Plasma Exchange for Lyme Neuroborreliosis delayed diagnosis: A case report

Lyme neuroborreliosis (LNB) is a rare infectious disease, caused by Borrelia burgdorferi spirochetes and responsible for a variety of neurological manifestations. The most common manifestations of LNB in children are cranial nerve involvement, especially facial nerve palsy often accompanied by lymphocytic meningitis. In this article, we present a case of a 4-year-old boy presented to our emergency department with abdominal pain evolving for a week and symmetrical ascending progression of weakness responsible for severe respiratory failure. Diagnosis of Guillain-Barré syndrome (GBS) was initially suspected. Although our patient had received 2 courses (each of 5 days) of Intravenous immunoglobulin (IVG) treatment, no clinical improvement was observed. The diagnosis of LNB was confirmed by detection of both IgG and IgM specific antibodies in serum. The patient's muscle weakness got better after a 2- week course of Ceftriaxone but respiratory muscle failure didn't improve with two extubation failures. Consequently, we decided to conduct plasmapheresis procedures. We managed to extubate the child and discharge him after a good recovery of his symptoms. Pediatricians must consider LNB disease in the differential diagnosis of GBS, especially when the patient didn't recover after IVG treatment. This case shows that plasmapheresis could be effective for pediatric neuroborreliosis cases with severe neurological disorders.

[A story of neuroborreliosis : case report]

Neuroborreliosis affects approximately 15 % of people infected with Borrelia burgdorferi. The symptoms are very varied, which can sometimes delay the diagnosis. We can diagnose a neuroborreliosis in front of a compatible clinic and laboratory examinations, in particular a lumbar puncture showing a pleocytosis, an intrathecal synthesis of antibodies against B. burgdorferi, and an increased level of chemokine CKCL13. We present the case of a patient in whom the diagnosis was delayed in connection with non-specific symptoms and we review the latest recommendations in terms of treatment of neuroborreliosis.

Functional signs in patients consulting for presumed Lyme borreliosis

INTRODUCTION

Little is known about the functional symptoms associated with Lyme borreliosis (LB) in Europe. We aimed to assess functional symptoms associated with presumed LB and to compare patients with and without confirmed LB.

MATERIALS AND METHODS

We performed a retrospective monocenter study. Patients consulting for presumed LB were included.

RESULTS

Between November 2015 and June 2018, 355patients were included (mean age: 51years, 52% of women) of which 48had LB: erythema migrans (42%), early disseminated LB (50%; 35% of neuroborreliosis cases), and late disseminated LB (8%). The most frequently reported functional symptoms were neuropathic pain (23%), arthralgia (23%), and asthenia (17%). Other functional symptoms were rare (≤10%). Three hundred and seven (86%) patients did not have LB. Patients with confirmed LB reported fewer functional symptoms than patients without LB (1.8 (±1.7) vs. 3.6 (±2.5), P<0.001) with a shorter duration of symptoms (< 3 months in 48% vs. 16% of cases, P<0.001). They less often reported asthenia (17% vs. 59%, P<0.001), widespread pain (10% vs. 31%, P=0.003), myalgia (10% vs. 32%, P=0.002), memory disorders (4% vs. 16%, P=0.03), irritability (2% vs. 23%, P±0.001), and sadness (0% vs. 16%, P=0.003).

CONCLUSION

In patients consulting for presumed LB, patients diagnosed with LB had fewer and shorter functional symptoms than patients without LB.

European neuroborreliosis: quality of life 30 months after treatment

OBJECTIVES

The prognosis after Lyme neuroborreliosis (LNB) is debated. The aim of this study was to assess health-related Quality of Life (QoL) and neurological symptoms 30 months after treatment in European patients with LNB.

MATERIALS AND METHODS

In a prospective case-control designed study, we investigated 50 well-characterized patients with LNB who had participated in a treatment trial for LNB 30 months earlier and 50 matched control persons with the health QoL questionnaire Short-Form 36 (SF-36), the Fatigue Severity Scale (FSS), the Montgomery and Åsberg Depression Rating Scale (MADRS), the Starkstein Apathy Scale (SAS), and the Mini Mental State (MMS). Clinical and demographic data were collected by semi-structured interviews and clinical neurological examination.

RESULTS

Lyme neuroborreliosis-treated patients scored lower than control persons in the SF-36 domains physical component summary (PCS) (44 vs 51 P < 0.001) and mental component summary (MCS) (49 vs 54 P = 0.010). They also scored lower than control persons in all the SF-36 subscales, except for bodily pain, and on FSS (3.5 vs 2.1 P < 0.001), but not on MMS (28 vs 29 P = 0.106). There was a difference in MADRS (3.1 vs 0. 8 P = 0.003) and SAS (13 vs 11 P = 0.016), but the scores were low in both groups. Fatigue was the most frequently reported symptom among LNB-treated patients (50%). Patients who reported complete recovery (56%) after LNB had similar QoL scores as the controls.

CONCLUSION

European persons treated for LNB have poorer health-related QoL and have more fatigue than persons without LNB.

[Clinical manifestations of neuroborreliosis in the Volga region]

Ixodes tick-borne borrelioses (TBB) are a group of etiologically independent acute infectious natural-focal transmissive and polysystemic diseases caused by Borrelia and transmitted by the ticks. These diseases tend to be chronic and recurrent, as well as latent, mainly involving the skin, nervous system, locomotor apparatus and heart. The signs of nervous system lesion are recorded in both acute (subacute) and chronic course of the disease. The comparatively low notification rate of TBB in the Ulyanovsk Region, particularly involving the nervous system, in the absence of the gold marker of this disease--erythema migrans (it was absent in both cases) did not allow clinicians to make a correct diagnosis at the early stages of patient examination. The currently available methods, in this case, Western blot, are of great importance in diagnosing the disease. By taking into account delayed antibody generation within the first weeks of the disease, it is necessary to continue examination by the methods available in the practical health arsenal (ELISA) and in the later periods, with the epidemiological history and clinical picture of encephalitis being borne in mind.

Motor neuron disease features in a patient with neuroborreliosis and a cervical anterior horn lesion

A variety of neurological syndromes has been described in neuroborreliosis: cranial nerve palsies, radiculopathy, axonal neuropathy, stroke, parkinsonism, transverse myelitis, supranuclear palsy, Guillain-Barré syndrome, ... We report a case of neuroborreliosis with cervical myelitis presenting clinically as a lower motor neuron syndrome of the upper and lower limbs with proximal and distal pareses and atrophies as well as bulbar dysarthria and dysphagia. During the course of the disease the patient developed the clinical picture of a meningoencephalitis. After initiating ceftriaxone treatment the patient showed a complete recovery. In endemic regions for Lyme disease, in all neurological syndromes neuroborreliosis has to be excluded.

Nervous system lyme disease: diagnosis and treatment

Lyme disease, the multisystem infectious disease caused by the tickborne spirochete Borrelia burgdorferi, frequently affects the peripheral and central nervous systems. The earliest indication of Lyme disease infection is usually erythema migrans. This large, typically macular erythema, often with a target-like pattern of concentric pale and red circles, gradually enlarges day by day, potentially reaching many centimeters in diameter. In a significant proportion of infected individuals, an acute disseminated phase leads to seeding elsewhere in the body. Up to 5% of patients develop cardiac involvement. In about 10% to 15% of patients, the nervous system becomes symptomatically involved. Current serologic diagnostic tools are quite useful, and standard treatment regimens are highly effective. Oral antimicrobials have been shown to be effective in European neuroborreliosis and presumably are equally potent in North American patients. Long-term antibiotic treatment does not provide any additional lasting improvement, but it is frequently associated with significant morbidity.

Management of neuroborreliosis in European adult patients

OBJECTIVES

To survey present knowledge and controversies in European neuroborreliosis.

MATERIAL AND METHODS

The article is based on available literature, own experience, and a speech held by the authors. together on the Norwegian annual neurological meeting.

RESULTS

Diagnosis of neuroborreliosis is based on clinical neurological findings, laboratory support of borrelia infection, and indications of causality between neurological findings and borreliosis. In the absence of means to identify B. burgdorferi, antibody tests are used for laboratory diagnosis. Two to three weeks courses of IV penicillin or ceftriaxone are highly effective in neuroborreliosis. Oral doxycyclin is probably equally effective. Remaining symptoms five years after treatment for neuroborreliosis are reported in 25-50% of patients.

CONCLUSIONS

We suggest two levels of diagnostic accuracy; definite and possible neuroborreliosis. These case definitions are proposed to make the basis for treatment decisions. The prognosis of neuroborreliosis and pathophysiology of post-treatment conditions need further studies. Extensive treatments with antibiotics are not recommended.

[Clinical forms of neuroborreliosis among hospitalized patients in the years 2000-2005]

THE AIM OF THE STUDY

To evaluate the frequency of clinical forms as well as laboratory and neuroimaging results of patients with diagnosed neuroborreliosis in the years 2000-2005 due to neuroborreliosis.

MATERIAL AND METHODS

The records of 125 patients at the age of 21-83 (mean 49 years) treated in the years 2000-2005 in the Department of Infectious Diseases and Neuroinfections, Medical University, Bialystok were subject to retrospective analysis. Diagnosis was based on case history along with a clinical picture and presence of antibodies against Borrelia burgdorferi, using ELISA test (Borrelia IgM and Borrelia IgG recombinant Biomedica). The subject of the detailed analysis was demographic data, clinical symptoms as well as subjective complaints, results of neurological examinations, the results of cerebrospinal fluid (CSF) parameters and results of serologic tests.

RESULTS

The most frequent clinical symptoms observed were: headaches 71%, vertigo 44%, meningeal symptoms 22% and neurological paresis 27% (including facial palsy--23%). Inflammatory changes in CSF in the form of increased proteins concentration and pleocytosis were present among 34% of patients. In all cases the antibodies against B. burgdorferi were present in CSF in diagnostically significant titer. Serum presence of antibodies antiborrelia IgM was found with 55% of patients and anibodies antiborrelia IgG with 76% of patients. 17% of patients suffering from neuroborreliosis were also coinfected with tick-borne encephalitis virus. Along with the neurological symptoms, which were crucial to diagnosis, general symptoms coexisted, such as: weakness 35%, arthralgia 54% and nausea 17%. In the analyzed period of time neuroborreliosis was diagnosed in a 13% of hospitalized patient suffering from borreliosis.

CONCLUSIONS

Absence of erythema migrans does not exclude existence of neuroborreliosis. Symptoms that may suggest presence of neuroborreliosis are not only neurological symptoms such as facial palsy, but also memory and concentration disorders and general symptoms.

Is neuroborreliosis a medical emergency?

Although Lyme disease affects the nervous system in many ways (collectively known as neuroborreliosis), only rarely does it present as a medical emergency. In extreme cases, it may cause (1) encephalitis, (2) a rapidly progressive peripheral neuropathy, or (3) a painful truncal radiculopathy that may be confused with a severe visceral process. Knowing when to consider this spirochetosis in the differential diagnosis requires an understanding of its true clinical spectrum, and of an appropriate diagnostic and therapeutic approach.

Spätmanifestationen der Lyme-Borreliose

Zu den Spätmanifestationen der Lyme-Borreliose zählen die Acrodermatitis chronica atrophicans, die Lyme-Arthritis und die Neuroborreliose. Durch antibiotische Therapie der Frühmanifestationen können diese Krankheitsbilder verhindert werden. Auf eine Antibiotikatherapie sprechen auch die Spätstadien üblicherweise gut an, verzögertes Ansprechen und residuelle Beschwerden kommen jedoch vor. Folgezustände unter der Bezeichnung «Post-Lyme Erkrankung» oder «chronische Lyme-Borreliose» sind schlecht umschrieben und kaum von anderen Beschwerdebildern abzugrenzen. Eine Persistenz des infektiösen Erregers kann bei diesen Zuständen nicht nachgewiesen werden, wiederholte und langdauernde Antibiotikatherapie haben keine günstige Wirkung gezeigt.

Research opportunities on human neuroborreliosis

A workshop, sponsored by the National Institutes of Health, was convened in September 2001 to evaluate the current knowledge in neurological Lyme disease. The meeting was centered into discussion of both clinical and basic aspects of the disease. Participants included researchers from the fields of infectious diseases, neurology, rheumatology, autoimmunity and basic immunology, largely but not exclusively focused on Lyme disease. This report summarizes the presentations made at the meeting.

Bilateral facial nerve palsy in the course of neuroborreliosis in children-dynamics, laboratory tests and treatment

PURPOSE

Presentation of four patients with bilateral peripheral facial nerve palsy as a clinical manifestation of neuroborreliosis in children--diagnostic, treatment and prognosis.

MATERIAL AND METHODS

In 2002-2004 in The Chair and Department of Developmental Neurology, 24 children from the Wielkopolska region were admitted with diagnosis of borreliosis. Among all the children with borreliosis, confirmed by serologic examination, 4 (16.7%) demonstrated bilateral peripheral facial palsy (PFP). We investigated the presence of IgM class and IgG class specific antibodies in the sera and cerebrospinal fluid (CSF) of 4 patients with bilateral PFP. (Detected by immunoenzymatic methods--ELISA.)

RESULTS

Before the occurrence of PFP all the children manifested unspecified systemic symptoms such as headaches, muscle and articulation pains, weakness and in two cases a mood depression. At first all patients demonstrated elevated IgM antibodies and proper levels of IgG antibodies. Control tests administered within 2-14 months later reduction of antibodies was indicated. Two patients demonstrated significant pleocytosis in CSF test, (without the meningeal symptoms). All children were treated with physiotherapeutic procedures and were administered antibiotic intravenously.

CONCLUSIONS

PFP is one of the most frequent neurological symptoms of borreliosis in children. In case of acute PFP and especially the bilateral form of PFP, neuroborreliosis is the most probable diagnosis. All children reported PFP at one side first and after several weeks the paresis of the facial nerve on the opposite side usually appeared. The clinical state of children started to improve after the introduction of physiotherapy and this process usually lasted several months.

Lyme disease and the peripheral nervous system

Lyme disease, the multisystem infectious disease caused by the tick-borne spirochete Borrelia burgdorferi, causes a broad variety of peripheral nerve disorders, including single or multiple cranial neuropathies, painful radiculopathies, and diffuse polyneuropathies. Virtually all appear to be varying manifestations of a mononeuropathy multiplex. Diagnosis requires that the patient should have had possible exposure to the only known vectors, Ixodes ticks, and also have either other pathognomonic clinical manifestations or laboratory evidence of exposure. Treatment with antimicrobial regimens is highly effective. The mechanism underlying these neuropathies remains unclear, although interactions between anti-Borrelia antibodies and several peripheral nerve constituent molecules raise intriguing possibilities.

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

OBJECTIVE

Acute facial palsy in children is believed to be a rather benign neurological condition. Follow-up-studies are sparse, especially including a thorough otoneurological re-examination. The aim of this study was to examine children with a history of facial palsy in order to register the incidence of complete recovery and the severity and nature of sequelae. We also wanted to investigate whether there was a correlation between sequelae and Lyme Borreliosis, treatment or other health problems.

METHODS

Twenty-seven children with a history of facial palsy were included. A re-examination was performed by an Ear-Nose-Throat (ENT) specialist 1-2.9 years (median 2) after the acute facial palsy. The otoneurological examination included grading the three branches of the facial nerve with the House-Brackman score, otomicroscopy and investigation with Frenzel glasses. A paediatrician interviewed the families. Medical files were analysed.

RESULT

The incidence of complete recovery was 78% at the 2-year follow-up. In six out of 27 children (22%), the facial nerve function was mildly or moderately impaired. Four children reported problems with tear secretion and pronunciation. There was no correlation between sequelae after the facial palsy and gender, age, related symptoms, Lyme neuroborreliosis (NB), treatment, other health problems or performance.

CONCLUSION

One fifth of children with an acute facial palsy get a permanent dysfunction of the facial nerve. Other neurological symptoms or health problems do not accompany the sequelae of the facial palsy. Lyme NB or treatment seems to have no correlation to clinical outcome. Factors of importance for complete recovery after an acute facial palsy are still not known.

[Lyme borreliosis]

Lyme disease is a multisystemic disease caused by a spirochete, Borrelia Burgdorferi that is transmitted by ticks. A clinical diagnosis is easy when a tick bite is followed 3 weeks later by erythema migrans, than by involvement of nervous system, joints or heart. In case of neuroborreliosis, serological tests, performed in blood and cerebro-spinal fluid, support the diagnosis and patients recover rapidly with antibacterial treatments. However an accurate diagnosis remains sometimes problematic, especially distinction between a coincidental positive serologic test and a nervous system Lyme borreliosis which require antibiotics. Furthermore, the role of autoimmunity in the pathophysiology of late Lyme disease, antibiotic choice in early disease, duration of treatment, and utility of vaccination are discussed.

A case of Bannwarth syndrome

A 72-year-old woman presented with a short history of radicular pain down her left leg. She was admitted to a cottage hospital where she developed progressive weakness in both legs. She was noted to develop a rash with target-like lesions, thought to be erythema multiforme. She was otherwise well and apyrexial.