Diagnosis and management of Lyme neuroborreliosis

Lyme neuroborreliosis: A case report

Key Clinical Message

Lyme neuroborreliosis is the manifestation of Lyme borreliosis that impacts the nervous system. It gives rise to various neurological and psychiatric conditions, and its diagnosis is challenging. The timely administration of antibiotics is effective.

Abstract

A male patient, aged 55, was admitted to the emergency department due to the sudden onset of tonic-clonic seizures. All standard laboratory examinations yielded unremarkable outcomes, except a favorable Wright and 2-mercaptoethanol test. The examination of cerebrospinal fluid revealed the presence of 380 white blood cells per milliliter. The protein level was also elevated, while the glucose level was within the normal range. The results of the serologic tests indicated the presence of both IgG and IgM antibodies to Borrelia burgdorferi. Following the administration of ceftriaxone, a significant improvement was observed in the patient's medical status, and he was subsequently discharged. Lyme neuroborreliosis is the manifestation of Lyme borreliosis that impacts the nervous system. It gives rise to various neurological and psychiatric conditions, and its diagnosis is challenging. The timely administration of antibiotics is effective in treating patients.

Comparative proteomics profiling revealed the involvement of GRB2-ROCK2 axis in Lyme neuroborreliosis caused by Borrelia Burgdorferi

The zoonotic Lyme neuroborreliosis (LNB) disease is caused by Borrelia burgdorferi, with wide distribution, rapid dissemination and high disability rate. However, the molecular mechanism underlying B. burgdorferi mediated neuroborreliosis remains largely unknown. Here, the frontal cortex from rhesus brains was incubated with B. burgdorferi, and proteomics profiling was evaluated by isobaric tag for relative and absolute quantitation. Proteins were identified and quantified, and differentially expressed proteins (DEPs) were isolated by comparing co-cultured samples and control samples. A total of 43, 164 and 368 DEPs were significantly altered after 6, 12 and 24 h treatment with B. burgdorferi respectively. Gene ontology and KEGG pathway analyses revealed that chemokine biological process was significantly enriched. Two genes in chemokine pathway including GRB2 and ROCK2 were significantly up-regulated after B. burgdorferi co-culturing. By in vitro assay, we confirmed that the expression of GRB2 and ROCK2 was increased after B. burgdorferi infection. In conclusion, our study revealed the involvement of chemokine pathway in the pathogenesis of LNB. GRB2 and ROCK2 may be novel biomarkers and therapeutic targets for LNB.

Acute Lyme neuroborreliosis with transient aphasia – Case report and review of current knowledge

Lyme borreliosis (LB) is a tick-borne infectious disease, endemic in the Northern hemisphere, with a polymorphic clinical spectrum (cutaneous, articular, and neurologic involvement). The variability of clinical manifestations poses LB as a diagnostic challenge. We describe a case of acute Lyme neuroborreliosis (LNB) in an adult female with a history of recent travel in Europe. There are few reports of acute LNB presenting as encephalitis in the literature. Suspicion for the diagnosis and prompt treatment seems to have a positive impact on patient outcomes.

The Role of Ticks in the Emergence of Borrelia burgdorferi as a Zoonotic Pathogen and Its Vector Control: A Global Systemic Review

Ticks are widely distributed across the globe, serving as hosts for numerous pathogens that make them major contributors to zoonotic parasitosis. Borrelia burgdorferi is a bacterial species that causes an emerging zoonotic tick-borne disease known as Lyme borreliosis. The role of ticks in the transmission of this pathogen was explored in this study. According to this systematic review, undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 19 tick species are known to carry Borrelia burgdorferi, with more than half of the recorded cases in the last two decades related to Ixodes ricinus and Ixodes scapularis ticks. Forty-six studies from four continents, Europe, North America, Asia, and Africa, reported this pathogen in ticks collected from vegetation, animals, and humans. This study highlights an increasing distribution of tick-associated Borrelia burgdorferi, likely driven by accelerated tick population increases in response to climate change coupled with tick dispersal via migratory birds. This updated catalogue helps in compiling all tick species responsible for the transmission of B. burgdorferi across the globe. Gaps in research exist on Borrelia burgdorferi in continents such as Asia and Africa, and in considering environmentally friendly vector control strategies in Europe and North America.

Bannwarth Syndrome: A Rare Manifestation of Pediatric Lyme Neuroborreliosis

Lymphocytic meningoradiculitis (Bannwarth syndrome) is a rare manifestation of Lyme neuroborreliosis in children. It is the most common clinical manifestation of early Lyme neuroborreliosis in adults in European countries where the disease is endemic but is rare in children. We report an imported case of Bannwarth syndrome in a pediatric patient and review the literature for other pediatric cases reported.

Comparison of Lyme Disease in the United States and Europe

Lyme disease, or Lyme borreliosis, is the most common tickborne disease in the United States and Europe. In both locations, Ixodes species ticks transmit the Borrelia burgdorferi sensu lato bacteria species responsible for causing the infection. The diversity of Borrelia species that cause human infection is greater in Europe; the 2 B. burgdorferi s.l. species collectively responsible for most infections in Europe, B. afzelii and B. garinii, are not found in the United States, where most infections are caused by B. burgdorferi sensu stricto. Strain differences seem to explain some of the variation in the clinical manifestations of Lyme disease, which are both minor and substantive, between the United States and Europe. Future studies should attempt to delineate the specific virulence factors of the different species of B. burgdorferi s.l. responsible for these variations in clinical features.

Medically Refractory Neuroborreliosis Case Presented with Coexistance Involvements of Cranial 7 and 8 Nerves

In the US, Lyme disease (LD) has become the most common vector-borne disease. Less than 10% of patients develop cranial nerve palsy or meningitis. There are few reports on cases of Lyme disease with more than one cranial neuropathy. Herein, we will discuss a case of persistent neurological deficits as a result of chronic Lyme disease resistant to standard therapy. Our case is unique due to involvements of cranial seven and eight nerves at the same time. Our case illustrates an extreme example of treatment resistance. However, early diagnosis and prompt establishment of adequate antibiotic treatment are still important to prevent progression to further stages of disease.

Positive Tests for Lyme Disease and Emergency Department Visits for Bell's Palsy Patients

BACKGROUND

Etiologies for Bell's palsy include herpes viruses and Lyme disease, with highest incidence in the colder and warmer months, respectively. In New Jersey, a Lyme-endemic area, the months with the most Lyme disease (80% of cases) are May through October ("Lyme months").

OBJECTIVE

Our aim was to determine whether positive tests for Lyme disease and visits are greater in the Lyme months than the rest of the year for patients with Bell's palsy in New Jersey emergency departments (EDs).

METHODS

We conducted a retrospective chart review from two New Jersey suburban EDs with consecutive patients from February 1, 2013 to January 31, 2018.We identified patients having Bell's palsy using the emergency physician diagnosis. We tabulated positive Lyme tests and visits for Bell's palsy by month of year. We calculated the ratio of positive tests and visits between the Lyme months and the rest of the year along with 95% confidence intervals (CIs).

RESULTS

There were 442 visits for Bell's palsy, 359 (81%) of these patients were tested for Lyme disease and 57 (16%) of the tests were positive. The Lyme months had 7.1 (95% CI 3.5-14.4) times more positive tests and 1.3 (95% CI 1.1-1.4) times more Bell's palsy visits than the rest of the year. Both measures peaked in July.

CONCLUSIONS

In a Lyme-endemic area, positive Lyme tests and ED visits for Bell's palsy are greatest in the Lyme months, peaking in July. This finding can help guide testing and treatment for patients in the ED with Bell's palsy during various months of the year.

Imaging of Lyme Neuroborreliosis: A Pictorial Review

Lyme neuroborreliosis is a common feature of Borrelia burgdorferi infection (as a neurological manifestation occurring in 10%–15% of all Lyme disease cases) and may involve any part of the nervous system, and its coverings, but usually manifests as lymphocytic meningitis, cranial neuritis, and/or radiculoneuritis. This review describes the imaging findings in Lyme neuroborreliosis: the focal point is on the manifestations of involvement visible on brain and spine imaging.

Subacute transverse myelitis with optic symptoms in neuroborreliosis: a case report

Background

Subacute transverse myelitis is one of the late manifestations of neuroborreliosis with only a few cases described to the present day.

Case presentation

We present magnetic resonance imaging, cerebrospinal fluid, and electroneurography findings of a young female patient suffering from neuroborreliosis-associated transverse myelitis with a wide constellation of symptoms including papilloedema. Magnetic resonance imaging of the cervical spine has shown an enlargement of the spinal cord in the mid-cervical region. Cerebrospinal fluid findings included lymphocytic pleocytosis, increased levels of anti - Borrelia antibodies, and increased intrathecal anti -Borrelia antibody index. Following the 28-day course of intravenous ceftriaxone, the patient attained complete recovery.

Conclusions

Subacute transverse myelitis in the course of neuroborreliosis should be considered in the differential diagnosis of patients with abnormal magnetic resonance scans of the spinal cord, lymphocytic pleocytosis, and intrathecal antibody production, especially in the tick-endemic areas, even if the tick bite was not reported. Infrequent accompanying symptoms such as papilloedema are diagnostically challenging and cannot be treated as clinching evidence.

Guillain-Barre Syndrome, Neuroborreliosis, or Both

Guillain-Barre syndrome (GBS) is an acute paralytic neuropathy. Limited reports of GBS caused by tick-borne pathogens exist. Lyme disease is a tick-borne infectious disease that is commonly caused by Borrelia burgdorferi. The nervous system may be involved and is called neuroborreliosis.

In this case, we report a 30-year-old female who presented to the emergency department with one week of diffuse, increasing weakness in the upper/lower extremities and face after a recent gastrointestinal illness and travel to the Northeastern United States. Areflexia was noted in bilateral lower extremities. Lumbar puncture results together with clinical presentation were consistent with a diagnosis of GBS. Lab results later revealed a possible Lyme infection in cerebrospinal fluid, which along with recent travel to endemic area gave high suspicion for Lyme disease. The patient was treated for both diseases with significant improvement.

Taking a good history is an essential first step in diagnosis, as travel history was key in testing for Lyme.

Atypical presentation of Lyme neuroborreliosis related meningitis and radiculitis

Lyme disease related central and peripheral nervous system manifestations can occur in isolation or together. Radiculitis or inflammation of the nerve root can be seen 3-5% of the time in acute neuroborreliosis affecting the PNS with a typical presentation and meningitis affecting the CNS is usually seen 1% of the time. The appropriate diagnosis and management of neuroborelliosis can be challenging and require meticulous medical approaches. Herein we present a unique case of Lyme disease with neurologic manifestations including both radiculitis and meningitis due to its atypical and challenging clinical presentation and management with updated literature review.

Meningoradiculitis and transaminitis from neuroborreliosis: A case of variant Bannwarth syndrome

BACKGROUND

Lyme disease is a common vector-borne illness in the U.S. caused by Borrelia species spirochetes. Neuroborreliosis has variable presentations, rarely manifesting as meningoradiculitis or "Bannwarth Syndrome", characterized by painful radiculopathy, neuropathy, varying degrees of motor weakness, peripheral facial nerve palsy and cerebrospinal fluid (CSF) lymphocytic pleocytosis. We present a case of Bannwarth Syndrome manifesting with transaminitis and significant weight loss.

CASE PRESENTATION

A 60-year-old man with history of hypertension presented with 3 weeks of progressive back pain, bilateral arm and leg weakness, bilateral hand numbness and a right facial droop in absence of sphincter dysfunction. He reported an 11.3 kg unintentional weight loss and recent holiday to Egypt. Patient was afebrile with normal vital signs but with profound transaminitis on presentation. Exam revealed a lower motor neuron right facial nerve palsy, diffuse quadriparesis, areflexia but isolated brisk ankle reflexes. A left complete facial palsy developed shortly after admission. Concern for leptomeningeal plus peripheral nerve involvement led to consideration of oncologic, infectious and inflammatory etiologies, along with Guillain-Barre variants. Contrasted MRI of the brain and total spine was normal. CSF revealed lymphocytic pleocytosis (cell count 134), elevated protein (156) with normal glucose, cytology, AFB culture, viral PCRs and paraneoplastic antibodies. Serum and CSF Lyme IgG and IgM were positive. IV Ceftriaxone 2 g daily was started one day after admission. EMG/Nerve conduction studies showed diffuse polyradiculopathy without evidence of Guillain-Barre syndrome. Babesia co-infection was considered given unexplained transaminitis but PCR and quantitation were negative. CSF following 1 week of antibiotics showed improving cell and protein counts with resolving transaminitis. On follow-up at 2 months, facial paralysis, pain, motor and sensory deficits had resolved with return to baseline weight and liver function tests.

CONCLUSIONS

Bannwarth syndrome, a subacute painful meningoradiculitis caused by Borrelia species infection, is an uncommon presentation of neuroborreliosis in the U.S. Our case demonstrates previously unreported features such as profound transaminitis and weight loss without evidence of co-infection. Clinical manifestations of neuroborreliosis are variable, thus it is important to consider Bannwarth syndrome in the differential of meningoradiculitis in areas where Lyme Disease is prevalent.

Atypical Lyme Neuroborreliosis, Guillain-Barré Syndrome or Conversion Disorder: Differential Diagnosis of Unusual Neurological Presentations

Nervous system Lyme disease and Guillain-Barré syndrome are common neurological conditions that may present with unusual symptoms rendering differential diagnosis difficult. We report the case of a 62-year-old woman presenting with asymmetrical tetraparesis and hyporeflexia. Initially the presumed diagnosis of Guillain-Barré syndrome with a possible functional component was suspected and treatment with intravenous immunoglobulin was initiated. Due to partial response to therapy and further test results including positive serologies and cerebrospinal fluid antibodies for Borrelia, the diagnosis of neuroborreliosis was considered. Further exploring revealed the possibility of exposure to ticks although there was no report of typical skin lesions. Daily physical therapy and appropriate antibiotic treatment with parenteral ceftriaxone resulted in significant improvement of motor symptoms and functional status. The patient was discharged with marked functional improvement and indication for further physical rehabilitation.

Identification of a novel variant of Golli myelin basic protein BG21 in the uniquely neuroprotective white-footed mouse

The myelin basic protein (MBP) gene is a complex gene which codes for several distinct forms of MBP. The various forms of MBP are functionally involved in the development of the nervous system, T-cell regulation, and myelination. Several neurological disorders have been linked to MBP abnormality, further demonstrating its functional significance in the nervous system. The white-footed mouse (Peromyscus leucopus) exhibits profound neuroprotective characteristics, is asymptomatic to various disease-states, and has a lifespan twice that of the house mouse (Mus musculus). We used M. musculus mouse MBP as a reference to explore MBP in P. leucopus mice. Through genetic and downstream proteomic data analysis, we identified a novel variant of the BG21 isoform of MBP in P. leucopus mice. Variation in this isoform is present at the genetic level between the two species of mice. Our results show differences within the open reading frame of the transcripts accompanied by corresponding differences in protein structure prediction. These data introduce the potential of MBP variation as one of many causal variables contributing to the unique presentation of enhanced neuroprotection and longevity in P. leucopus mice.

Acute transverse myelitis - A rare clinical manifestation of Lyme neuroborreliosis

Acute transverse myelitis (ATM) is a rare, potentially devastating neurological syndrome that has variety of causes, infectious being one of them. Lyme disease (LD) is the most common vector borne zoonosis in the United States (U.S.). While neurologic complications of LD are common, acute transverse myelitis is an exceedingly rare complication. We present a case of a previously healthy 25-year-old man who presented with secondary erythema migrans, aseptic meningitis and clinical features of transverse myelitis including bilateral lower extremity motor and sensory deficits manifesting as weakness and numbness, urinary retention and constipation. Despite negative serum antibodies against Borrelia burgdoferi, cerebrospinal fluid (CSF) was positive for Borrelia burgdorferi PCR. Following treatment with methylprednisolone and ceftriaxone, he attained complete recovery apart from neurogenic bladder necessitating intermittent self-catheterization. We report rare manifestation of a common disease and emphasize the importance of considering LD in the differential diagnosis of acute transverse myelitis, particularly in residents of endemic areas.

Two cases of sarcoidosis presenting as longitudinally extensive transverse myelitis

Neurosarcoidosis is uncommon with an incidence of approximately 5 to 15%. Central nervous system involvement can be divided into brain and spinal cord neurosarcoidosis. Spinal cord sarcoidosis is extremely rare, occurring in less than 1% of all sarcoidosis cases. Its manifestations may include cauda equina syndrome, radiculopathy, syringomyelia, cord atrophy, arachnoiditis, and myelopathy or transverse myelitis. We highlight two cases of spinal cord sarcoidosis, each presenting with longitudinally extensive transverse myelitis, that demonstrate the dilemmas that physicians face with regard to diagnosis and treatment. Given its rarity and the diversity of possible manifestations, establishing the diagnosis of spinal cord sarcoidosis is often very difficult. Extensive evaluation must be conducted to rule out primary neurologic, primary rheumatologic, infectious, and neoplastic diseases. MRI often demonstrates hyperintensity on T2-weighted images and enhancement following gadolinium administration. CSF analysis most consistently shows a lymphocytic pleocytosis and elevated proteins. While these less invasive investigations may be helpful, the gold standard for diagnosis is biopsy of neurologic or non-neurologic tissue confirming the presence of non-caseating granulomas. Evidence-based guidelines for the treatment of transverse myelitis secondary to sarcoidosis are lacking due to its rarity; therefore, therapy is based on expert and anecdotal experience and usually consists of high doses of steroids in combination with various immunosuppressive agents. The use of infliximab in particular appears promising, but there is a need for further investigation into the ideal treatment regimen.