treatment trials have demonstrated the efficacy of relatively brief courses of oral antimicrobial agents, even in peripheral nervous system infection and meningitis. Several well-performed studies have clearly shown that prolonged antimicrobial treatment of "post-Lyme disease" is ineffective. Diagnosis and treatment of Lyme disease continue to improve.