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Bloch J, Schmidt L, Vissing N, Nielsen ACY, Glenthøj JP, Smith B, Lisby JG, Nielsen L, Tetens M, Lebech AM, Nygaard U. Peripheral facial palsy in children: Serum Borrelia antibodies may reduce the need for lumbar puncture. Acta Paediatr 2024. [PMID: 39221969 DOI: 10.1111/apa.17414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/13/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
AIM We aimed to investigate the causes of acute peripheral facial palsy (PFP) in Danish children and to explore whether neuroborreliosis-related PFP could be diagnosed without lumbar puncture using clinical symptoms and serum Borrelia burgdorferi (Bb) antibodies. METHODS This retrospective population-based cohort study included children undergoing lumbar puncture for PFP between 2019 and 2023 in Denmark's Capital Region. Diagnostic performance measures for neuroborreliosis-related PFP were compared between serum Bb IgG alone and clinical risk scores combining Bb IgG with clinical parameters. RESULTS Of the 326 patients with PFP, 137 (42%) were diagnosed with neuroborreliosis and 151 (46%) had Bell's palsy. Positive predictive value for serum Bb IgG alone was 88% (95% CI 79-93) and negative predictive value was 83% (95% CI 75-88). The positive predictive value of a risk score with seven additional parameters was 90% (95% CI 81-95) and negative predictive value 87% (95% CI 80-92). CONCLUSION The positive predictive value of serum Bb IgG alone was high in our setting, where nearly half of children with PFP had neuroborreliosis. In high endemic settings, lumbar punctures may be reduced by (i) treating all children with PFP with doxycycline or (ii) treating Bb IgG positive children and performing lumbar puncture in seronegative children.
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Affiliation(s)
- Joakim Bloch
- Department of Paediatrics and Adolescent Medicine, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Lisbeth Schmidt
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Children and Adolescents, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Nadja Vissing
- Department of Paediatrics and Adolescent Medicine, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Alex Christian Yde Nielsen
- Department of Clinical Microbiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jonathan Peter Glenthøj
- Department of Children and Adolescents, Copenhagen University Hospital - North Zealand Hospital, Hilleroed, Denmark
| | - Birgitte Smith
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Children and Adolescents, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Jan Gorm Lisby
- Department of Clinical Microbiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Lene Nielsen
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Malte Tetens
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Children and Adolescents, Copenhagen University Hospital - North Zealand Hospital, Hilleroed, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
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Tetens MM, Omland LH, Andersen NS, Bangsborg J, Bodilsen J, Dessau RB, Ellermann-Eriksen S, Jørgensen CS, Møller JK, Nielsen ACY, Pedersen M, Søgaard KK, Obel N, Lebech AM. Healthcare-seeking behaviour preceding diagnosis of Lyme neuroborreliosis: population-based nationwide matched nested case-control study. Clin Microbiol Infect 2024:S1198-743X(24)00315-X. [PMID: 38992431 DOI: 10.1016/j.cmi.2024.07.004] [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: 04/23/2024] [Revised: 06/19/2024] [Accepted: 07/03/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVES To identify diagnostic opportunities, we investigated healthcare-seeking behaviour among patients with Lyme neuroborreliosis (LNB) within 28 weeks before diagnosis. METHODS We conducted a population-based, nationwide matched nested case-control study (Denmark, 2009-2021). As cases, we included all Danish residents with LNB (positive Borrelia burgdorferi intrathecal antibody index test and cerebrospinal fluid pleocytosis). We randomly selected controls from the general population and matched 10:1 on date of birth and sex. Exposures were assignment of diagnostic codes for symptoms, contact to medical specialties, medical wandering, and undergoing diagnostic procedures. We calculated the weekly and 3-month proportions of individuals with exposures and calculated absolute risk differences with corresponding 95% CI. RESULTS We included 1056 cases with LNB and 10 560 controls. Within 3 months before diagnosis, the most frequent assigned symptoms were pain (difference: 13.0%, 95% CI: 10.9-15.1). Cases with LNB exhibited increased contact with most specialties, particularly general practitioners (difference: 48.7%, 95% CI: 46.0-51.4), neurology (difference: 14.3%, 95% CI: 11.7-16.8), and internal medicine (difference: 11.1%, 95% CI: 8.7-13.5), and medical wandering (difference: 17.1%, 95% CI: 14.3-20.0). Common diagnostic procedures included imaging of the brain (difference: 10.2, 95% CI: 8.3-12.1), the spine (difference: 8.8%, 85% CI: 7.0-10.6), and the abdomen (difference: 7.2%, 95% CI: 5.4-9.1). The increase in healthcare-seeking behaviour was observed ≤12 weeks preceding diagnosis. DISCUSSION Pain appears to be an ambiguous symptom of LNB, potentially contributing to delays in establishing the correct diagnosis. It would be difficult to identify patients with LNB more effectively as the increased healthcare-seeking behaviour preceding diagnosis is distributed across many medical specialties.
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Affiliation(s)
- Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Lars Haukali Omland
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Nanna S Andersen
- Clinical Centre for Emerging and Vector-borne Infections, Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark; Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Jette Bangsborg
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev Hospital, Herlev, Denmark
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Zealand University Hospital, Slagelse, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Jens Kjølseth Møller
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Clinical Microbiology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Alex Christian Yde Nielsen
- Department of Clinical Microbiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Michael Pedersen
- Department of Clinical Microbiology, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark
| | - Kirstine K Søgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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3
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Shafquat M, Angulo FJ, Pilz A, Moïsi JC, Stark JH. The Incidence of Lyme Borreliosis Among Children. Pediatr Infect Dis J 2023; 42:867-874. [PMID: 37406218 PMCID: PMC10501351 DOI: 10.1097/inf.0000000000004040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND First recognized in children in the United States, Lyme borreliosis (LB) is the most prevalent tickborne illness in North America and Europe. However, the incidence of LB in children, including geographic variation and difference from that in adults, is incompletely described. METHODS We compiled surveillance data from public health agency websites reporting age-stratified LB case data, which was combined with census data to derive incidence estimates. Additional incidence estimates were obtained through a systematic literature review. RESULTS We identified 18 surveillance systems and 15 published studies for derivation of LB incidence in children. National incidence of >10 cases in children per 100,000 per year were estimated for the United States and parts of Eastern, Western and Northern Europe. However, there was substantial variation in incidence among countries in some European regions. National incidence estimates from the literature largely aligned with estimates from surveillance. Surveillance-reported pediatric incidence was lower than adult incidence in adults in 8 countries, similar to adult incidence in 3 countries, and higher than adult incidence in 1 country. Among all pediatric age strata, the 5-9 years of age stratum had the highest proportion of pediatric cases in most countries. CONCLUSIONS As pediatric LB represents a substantial proportion of overall LB incidence across countries in Europe and North America, LB prevention and control efforts should target pediatric as well as adult populations. However, better data are needed to fully characterize the difference in incidence across geographic regions.
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Affiliation(s)
- Madiha Shafquat
- From the Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Collegeville, Pennsylvania
| | - Frederick J. Angulo
- From the Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Collegeville, Pennsylvania
| | - Andreas Pilz
- Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Vienna, Austria
| | - Jennifer C. Moïsi
- Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Paris, France
| | - James H. Stark
- From the Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Collegeville, Pennsylvania
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4
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Bruinsma RA, Zomer TP, Skogman BH, van Hensbroek MB, Hovius JW. Clinical manifestations of Lyme neuroborreliosis in children: a review. Eur J Pediatr 2023; 182:1965-1976. [PMID: 36856886 DOI: 10.1007/s00431-023-04811-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 03/02/2023]
Abstract
Lyme neuroborreliosis (LNB) is a manifestation of Lyme disease involving the central and peripheral nervous system. It is caused by the spirochete Borrelia burgdorferi, transmitted by tick bites to a human host. Clinical signs of LNB develop after the dissemination of the pathogen to the nervous system. The infection occurs in children and adults, but the clinical manifestations differ. In adults, painful meningoradicultis is the most common manifestation of LNB, while children often present with facial nerve palsy and/or subacute meningitis. Subacute headache can be the only manifestation of LNB in children, especially during the summer months in Lyme disease-endemic regions. Non-specific symptoms, such as loss of appetite, fatigue or mood changes, may also occur, especially in young children. A high level of suspicion and early recognition of the various clinical manifestations presented by children with LNB is essential to minimize delay in diagnosis and optimize management. This review provides an overview of the spectrum of clinical manifestations, and discusses diagnosis, antibiotic treatment, and clinical outcome of LNB in children.
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Affiliation(s)
- R A Bruinsma
- Lyme Center Apeldoorn, Gelre Hospital, Apeldoorn, P.O. Box 9014, 7300 DS, the Netherlands.,Department of Pediatrics, Gelre Hospital, Apeldoorn, the Netherlands
| | - T P Zomer
- Lyme Center Apeldoorn, Gelre Hospital, Apeldoorn, P.O. Box 9014, 7300 DS, the Netherlands.
| | - B H Skogman
- Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden.,Department of Medical Sciences, Örebro University, Örebro, Sweden
| | - M Boele van Hensbroek
- Department of Pediatrics, Amsterdam Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J W Hovius
- Amsterdam UMC Multidisciplinary Lyme borreliosis Center, Amsterdam UMC Medical Centers, location AMC, University of Amsterdam, Amsterdam, the Netherlands
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5
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De Larochellière E, Langley JM, Bata BM. Unilateral ptosis and mydriasis secondary to presumed Lyme neuroborreliosis. J AAPOS 2022; 26:278-280. [PMID: 36108883 DOI: 10.1016/j.jaapos.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/11/2022] [Accepted: 07/17/2022] [Indexed: 11/25/2022]
Abstract
We report a case of unilateral acute-onset ptosis and mydriasis in a girl 2 years and 7 months of age from an area endemic for Lyme disease. She lacked other signs of oculomotor nerve palsy. She tested positive for Borrelia burgdorferi and negative for Bartonella henselae on serology and was diagnosed with Lyme neuroborreliosis. The ptosis and mydriasis resolved after 1 week of oral doxycycline.
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Affiliation(s)
- Elianne De Larochellière
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia; Department of Ophthalmology, Université Laval, Québec, Quebec
| | - Joanne M Langley
- Departments of Pediatrics and Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia
| | - Bashar M Bata
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia.
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6
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Abstract
Most patients with Lyme disease will fully recover with recommended antibiotic therapy. However, some patients report persisting nonspecific symptoms after treatment, referred to as posttreatment Lyme disease symptoms (PTLDs) or syndrome (PTLDS), depending on the degree to which the individual's symptoms impact their quality of life. PTLDs occur in a portion of patients diagnosed with chronic Lyme disease (CLD), a controversial term describing different patient populations, diagnosed based on unvalidated tests and criteria. Practitioners should review the evidence for the Lyme disease diagnosis and not overlook unrelated conditions. Current evidence shows that prolonged antibiotic therapy provides little benefit and carries significant risk. Further research to elucidate the mechanisms underlying persistent symptoms after Lyme disease and to understand CLD is needed.
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Affiliation(s)
- Adriana Marques
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, BG 10 RM 12C118 MSC 1888 10 Center, Bethesda, MD 20892-1888, USA.
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7
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Arnason S, Skogman BH. Effectiveness of antibiotic treatment in children with Lyme neuroborreliosis - a retrospective study. BMC Pediatr 2022; 22:332. [PMID: 35676665 PMCID: PMC9178872 DOI: 10.1186/s12887-022-03335-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background Lyme neuroborreliosis (LNB) is a tick-borne infection caused by the spirochete Borrelia burgdorferi sensu lato complex with various neurological manifestations. The recommended treatment for LNB in Swedish children has been intravenous ceftriaxone 50–100 mg/kg × 1 (< 8 years of age) or oral doxycycline 4 mg/kg × 1 (≥ 8 years of age) for 10–14 days. Studies on adult LNB patients have shown equal efficacy for ceftriaxone and doxycycline, but no such studies have been conducted on pediatric LNB patients. The aim of this study is to retrospectively evaluate clinical outcome in children with LNB who have received intravenous ceftriaxone or oral doxycycline. Results Clinical and laboratory data from three previously conducted prospective studies on children with LNB (1998–2014) were retrospectively analyzed. A total of 321 children (1–19 years of age), who received antibiotic treatment for definite LNB or possible LNB, were included. Clinical outcome at the 2-month follow-up (recovery/non-recovery) was evaluated using Chi2 test and logistic multivariate regression analysis. Out of 321 LNB patients, 194 children (60%) had received ceftriaxone and 127 children (40%) had received doxycycline. When comparing clinical outcome between treatment groups, no difference was found (p = 0,217). Results did not change when incorporating relevant clinical and laboratory data into the logistic multivariate regression analysis. Conclusion In this large retrospective study, no difference in clinical outcome was found, independent of age, when comparing children who received ceftriaxone with those who received doxycycline, supporting an equal effectiveness for treatment of LNB pediatric patients. However, future randomized comparative treatment studies are warranted for evaluation of efficacy of antibiotic treatment in pediatric LNB patients.
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Affiliation(s)
- Sigurdur Arnason
- Department of Clinical Science, Intervention and Technology - CLINTEC, Alfred Nobels Allé 8, S-141 52, Huddinge, Sweden.,Department of Pediatric Infectious Diseases, Astrid Lindgren's Children's Hospital, Karolinska Vägen 22, S-171 64 Solna, Stockholm, Sweden
| | - Barbro H Skogman
- Center for Clinical Research Dalarna - Uppsala University, Nissers Väg 3, S-791 82, Falun, Sweden. .,Department of Clinical Science, Intervention and Technology - CLINTEC, Karolinska Institutet, Alfred Nobels Allé 8, S-141 52, Huddinge, Sweden. .,Department of Medical Sciences, Örebro University, Södra Grev Rosengatan 42 B, S-703 62, Örebro, Sweden.
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8
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Chhajed M, Jain A, Gunasekaran PK, Dhaliwal N, Saini L. Lyme Neuroborreliosis with Intracranial Hypertension and Erythema Multiforme: A Rare Presentation. J Trop Pediatr 2022; 68:6648460. [PMID: 35867049 DOI: 10.1093/tropej/fmac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A 9-year-old previously healthy boy presented with high-grade intermittent fever, severe headache associated with neck stiffness for 5 days, rash over trunk and extremities for 4 days, vomiting for 3 days and diplopia for 2 days. There was no history of seizures, abnormal body movements, altered sensorium or focal deficits. On examination, he had maculopapular erythematous rashes over the trunk and extremities and erythema multiforme. He had bilateral abducens nerve palsy and the rest of the cranial nerve, sensory and motor examination was normal. He had neck stiffness and positive Kernig's sign. Fundus examination showed grade 4 papilledema. Cerebrospinal fluid workup revealed elevated opening pressure, lymphocytic pleocytosis, normal protein and glucose levels. Neuroimaging showed features suggestive of intracranial hypertension. Borrelia IgM and IgG antibodies came positive. The uniqueness of our case lies with two rare presenting manifestations of Lyme neuroborreliosis in the same child.
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Affiliation(s)
- Monika Chhajed
- Department of Pediatrics, Chaitanya Hospital, Chandigarh 160047, India
| | - Amit Jain
- Department of Radiodiagnosis, MM Institute of Medical Sciences and Research, Ambala, Haryana 133207, India
| | | | - Navdeep Dhaliwal
- Department of Pediatrics, Chaitanya Hospital, Chandigarh 160047, India
| | - Lokesh Saini
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342005, India
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9
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Arnason S, Molewijk K, Henningsson AJ, Tjernberg I, Skogman BH. Brain damage markers neuron-specific enolase (NSE) and S100B in serum in children with Lyme neuroborreliosis-detection and evaluation as prognostic biomarkers for clinical outcome. Eur J Clin Microbiol Infect Dis 2022; 41:1051-1057. [PMID: 35665437 PMCID: PMC9250468 DOI: 10.1007/s10096-022-04460-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/16/2022] [Indexed: 11/22/2022]
Abstract
Lyme borreliosis (LB) is the most common tick-borne infection in Europe, with Lyme neuroborreliosis (LNB) its second most frequent clinical manifestation. Prognostic factors for clinical outcomes in LNB have not been identified. Elevated serum levels of the brain damage markers neuron-specific enolase (NSE) and S100 calcium-binding protein B (S100B) have been associated with poor clinical outcomes in other disorders of the central nervous system. The aim of this study is to assess NSE and S100B in serum as prognostic biomarkers for clinical outcomes in paediatric LNB patients. Children evaluated for LNB (n = 121) in Sweden were prospectively included during 2010–2014, serum samples were collected on admission, and all children underwent a 2-month follow-up. Patients with pleocytosis and anti-Borrelia antibodies in cerebrospinal fluid (CSF) were classified as having LNB (n = 61). Controls were age- and gender-matched non-LNB patients (n = 60). NSE was elevated in 38/61 (62%) LNB patients and in 31/60 (52%) controls. S100B was elevated in 3/60 (5%) LNB patients and 0/59 (0%) controls. NSE and S100B concentrations did not differ significantly when comparing LNB patients with controls. No differences were found in the concentrations when comparing the clinical recovery of LNB patients at the 2-month follow-up. NSE was detectable in the majority of LNB patients and controls, whereas S100B was detectable in only a few LNB patients and no controls. NSE and S100B in serum cannot be recommended as prognostic biomarkers for clinical outcomes in children with LNB.
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Affiliation(s)
- Sigurdur Arnason
- Department of Clinical Science, Intervention and Technology - CLINTEC, Alfred Nobels Allé 8, 141 52, Huddinge, Stockholm, Sweden. .,Department of Pediatric Infectious Diseases, Astrid Lindgren's Children's Hospital, Eugeniavägen 23, 171 64, Solna, Stockholm, Sweden.
| | - Kesia Molewijk
- Faculty of Health and Medical Sciences, Örebro University, Södra Grev Rosengatan 42 B, S-703 62, Örebro, Sweden
| | - Anna J Henningsson
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden.,National Reference Laboratory for Borrelia and Other Tick-Borne Bacteria, Division of Clinical Microbiology, Laboratory Medicine, Region Jönköping County, Linköping University, Linköping, Sweden.,Department of Clinical Microbiology in Linköping, Linköping University, Linköping, Sweden
| | - Ivar Tjernberg
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry and Transfusion Medicine, Region Kalmar County, Kalmar, Sweden
| | - Barbro H Skogman
- Faculty of Health and Medical Sciences, Örebro University, Södra Grev Rosengatan 42 B, S-703 62, Örebro, Sweden.,Center for Clinical Research Dalarna - Uppsala University, Nissers väg 3, S-791 82, Falun, Sweden.,Department of Clinical Science, Intervention and Technology - CLINTEC, Karolinska Institutet, Alfred Nobels Allé 8, S-141 52, Huddinge, Stockholm, Sweden
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10
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Abstract
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.
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11
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Garrabe E, Dubois D, Chaix Y, Baudou E, Cheuret E, Brehin C. Lyme neuroborreliosis in pediatrics: A retrospective, descriptive study in southwest France. Arch Pediatr 2021; 28:537-543. [PMID: 34509348 DOI: 10.1016/j.arcped.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/26/2021] [Accepted: 08/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The neurological effects of Lyme borreliosis in children are varied and their clinical progression is not widely reported in the French literature. We carried out a retrospective study to describe the clinical characteristics of Lyme neuroborreliosis in children in southwest France and their clinical progression at 6 months. METHODS This study was carried out at Toulouse University Hospital during the period 2006-2017 using patient records. Case definition was based on the combined French clinical and laboratory diagnostic criteria. RESULTS In total, 26 children were included. The median age was 8 years (4-14 years). The different neurological symptoms reported were: meningoradiculitis (62%), which was usually associated with facial palsy (54%); isolated facial palsy (15%); isolated meningitis (8%); polyradiculoneuritis (4%); benign intracranial hypertension (4%) and myelomeningoradiculitis (4%). The most common functional symptoms were headaches (54%), the perception of asthenia (42%), neck pain (27%), and a loss of appetite (19%). Patients with laboratory meningitis (84%) often had no signs of meningism or headaches (38%). CONCLUSION The majority of the cases involved meningoradiculitis but other, less common, neurological conditions have been described. The clinical signs suggestive of meningitis are not very marked and might delay the diagnosis.
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Affiliation(s)
- E Garrabe
- Service Neurologie pédiatrique, CHU Toulouse, 330, avenue de Grande-Bretagne 31059 Toulouse, France.
| | - D Dubois
- Service Bactériologie/Hygiène, CHU de Toulouse, 330, avenue de Grande-Bretagne 31059 Toulouse, France
| | - Y Chaix
- Service Neurologie pédiatrique, CHU Toulouse, 330, avenue de Grande-Bretagne 31059 Toulouse, France
| | - E Baudou
- Service Neurologie pédiatrique, CHU Toulouse, 330, avenue de Grande-Bretagne 31059 Toulouse, France
| | - E Cheuret
- Service Neurologie pédiatrique, CHU Toulouse, 330, avenue de Grande-Bretagne 31059 Toulouse, France
| | - C Brehin
- Service Pédiatrie générale/POSU/urgences médico-chirurgicale, CHU Toulouse, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
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12
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Lyme Neuroborreliosis in Children. Brain Sci 2021; 11:brainsci11060758. [PMID: 34200467 PMCID: PMC8226969 DOI: 10.3390/brainsci11060758] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 12/22/2022] Open
Abstract
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.
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13
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Karlsson S, Arnason S, Hadziosmanovic N, Laestadius Å, Hultcrantz M, Marsk E, Skogman BH. The facial nerve palsy and cortisone evaluation (FACE) study in children: protocol for a randomized, placebo-controlled, multicenter trial, in a Borrelia burgdorferi endemic area. BMC Pediatr 2021; 21:220. [PMID: 33947355 PMCID: PMC8097886 DOI: 10.1186/s12887-021-02571-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/24/2021] [Indexed: 12/20/2022] Open
Abstract
Background Children with acute peripheral facial nerve palsy cannot yet be recommended corticosteroid treatment based on evidence. Adults with idiopathic facial nerve palsy are treated with corticosteroids, according to guidelines resulting from a meta-analysis comprising two major randomized placebo-controlled trials. Corresponding trials in children are lacking. Furthermore, acute facial nerve palsy in childhood is frequently associated with Lyme neuroborreliosis, caused by the spirochete Borrelia burgdorferi. The efficacy and safety of corticosteroid treatment of acute facial nerve palsy associated with Lyme neuroborreliosis, has not yet been determined in prospective trials in children, nor in adults. Method This randomized double-blind, placebo-controlled study will include a total of 500 Swedish children aged 1–17 years, presenting with acute facial nerve palsy of either idiopathic etiology or associated with Lyme neuroborreliosis. Inclusion is ongoing at 12 pediatric departments, all situated in Borrelia burgdorferi endemic areas. Participants are randomized into active treatment with prednisolone 1 mg/kg/day (maximum 50 mg/day) or placebo for oral intake once daily during 10 days without taper. Cases associated with Lyme neuroborreliosis are treated with antibiotics in addition to the study treatment. The House-Brackmann grading scale and the Sunnybrook facial grading system are used for physician-assessed evaluation of facial impairment at baseline, and at the 1- and 12-month follow-ups. Primary outcome is complete recovery, measured by House-Brackmann grading scale, at the 12-month follow-up. Child/parent-assessed questionnaires are used for evaluation of disease-specific quality of life and facial disability and its correlation to physician-assessed facial impairment will be evaluated. Furthermore, the study will evaluate factors of importance for predicting recovery, as well as the safety profile for short-term prednisolone treatment in children with acute facial nerve palsy. Discussion This article presents the rationale, design and content of a protocol for a study that will determine the efficacy of corticosteroid treatment in children with acute facial nerve palsy of idiopathic etiology, or associated with Lyme neuroborreliosis. Future results will attribute to evidence-based treatment guidelines applicable also in Borrelia burgdorferi endemic areas. Trial registration The study protocol was approved by the Swedish Medical Product Agency (EudraCT nr 2017–004187-35) and published at ClinicalTrials.gov (NCT03781700, initial release 12/14/2018).
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Affiliation(s)
- Sofia Karlsson
- Center for Clinical Research Dalarna - Uppsala University, Region Dalarna County, Falun, Sweden. .,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Department of Otorhinolaryngology, Region Dalarna County, Falun, Sweden.
| | - Sigurdur Arnason
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Infectious Diseases, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Solna, Sweden
| | | | - Åsa Laestadius
- Department of Pediatric Nephrology, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Solna, Sweden.,Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden
| | - Malou Hultcrantz
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Elin Marsk
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden
| | - Barbro H Skogman
- Center for Clinical Research Dalarna - Uppsala University, Region Dalarna County, Falun, Sweden.,Department of Pediatrics, Region Dalarna County, Falun, Sweden.,Faculty of Medical and Health Sciences, Örebro Universitet, Örebro, Sweden
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14
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Abstract
Lyme disease is a multisystem disease caused by Borrelia burgdorferi infection and accounts for well-defined manifestations, appearing either at an early or late stage. Appropriate antibiotic therapy generally leads to a favorable outcome. Still, unspecific persisting symptoms such as fatigue, myalgia, arthralgia or cognitive dysfunction are reported by several patients months to years after adequate treatment. Their underlying pathophysiologic mechanism is unclear. However, there is no evidence for microbiological persistence in these cases and attempts to resolve the symptoms by repeated or prolonged antibiotic treatment have not been convincingly successful, but they may rather be harmful. To narrow down the controversially handled entity of posttreatment Lyme disease syndrome (PTLDS) and to avoid overdiagnosis and overtreatment, case definitions have been proposed, acknowledging PTLDS as a complex of nonspecific, subjective symptoms, which are neither caused by ongoing infection nor by any other identifiable disease. PTLDS is mainly a diagnosis of exclusion and requires careful evaluation of differential diagnosis followed by counseling about optimal management in light of missing specific therapeutic options.
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Affiliation(s)
- Hanna Schmid
- From the University of Basel Children's Hospital, Paediatric Infectious Diseases and Vaccinology, Basel, Switzerland
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15
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Mac S, Bahia S, Simbulan F, Pullenayegum EM, Evans GA, Patel SN, Sander B. Long-Term Sequelae and Health-Related Quality of Life Associated With Lyme Disease: A Systematic Review. Clin Infect Dis 2021; 71:440-452. [PMID: 31773171 DOI: 10.1093/cid/ciz1158] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022] Open
Abstract
Lyme disease (LD) is the most commonly reported vector-borne disease, but its clinical consequences remain uncertain. We conducted a systematic review of the long-term sequelae and health-related quality of life (HRQoL) associated with LD in North America and Europe. We performed searches in 6 electronic databases up to December 2018 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including observational studies reporting long-term sequelae, HRQoL, and prognostic factors. We included 46 studies, published between 1994 and 2019. Based on 21 studies reporting attributable outcomes, higher proportions of sequelae reported from exposed patients were: neck pain, myalgia, arthralgia, paresthesia, sleep disorder, poor appetite, and concentration difficulties. Patients with PTLDS reported impaired HRQoL compared to the general US population. Included studies were highly heterogeneous in terms of study design, settings, patient characteristics, and quality. Patients with LD are more likely to report nonspecific long-term sequelae, especially those experiencing persistent symptoms posttreatment. Opportunities exist for prospective longitudinal studies to better understand LD outcomes.
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Affiliation(s)
- Stephen Mac
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,THETA Collaborative, University Health Network, Toronto, Canada
| | - Simran Bahia
- Department of Biochemistry, University of Ottawa, Ottawa, Canada
| | | | - Eleanor M Pullenayegum
- The Hospital for Sick Children (SickKids), Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Gerald A Evans
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Queen's University, Kingston, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Samir N Patel
- Public Health Ontario, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,THETA Collaborative, University Health Network, Toronto, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Canada.,Public Health Ontario, Toronto, Canada
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16
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Skogman BH, Wilhelmsson P, Atallah S, Petersson AC, Ornstein K, Lindgren PE. Lyme neuroborreliosis in Swedish children-PCR as a complementary diagnostic method for detection of Borrelia burgdorferi sensu lato in cerebrospinal fluid. Eur J Clin Microbiol Infect Dis 2021; 40:1003-1012. [PMID: 33387122 PMCID: PMC8084766 DOI: 10.1007/s10096-020-04129-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/13/2020] [Indexed: 12/23/2022]
Abstract
The aim of this study was to evaluate polymerase chain reaction (PCR) as a diagnostic method for the detection of Borrelia burgdorferi s.l. in CSF of Swedish children with LNB. This study was performed retrospectively on CSF and serum samples collected from children evaluated for LNB (n = 233) and controls with other specific neurological disorders (n = 59) in a Swedish Lyme endemic area. For anti-Borrelia antibody index, the IDEIA Lyme Neuroborreliosis kit (Oxoid) was used. Two in-house real-time PCR assays targeting the 16S rRNA gene were evaluated (TaqMan® and LUX™). Among patients classified as LNB cases (n = 102), five children (5%) were Borrelia PCR-positive in CSF with the TaqMan® assay. In the Non-LNB group (n = 131), one patient was Borrelia PCR positive with the TaqMan® assay. Among controls (n = 59), all CSF samples were PCR negative. When amplifying and sequencing ospA, we found B. garinii (n = 2), B. afzelii (n = 2), B. bavariensis (n = 1), and one untypable (n = 1). With the LUX™ technology, all CSF samples were PCR negative. The TaqMan® assay could detect only few cases (n = 6) of B. burgdorferi s.l. in CSF among children with LNB and the sensitivity was very low (5%). However, using larger CSF volumes and centrifugation of samples, the PCR technique could still be useful as a complementary diagnostic method when evaluating LNB. Furthermore, detection of spirochete DNA in clinical matrices, including CSF, is the method of choice for studying epidemiological aspects of LNB, a tick-borne emerging disease.
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Affiliation(s)
- Barbro H Skogman
- Center for Clinical Research Dalarna - Uppsala University, Region Dalarna County, Falun, Sweden. .,Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Peter Wilhelmsson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Microbiology, Region Jönköping County, Jönköping, Sweden
| | - Stephanie Atallah
- Department of infectious diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Katarina Ornstein
- Ystad Hospital, Skåne University Health Care, Region Skåne, Ystad, Sweden
| | - Per-Eric Lindgren
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Division of Clinical Microbiology, Laboratory Medicine, Ryhov County Hospital, Jönköping, Sweden
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17
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Savasta S, Fiorito I, Foiadelli T, Pichiecchio A, Cambieri P, Mariani B, Marone P, Marseglia G. Abdominal pain as first manifestation of lyme neuroborreliosis in children, case report and review of literature. Ital J Pediatr 2020; 46:172. [PMID: 33228741 PMCID: PMC7684897 DOI: 10.1186/s13052-020-00936-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/16/2020] [Indexed: 11/28/2022] Open
Abstract
Background Lyme neuroborreliosis can cause a variety of neurological manifestations. European children usually present facial nerve palsy, other cranial nerve palsies and aseptic meningitis. Case presentation We hereby report a case of Lyme neuroborreliosis in a 9-year-old boy with abdominal pain as first symptom and subsequent onset of attention deficit and ataxia. Diagnosis was made by detection of specific antibody in both serum and cerebrospinal fluid with neuro-radiological images suggestive for this infectious disease. A 12-months follow-up was performed during which no relevant neurological sequelae were revealed. Conclusion This case report shows that abdominal radiculitis, although extremely rare, could be the first manifestation of early Lyme neuroborreliosis in pediatric patients. Pediatricians must consider Lyme disease in the differential diagnosis of abdominal pain of unknown origin in children, especially in countries where the infection is endemic.
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Affiliation(s)
| | - Ivan Fiorito
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Thomas Foiadelli
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Anna Pichiecchio
- Neuroradiology Department, Foundation Casimiro Mondino, Pavia, Italy
| | | | - Bianca Mariani
- Virology Department, Foundation Policlinic San Matteo, Pavia, Italy
| | - Piero Marone
- Virology Department, Foundation Policlinic San Matteo, Pavia, Italy
| | - Gianluigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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18
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Walker AR, Morales-Yurick T. A Noteworthy Case Report of Neuroborreliosis in an Unvaccinated Pediatric Patient. Clin Pract Cases Emerg Med 2020; 4:671-674. [PMID: 33217305 PMCID: PMC7676800 DOI: 10.5811/cpcem.2020.9.48688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/19/2020] [Accepted: 09/15/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Lyme disease typically presents with viral-like symptoms and a pathognomonic rash. With disease progression, symptoms of nervous system involvement usually include facial nerve palsy and meningitis, but other atypical neurologic manifestations have less commonly been documented. CASE REPORT A six-year-old male presented with prolonged fevers, rash, headache, and non-specific neurologic symptoms. The diagnosis of neuroborreliosis with meningitis and polyradiculitis was confirmed with laboratory evaluation and lumbar puncture. CONCLUSION Neuroborreliosis is a disseminated form of Lyme disease. While meningitis is a common sign, the presentation of polyradiculitis in children is rare and can lead to misdiagnosis and delay in treatment.
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Affiliation(s)
- Amber R Walker
- Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
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19
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Forde KM, O'Gorman J, Gavin PJ, Dryden MS, Keady D, Hanahoe B, McDonnell C, Power L, Cryan B, Sweeney J, Conyard KF, O'Grady MJ. The clinical presentation, treatment and outcome of serologically confirmed paediatric Lyme disease in the Republic of Ireland over a 5-year period: a retrospective cohort study. Eur J Clin Microbiol Infect Dis 2020; 40:725-734. [PMID: 33040217 DOI: 10.1007/s10096-020-04064-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/01/2020] [Indexed: 01/04/2023]
Abstract
Lyme disease (LD) is the most common tick-borne illness in Europe. Population-based studies in European children are few. This study aimed to assess the incidence, clinical presentation, treatment and outcome of serologically confirmed paediatric LD in the Republic of Ireland over a 5-year period. A retrospective review of records from accredited laboratories performing Borrelia burgdorferi serological testing was undertaken. Proformas were distributed to clinicians of children and adolescents with positive Lyme serology. Data were requested regarding clinical presentation, treatment and outcome. Updated NICE guidelines were used to classify clinical cases. Serology testing for B. burgdorferi was performed on 2908 samples. Sixty-three (2.2%) children were two-tier positive, generating a crude annual incidence rate of 1.15/100,000. Proformas were returned for 55 (87%) and 47 met clinical and laboratory criteria for LD. Twenty-seven (57%) presented with non-focal symptoms (erythema migrans and/or influenza-like symptoms), and 20 (43%) with focal symptoms (cranial nerve involvement, 11; CNS involvement, 8; arthritis, 1). Median age at presentation was 8.2 (2.5-17.9) years. Seventeen (36%) acquired LD overseas. Twenty-five (83%) of the remaining 30 children acquired infection in the West/Northwest of Ireland. Full resolution of symptoms was reported in 97% of those with available data. Serologically confirmed LD in children is relatively rare in the Republic of Ireland. Ninety-eight percent of children tested were seronegative. Of the seropositive cases, 40% could have been diagnosed based on clinical findings alone. Neurological presentations (40%) were common. Full resolution of symptoms occurred in almost all (97%) where data were available.
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Affiliation(s)
- Karina M Forde
- Department of Paediatrics, Regional Hospital Mullingar, Westmeath, Ireland. .,Department of Paediatric Infectious Diseases, Children's Health Ireland, Crumlin and Temple St., Dublin, Ireland.
| | - Joanne O'Gorman
- National Virus Reference Laboratory, University College Dublin, Belfield, Dublin 4, Ireland
| | - Patrick J Gavin
- Department of Paediatric Infectious Diseases, Children's Health Ireland, Crumlin and Temple St., Dublin, Ireland
| | - Matthew S Dryden
- Rare and Imported Pathogens Laboratory, Public Health England, Porton Down, Salisbury, UK
| | - Deirbhile Keady
- Department of Medical Microbiology, Galway University Hospital, Galway, Ireland
| | - Belinda Hanahoe
- Department of Medical Microbiology, Galway University Hospital, Galway, Ireland
| | - Colm McDonnell
- Department of Medical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Lorraine Power
- Department of Medical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Bartley Cryan
- Department of Medical Microbiology, Cork University Hospital, Wilton, Cork, Ireland
| | - James Sweeney
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Karl F Conyard
- CSTAR, University College Dublin, Belfield, Dublin 4, Ireland
| | - Michael J O'Grady
- Department of Paediatrics, Regional Hospital Mullingar, Westmeath, Ireland.,Women's and Children's Health, University College Dublin, Belfield, Dublin 4, Ireland
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20
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Tjernberg I, Johansson M, Henningsson AJ. Diagnostic performance of cerebrospinal fluid free light chains in Lyme neuroborreliosis - a pilot study. Clin Chem Lab Med 2020; 57:2008-2018. [PMID: 31199760 DOI: 10.1515/cclm-2019-0315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/18/2019] [Indexed: 11/15/2022]
Abstract
Background The aim of this study was to evaluate the diagnostic performance of cerebrospinal fluid (CSF) free light chains (FLCs) in the diagnosis of Lyme neuroborreliosis (LNB). Methods Serum and CSF levels of κ- and λ-FLC, albumin and total concentration of immunoglobulin M (IgM) were determined together with CSF chemokine CXCL13 in 23 patients with definite LNB, 35 inflammatory neurological disease control (INDC) and 18 non-inflammatory control (NIC) patients. Indices and intrathecal fractions (IFs) of FLC and IgM were calculated. Results Significant differences in FLC indices and IFs were found between the LNB group and both control groups, p ≤ 0.007. Sensitivity of intrathecal κ- and λ-FLC synthesis reached 78%-87% in LNB patients with a specificity of 94%-100% in NIC patients, whereas specificity in INDC patients was 69%. The corresponding frequencies of positive results for IF and index of IgM and CSF CXCL13 in these three diagnostic groups were 74%-96% in LNB patients, 0% in NIC patients and 3%-6% in INDC patients at the chosen cut-off levels. Conclusions The findings of this study show a moderate to high sensitivity of CSF κ- and λ-FLC in LNB patients with a high specificity in NIC patients. However, overlap in CSF κ- and λ-FLC levels between LNB and INDC patients calls for caution in the interpretation and limits the diagnostic usefulness in the LNB diagnosis. CSF CXCL13 appears to be the most valuable additional biomarker of LNB aside from routine parameters such as CSF pleocytosis and anti-Borrelia antibody index.
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Affiliation(s)
- Ivar Tjernberg
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry and Transfusion Medicine, Region Kalmar County, Kalmar, Sweden
| | - Marcus Johansson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Clinical Microbiology, Region Kalmar County, Kalmar, Sweden
| | - Anna J Henningsson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Clinical Microbiology, Region Jönköping County, Jönköping, Sweden.,Clinical Microbiology, Region Östergötland, Linköping, Sweden
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21
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Nonspecific Symptoms in Children Referred to a Lyme Borreliosis Center. Pediatr Infect Dis J 2020; 39:775-780. [PMID: 32379202 DOI: 10.1097/inf.0000000000002675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nonspecific symptoms in children suspected of Lyme borreliosis (LB) are challenging for clinicians. We assessed whether nonspecific symptoms are more prevalent among children with positive immunoglobulin G (IgG) serology or a history of clinical LB. METHODS We included children (<18 years) suspected of LB who visited the Lyme Center Apeldoorn of Gelre Hospital between 2008 and 2017. Serum samples were taken, and questionnaires on nonspecific symptoms completed. Clinical data were collected from patients' medical records. The prevalence of nonspecific symptoms was compared between patients with positive versus negative IgG serology and between patients with versus without previous LB with the χ and Fisher exact tests with Bonferroni correction. A history of LB was anamnestically determined. Patients with active Lyme manifestations were excluded. RESULTS Included were 149 children (66% female; median age 13 years); 29 (19%) had positive IgG serology; 36 (24%) had previous LB; 12 (8%) had both. Common nonspecific symptoms were sleep disturbances (58%), severe fatigue (57%) and headache (42%). The prevalence of nonspecific symptoms was similar in children with positive versus negative IgG serology. None of the nonspecific symptoms occurred more frequently in children with previous LB compared with children without. More prevalent in children without previous LB were sleep disturbances (40 vs. 66%; P = 0.002) and tingling (6 vs. 34%; P < 0.001). CONCLUSIONS Nonspecific symptoms were not more prevalent in children with positive IgG serology nor in children with previous LB, where some were significantly less prevalent. Hence, questionnaires on nonspecific symptoms cannot be used to identify children for serologic testing in Lyme centers.
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22
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A retrospective observational study of Lyme neuroborreliosis in the southwest of England. CLINICAL INFECTION IN PRACTICE 2020. [DOI: 10.1016/j.clinpr.2020.100017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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23
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Skogman BH, Lager M, Brudin L, Jenmalm MC, Tjernberg I, Henningsson AJ. Cytokines and chemokines in cerebrospinal fluid in relation to diagnosis, clinical presentation and recovery in children being evaluated for Lyme neuroborreliosis. Ticks Tick Borne Dis 2020; 11:101390. [DOI: 10.1016/j.ttbdis.2020.101390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/06/2019] [Accepted: 01/26/2020] [Indexed: 01/14/2023]
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24
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Barstad B, Henningsson AJ, Tveitnes D, Ushakova A, Noraas S, Ask IS, Bosse FJ, Øymar K. Cerebrospinal fluid cytokines and chemokines in children with Lyme neuroborreliosis; pattern and diagnostic utility. Cytokine 2020; 130:155023. [PMID: 32199247 DOI: 10.1016/j.cyto.2020.155023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 12/14/2019] [Accepted: 01/29/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) is characterized by cerebrospinal fluid (CSF) inflammation with several cytokines/chemokines and B-lymphocytes. Clinically, LNB in children may be difficult to discriminate from non-Lyme aseptic meningitis (NLAM). We aimed to identify CSF cytokine/chemokine patterns in children with LNB, NLAM and controls and elucidate the diagnostic value of these cytokines/chemokines alone or in combination to discriminate between LNB and NLAM. METHODS Children with symptoms suggestive of LNB were included prospectively and categorized as LNB, NLAM or controls (no pleocytosis). Cytokines/chemokines in CSF were measured by multiplex bead assays and levels were compared between the three groups by nonparametric statistical tests. Previous results from the same children on the established biomarker, CXCL13, were included in the statistical analyses. The diagnostic properties of cytokines/chemokines to discriminate between LNB and NLAM were determined by receiver operating characteristic curve analyses with estimates of area under curve (AUC). To explore diagnostic properties of combinations of cytokines/chemokines, prediction models based on logistic regression were used. RESULTS We included 195 children with LNB (n = 77), NLAM (n = 12) and controls (n = 106). Children with LNB had higher CSF levels of CCL19, CCL22 and CXCL13 compared to NLAM and controls, whereas INFγ was higher in NLAM than in LNB and controls. CXCL13 was the superior single cytokine/chemokine to discriminate LNB from NLAM (AUC 0.978). The combination CXCL13/CCL19 (AUC 0.992) may possibly improve the specificity for LNB, especially for children with moderate CXCL13 levels. CONCLUSIONS The intrathecal immune reaction in LNB is characterized by B cell associated chemokines. Whether the combination CXCL13/CCL19 further improves discrimination between LNB and NLAM beyond the diagnostic improvements by CXCL13 alone needs to be tested in new studies.
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Affiliation(s)
- Bjørn Barstad
- Department of Pediatric and Adolescent Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Anna J Henningsson
- Division of Clinical Microbiology, Laboratory Medicine, Jönköping Region Jönköping County, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Sweden; Division of Clinical Microbiology, Department of Clinical and Experimental Medicine, Linköping University Hospital, Linköping, Sweden.
| | - Dag Tveitnes
- Department of Pediatric and Adolescent Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Anastasia Ushakova
- Department of Research, Section of Biostatistics, Stavanger University Hospital, Stavanger, Norway.
| | - Sølvi Noraas
- Department of Medical Microbiology, Hospital of Southern Norway Trust, Kristiansand, Norway.
| | - Ingvild S Ask
- Department of Pediatric and Adolescent Medicine, Hospital of Southern Norway Trust, Kristiansand, Norway.
| | - Franziskus J Bosse
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Knut Øymar
- Department of Pediatric and Adolescent Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
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25
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Rauer S, Kastenbauer S, Hofmann H, Fingerle V, Huppertz HI, Hunfeld KP, Krause A, Ruf B, Dersch R. Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc03. [PMID: 32341686 PMCID: PMC7174852 DOI: 10.3205/000279] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 12/12/2022]
Abstract
Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis. This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults. Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany). The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.
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Affiliation(s)
| | | | | | - Volker Fingerle
- German Society for Hygiene and Microbiology (DGHM), Münster, Germany
| | - Hans-Iko Huppertz
- German Society of Paediatrics and Adolescent Medicine (DGKJ), Berlin, Germany.,German Society of Paediatric Infectology (DGPI), Berlin, Germany
| | - Klaus-Peter Hunfeld
- The German United Society of Clinical Chemistry and Laboratory Medicine (DGKL), Bonn, Germany.,INSTAND e.V., Düsseldorf, Germany
| | | | - Bernhard Ruf
- German Society of Infectious Diseases (DGI), Berlin, Germany
| | - Rick Dersch
- German Society of Neurology (DGN), Berlin, Germany.,Cochrane Germany, Faculty of Medicine, University of Freiburg, Germany
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26
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Abstract
BACKGROUND Lyme neuroborreliosis (NB) is a tick-borne infectious disorder of the nervous system caused by Borrelia burgdorferi spirochetes. There are not many data available regarding the differences in the course of NB in children and adults. The aim of our study was to compare the clinical course of NB between children and adults. METHODS Retrospective analysis of medical documentation of 181 patients with NB was performed. The patients were divided into 2 groups: Group I: 57 children with NB; Group II: 124 adults with NB. Medical data, such as patients' age, sex, place of living (residence), time from a tick bite, subjective complaints, general examination results, laboratory parameters and treatment were analyzed. RESULTS In children, the most common symptoms were headache (89.5%), neck stiffness (64.9%) and nausea and vomiting (56.1%). In adults, the most common symptoms were headache (77.4%), facial nerve palsy (59.7%), neck stiffness (59.7%), vertigo (41.9%) and lumbosacral region pain (37.1%). Bannwarth's syndrome was observed in 10.5% of children and 36.3% of adults. In cerebrospinal fluid (CSF) in children, the pleocytosis at admission was higher than in adults, but protein concentration was significantly lower. There were no differences in percentage of mononuclear cells in CSF smear between the groups. In CSF examination after treatment, a decrease in pleocytosis and protein concentration was observed in both groups. Analysis of effectiveness of treatment mostly with third generation cephalosporins (defined as complete recovery) between the groups, calculated by the Kaplan-Meier method and compared with the use of the log-rank test, showed no significant differences between children and adults (log-rank P = 0.619). CONCLUSIONS In children, NB more frequently presented as meningitis, and in adults in the form of Bannwarth's syndrome. CSF pleocytosis in children with NB was higher than in adults, while the protein concentration in children was lower. Outcomes in children and adults were favorable and did not differ after standard NB treatment.
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Appelgren D, Enocsson H, Skogman BH, Nordberg M, Perander L, Nyman D, Nyberg C, Knopf J, Muñoz LE, Sjöwall C, Sjöwall J. Neutrophil Extracellular Traps (NETs) in the Cerebrospinal Fluid Samples from Children and Adults with Central Nervous System Infections. Cells 2019; 9:cells9010043. [PMID: 31877982 PMCID: PMC7016761 DOI: 10.3390/cells9010043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/05/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023] Open
Abstract
Neutrophils operate as part of the innate defence in the skin and may eliminate the Borrelia spirochaete via phagocytosis, oxidative bursts, and hydrolytic enzymes. However, their importance in Lyme neuroborreliosis (LNB) is unclear. Neutrophil extracellular trap (NET) formation, which is associated with the production of reactive oxygen species, involves the extrusion of the neutrophil DNA to form traps that incapacitate bacteria and immobilise viruses. Meanwhile, NET formation has recently been studied in pneumococcal meningitis, the role of NETs in other central nervous system (CNS) infections has previously not been studied. Here, cerebrospinal fluid (CSF) samples from clinically well-characterised children (N = 111) and adults (N = 64) with LNB and other CNS infections were analysed for NETs (DNA/myeloperoxidase complexes) and elastase activity. NETs were detected more frequently in the children than the adults (p = 0.01). NET presence was associated with higher CSF levels of CXCL1 (p < 0.001), CXCL6 (p = 0.007), CXCL8 (p = 0.003), CXCL10 (p < 0.001), MMP-9 (p = 0.002), TNF (p = 0.02), IL-6 (p < 0.001), and IL-17A (p = 0.03). NETs were associated with fever (p = 0.002) and correlated with polynuclear pleocytosis (rs = 0.53, p < 0.0001). We show that neutrophil activation and active NET formation occur in the CSF samples of children and adults with CNS infections, mainly caused by Borrelia and neurotropic viruses. The role of NETs in the early phase of viral/bacterial CNS infections warrants further investigation.
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Affiliation(s)
- Daniel Appelgren
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden;
| | - Helena Enocsson
- Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, SE-581 85 Linköping, Sweden; (H.E.); (C.S.)
| | - Barbro H. Skogman
- Center for Clinical Research Dalarna-Uppsala University, Region Dalarna and Faculty of Medicine and Health Sciences, Örebro University, SE-702 81 Örebro, Sweden;
| | - Marika Nordberg
- Åland Central Hospital, Department of Infectious Diseases, AX-22 100 Mariehamn, Åland, Finland; (M.N.); (L.P.); (C.N.)
| | - Linda Perander
- Åland Central Hospital, Department of Infectious Diseases, AX-22 100 Mariehamn, Åland, Finland; (M.N.); (L.P.); (C.N.)
| | - Dag Nyman
- Bimelix AB, AX-22 100 Mariehamn, Åland, Finland;
| | - Clara Nyberg
- Åland Central Hospital, Department of Infectious Diseases, AX-22 100 Mariehamn, Åland, Finland; (M.N.); (L.P.); (C.N.)
| | - Jasmin Knopf
- Department of Internal Medicine 3-Rheumatology and Immunology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), DE-91 054 Erlangen, Germany; (J.K.); (L.E.M.)
| | - Luis E. Muñoz
- Department of Internal Medicine 3-Rheumatology and Immunology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), DE-91 054 Erlangen, Germany; (J.K.); (L.E.M.)
| | - Christopher Sjöwall
- Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, SE-581 85 Linköping, Sweden; (H.E.); (C.S.)
| | - Johanna Sjöwall
- Clinic of Infectious Diseases, Linköping University Hospital, SE-581 85 Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, SE-581 85 Linköping, Sweden
- Correspondence:
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Lyme Neuroborreliosis in Children: Etiology and Comparison of Clinical Findings of Lyme Neuroborreliosis Caused by Borrelia garinii and Borrelia afzelii. Pediatr Infect Dis J 2019; 38:e279-e284. [PMID: 31306350 DOI: 10.1097/inf.0000000000002415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Information on the etiology of Lyme neuroborreliosis (LNB) in children in Europe and the influence of Borrelia burgdorferi sensu lato species isolated from cerebrospinal fluid (CSF) on clinical presentation of LNB in children are limited. METHODS The study was monocentric. During its 17-year period, children younger than 15 years with presentation suggestive of LNB or confirmed Lyme borreliosis that had B. burgdorferi sensu lato isolated from CSF and had species of B. burgdorferi sensu lato identified by pulsed-field gel electrophoresis were included. Demographic and medical data were compared for children infected with Borrelia garinii to those infected with Borrelia afzelii. RESULTS One hundred and fifty-three children had B. burgdorferi sensu lato isolated from CSF. In 71/113 (62.8%) and 42/113 (37.2%) patients, B. garinii and B. afzelii, respectively, were identified. Patients infected with B. garinii did not report symptoms suggestive of central nervous system (CNS) involvement or any other symptoms more often than patients infected with B. afzelii. Compared with children infected with B. afzelii, children infected with B. garinii had erythema migrans less often (18.3% vs. 45.2%) but had positive meningeal signs (69.0% vs. 38.1%), CSF lymphocytic predominance (97.1% vs. 75.0%), and elevated albumin CSF/serum quotient (80.6% vs. 50.0%) more often. CONCLUSIONS In Slovenia, LNB in children is more often caused by B. garinii, followed by B. afzelii. The clinical picture of LNB in children caused by B. garinii is not more often suggestive of CNS involvement, but CNS inflammation is more pronounced in children infected with B. garinii, compared with children infected with B. afzelii.
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Barstad B, Tveitnes D, Dalen I, Noraas S, Ask IS, Bosse FJ, Øymar K. The B-lymphocyte chemokine CXCL13 in the cerebrospinal fluid of children with Lyme neuroborreliosis: associations with clinical and laboratory variables. Infect Dis (Lond) 2019; 51:856-863. [PMID: 31573360 DOI: 10.1080/23744235.2019.1671988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background: The B-lymphocyte chemokine CXCL13 is increasingly considered as a useful early phase diagnostic marker of Lyme neuroborreliosis (LNB). However, the large variation in level of CXCL13 in the cerebrospinal fluid (CSF) observed in LNB patients is still unexplained. We aimed to identify factors associated with the level of CXCL13 in children with LNB, possibly improving the interpretation of CXCL13 as a diagnostic marker of LNB. Methods: Children with confirmed and probable LNB were included in a prospective study on CXCL13 in CSF as a diagnostic marker of LNB. The variables age, sex, facial nerve palsy, generalized inflammation symptoms (fever, headache, neck-stiffness and/or fatigue), duration of symptoms, Borrelia antibodies in CSF, Borrelia antibody index (AI), CSF white blood cells (WBC), CSF protein and detection of the genospecies Borrelia garinii by PCR were included in simple and multivariable regression analyses to study the associations with the CXCL13 level. Results: We included 53 children with confirmed and 17 children with probable LNB. CXCL13 levels in CSF were positively associated with WBC, protein and Borrelia antibodies in CSF in both simple and multivariable analyses. We did not find any associations between CXCL13 and age, sex, clinical symptoms, duration of symptoms, AI or the detection of Borrelia garinii. Conclusions: High levels of CSF CXCL13 are present in the early phase of LNB and correlate with the level of CSF WBC and protein. Our results indicate that CSF CXCL13 in children evaluated for LNB can be interpreted independently of clinical features or duration of symptoms.
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Affiliation(s)
- Bjørn Barstad
- Department of Pediatric and Adolescent Medicine, Stavanger University Hospital , Stavanger , Norway.,Department of Clinical Science, University of Bergen , Bergen , Norway
| | - Dag Tveitnes
- Department of Pediatric and Adolescent Medicine, Stavanger University Hospital , Stavanger , Norway
| | - Ingvild Dalen
- Department of Research, Section of Biostatistics, Stavanger University Hospital , Stavanger , Norway
| | - Sølvi Noraas
- Department of Medical Microbiology, Hospital of Southern Norway Trust , Kristiansand , Norway
| | - Ingvild S Ask
- Department of Pediatric and Adolescent Medicine, Hospital of Southern Norway Trust , Kristiansand , Norway
| | - Franziskus J Bosse
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital , Bergen , Norway
| | - Knut Øymar
- Department of Pediatric and Adolescent Medicine, Stavanger University Hospital , Stavanger , Norway.,Department of Clinical Science, University of Bergen , Bergen , Norway
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Lager M, Dessau RB, Wilhelmsson P, Nyman D, Jensen GF, Matussek A, Lindgren PE, Henningsson AJ, Baqir H, Serrander L, Johansson M, Tjernberg I, Skarstein I, Ulvestad E, Grude N, Pedersen AB, Bredberg A, Veflingstad R, Wass L, Aleke J, Nordberg M, Nyberg C, Perander L, Bojesson C, Sjöberg E, Lorentzen ÅR, Eikeland R, Noraas S, Henriksson GA, Petrányi G. Serological diagnostics of Lyme borreliosis: comparison of assays in twelve clinical laboratories in Northern Europe. Eur J Clin Microbiol Infect Dis 2019; 38:1933-1945. [PMID: 31399914 PMCID: PMC6778534 DOI: 10.1007/s10096-019-03631-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/04/2019] [Indexed: 11/30/2022]
Abstract
Lyme borreliosis (LB), caused by spirochetes belonging to the Borrelia burgdorferi sensu lato complex, is the most common tick-borne infection in Europe. Laboratory diagnosis of LB is mainly based on the patients’ medical history, clinical signs and symptoms in combination with detection of Borrelia-specific antibodies where indirect enzyme-linked-immunosorbent assay (ELISA) is the most widely used technique. The objective of the study was to evaluate and compare the diagnostic accuracy (sensitivities and specificities) of serological tests that are currently in use for diagnosis of LB in clinical laboratories in Northern Europe, by use of a large serum panel. The panel consisted of 195 serum samples from well-characterized and classified patients under investigation for clinically suspected LB (n = 59) including patients with Lyme neuroborreliosis, Lyme arthritis, acrodermatitis chronica atrophicans, erythema migrans or other diseases (n = 112). A total of 201 serum samples from healthy blood donors were also included. The panel (396 serum samples altogether) was sent to 12 clinical laboratories (using five different ELISA methods) as blinded for group affiliation and the laboratories were asked to perform serological analysis according to their routine procedure. The results from the study demonstrated high diagnostic concordance between the laboratories using the same diagnostic assay and lower diagnostic concordance between laboratories using different diagnostic assays. For IgG, the results were in general rather homogenous and showed an average sensitivity of 88% (range 85–91%) compared to IgM which showed lower average sensitivity of 59% (range 50–67%) and more heterogeneous results between assays and laboratories.
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Affiliation(s)
- Malin Lager
- Division of Clinical Microbiology, Laboratory Medicine, Jönköping Region Jönköping County, Sweden and Department of Clinical and Experimental Medicine, Linköping University, Ryhov County Hospital, SE-551 85, Jönköping, Sweden. .,Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Peter Wilhelmsson
- Division of Clinical Microbiology, Laboratory Medicine, Jönköping Region Jönköping County, Sweden and Department of Clinical and Experimental Medicine, Linköping University, Ryhov County Hospital, SE-551 85, Jönköping, Sweden.,Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Dag Nyman
- The Åland Group for Borrelia Research, Åland, Mariehamn, Finland
| | - Guro F Jensen
- Department of Medical Microbiology, Sørlandet Hospital, Kristiansand, Norway
| | - Andreas Matussek
- Division of Clinical Microbiology, Laboratory Medicine, Jönköping Region Jönköping County, Sweden and Department of Clinical and Experimental Medicine, Linköping University, Ryhov County Hospital, SE-551 85, Jönköping, Sweden.,Karolinska University Laboratory, Stockholm, Sweden.,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Per-Eric Lindgren
- Division of Clinical Microbiology, Laboratory Medicine, Jönköping Region Jönköping County, Sweden and Department of Clinical and Experimental Medicine, Linköping University, Ryhov County Hospital, SE-551 85, Jönköping, Sweden.,Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Anna J Henningsson
- Division of Clinical Microbiology, Laboratory Medicine, Jönköping Region Jönköping County, Sweden and Department of Clinical and Experimental Medicine, Linköping University, Ryhov County Hospital, SE-551 85, Jönköping, Sweden.,Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Division of Clinical Microbiology, Department of Clinical and Experimental Medicine, Linköping University Hospital, Linköping, Sweden
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Lyme neuroborreliosis in children: Report of nine cases and a review of the literature. Arch Pediatr 2019; 26:133-137. [DOI: 10.1016/j.arcped.2019.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/07/2019] [Accepted: 02/09/2019] [Indexed: 11/19/2022]
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The chemokine CXCL13 in cerebrospinal fluid in children with Lyme neuroborreliosis. Eur J Clin Microbiol Infect Dis 2018; 37:1983-1991. [PMID: 30083887 PMCID: PMC6154094 DOI: 10.1007/s10096-018-3334-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/16/2018] [Indexed: 12/03/2022]
Abstract
Anti-Borrelia antibodies in the cerebrospinal fluid (CSF) are required for definite diagnosis of Lyme neuroborreliosis (LNB). However, children often present with early LNB, and antibody production in the CSF may not be demonstrated. Recent studies have suggested the chemokine CXCL13 to be an early marker for LNB. The aim of the study was to evaluate CXCL13 for laboratory diagnosis in pediatric LNB patients and to evaluate the association with pleocytosis in CSF, clinical features, and recovery. CSF samples were collected from LNB patients, classified as definite LNB (n = 44) or possible LNB (n = 22), and controls classified as non-LNB (n = 102) or other specific diagnoses (n = 23). CSF samples were analyzed with the recomBead CXCL13 assay (Mikrogen Diagnostik, Germany), cut-off 160 pg/mL. CXCL13 was significantly higher in LNB patients compared to controls (p < 0.001). Among LNB patients, 58/66 had elevated CXCL13, and among controls, 111/125 had CXCL13 levels under cut-off (sensitivity 88%, specificity 89%). In LNB patients with pleocytosis but no detectable anti-Borrelia antibodies in CSF (possible LNB), CXCL13 was elevated in 16/22 (73%). A weak correlation between CXCL13 and pleocytosis in CSF was found in LNB patients (Rho = 0.46, p < 0.01), but no differences in CXCL13 levels in relation to specific clinical features. In conclusion, CXCL13 is elevated in CSF in children with LNB, showing acceptable sensitivity and specificity. In patients with possible LNB, CXCL13 was elevated in a majority of cases (73%) and is suggested as a complementary diagnostic tool in pediatric LNB patients. CXCL13 was not associated with specific clinical features or recovery.
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Lyme Neuroborreliosis is a Severe and Frequent Neurological Disease in Mexico. Arch Med Res 2018; 49:399-404. [DOI: 10.1016/j.arcmed.2018.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/13/2018] [Accepted: 11/30/2018] [Indexed: 11/22/2022]
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Occurrence of erythema migrans in children with Lyme neuroborreliosis and the association with clinical characteristics and outcome - a prospective cohort study. BMC Pediatr 2018; 18:189. [PMID: 29890951 PMCID: PMC5996539 DOI: 10.1186/s12887-018-1163-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/01/2018] [Indexed: 12/18/2022] Open
Abstract
Background Erythema migrans (EM) is the most common manifestation of Lyme borreliosis (LB), caused by the spirochete Borrelia burgdorferi sensu lato. The infection can disseminate into the nervous system and cause Lyme neuroborreliosis (LNB), the second most frequent LB manifestation in children. The aim of this prospective cohort study is to describe the occurrence of EM among children with LNB and to evaluate possible differences in clinical characteristics or outcome between LNB patients with and without EM. Method Children being evaluated for LNB in southeast Sweden during the period 2010–2014 underwent a clinical examination, laboratory testing and filled out a questionnaire regarding duration and nature of symptoms, EM and the child’s health. Children were classified according to European guidelines for LNB. Clinical recovery was evaluated at a 2-month follow-up. Results The occurrence of EM among children with LNB was 37 out of 103 (36%). Gender, age, observed tick bite, clinical features, duration of neurological symptoms or clinical outcome did not differ significantly between LNB patients with or without EM. However, facial nerve palsy was significantly more common among children with EM in the head and neck area. Conclusion EM occurred in 36% of children with LNB and the location on the head and neck was more common among children with facial nerve palsy. EM was not associated with other specific clinical characteristics or outcome. Thus, the occurrence of EM in children with LNB cannot be useful as a prognostic factor for clinical outcome. This aspect has not previously been highlighted but seems to be relevant for the paediatrician in a clinical setting. Electronic supplementary material The online version of this article (10.1186/s12887-018-1163-2) contains supplementary material, which is available to authorized users.
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Direct Molecular Detection and Genotyping of Borrelia burgdorferi Sensu Lato in Cerebrospinal Fluid of Children with Lyme Neuroborreliosis. J Clin Microbiol 2018; 56:JCM.01868-17. [PMID: 29467195 DOI: 10.1128/jcm.01868-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/17/2018] [Indexed: 01/01/2023] Open
Abstract
The current diagnostic marker of Lyme neuroborreliosis (LNB), the Borrelia burgdorferisensu lato antibody index (AI) in the cerebrospinal fluid (CSF), has insufficient sensitivity in the early phase of LNB. We aimed to elucidate the diagnostic value of PCR for B. burgdorferisensu lato in CSF from children with symptoms suggestive of LNB and to explore B. burgdorferisensu lato genotypes associated with LNB in children. Children were prospectively included in predefined groups with a high or low likelihood of LNB based on diagnostic guidelines (LNB symptoms, CSF pleocytosis, and B. burgdorferisensu lato antibodies) or the detection of other causative agents. CSF samples were analyzed by two B. burgdorferisensu lato-specific real-time PCR assays and, if B. burgdorferisensu lato DNA was detected, were further analyzed by five singleplex real-time PCR assays for genotype determination. For children diagnosed as LNB patients (58 confirmed and 18 probable) (n = 76) or non-LNB controls (n = 28), the sensitivity and specificity of PCR for B. burgdorferisensu lato in CSF were 46% and 100%, respectively. B. burgdorferisensu lato DNA was detected in 26/58 (45%) children with AI-positive LNB and in 7/12 (58%) children with AI-negative LNB and symptoms of short duration. Among 36 children with detectable B. burgdorferisensu lato DNA, genotyping indicated Borrelia garinii (n = 27) and non-B. garinii (n = 1) genotypes, while 8 samples remained untyped. Children with LNB caused by B. garinii did not have a distinct clinical picture. The rate of detection of B. burgdorferisensu lato DNA in the CSF of children with LNB was higher than that reported previously. PCR for B. burgdorferisensu lato could be a useful supplemental diagnostic tool in unconfirmed LNB cases with symptoms of short duration. B. garinii was the predominant genotype in children with LNB.
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Cerebrospinal Fluid B-lymphocyte Chemoattractant CXCL13 in the Diagnosis of Acute Lyme Neuroborreliosis in Children. Pediatr Infect Dis J 2017; 36:e286-e292. [PMID: 28661964 DOI: 10.1097/inf.0000000000001669] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current markers of Lyme neuroborreliosis (LNB) in children have insufficient sensitivity in the early stage of disease. The B-lymphocyte chemoattractant CXCL13 in the cerebrospinal fluid (CSF) may be useful in diagnosing LNB, but its specificity has not been evaluated in studies including children with clinically relevant differential diagnoses. The aim of this study was to elucidate the diagnostic value of CSF CXCL13 in children with symptoms suggestive of LNB. METHODS Children with symptoms suggestive of LNB were included prospectively into predefined groups with a high or low likelihood of LNB based on CSF pleocytosis and the detection of Borrelia antibodies or other causative agents. CSF CXCL13 levels were compared between the groups, and receiver-operating characteristic analyses were performed to indicate optimal cutoff levels to discriminate LNB from non-LNB conditions. RESULTS Two hundred and ten children were included. Children with confirmed LNB (n=59) and probable LNB (n=18) had higher CSF CXCL13 levels than children with possible LNB (n=7), possible peripheral LNB (n=7), non-Lyme aseptic meningitis (n=12), non-meningitis (n=91) and negative controls (n=16). Using 18 pg/mL as a cutoff level, both the sensitivity and specificity of CSF CXCL13 for LNB (confirmed and probable) were 97%. Comparing only children with LNB and non-Lyme aseptic meningitis, the sensitivity and specificity with the same cutoff level were 97% and 83%, respectively. CONCLUSION CSF CXCL13 is a sensitive marker of LNB in children. The specificity to discriminate LNB from non-Lyme aseptic meningitis may be more moderate, suggesting that CSF CXCL13 should be used together with other variables in diagnosing LNB in children.
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Neuroborreliosis in Swedish Children: A Population-based Study on Incidence and Clinical Characteristics. Pediatr Infect Dis J 2017; 36:1052-1056. [PMID: 28654563 DOI: 10.1097/inf.0000000000001653] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Borrelia burgdorferi is a common cause of bacterial meningitis, but there are very few studies on incidence in Europe. The aim of this study was to report the incidence and symptoms of neuroborreliosis in Swedish children. METHODS Medical records of children (< 15 years) treated for neuroborreliosis 2002-2014 were studied retrospectively. The patients were identified in the computerized registers of discharge diagnoses at the Departments of Pediatrics and Infectious Diseases in Gothenburg, Borås, Trollhättan and Halmstad using International Classification of Diseases 10 diagnosis codes G51.0, G01.9 and/or A69.1. Of those, patients with symptoms compatible with neuroborreliosis and a white blood cell count in cerebrospinal fluid ≥ 7 cells/mm with ≥ 80% mononuclear cells were included. Only children living in the city of Gothenburg and 10 surrounding municipalities were included. RESULTS Five hundred forty-eight children were included. The median age was 7 (1-14) years. The total incidence for the 13-year-period was 2.8/10,000 and remained unchanged during the period. The incidence was significantly higher in rural (4.0/10,000) than in urban municipalities (2.1/10,000). The most common presenting symptoms were headache (n = 335), fatigue (n = 330) and cranial nerve palsies (n = 329). The median duration of symptoms before admittance was 4.0 days for facial palsy and 14.0 days for other symptoms (P < 0.001). The median white blood cell count in cerebrospinal fluid was 129 (7-1069) cells/mm. CONCLUSIONS This study is the largest so far in a pediatric population. The incidence of neuroborreliosis was higher than in previous European reports. This might be explained by increased Borrelia awareness, the distribution of tick population in Sweden, and the possibility that Swedish children more frequently play outdoors.
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Remy MM, Schöbi N, Kottanattu L, Pfister S, Duppenthaler A, Suter-Riniker F. Cerebrospinal fluid CXCL13 as a diagnostic marker of neuroborreliosis in children: a retrospective case-control study. J Neuroinflammation 2017; 14:173. [PMID: 28859668 PMCID: PMC5580331 DOI: 10.1186/s12974-017-0948-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023] Open
Abstract
Background Lyme neuroborreliosis (LNB) is a frequent manifestation of Lyme disease in children and its current diagnosis has limitations. The elevation of the chemokine CXCL13 in the cerebrospinal fluid (CSF) of adult patients with LNB has been demonstrated and suggested as a new diagnostic marker. Our aim was to evaluate this marker in the CSF of children with suspected LNB and to determine a CXCL13 cut-off concentration that would discriminate between LNB and other central nervous system (CNS) infections. Methods For this single-center retrospective case-control study we used a diagnostic-approved ELISA to measure CXCL13 concentrations in the CSF of 185 children with LNB suspicion at presentation. Patients were classified into definite LNB (cases), non-LNB (controls with other CNS affections), and possible LNB. A receiver-operating characteristic curve was generated by comparison of cases and controls. Results CXCL13 was significantly elevated in the CSF of 53 children with definite LNB (median 774.7 pg/ml) compared to 91 control patients (median 4.5 pg/ml, p < 0.001). A cut-off of 55 pg/ml resulted in a sensitivity of 96.7% and a specificity of 98.1% for the diagnosis of definite LNB and the test exhibited a diagnostic odds ratio of 1525.3. Elevated CSF CXCL13 levels were also detected in three controls with viral meningitis (enterovirus n = 1, varicella-zoster virus n = 2) while other CNS affections such as idiopathic facial palsy did not lead to CXCL13 elevation. Of the 41 patients with possible LNB, 27% had CXCL13 values above the cut-off of 55 pg/ml (median 16.7 pg/ml). Conclusions CSF CXCL13 is highly elevated in children during early LNB as previously shown in adults. CXCL13 is a highly sensitive and specific marker that helps to differentiate LNB from other CNS affections in children.
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Affiliation(s)
- M M Remy
- Institute of Infectious Diseases, University of Bern, Friedbühlstrasse 51, 3001, Bern, Switzerland.
| | - N Schöbi
- Department of Pediatrics, Bern University Hospital, University of Bern, Bern, Switzerland
| | - L Kottanattu
- Department of Pediatrics, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Pfister
- Institute of Infectious Diseases, University of Bern, Friedbühlstrasse 51, 3001, Bern, Switzerland
| | - A Duppenthaler
- Department of Pediatrics, Bern University Hospital, University of Bern, Bern, Switzerland
| | - F Suter-Riniker
- Institute of Infectious Diseases, University of Bern, Friedbühlstrasse 51, 3001, Bern, Switzerland
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Skogman BH, Lager M, Henningsson AJ, Tjernberg I. The recomBead Borrelia antibody index, CXCL13 and total IgM index for laboratory diagnosis of Lyme neuroborreliosis in children. Eur J Clin Microbiol Infect Dis 2017; 36:2221-2229. [PMID: 28730535 PMCID: PMC5653714 DOI: 10.1007/s10096-017-3049-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/18/2017] [Indexed: 11/26/2022]
Abstract
For laboratory diagnostics of Lyme neuroborreliosis (LNB), the recomBead Borrelia antibody index (AI) assay has shown promising results in a mixed age population, but has not previously been evaluated with specific focus on paediatric patients. The aim of the study was to evaluate the recomBead Borrelia AI assay in cerebrospinal fluid (CSF) for the laboratory diagnosis of LNB in children. We also wanted to explore whether early markers, such as CXCL13 in CSF and/or total IgM index could be useful as complementary diagnostic tools. Children being evaluated for LNB in a Swedish Lyme endemic area were included in the study (n = 146). Serum and CSF were collected on admission. Patients with other specific diagnoses were controls (n = 15). The recomBead Borrelia AI assay and the recomBead CXCL13 assay (Mikrogen) were applied together with total IgM index. The overall sensitivity for recomBead Borrelia AI (IgM and IgG together) was 74% and the specificity was 97%. However, the highest sensitivity (91%) at an acceptable level of specificity (90%) was obtained by recomBead Borrelia AI together with CXCL13 and total IgM index, showing a positive predictive value of 84% and a negative predictive value of 95%. Thus, the recomBead Borrelia AI assay performs with moderate sensitivity and high specificity in paediatric LNB patients. The major advantage seems to be increased sensitivity in the possible LNB group compared to the IDEIA assay. The diagnostic sensitivity may be further increased by using a combination of early markers, such as CXCL13 in CSF and total IgM index.
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Affiliation(s)
- B. H. Skogman
- Center for Clinical Research (CKF) Dalarna, Uppsala University, Nissers väg 3, 791 82 Falun, Sweden
| | - M. Lager
- Laboratory Medicine, Region Jönköping County, Jönköping, Sweden
| | | | - I. Tjernberg
- Department of Clinical Chemistry and Transfusion Medicine, Kalmar County Council, Kalmar, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Paydar-Darian N, Kimia AA, Lantos PM, Fine AM, Gordon CD, Gordon CR, Landschaft A, Nigrovic LE. Diagnostic Lumbar Puncture Among Children With Facial Palsy in a Lyme Disease Endemic Area. J Pediatric Infect Dis Soc 2017; 6:205-208. [PMID: 27422867 DOI: 10.1093/jpids/piw036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/01/2016] [Indexed: 11/13/2022]
Abstract
We identified 620 children with peripheral facial palsy of which 211 (34%) had Lyme disease. The 140 children who had a lumbar puncture performed were more likely to be hospitalized (73% LP performed vs 2% no LP) and to receive parenteral antibiotics (62% LP performed vs 6% no LP).
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Affiliation(s)
| | - Amir A Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | - Paul M Lantos
- Divisions of General Internal Medicine and Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, and
| | - Andrew M Fine
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | - Caroline D Gordon
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | - Catherine R Gordon
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | | | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
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Dersch R, Hottenrott T, Schmidt S, Sommer H, Huppertz HI, Rauer S, Meerpohl JJ. Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis in children: a systematic review. BMC Neurol 2016; 16:189. [PMID: 27686962 PMCID: PMC5043629 DOI: 10.1186/s12883-016-0708-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 09/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many aspects of pharmacological treatment of Lyme neuroborreliosis in children, such as choice of drug, dosage, and duration are subject to intense debates, leading to uncertainties in patients' parents and healthcare providers alike. To assess the available evidence for pharmacological treatment for children with Lyme neuroborreliosis we conducted a systematic review. METHODS The comprehensive systematic literature search included randomized-controlled trials (RCTs) and non-randomized studies (NRS) on treatment of Lyme neuroborreliosis in children (age <18 years). Our primary outcome was neurological symptoms after treatment. Risk of bias was assessed with the Cochrane risk of bias tools for RCTs and NRS. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Two RCTs and four NRS were eligible for inclusion. Risk of bias in RCTs and NRS was generally high. Reporting of studies was generally poor. Regarding the primary outcome neurological symptoms at 1-3 months, no statistically significant difference could be found in cohort studies between doxycycline and beta-lactam antibiotics. In two RCTs comparing penicillin G and ceftriaxone, no patient experienced residual neurological symptoms at the last reported time points. Quality of evidence according to GRADE was judged very low. CONCLUSIONS Data is scarce and with limited quality. Several issues could not be addressed due to scarcity of information. No eligible study compared different treatment durations. According to the available evidence, there seems to be no difference between different antibiotic agents for the treatment of Lyme neuroborreliosis in children regarding neurological symptoms. We found no evidence that supports extended antibiotic regimes. REVIEW REGISTRATION Systematic review registration: CRD42014008839 .
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Affiliation(s)
- Rick Dersch
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, D-79110 Freiburg im Breisgau, Germany
- Department of Neurology, Medical Center-University of Freiburg, Breisacher Str. 64, D-79106 Freiburg, Germany
| | - Tilman Hottenrott
- Department of Neurology, Medical Center-University of Freiburg, Breisacher Str. 64, D-79106 Freiburg, Germany
| | - Stefanie Schmidt
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, D-79110 Freiburg im Breisgau, Germany
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - Harriet Sommer
- Institute of Medical Biometry and Statistics, Medical Center-University of Freiburg, Stefan-Meier-Str- 26, D-79104 Freiburg, Germany
| | - Hans-Iko Huppertz
- Prof.-Hess-Kinderklinik, Klinikum Bremen-Mitte, Sankt-Jürgen-Str. 1, D-28177 Bremen, Germany
| | - Sebastian Rauer
- Department of Neurology, Medical Center-University of Freiburg, Breisacher Str. 64, D-79106 Freiburg, Germany
| | - Joerg J. Meerpohl
- Cochrane Germany, Medical Center-University of Freiburg, Berliner Allee 29, D-79110 Freiburg im Breisgau, Germany
- Centre de Recherche Épidémiologie et Statistique INSERM Sorbonne Paris, Cochrane France, Hôpital Hôtel-Dieu, 1 place du Parvis Notre Dame, 75181 Paris Cedex 04, France
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Skogman BH, Sjöwall J, Lindgren PE. The NeBoP score - a clinical prediction test for evaluation of children with Lyme Neuroborreliosis in Europe. BMC Pediatr 2015; 15:214. [PMID: 26678681 PMCID: PMC4682231 DOI: 10.1186/s12887-015-0537-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 12/12/2015] [Indexed: 11/25/2022] Open
Abstract
Background The diagnosis of Lyme neuroborreliosis (LNB) in Europe is based on clinical symptoms and laboratory data, such as pleocytosis and anti-Borrelia antibodies in serum and CSF according to guidelines. However, the decision to start antibiotic treatment on admission cannot be based on Borrelia serology since results are not available at the time of lumbar puncture. Therefore, an early prediction test would be useful in clinical practice. The aim of the study was to develop and evaluate a clinical prediction test for children with LNB in a relevant European setting. Method Clinical and laboratory data were collected retrospectively from a cohort of children being evaluated for LNB in Southeast Sweden. A clinical neuroborreliosis prediction test, the NeBoP score, was designed to differentiate between a high and a low risk of having LNB. The NeBoP score was then prospectively validated in a cohort of children being evaluated for LNB in Central and Southeast Sweden (n = 190) and controls with other specific diagnoses (n = 49). Results The sensitivity of the NeBoP score was 90 % (CI 95 %; 82–99 %) and the specificity was 90 % (CI 95 %; 85–96 %). Thus, the diagnostic accuracy (i.e. how the test correctly discriminates patients from controls) was 90 % and the area under the curve in a ROC analysis was 0.95. The positive predictive value (PPV) was 0.83 (CI 95 %; 0.75–0.93) and the negative predictive value (NPV) was 0.95 (CI 95 %; 0.90–0.99). Conclusion The overall diagnostic performance of the NeBoP score is high (90 %) and the test is suggested to be useful for decision-making about early antibiotic treatment in children being evaluated for LNB in European Lyme endemic areas. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0537-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Barbro H Skogman
- Paediatric clinic, Falun General Hospital, Nissers väg 3, S-791 82, Falun, Sweden. .,Center for Clinical Research (CKF) Dalarna-Uppsala University, S-791 31, Falun, Sweden.
| | - Johanna Sjöwall
- Clinic of Infectious Diseases, Linköping University Hospital, S-581 85, Linköping, Sweden.
| | - Per-Eric Lindgren
- Department of Clinical and Experimental Medicine, Medical Microbiology, Linköping University, S-581 85, Linköping, Sweden. .,Microbiological Laboratory, Medical Services, County Hospital Ryhov, S-551 85, Jönköping, Sweden.
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Tveitnes D, Øymar K. Gender Differences in Childhood Lyme Neuroborreliosis. Behav Neurol 2015; 2015:790762. [PMID: 26576072 PMCID: PMC4630376 DOI: 10.1155/2015/790762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/01/2015] [Accepted: 10/04/2015] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Many neurological diseases show differences between genders. We studied gender differences in childhood Lyme neuroborreliosis (LNB) in an endemic area of Lyme borreliosis in Norway. METHODS In a population based study, all children (<14 years of age) with symptoms suspicious of LNB, including all children with acute facial nerve palsy, were evaluated for LNB by medical history, clinical examination, blood tests, and lumbar puncture. LNB was diagnosed according to international criteria. RESULTS 142 children were diagnosed with LNB during 2001-2009. Facial nerve palsy was more common in girls (86%) than in boys (62%) (p < 0.001), but headache and/or neck stiffness as the only symptom was more common in boys (30%) than in girls (10%) (p = 0.003). The girls were younger than boys and had a shorter duration of symptoms, but boys had a higher level of pleocytosis than girls. In a multivariate analysis, both gender and having headache and neck stiffness were associated with a higher level of pleocytosis. CONCLUSION Girls and boys have different clinical presentations of LNB, and boys have a higher level of inflammation than girls independent of the clinical presentation.
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Affiliation(s)
- Dag Tveitnes
- Department of Pediatrics, Stavanger University Hospital, Gerd Ragna Bloch Thorsens Gate 8, 4011 Stavanger, Norway
| | - Knut Øymar
- Department of Pediatrics, Stavanger University Hospital, Gerd Ragna Bloch Thorsens Gate 8, 4011 Stavanger, Norway
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
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Dersch R, Sarnes AA, Maul M, Hottenrott T, Baumgartner A, Rauer S, Stich O. Quality of life, fatigue, depression and cognitive impairment in Lyme neuroborreliosis. J Neurol 2015; 262:2572-7. [DOI: 10.1007/s00415-015-7891-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/26/2015] [Accepted: 08/27/2015] [Indexed: 11/28/2022]
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Schmidt H, Djukic M, Jung K, Holzgraefe M, Dechent P, von Steinbüchel N, Blocher J, Eiffert H, Schmidt-Samoa C. Neurocognitive functions and brain atrophy after proven neuroborreliosis: a case-control study. BMC Neurol 2015; 15:139. [PMID: 26286440 PMCID: PMC4545711 DOI: 10.1186/s12883-015-0386-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 07/17/2015] [Indexed: 12/05/2022] Open
Abstract
Background Patients often report neurocognitive difficulties after neuroborreliosis (NB). The frequency and extent of cognitive problems in European patients have been studied incompletely. Methods Sixty patients received a neurological and neuropsychological work-up 6 months or longer after treatment for proven NB. Quality of life, psychiatric symptom load, and brain atrophy were measured. All results were compared with a group of 30 healthy control persons adapted for age, gender and education being serologically negative for Borrelia burgdorferi senso latu. A cognitive sum score and a global sum score including cognitive, psychological results and quality of life data was calculated for both groups. Results Patients after NB showed a lower (i.e. more impaired) score on the Scripps Neurological rating scale (SNRS), but the observed neurological deficits were generally mild (mean ± SD: 97.1 ± 4.7 vs. 99.1 ± 2.4, p = 0.02). The mean neuropsychological domain results of the NB group were all within the normal range. However, a lower performance was found for the frontal executive function z-values (mean ± SD –0.29 ± 0.60 vs. 0.09 ± 0.60; p = 0.0059) of NB patients. Comparing the global sum score (mean ± SD 11.3 ± 4.2 NB vs. 14.3 ± 2.9 control, p = 0.001) and the cognitive sum score of the NB group with those of the control group (mean ± SD -0.15 ± 0.42 NB vs. 0.08 ± 0.31 control, p = 0.0079), both differences were statistically different. The frequencies of impaired global sum scores and those of the pathological cognitive sum scores (p = 0.07) did not differ statistically. No significant differences were found for health-related quality of life (hrQoL), sleep, psychiatric symptom load, or brain atrophy. Conclusion The mean cognitive functions of patients after proven NB were in the normal range. However, we were able to demonstrate a lower performance for the domain of frontal executive functions, for the mean cognitive sum score and the global sum score as a sign of subtle but measurable sequelae of neuroborreliosis. Brain atrophy is not a common consequence of neuroborreliosis.
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Affiliation(s)
- Holger Schmidt
- University Medical Centre Göttingen, Department of Neurology, Robert-Koch-Str. 40, Göttingen, 37075, Germany. .,Elbe Kliniken Stade-Buxtehude, Department of Neurology, Bremervörder Str. 111, Stade, 21682, Germany.
| | - Marija Djukic
- Ev. Hospital Göttingen-Weende, Department of Geriatrics, An der Lutter 24, Göttingen, 37075, Germany. .,University Medical Centre Göttingen, Department of Neuropathology, Robert-Koch-Str. 40, Göttingen, 37075, Germany.
| | - Klaus Jung
- University Medical Centre Göttingen, Department of Medical Statistics, Humboldtallee 32, Göttingen, 37073, Germany.
| | - Manfred Holzgraefe
- Asklepios Schildautal-Hospital Seesen, Department of Neurological Rehabilitation, Karl-Herold-Str. 1, Seesen/Harz, 38723, Germany.
| | - Peter Dechent
- University Medical Centre Göttingen, Department of Cognitive Neurology, Robert-Koch-Str. 40, Göttingen, 37075, Germany.
| | - Nicole von Steinbüchel
- University Medical Centre Göttingen, Department of Medical Psychology and Medical Sociology, Waldweg 37, Göttingen, 37073, Germany.
| | - Joachim Blocher
- University Medical Centre Göttingen, Department of Neurology, Robert-Koch-Str. 40, Göttingen, 37075, Germany.
| | - Helmut Eiffert
- University Medical Centre Göttingen, Department of Medical Microbiology, Kreuzbergring 57, Göttingen, 37075, Germany.
| | - Carsten Schmidt-Samoa
- University Medical Centre Göttingen, Department of Neurology, Robert-Koch-Str. 40, Göttingen, 37075, Germany. .,University Medical Centre Göttingen, Department of Cognitive Neurology, Robert-Koch-Str. 40, Göttingen, 37075, Germany.
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Abstract
Lyme disease, caused by the Borrelia burgdorferi bacterium, is the most common vector-borne disease in the northern hemisphere. The clinical presentation varies with disease stage, and neurological manifestations (often referred to as Lyme neuroborreliosis) are reported in up to 12% of patients with Lyme disease. Most aspects of the epidemiology, clinical manifestation and treatment of Lyme neuroborreliosis are well known and accepted; only the management of so-called chronic Lyme disease is surrounded by considerable controversy. This term is used for disparate patient groups, including those who have untreated late-stage infection (for example, late neuroborreliosis), those with subjective symptoms that persist after treatment (termed 'post-treatment Lyme disease syndrome' [PTLDS]), and those with unexplained subjective complaints that may or may not be accompanied by positive test results for B. burgdorferi infection in serum (here called 'chronic Lyme disease'). The incidence of PTLDS is still a matter of debate, and its pathogenesis is unclear, but there is evidence that these patients do not have ongoing B. burgdorferi infection and, thus, do not benefit from additional antibiotic therapy. Chronic Lyme disease lacks an accepted clinical definition, and most patients who receive this diagnosis have other illnesses. Thus, a careful diagnostic work-up is needed to ensure proper treatment.
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Affiliation(s)
- Uwe Koedel
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
| | - Volker Fingerle
- Bavarian Health and Food Safety Authority &German National Reference Centre for Borrelia, Veterinärstrasse 2, 85764 Oberschleissheim, Germany
| | - Hans-Walter Pfister
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
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Mukkada S, Buckingham SC. Recognition of and Prompt Treatment for Tick-Borne Infections in Children. Infect Dis Clin North Am 2015; 29:539-55. [PMID: 26188606 DOI: 10.1016/j.idc.2015.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Tick-borne infections create diagnostic challenges because they tend to present with nonspecific findings. Because clinicians often fail to recognize tick-borne illnesses in early stages, therapy is frequently delayed or omitted. This is especially problematic for rickettsial infections (Rocky Mountain spotted fever, ehrlichiosis, and anaplasmosis), because the risk of long-term morbidity and mortality increases with delayed treatment. We emphasize the need for clinicians to maintain a high index of suspicion for tick-borne infections; to diagnose these illnesses presumptively, without waiting for confirmatory laboratory test results; and to promptly start therapy with doxycycline, even in young children, when rickettsial infections are suspected.
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Affiliation(s)
- Sheena Mukkada
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee College of Medicine, 50 North Dunlap Street, Memphis, TN 38103, USA; Department of Infectious Diseases, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Steven C Buckingham
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee College of Medicine, 50 North Dunlap Street, Memphis, TN 38103, USA.
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Buckingham SC. Tick-borne diseases of the USA: Ten things clinicians should know. J Infect 2015; 71 Suppl 1:S88-96. [DOI: 10.1016/j.jinf.2015.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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Correll MH, Datta N, Arvidsson HSS, Melsom HA, Thielberg AK, Bjerager M, Brodsky MC, Saunte JP. Lyme neuroborreliosis: a treatable cause of acute ocular motor disturbances in children. Br J Ophthalmol 2015; 99:1401-4. [PMID: 25868792 DOI: 10.1136/bjophthalmol-2015-306855] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/20/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) designates central nervous system involvement caused by the tick-borne spirochaete Borrelia burgdorferi (Bb). The present study describes a spectrum of acquired ocular motor disorders in children with LNB. METHODS Six paediatric patients (age 3-15 years) with ocular motor symptoms as first manifestations of LNB evaluated by a paediatrician and ophthalmologist are presented. Diagnosis was based on new onset ocular motor disturbances and detection of cerebrospinal fluid (CSF) pleocytosis and intrathecal synthesis of Bb IgM and/or IgG antibodies by lumbar puncture. The children were evaluated before and after antibiotic treatment with a follow-up time of 1-7 months. Videos were obtained both pre and post treatment in four patients. RESULTS Two children presented with acquired nystagmus, one with combined nystagmus and partial sixth nerve palsy, one with partial sixth nerve palsy, one with ptosis and one with Adie's pupil. Five of the patients presented with severe fatigue, malaise, nausea, headache and fever. Four had recognised a tick bite recently, and two developed erythema migrans. Intrathecal synthesis of IgM and/or IgG antibodies specific for Bb was positive in all children, and five showed CSF pleocytosis. Cerebral MRI or CT of the brain were normal. Treatment with intravenous or oral antibiotics produced rapid clinical improvement in five of the six children. CONCLUSIONS LNB can present as acute ocular motor disorders in conjunction with fatigue and other clinical manifestations. In endemic areas, children with unexplained, acquired ocular motor abnormalities should be evaluated for LNB, a treatable medical condition.
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Affiliation(s)
- M H Correll
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark Department of Ophthalmology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - N Datta
- Department of Ophthalmology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - H S S Arvidsson
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - H A Melsom
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - A K Thielberg
- Department of Pediatrics, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - M Bjerager
- Department of Pediatrics, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - M C Brodsky
- Departments of Ophthalmology and Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - J P Saunte
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark Department of Ophthalmology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
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Lyme disease: A rigorous review of diagnostic criteria and treatment. J Autoimmun 2015; 57:82-115. [DOI: 10.1016/j.jaut.2014.09.004] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 01/07/2023]
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