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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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Mah JM, Lo C, O'Connor MD. Isolated Intracranial Hypertension as a Presentation of Pediatric Lyme Borreliosis: A Case Report and Literature Review. Pediatr Neurol 2024; 152:196-199. [PMID: 38301323 DOI: 10.1016/j.pediatrneurol.2023.12.025] [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] [Received: 07/25/2023] [Revised: 12/10/2023] [Accepted: 12/28/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND It is extremely rare for Lyme borreliosis to present solely with features of increased intracranial pressure. The treatment of pediatric Lyme neuroborreliosis with oral versus intravenous antibiotics remains controversial. METHODS Case report and literature review. RESULTS A 13-year-old male presented with five days of binocular diplopia, several weeks of headache, and a history of multiple tick bites six weeks prior. His examination showed a left eye abduction deficit and bilateral optic disc edema. Magnetic resonance imaging (MRI) of the brain with contrast showed tortuosity of the optic nerves, prominence of the optic nerve sheaths, and enhancement of the left fifth and bilateral sixth cranial nerves. Lumbar puncture showed an elevated opening pressure and a lymphocytic pleocytosis. Lyme IgM and IgG antibodies were positive in the serum and cerebrospinal fluid. The patient was treated with intravenous ceftriaxone for two days empirically followed by doxycycline by mouth for 19 days. Symptoms began improving after 48 hours. The strabismus resolved after two weeks, and the papilledema improved slowly with complete resolution at six months. CONCLUSIONS Lyme neuroborreliosis can present as isolated intracranial hypertension in the pediatric population; it can be differentiated from idiopathic intracranial hypertension on MRI, and lumbar puncture and can be confirmed with serum antibody testing. Oral doxycycline can be considered for Lyme neuroborreliosis in children.
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Affiliation(s)
- Jeffrey M Mah
- Department of Ophthalmology, University of Ottawa, Roger Guindon Hall, Ottawa, Ontario.
| | - Cody Lo
- Department of Ophthalmology, University of Ottawa, Roger Guindon Hall, Ottawa, Ontario
| | - Michael D O'Connor
- Department of Ophthalmology, University of Ottawa, Roger Guindon Hall, Ottawa, Ontario
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Dersch R, Rauer S. Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis: An updated systematic review. Eur J Neurol 2023; 30:3780-3788. [PMID: 37565386 DOI: 10.1111/ene.16034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Evidence-based recommendations for treatment of Lyme neuroborreliosis (LNB) should rely on the available literature. As new data emerges, close review and evaluation of the recent literature is needed to build evidence-based recommendations to inform clinical practice and management of LNB. We performed an update of a previous systematic review on treatment of LNB. METHODS A systematic literature search of Medline and CENTRAL was performed for published studies from 2015 to 2023 to update a previous systematic review. Randomized controlled trials (RCTs) and non-randomized studies (NRS) were evaluated. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs; NRS were assessed using the ROBINS-I-tool. Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data were integrated into an existing meta-analysis of the available literature. RESULTS After screening 1530 records, two RCTs and five NRS with new and relevant data were additionally identified. Meta-analysis showed no statistically significant difference between doxycycline and beta-lactam antibiotics regarding residual neurological symptoms after 12 months. Meta-analysis showed no benefit of extended antibiotic treatment of LNB. Three NRS show no benefit for additional steroid use in LNB with facial palsy. DISCUSSION Additional incorporated recent research corroborates existing guideline recommendations for treatment of LNB. New RCTs add to the certainty of previous analysis showing similar efficacy for doxycycline and beta-lactam antibiotics in LNB. Available evidence shows no benefit for extended antibiotic treatment in LNB. NRS do not suggest a role for steroids in facial palsy due to LNB.
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Affiliation(s)
- Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Rauer
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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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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