Characterization of Lyme meningitis and comparison with viral meningitis in children

Lyme Disease and Papilledema: A Retrospective Study on Clinical Characteristics and Outcomes

OBJECTIVE

Describe the clinical characteristics, treatment strategies, and outcome data of children with papilledema associated with Lyme disease at a large tertiary care pediatric hospital.

METHODS

Retrospective cohort study of children 1-18 years old who received care at our institution between 1995 and 2019 with concurrent diagnoses of papilledema and Lyme disease. Data were abstracted from records and prospective family surveys.

RESULTS

Among 44 children included (median age 9.7 years), 66% (29/44) had additional cranial neuropathies, and 78% (32/41) had cerebrospinal fluid pleocytosis. All children were treated with antibiotics (39% oral, 55% intravenous, 7% both); 61% (27/44) were also treated with oral acetazolamide. Symptoms fully resolved in 86% (30/35) of children with follow-up data. Proportion recovered did not significantly differ by antibiotic administration route or presence/absence of cerebrospinal fluid pleocytosis.

CONCLUSIONS

Papilledema in Lyme disease may occur with or without cerebrospinal fluid pleocytosis. Most children recover without residual deficits following treatment, although exceptions exist.

Seroprevalence of Lyme Disease in Children With Facial Nerve Palsy

This retrospective chart review examined children with documented Lyme disease serology in New Jersey aged <21 years presenting with facial nerve palsy. The presence of symptoms including tick bite, fever, headache, and arthritis was recorded. Data were categorized based on demographic factors, and multivariate regression was employed. We enrolled 122 children, 54% female (mean age of 11.4 ± 5.1 years); 22.1% had Lyme disease. Fever was a significant predictor of Lyme disease (P = .01), confirmed by multivariate regression (odds ratio [OR] = 16.11, 95% confidence interval [CI] = 2.04, 366.14), as was male gender (P = .01, OR = 3.68, 95% CI = 1.21, 12.89). This association held especially true in Lyme-endemic regions (prevalence ≥ 0.35). The combination of headache with fever was also significantly predictive (P = .01). We found no significant predictive value in the remaining symptoms. These findings suggest that clinical predictors may be useful in diagnosing Lyme disease and initiating early empiric treatment.

Cranial nerve involvement, visual complications and headache syndromes in Lyme disease

PURPOSE OF REVIEW

To provide a summary of the visual manifestations and cranial neuropathies seen in Lyme disease.

RECENT FINDINGS

Lyme facial palsy remains the most common manifestation of Lyme neuroborreliosis. Recent investigations show likely evidence of vagal involvement in Lyme disease.

SUMMARY

The literature on Lyme neuroborreliosis continues to evolve. Lyme disease can affect nearly any cranial nerve in addition to causing various headache syndromes. The most common manifestation is Lyme disease facial palsy, occurring in up to 5-10% of patients with documented Lyme disease. Headache syndromes are common in the context of facial palsy but can occur in isolation, and more specific headache syndromes including trigeminal and geniculate neuralgias can occur rarely. Signs and symptoms indicative of vestibulocochlear nerve involvement are relatively common, although it could be that these represent other vestibular involvement rather than a specific cranial neuropathy. Optic neuritis is a controversial entity within Lyme disease and is likely overdiagnosed, but convincing cases do exist. Physicians who see any cranial neuropathy, including optic neuritis, in an endemic area can consider Lyme disease as a possible cause.

Lyme Disease in Children

Lyme disease is now the most frequently reported vector-borne disease in the United States. The highest incidence is in children aged 5 to 9 years with a male predominance. The most common manifestation, erythema migrans, is sometimes not recognized, leading to risk of complications. Testing for Lyme disease should only be done if there is a consistent clinical syndrome with exposure in a Lyme-endemic area. Most forms of Lyme disease are successfully treated with short courses of oral therapy. Prevention and management of tick bites is important.

Early Disseminated Lyme Disease: Cranial Neuropathy, Meningitis, and Polyradiculopathy

Early disseminated Lyme disease can involve the peripheral or central nervous system, but with early diagnosis and treatment, prognosis for full recovery is excellent. The typical clinical presentations of neuroborreliosis are highlighted, and an approach to diagnosis and treatment is described.

Papilledema Secondary to Neurologic Lyme Borreliosis: A Meta-Case Series

BACKGROUND

Papilledema can be a manifestation of neurologic Lyme borreliosis (LB). The clinical manifestations and progression of these cases have not been comprehensively documented to date. We aimed to describe clinical and diagnostic features and to assess patient outcomes in cases of papilledema secondary to neurologic LB.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Database from inception to August 2019. We did not restrict our search by study design or by publication date, status, or language.

RESULTS

Twenty-eight studies describing 46 cases of papilledema secondary to neurologic LB were included. Common clinical features included cranial neuropathy (68%) and diplopia (61%). Most patients did not recall tick bite (71%) and were afebrile (74%). Brain imaging was normal in 64% cases. Cerebrospinal fluid analysis showed lymphocytic pleocytosis (77%). Initial treatment with intravenous ceftriaxone was given in 52% of cases and resulted in a 100% resolution rate. Concomitant treatment with acetazolamide resulted in favorable outcomes.

CONCLUSIONS

For patients in endemic regions who describe symptoms suggestive of intracranial hypertension and papilledema, especially accompanied by facial nerve palsy and other cranial nerve palsies, underlying neurologic LB should be considered.

Papilledema as the Sole Manifestation of Neuroborreliosis

Lyme disease is reportable, and approximately 30,000 cases/year are notified to the local and state health departments. However, other estimates based on insurance records suggest there are close to 476,000 cases/year that are diagnosed and treated. In addition to a large burden of illness, areas where Lyme disease is common are expanding. Therefore, clinicians should be aware of uncommon presentations of this condition. We describe the case of a 5-year-old girl who presented with papilledema as an isolated manifestation of Lyme disease. Of note, her ocular symptoms were intermittent and worse when tired. In endemic areas, Lyme disease must be considered in the differential diagnosis for patients presenting with isolated ophthalmic findings even outside the usual Lyme season.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

Tick-Borne-Associated Illnesses in the Pediatric Intensive Care Unit

When unrecognized and antibiotic delay occurs, Lyme disease, Rocky Mountain–spotted fever, babesiosis, and human ehrlichiosis and anaplasmosis can result in multiorgan system dysfunction and potentially death. This review focuses on the early recognition, evaluation, and stabilization of the rare life-threatening sequelae seen in tick-borne illnesses that require admission in the pediatric intensive care unit.

Insights From the Geographic Spread of the Lyme Disease Epidemic

Background

Lyme disease is the most common reportable zoonotic infection in the United States. Recent data suggest spread of the Ixodes tick vector and increasing incidence of Lyme disease in several states, including Pennsylvania. We sought to determine the clinical presentation and healthcare use patterns for pediatric Lyme disease in western Pennsylvania.

Methods

The electronic medical records of all patients with an International Classification of Disease, Ninth Revision, diagnosis of Lyme disease between 2003 and 2013 at Children's Hospital of Pittsburgh were individually reviewed to identify confirmed cases of Lyme disease. The records of 773 patients meeting these criteria were retrospectively analyzed for patient demographics, disease manifestations, and healthcare use.

Results

An Lyme disease increased exponentially in the pediatric population of western Pennsylvania. There was a southwestward migration of Lyme disease cases, with a shift from rural to nonrural zip codes. Healthcare provider involvement evolved from subspecialists to primary care pediatricians and emergency departments (EDs). Patients from nonrural zip codes more commonly presented to the ED, while patients from rural zip codes used primary care pediatricians and EDs equally.

Conclusions

The current study details the conversion of western Pennsylvania from a Lyme-naive to a Lyme-epidemic area, highlighting changes in clinical presentation and healthcare use over time. Presenting symptoms and provider type differed between those from rural and nonrural zip codes. By elucidating the temporospatial epidemiology and healthcare use for pediatric Lyme disease, the current study may inform public health measures regionally while serving as an archetype for other areas at-risk for Lyme disease epidemics.

Oral Management for Pediatric Lyme Meningitis

BACKGROUND

Guidelines for pediatric Lyme meningitis recommend treatment with parenteral therapy [1, 2]. Adult studies suggest that Lyme meningitis can be successfully treated with oral therapy. Our objective was to evaluate the clinical response, side effects and outcome of oral therapy for Lyme meningitis in the pediatric population compared with parenteral therapy in an area endemic for Lyme disease.

METHODS

We conducted a case series chart review from January 2012 to May 2017 of pediatrics patient diagnosed and treated for Lyme meningitis. We recorded clinical presentation, laboratory values, antimicrobial therapy and follow up after therapy to compare the efficacy of oral versus parenteral route of therapy.

RESULTS

We identified 38 patients diagnosed with Lyme meningitis. Thirty-two patients were discharge with exclusively oral therapy with: doxycycline and amoxicillin. We had only 2 patients developed potential adverse effects from oral doxycycline therapy. All patients treated with oral antibiotics had resolution of symptoms on follow up appointments.

CONCLUSIONS

Oral therapy for Lyme meningitis yields no serious adverse events, was well tolerated and showed resolution of symptoms.

Symptom Resolution in Pediatric Patients With Lyme Disease

We performed a retrospective study to determine the time frame for symptom resolution in 78 pediatric patients hospitalized with laboratory-confirmed early-disseminated or late-stage Lyme disease. The vast majority of the patients improved promptly after receiving appropriate antibiotics. Patients with a longer duration of arthritis before the institution of therapy experienced a longer time to recovery.

The NeBoP score - a clinical prediction test for evaluation of children with Lyme Neuroborreliosis in Europe

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.

Peripheral nervous system manifestations of infectious diseases

Infectious causes of peripheral nervous system (PNS) disease are underrecognized but potentially treatable. Heightened awareness educed by advanced understanding of the presentations and management of these infections can aid diagnosis and facilitate treatment. In this review, we discuss the clinical manifestations, diagnosis, and treatment of common bacterial, viral, and parasitic infections that affect the PNS. We additionally detail PNS side effects of some frequently used antimicrobial agents.

Lyme disease: clinical diagnosis and treatment

Background

Lyme disease is an emerging zoonotic infection in Canada. As the Ixodes tick expands its range, more Canadians will be exposed to Borrelia burgdorferi, the bacterium that causes Lyme disease.

Objective

To review the clinical diagnosis and treatment of Lyme disease for front-line clinicians.

Methods

A literature search using PubMed and restricted to articles published in English between 1977 and 2014.

Results

Individuals in Lyme-endemic areas are at greatest risk, but not all tick bites transmit Lyme disease. The diagnosis is predominantly clinical. Patients with Lyme disease may present with early disease that is characterized by a "bull's eye rash", fever and myalgias or with early disseminated disease that can manifest with arthralgias, cardiac conduction abnormalities or neurologic symptoms. Late Lyme disease in North America typically manifests with oligoarticular arthritis but can present with a subacute encephalopathy. Antibiotic treatment is effective against Lyme disease and works best when given early in the infection. Prophylaxis with doxycyline may be indicated in certain circumstances. While a minority of patients may have persistent symptoms, evidence does not demonstrate that prolonged courses of antibiotics improve outcome.

Conclusion

Clinicians need to be aware of the signs and symptoms of Lyme disease. Knowing the regions where Borrelia infection is endemic in North America is important for recognizing patients at risk and informing the need for treatment.

Enteroviral testing and length of hospital stay for children evaluated for lyme meningitis

BACKGROUND

In Lyme disease-endemic areas, many children with aseptic meningitis are hospitalized while awaiting Lyme serology results. Although Lyme serology takes several days, an enteroviral polymerase chain reaction (EV PCR) test takes only a few hours to return results.

OBJECTIVE

Our aim was to measure the impact of EV PCR testing on duration of stay for children evaluated for Lyme meningitis.

METHODS

A retrospective cohort study was performed with children evaluated for Lyme meningitis at 3 Emergency Departments located in Lyme disease-endemic areas. We defined Lyme meningitis using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans rash). The duration of stay was compared by EV PCR test result (positive, negative, and not obtained).

RESULTS

There were 423 study patients identified, 117 (28%) of whom had Lyme meningitis and 209 (49%) had an EV PCR test performed. Median length of stay varied by the EV PCR test status: children with a positive EV PCR test (n = 103; 28 h; interquartile range 17-48 h), those with a negative EV PCR test (n = 106; 72 h; interquartile range 48-120 h), and those who did not have an EV PCR test obtained (n = 214; 48 h; interquartile range 24-96 h; p ≤ 0.001).

CONCLUSIONS

Rapid EV PCR testing could assist clinical decision making by Emergency Physicians, avoiding potentially unnecessary hospitalization and parenteral antibiotics for children at low risk of Lyme meningitis.

Validation of a clinical prediction rule to distinguish Lyme meningitis from aseptic meningitis

OBJECTIVES

The "Rule of 7's," a Lyme meningitis clinical prediction rule, classifies children at low risk for Lyme meningitis when each of the following 3 criteria are met: <7 days of headache, <70% cerebrospinal fluid (CSF) mononuclear cells, and absence of seventh or other cranial nerve palsy. The goal of this study was to test the performance of the Rule of 7's in a multicenter cohort of children with CSF pleocytosis.

METHODS

We performed a retrospective cohort study of children evaluated at 1 of 3 emergency departments located in Lyme disease-endemic areas with CSF pleocytosis and Lyme serology obtained. Lyme meningitis was defined using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans [EM] rash). We calculated the performance of the Rule of 7's in our overall study population and in children without physician-documented EM.

RESULTS

We identified 423 children, of whom 117 (28% [95% confidence interval (CI): 24%-32%]) had Lyme meningitis, 306 (72% [95% CI: 68%-76%]) had aseptic meningitis, and 0 (95% CI: 0%-1%) had bacterial meningitis. Of the 130 classified as low risk, 5 had Lyme meningitis (sensitivity, 112 of 117 [96% (95% CI: 90%-99%)]; specificity, 125 of 302 [41% (95% CI: 36%-47%)]). In the 390 children without EM, 3 of the 127 low-risk patients had Lyme meningitis (2% [95% CI: 0%-7%]).

CONCLUSIONS

Patients classified as low risk by using the Rule of 7's were unlikely to have Lyme meningitis and could be managed as outpatients while awaiting results of Lyme serology tests.

[Children Lyme Borreliosis: retrospective study of 16 cases]

OBJECTIVES

Lyme Borreliosis exists in an endemic way for adult's in Alsace and the clinical demonstrations are well known. For children, there are no data in France. The objective of this study was to list the cases of Lyme Borreliosis seen in pediatric consultation in the Bas-Rhin and to study the clinical presentation.

METHODS

We realized an investigation with 70 pediatricians of the Bas-Rhin between April 2006 and March 2008 which allowed us to count 16 cases of Lyme Borreliosis.

RESULTS

It is about nine girls and seven boys, seven-years-old on average. Thirteen had an erythema migrans, two a neuroborreliosis and one arthritis of Lyme. Tick injection (notion established in 81 % of the cases) sat in upper limbs in the majority of the cases (39 %). The delay between the injection and the first signs was established in seven cases on 13 and varied from five to 30 days. The first signs of the disease appeared in spring or in summer for 81 % of the children. Amoxicilline was the the most used treatment for the erythema migrans; ceftriaxone for neuroborreliosis or Lyme arthritis. Those treatments were effective in every cases.

CONCLUSION

Lyme Borreliosis in children exists in Alsace. Its main demonstration is the erythema migrans, but there are also neurological and articular demonstrations. With an appropriate treatment, its evolution is excellent.

Lyme neuroborreliosis in children

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

Etiology of aseptic meningitis, peripheral facial nerve palsy, and a combination of both in children

BACKGROUND

A variety of microorganisms have been shown to cause peripheral facial nerve palsy (PFNP) and/or aseptic meningitis in children. Clinical findings and history may help to predict the specific etiology of these entities.

METHOD

Children > or =12 months old hospitalized at the University Children's Hospital Basel, Switzerland, from 2000 to 2005 with clinical signs of PFNP and/or aseptic meningitis were studied retrospectively. History, clinical, and laboratory findings were evaluated using analysis of variance with Bonferroni (Dunn) correction.

RESULTS

Of 181 patients, 123 (68%) had aseptic meningitis, 28 (15%) had PFNP, and 30 (17%) had a combination of both. PFNP with aseptic meningitis was associated with Borrelia burgdorferi (Bb) infection in the majority of patients (73%) compared with 11% and 9% of patients with PFNP or aseptic meningitis, respectively. The majority of patients with aseptic meningitis without PFNP had enterovirus infection (63%). In patients with aseptic meningitis, mean leukocyte counts in cerebrospinal fluid (CSF) were higher with enterovirus (565/microL) compared with Bb infection (191/microL; P < 0.01) or unknown causes (258/microL; P < 0.01). Further, CSF mean mononuclear cell proportion was higher in patients with Bb (89%) than in those with enterovirus infection (51%; P < 0.01) or unknown causes (60%; P < 0.01). Mean time interval between onset of disease and admission to hospital showed significant differences between Bb (7.6 days) and enterovirus infection (2.8 days; P < 0.01) or unknown causes (2.0 days; P < 0.01).

CONCLUSIONS

Time interval between onset of disease and hospital admission and CSF characteristics can contribute to distinguishing the etiology of aseptic meningitis with or without PFNP. As expected, the most common etiology for aseptic meningitis with PFNP was Bb infection whereas enterovirus infection was the predominant cause for aseptic meningitis alone.

Prospective validation of a clinical prediction model for Lyme meningitis in children

OBJECTIVE

Lyme meningitis is difficult to differentiate from other causes of aseptic meningitis in Lyme disease-endemic regions. Parenteral antibiotics are indicated for Lyme meningitis but not viral causes of aseptic meningitis. A clinical prediction model was developed to distinguish Lyme meningitis from other causes of aseptic meningitis. Our objective was to prospectively validate this model.

METHODS

Children between 2 and 18 years of age presenting to Hasbro Children's Hospital from April through October of 2006 and 2007 were enrolled if a lumbar puncture for meningitis showed a cerebrospinal fluid white blood cell count of >8 cells per microL. Cerebrospinal fluid was sent for Lyme antibody testing. The probability of Lyme meningitis was calculated by using the percentage of cerebrospinal fluid mononuclear cells, duration of headache, and presence of cranial neuropathy by using the prediction model. Definite Lyme meningitis cases were defined as cerebrospinal fluid pleocytosis with (1) positive Lyme serology confirmed by immunoblot or (2) erythema migrans rash. Possible Lyme meningitis cases were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody. Sensitivity, specificity, and likelihood ratios for definite and possible Lyme meningitis were determined by using 10% increments of calculated probability of Lyme meningitis.

RESULTS

Fifty children were enrolled, including 14 children with definite Lyme meningitis, 6 with possible Lyme meningitis, and 30 with aseptic meningitis. A calculated probability of <10% for Lyme meningitis had a negative likelihood ratio of 0.006 for definite and possible Lyme meningitis cases. A calculated probability of >50% for Lyme meningitis had a positive likelihood ratio of 100 using these definitions.

CONCLUSIONS

A clinical prediction model using the percentage of cerebrospinal fluid mononuclear cells, headache duration, and presence of cranial neuropathy can differentiate children with Lyme meningitis from children with aseptic meningitis. Our findings suggest categories of low (<10%), indeterminate (10%-50%), and high (>50%) probability of Lyme meningitis.

Prediction of Lyme meningitis based on a logistic regression model using clinical and cerebrospinal fluid analysis: a European study

BACKGROUND

A prediction model based on clinical and cerebrospinal fluid (CSF) analysis has been proposed for the differentiation of Lyme meningitis (LM) from non-Lyme aseptic meningitis (NLAM) in the United States. No similar model has ever been proposed for European patients. The objective of our study was to develop a prediction model to differentiate LM from NLAM based on clinical and CSF biologic data.

METHODS

The medical charts of all children older than 2 years of age admitted to our hospital from 1996 through 2006 with a definite diagnosis of LM were analyzed and compared retrospectively with those having a diagnosis of NLAM. Chart review included the duration of symptoms, the presence of cranial neuropathy, and CSF analysis.

RESULTS

A total of 93 patients were included (LM: 26 patients; NLAM: 67 patients) in the study. Patients with LM had statistically more frequent cranial neuropathy (73% vs. 4%), displayed a longer duration of symptoms before admission (8.8 vs. 1.8 days), had a higher CSF protein (71 vs. 38 mg/d), and had a lower percentage of neutrophil cells in the CSF (3.4% vs. 51%) than patients with NLAM. A predicted probability was derived from these 4 variables. At a cutoff point of >0.432, the model had a negative predictive value of 100% and a positive predictive value of 92.3%, with a sensitivity of 100% and a specificity of 97%.

CONCLUSIONS

We report the first European prediction model for LM. Owing to its high negative predictive value, this model may assist physicians in managing aseptic meningitis (AM) while awaiting serologic tests, especially in Lyme endemic regions.

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

BACKGROUND

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

MATERIAL/METHODS

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

RESULTS

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

CONCLUSIONS

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

Lyme disease update

PURPOSE OF REVIEW

Lyme disease is endemic to areas in both Europe and the United States and the incidence is increasing. Despite published guidelines, controversy persists about its diagnosis and management in patients who do not meet strict diagnostic criteria. This review summarizes important recently published studies and recommendations for the diagnosis and management of Lyme disease.

RECENT FINDINGS

Recent comprehensive guidelines have been published for the diagnosis and management of pediatric Lyme disease. In addition, recent studies may help physicians differentiate between Lyme and aseptic meningitis, as well as show the poor sensitivity of cerebrospinal fluid polymerase chain reaction. Controversy continues about the diagnosis and management of "chronic Lyme disease", despite the current medical literature. Recently published studies in the US have also better described southern tick-associated rash illness, an entity that may present a similar clinical picture to Lyme disease. Guidelines have also been published on the management and diagnosis of other tick-borne illnesses often seen as co-infections with Lyme disease. Finally, case reports have been published describing new cardiac manifestations associated with Lyme disease.

SUMMARY

Controversies persist about the diagnosis and management of Lyme disease. Recently published guidelines and primary research can aid clinicians in diagnosing Lyme properly.

What we have learned about Lyme borreliosis from studies in children

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

The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis were prepared by an expert panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 31[Suppl 1]:1-14). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. For each of these Ixodes tickborne infections, information is provided about prevention, epidemiology, clinical manifestations, diagnosis, and treatment. Tables list the doses and durations of antimicrobial therapy recommended for treatment and prevention of Lyme disease and provide a partial list of therapies to be avoided. A definition of post-Lyme disease syndrome is proposed.

Prediction of Lyme meningitis in children from a Lyme disease-endemic region: a logistic-regression model using history, physical, and laboratory findings

BACKGROUND

Differentiating Lyme meningitis (LM) from other forms of aseptic meningitis (AM) in children is a common diagnostic dilemma in Lyme disease-endemic regions. Prior studies have compared clinical characteristics of patients with LM versus patients with documented enteroviral infections. No large studies have compared patients with LM to all patients presenting with AM and attempted to define a clinical prediction model.

OBJECTIVE

To create a statistical model to predict LM versus AM in children based on history, physical, and laboratory findings during the initial presentation of meningitis.

METHODS

Children older than 2 years presenting to the Alfred I. duPont Hospital for Children between October 1999 and September 2004 were identified if both Lyme serology and cerebrospinal fluid (CSF) were collected during the same hospital encounter. Patients were considered to have Lyme disease only if they met Centers for Disease Control and Prevention criteria (documented erythema migrans and/or positive Lyme serology). Patients were eligible for study inclusion if they had documented meningitis (CSF white blood cell count: >8 per mm3). Retrospective chart review abstracted duration of headache and cranial neuritis (papilledema or cranial nerve palsy) on physical examination and percent CSF mononuclear cells. Using logistic-regression analysis, the type of meningitis (LM versus AM) was simultaneously regressed on these 3 variables. The Hosmer-Lemeshow test was performed and the area under the receiver operating characteristic curve was calculated.

RESULTS

A total of 175 children with meningitis were included in the final statistical model. Logistic-regression analysis included 27 patients with LM and 148 patients classified as having AM. Duration of headache, cranial neuritis, and percent CSF mononuclear cells independently predicted LM. The Hosmer-Lemeshow test revealed a good fit for the model, and the Nagelkerke R2 effect size demonstrated good predictive efficacy. Odds ratios based on the logistic-regression results were calculated for these variables. The final model was transformed into a clinical prediction model that allows practitioners to calculate the probability of a child having LM.

CONCLUSIONS

Longer duration of headache, presence of cranial neuritis, and predominance of CSF mononuclear cells are predictive of LM in children presenting with meningitis in a Lyme disease-endemic region. The clinical prediction model can help guide the clinician about the need for parenteral antibiotics while awaiting serology results.

Diagnostic utility of Borrelia burgdorferi cerebrospinal fluid polymerase chain reaction in children with Lyme meningitis

BACKGROUND

Cerebrospinal fluid (CSF) laboratory tests are frequently collected to help differentiate Lyme meningitis from other causes of aseptic meningitis. Previous studies using Lyme CSF polymerase chain reaction (PCR) have yielded varied results (sensitivity between 10 and 90%). No studies have specifically examined the diagnostic utility of Lyme CSF-PCR in North American children with Lyme meningitis.

METHODS

Retrospective chart review of children presenting to a children's hospital in a Lyme-endemic region between October 1999 and September 2004. Patients were included if they had both Lyme serology and Lyme CSF-PCR performed during the same hospital encounter and had documented meningitis. Patients were considered to have Lyme meningitis if they had meningitis and met CDC criteria for Lyme disease. The Lyme CSF-PCR assay amplified a Borrelia burgdorferi DNA flagellin gene sequence.

RESULTS

Of 108 patients with meningitis who qualified for the study, 20 patients met criteria for Lyme meningitis and 88 were classified as aseptic meningitis. Positive Lyme CSF-PCR was found in 1 patient (1 of 20, 5%) with Lyme meningitis and one patient classified as aseptic meningitis (1 of 88, 1%). Lyme CSF-PCR had a sensitivity of 5% and a specificity of 99%. The only Lyme meningitis patient with positive Lyme CSF-PCR had the highest CSF white blood cell count and CSF protein values compared with the other Lyme meningitis patients.

CONCLUSIONS

This is the first study to evaluate Lyme CSF-PCR exclusively in North American children. This commercially available laboratory test is not generally helpful for identifying Lyme meningitis because of its low sensitivity.

New antigens for serologic diagnosis of neuroborreliosis in children

OBJECTIVE

To evaluate serology with novel Borrelia-specific protein or peptide antigens in the laboratory diagnosis of neuroborreliosis (NB) in children.

METHODS

The performance of enzyme-linked immunosorbent assays with several recombinant borrelial protein antigens and invariable region 6 synthetic peptide antigen and of a commercial enzyme-linked immunosorbent assay with the flagella antigen were evaluated in the serodiagnosis and follow-up of children with clinical suspicion of NB. Serum samples were obtained from 20 children with neurologic symptoms indicative of NB. The patients were retrospectively divided into 2 groups based on the laboratory tests at presentation indicating definite (n = 7) or probable (n = 13) NB.

RESULTS

In addition to cerebrospinal fluid (CSF) lymphocytic pleocytosis and CSF antiflagella antibodies, all 7 patients with definite NB had serum IgG antibodies to at least 2 of the 3 novel antigens at presentation. The 13 patients with probable NB had variable laboratory findings: CSF pleocytosis (n = 7), CSF antiflagella IgM antibodies (n = 4), serum antiflagella IgM and/or IgG antibodies (n = 10). Of these 13 patients, 7 had serum IgG antibodies to 2 of the 3 novel antigens at presentation. During long term follow-up, serum anti-invariable region 6 antibodies disappeared.

CONCLUSIONS

The present study suggests that assessment of serum antibodies to a panel of Borrelia-specific antigens could improve the laboratory diagnosis of NB at presentation.

Early differentiation of Lyme from enteroviral meningitis

BACKGROUND

Differentiating Lyme meningitis from enteroviral meningitis remains difficult because both occur mostly in the summer and early fall. This distinction is clinically important because pathogen-specific diagnostic test results are not available immediately and only patients with Lyme meningitis require parenteral antibiotic therapy.

OBJECTIVES

The objective of this study was to identify clinical and laboratory features that might help clinicians distinguish patients with Lyme meningitis from those with enteroviral meningitis.

METHODS

This cross-sectional study compared patients diagnosed with Lyme or enteroviral meningitis evaluated at a large children's hospital between January 1, 1999 and September 20, 2002.

RESULTS

Twenty-four patients with Lyme meningitis and 151 patients with enteroviral meningitis had median ages of 10.5 and 5.5 years, respectively (P < 0.0001). There was an equal proportion of boys with Lyme (63%) and enteroviral meningitis (62%; P = 1.0). The duration of symptoms before evaluation was longer for patients with Lyme meningitis (12 days) than with enteroviral meningitis (1 day; P < 0.0001). Cranial neuropathy was a presenting feature in 71% of children with Lyme meningitis. Cranial neuropathy, erythema migrans rash or papilledema occurred in 88% of patients with Lyme meningitis; no patients with enteroviral meningitis exhibited any of these findings (P < 0.0001). Lyme meningitis was unlikely when cerebrospinal fluid neutrophils exceeded 10% (negative predictive value, 99%).

CONCLUSIONS

We identified several clinical and laboratory features that may permit early differentiation of Lyme from enteroviral meningitis. These results may assist clinicians with decisions regarding additional testing and empiric antibiotic therapy.

The Therapy of Lyme Neuroborreliosis

The challenge for the neurologist in the treatment of Lyme neuroborreliosis is not in the treatment per se, but in the diagnosis. Neurological manifestations of Lyme disease can present in many forms, and diagnostic techniques which detect the spirochete directly; the culture or polymerase chain reaction of the spirochete in cerebrospinal fluid, are of disappointingly low yield. Therefore, the diagnosis is frequently not easy. After the diagnosis is made, antibiotic therapy is straightforward; Lyme neuroborreliosis should be treated with at least 2 weeks of antibiotics. In the United States, intravenous therapy with ceftriaxone or penicillin for 2 weeks is the standard, whereas in Europe oral doxycycline therapy is commonly administered. Either is effective, and my choice of therapy generally depends on the patient. Many patients have symptoms which continue after antibiotic therapy referable to persistent inflammation, and, for those patients, I will commonly prescribe nonsteroidal anti-inflammatory medications.

Lyme borreliosis: from infection to autoimmunity

Lyme borreliosis in humans is an inflammatory disease affecting multiple organ systems, including the nervous system, cardiovascular system, joints and muscles. The causative agent, the spirochaete Borrelia burgdorferi, is transmitted to the host by a tick bite. The pathogenesis of the disease in its early stages is associated largely with the presence of viable bacteria at the site of inflammation, whereas in the later stages of disease, autoimmune features seem to contribute significantly. In addition, it has been suggested that chronic persistence of B. burgdorferi in affected tissues is of pathogenic relevance. Long-term exposure of the host immune system to spirochaetes and/or borrelial compounds may induce chronic autoimmune disease. The study of bacterium-host interactions has revealed a variety of proinflammatory and also immunomodulatory-immunosuppressive features caused by the pathogen. Therapeutic strategies using antibiotics are generally successful, but chronic disease may require immunosuppressive treatment. Effective and safe vaccines using recombinant outer surface protein A have been developed, but have not been propagated because of fears that autoimmunity might be induced. Nevertheless, new insights into the modes of transmission of B. burgdorferi to the warm-blooded host have been generated by studying the action of these vaccines.

Hypoglycorrhachia in Lyme meningitis

We describe a previously healthy 11-year-old girl with acute neuroborreliosis, who presented with left sixth cranial nerve palsy, elevated intracranial pressure, markedly elevated cerebrospinal fluid leukocyte count and protein concentration and severe hypoglycorrhachia. These laboratory findings are atypical for neuroborreliosis.

Lyme disease presenting with persistent headache

Increased intracranial pressure in patients with Lyme disease is an uncommon but reported finding. We discuss 2 patients from Lyme endemic areas who initially presented with headache, nausea, and vomiting and were eventually found to have increased intracranial pressure, a mild cerebrospinal fluid pleocytosis, and positive Lyme titers. It has been shown that increased intracranial pressure in association with neuroborreliosis can lead to blindness. In endemic areas, it is important for practitioners to consider Lyme disease when patients present with persistent headache, especially in those who have evidence of increased intracranial pressure.

Clinical data and cerebrospinal fluid findings in Lyme meningitis versus aseptic meningitis

The purpose of this study was to characterise Lyme meningitis (LM) in a Belgian paediatric population and to suggest findings that could allow early distinction from aseptic meningitis (AM). The medical records of patients hospitalised between 1993 and 2000 and with a discharge diagnosis of LM (n=14) or AM (n=16) were retrospectively reviewed. The Kruskal-Wallis test was used to compare data. Of the patients, 16 were identified with AM and 14 with LM, amongst which 7 presented with isolated LM and 7 with associated peripheral facial palsy (PFP). Patients with AM, when compared with LM, complained of more pronounced signs and symptoms of meningitis (fever, headaches, and neck stiffness); they statistically displayed a shorter period of symptoms before admission (1.6 vs 15 days), higher neutrophilic component (mean 56% vs 2.4%), and lower protein levels (mean 0.39 vs 1.12 g/l) on cerebrospinal fluid analysis. In the neuroborreliosis group, the duration of symptoms was shorter and the cerebrospinal protein level was lower in cases of LM associated with PFP compared to isolated LM (mean 1.3 vs 15 days; mean 0.55 g/l vs 1.12 g/l). Conclusions. Our results suggest that some clinical data and laboratory findings may help the physician to diagnose aseptic or Lyme meningitis before completion of serologic testing. LM should be suspected in cases of meningitis with very low CSF neutrophilic counts and high protein levels associated with prolonged duration of symptoms, low grade fever, and absence of pronounced signs of meningitis.

Neurologic aspects of Lyme disease

Lyme disease has emerged as a major infection with frequent neurologic manifestations. These manifestations probably reflect several predominantly indirect pathogenetic mechanisms and involve host, vector, and organism factors. With early diagnosis and appropriate antibiotic treatment, patients do well. Because culture is not reliable, diagnosis has relied on positive serology to document exposure. Serology should improve as second-generation assays become available. Although there is a preventive vaccine based on the lipoprotein OspA, newer vaccines in development may prove more desirable. Lyme disease provides a valuable model to study how infectious pathogens cause neurologic disease.

Lyme disease in children

Lyme borreliosis is a multisystem disorder caused by Borrelia burgdorferi and transmitted by ticks in the northern hemisphere. The disease is common in children. In addition to frequently recognized manifestations such as erythema migrans, neuroborreliosis, and Lyme arthritis, rarer manifestations, including eye and ear disease, are increasingly understood. Clinical diagnosis is supported by serologic confirmation. Improvement of laboratory methodology, especially polymerase chain reaction-based tests, is continuing. Actual treatment recommendations based on controlled studies reflect expanding scientific knowledge. In the United States, license of a vaccine to prevent infection in children is awaited. Lyme borreliosis is an intriguing human example of bacterial persistence in the presence of the host immune system. Chronic Lyme arthritis is a model of chronic arthritis resembling forms of arthritis of unknown cause, such as rheumatoid arthritis and juvenile idiopathic arthritis.

Optic neuropathy in children with Lyme disease

Involvement of the optic nerve, either because of inflammation or increased intracranial pressure, is a rare manifestation of Lyme disease. Of the 4 children reported here with optic nerve abnormalities, 2 had decreased vision months after disease onset attributable to optic neuritis, and 1 had headache and diplopia early in the infection because of increased intracranial pressure associated with Lyme meningitis. In these 3 children, optic nerve involvement responded well to intravenous ceftriaxone therapy. The fourth child had headache and visual loss attributable to increased intracranial pressure and perhaps also to optic neuritis. Despite treatment with ceftriaxone and steroids, he had persistent increased intracranial pressure leading to permanent bilateral blindness. Clinicians should be aware that neuro-ophthalmologic involvement of Lyme disease may have significant consequences. If increased intracranial pressure persists despite antibiotic therapy, measures must be taken quickly to reduce the pressure.