CXCL13 as a biomarker in the diagnostics of European lyme Neuroborreliosis - A prospective multicentre study in Austria

Background

'Definite Neuroborreliosis (NB)' is diagnosed with the presence of NB-specific symptoms, cerebrospinal fluid (CSF) pleocytosis and an elevated Borrelia Burgdorferi antibody index. However, some diagnostic uncertainties exist. The B-cell chemokine CXCL13 represents an emerging biomarker for the diagnosis and treatment of NB because its intrathecal concentration rises prior to the Borrelia antibody index and drops rapidly after antibiotic therapy. Nevertheless, due to lacking prospective data, a definite CXCL13 cut-off for the diagnosis of NB is still pending.

Objective

Definition of a CSF CXCL13 cut-off for the diagnosis of acute and untreated NB in a prospective study setting.

Design and methods

This multicentre prospective study involved 6 neurological departments treating patients in the Lower Austria district (1.7 million inhabitants). The controls were patients scheduled for a spinal tap but not clinically diagnosed with NB. Demographic data, clinical characteristics and blood counts, as well as inflammatory CSF values and CSF CXCL13-concentration were analysed.

Results

We recruited 440 adult patients, of whom 42 have been diagnosed as having an acute and untreated 'definite NB'. Three hundred ninety-eight patients were assigned to the control group. The median intrathecal CXCL13 concentration was 2384 pg/ml for patients with NB and 0 pg/ml for controls. The difference was highly statistically significant (P ≤ .001). A CSF CXCL13 cut-off of 271 pg/ml resulted in a sensitivity of 95.2% and a specificity of 97.2% for the confirmation or exclusion of NB.

Conclusion

Based on our results, we propose a CSF CXCL13 cut-off of 271 pg/ml with Euroimmun-Elisa for the diagnosis of acute and untreated NB. Due to its high sensitivity and specificity, CXCL13 is a strong candidate biomarker for routine NB assessment, especially in clinically unclear cases.

Clinical characteristics of children with Borrelia-related peripheral facial palsy and utility of cerebrospinal fluid testing

AIM

To describe the aetiology and clinical characteristics of acute peripheral facial palsy (PFP) in children and investigate the utility of the European Federation of Neurological Societies (EFNS) criteria for diagnosing Borrelia-related PFP (BPFP) based on cerebrospinal fluid (CSF) testing and the Centers for Disease Control and Prevention (CDC) criteria based on serology.

METHODS

We retrospectively identified children aged <18 years diagnosed with acute PFP between 2014 and 2020. We used the EFNS criteria as the gold standard and the CDC criteria for diagnosing BPFP.

RESULTS

Out of 257 children with PFP, 93 (36%) fulfilled the EFNS or CDC criteria for BPFP. We found a discrepancy between the EFNS criteria with CSF testing and the CDC without CSF testing in 27 (14%) of the 190 children with available data. Of the 37 children with PFP and ≥2 symptoms of fever, fatigue, nausea/vomiting or meningeal symptoms, 31 (84%) fulfilled the EFNS criteria for BPFP.

CONCLUSION

Borrelia is a common cause of PFF in children, and its prevalence is higher in children with systemic symptoms. Also, CSF testing did not have decisive management implications in most cases. Therefore, clinical evaluation and Borrelia serology could be the initial steps in the diagnosis of PFP in children.

Anti-NMDA-receptor encephalitis and concurrent neuroborreliosis misdiagnosed for post-COVID-19-syndrome: a case report

We present a case of a 42-year-old woman with paraneoplastic anti-N-Methyl-D-Aspartat (NMDA)-receptor encephalitis and concurrent neuroborreliosis that was initially misdiagnosed as post-COVID-19 syndrome. Clinically, the patient presented with a range of chronic and subacute neuropsychiatric symptoms and recalled a tick bite weeks prior to admission. The patient had undergone psychiatric and complementary medical treatments for 1 year before admission and was initially diagnosed with post-COVID-19 syndrome. Admission was performed because of acute worsening with fever, confusion, and unsteady gait. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with elevated borrelia Immunoglobulin M (IgM) and Immunoglobulin M (IgG) CSF/blood antibody indices, indicating acute neuroborreliosis. Anti-NMDA receptor antibodies were identified in the CSF via a cell-based assay and were confirmed by an external laboratory. Other paraneoplastic antibodies were ruled out during in-house examination. Cranial Magnetic resonance imaging (MRI) revealed basal meningitis, rhomb- and limbic encephalitis. A subsequent pelvic Computer tomography (CT) scan identified an ovarian teratoma. The patient's clinical condition improved dramatically with antibiotic treatment and plasmapheresis, the teratoma was surgically removed and she was started on rituximab. Our case highlights that amidst the prevailing focus on COVID-19-related health concerns, other well-established, but rare neurological conditions should not be neglected. Furthermore, our case illustrates that patients may suffer from multiple, concurrent, yet pathophysiologically unrelated neuroinflammatory conditions.

CXCL13 in Cerebrospinal Fluid: Clinical Value in a Large Cross-Sectional Study

C-X-C-motif chemokine ligand 13 (CXCL13) in cerebrospinal fluid (CSF) is increasingly used in clinical routines, although its diagnostic specificity and divergent cut-off values have been defined so far mainly for neuroborreliosis. Our aim was to evaluate the value of CSF-CXCL13 as a diagnostic and treatment response marker and its role as an activity marker in a larger disease spectrum, including neuroborreliosis and other neuroinflammatory and malignant CNS-disorders. Patients who received a diagnostic lumbar puncture (LP) (n = 1234) between July 2009 and January 2023 were included in our retrospective cross-sectional study. The diagnostic performance of CSF-CXCL13 for acute neuroborreliosis was highest at a cut-off of 428.92 pg/mL (sensitivity: 92.1%; specificity: 96.5%). In addition, CXCL13 levels in CSF were significantly elevated in multiple sclerosis with clinical (p = 0.001) and radiographic disease activity (p < 0.001). The clinical utility of CSF-CXCL13 appears to be multifaceted. CSF-CXCL13 is significantly elevated in patients with neuroborreliosis and shows a rapid and sharp decline with antibiotic therapy, but it is not specific for this disease and is also highly elevated in less common subacute neuroinfectious diseases, such as neurosyphilis and cryptococcal meningitis or in primary/secondary B-cell lymphoma.

Concurrent Infection of the Human Brain with Multiple Borrelia Species

Lyme disease (LD) spirochetes are well known to be able to disseminate into the tissues of infected hosts, including humans. The diverse strategies used by spirochetes to avoid the host immune system and persist in the host include active immune suppression, induction of immune tolerance, phase and antigenic variation, intracellular seclusion, changing of morphological and physiological state in varying environments, formation of biofilms and persistent forms, and, importantly, incursion into immune-privileged sites such as the brain. Invasion of immune-privileged sites allows the spirochetes to not only escape from the host immune system but can also reduce the efficacy of antibiotic therapy. Here we present a case of the detection of spirochetal DNA in multiple loci in a LD patient's post-mortem brain. The presence of co-infection with Borrelia burgdorferi sensu stricto and Borrelia garinii in this LD patient's brain was confirmed by PCR. Even though both spirochete species were simultaneously present in human brain tissue, the brain regions where the two species were detected were different and non-overlapping. The presence of atypical spirochete morphology was noted by immunohistochemistry of the brain samples. Atypical morphology was also found in the tissues of experimentally infected mice, which were used as a control.

The Rrp2-RpoN-RpoS pathway plays an important role in the blood-brain barrier transmigration of the Lyme disease pathogen

Lyme disease, caused by Borrelia (or Borreliella) burgdorferi, is a complex multisystemic disorder that includes Lyme neuroborreliosis resulting from the invasion of both the central and peripheral nervous systems. However, factors that enable the pathogen to cross the blood-brain barrier (BBB) and invade the central nervous system (CNS) are still not well understood. The objective of this study was to identify the B. burgdorferi factors required for BBB transmigration. We utilized a transwell BBB model based on human brain-microvascular endothelial cells and focused on investigating the Rrp2-RpoN-RpoS pathway, a central regulatory pathway that is essential for mammalian infection by B. burgdorferi. Our results demonstrated that the Rrp2-RpoN-RpoS pathway is crucial for BBB transmigration. Furthermore, we identified OspC, a major surface lipoprotein controlled by the Rrp2-RpoN-RpoS pathway, as a significant contributor to BBB transmigration. Constitutive production of OspC in a mutant defective in the Rrp2-RpoN-RpoS pathway did not rescue the impairment in BBB transmigration, indicating that this pathway controls additional factors for this process. Two other major surface lipoproteins controlled by this pathway, DbpA/B and BBK32, appeared to be dispensable for BBB transmigration. In addition, both the surface lipoprotein OspA and the Rrp1 pathway, which are required B. burgdorferi colonization in the tick vector, were found not required for BBB transmigration. Collectively, our findings using in vitro transwell assays uncover another potential role of the Rrp2-RpoN-RpoS pathway in BBB transmigration of B. burgdorferi and invasion into the CNS.

Primary perineuritis, a rare but treatable neuropathy: Review of perineurial anatomy, clinicopathological features, and differential diagnosis

The perineurium surrounds each fascicle in peripheral nerves, forming part of the blood-nerve barrier. We describe its normal anatomy and function. "Perineuritis" refers to both a nonspecific histopathological finding and more specific clinicopathological entity, primary perineuritis (PP). Patients with PP are often assumed to have nonsystemic vasculitic neuropathy until nerve biopsy is performed. We systematically reviewed the literature on PP and developed a differential diagnosis for histopathologically defined perineuritis. We searched PubMed, Embase, Scopus, and Web of Science for "perineuritis." We identified 20 cases (11 M/9F) of PP: progressive, unexplained neuropathy with biopsy showing perineuritis without vasculitis or other known predisposing condition. Patients ranged in age from 18 to 75 (mean 53.7) y and had symptoms 2-24 (median 4.5) mo before diagnosis. Neuropathy was usually sensory-motor (15/20), painful (18/19), multifocal (16/20), and distal-predominant (16/17) with legs more affected than arms. Truncal numbness occurred in 6/17; 10/18 had elevated cerebrospinal fluid (CSF) protein. Electromyography (EMG) and nerve conduction studies (NCS) demonstrated primarily axonal changes. Nerve biopsies showed T-cell-predominant inflammation, widening, and fibrosis of perineurium; infiltrates in epineurium in 10/20 and endoneurium in 7/20; and non-uniform axonal degeneration. Six had epithelioid cells. 19/20 received corticosteroids, 8 with additional immunomodulators; 18/19 improved. Two patients did not respond to intravenous immunoglobulin (IVIg). At final follow-up, 13/16 patients had mild and 2/16 moderate disability; 1/16 died. Secondary causes of perineuritis include leprosy, vasculitis, neurosarcoidosis, neuroborreliosis, neurolymphomatosis, toxic oil syndrome, eosinophilia-myalgia syndrome, and rarer conditions. PP appears to be an immune-mediated, corticosteroid-responsive disorder. It mimics nonsystemic vasculitic neuropathy. Cases with epithelioid cells might represent peripheral nervous system (PNS)-restricted forms of sarcoidosis.

Borrelia bavariensis in Questing Ixodes ricinus Ticks, United Kingdom

We detected Borrelia bavariensis in Ixodes ricinus ticks collected near 2 towns in the United Kingdom. Human B. bavariensis infections have not been reported previously in the country, underscoring the value of tick surveillance to warn of emerging human disease. B. bavariensis should be considered in patients with suspected neuroborreliosis.

Neuroborreliosis Presenting as Guillain-Barré Syndrome

Lyme disease (LD) is the most common vector-borne disease in the United States. The early localized disease presents with erythema migrans and nonspecific constitutional symptoms. A neurological manifestation of LD (neuroborreliosis) is only seen in 10-15% of LD cases, and it typically presents as cranial neuritis or painful radiculitis. We report a case of a 33-year-old male who presented with progressive ascending bilateral lower extremities weakness with paresthesia in hands and feet following an upper respiratory tract infection and an abdominal rash. Cerebrospinal fluid (CSF) analysis revealed albuminocytologic dissociation. An electrodiagnostic study showed prolonged distal motor latency, conduction block, and absent F-wave response. Magnetic resonance imaging of the lumbar spine revealed enhancement of the cauda equina nerve roots. After a lack of improvement with intravenous immunoglobulin for presumed Guillain-Barré syndrome (GBS), Lyme serologies were sent and showed positive Lyme antibodies in serum and CSF as well as positive western blot IgM followed by IgG seroconversion a week later. The patient was started on IV ceftriaxone and doxycycline for four weeks with significant improvement in his symptoms. This is a rare case of LD presenting as GBS. Lyme can have diverse neurologic manifestations and should be considered in the differential diagnosis of GBS in the appropriate settings.

Lyme neuroborreliosis: An unusual case with extensive (peri)vasculitis of the middle cerebral artery

Lyme disease is a tick-borne infection caused by Borrelia burgdorferi sensu latu. Neuroborreliosis is reported in approximately 10% of patients with Lyme disease. We report a patient with central nervous system (CNS) large vessel vasculitis, ischemic stroke, and tumefactive contrast-enhancing brain lesions, an unusual complication of neuroborreliosis. A 56-year-old man presented with headache and disorientation for 1 month. Magnetic resonance imaging revealed basal meningitis with rapidly progressing frontotemporoinsular edema and (peri)vasculitis. Transcranial ultrasound confirmed stenosed medial cerebral arteries. [¹⁸ F]GE-180 microglia positron emission tomography (PET) showed frontotemporoinsular signal more pronounced on the right. [¹⁸ F]FET amino acid PET demonstrated low tracer uptake, suggesting an inflammatory process. Cerebrospinal fluid (CSF) showed lymphomonocytosis (243/μl), intrathecal anti-Borrelia IgM (CSF/serum index = 15.65, normal < 1.5) and anti-Borrelia IgG (CSF/serum index = 6.5, normal < 1.5), and elevated CXCL13 (29.2 pg/ml, normal < 10 pg/ml). Main differential diagnoses of neurotuberculosis and perivascular CNS lymphoma were ruled out by biopsy and Quantiferon enzyme-linked immunosorbent assay. Ceftriaxone (28 days), cortisone, and nimodipine (3 months) led to full recovery. Neuroborreliosis is an important differential diagnosis in patients with CNS large vessel vasculitis and tumefactive contrast-enhancing brain lesions, mimicking perivascular CNS lymphoma or neurotuberculosis as main neuroradiological differential diagnoses. Vasculopathy and cerebrovascular events are rare in neuroborreliosis but should be considered, especially in endemic areas.

An Unusual Case of Lyme Carditis With Persistent Third-Degree Heart Block

Lyme's carditis and neuroborreliosis are common manifestation of disseminated Lyme disease. However, third-degree atrioventricular blocks with Lyme's carditis requiring permanent pacemaker with neuroborreliosis and Lyme's disease-associated immunodeficiency are uncommon. Here we present a case of 64-year-old female presenting with neurological symptoms and electrocardiogram changes suggestive of complete heart block with no improvement in the degree of heart block with intravenous antibiotics, requiring permanent pacemaker implantation and course complicated by fungemia.

Descriptive Data on Trends Among Patients Hospitalized With Lyme Disease in Southwest Michigan, 2017-2021

This retrospective chart review identifies hospitalizations for Lyme disease at two southwest Michigan hospital systems, 2017-2021. Lyme admissions increased sharply, while admissions for Lyme carditis and neuroborreliosis increased in parallel. Southwest Michigan is becoming an endemic area for Lyme disease.

Attenuation of relapsing fever neuroborreliosis in mice by IL-17A blockade

Spirochetes of the genus Borrelia can spread to various organs including the central nervous system. The neurological disease manifestations in these bacterial infections are commonly referred as neuroborreliosis. Currently, long-term antibiotic treatment is the only the United States Food and Drug Administration-approved option for those suffering from neuroborreliosis. Using Borrelia hermsii infection in mice, we have previously established a relapsing fever neuroborreliosis model. In this model, we found that the induction of interleukin (IL)-17A signaling plays a major role in the pathogenesis of relapsing fever neuroborreliosis. We show that anti-IL-17A antibody treatment can ameliorate the pathology. Our data suggest that IL-17A blockade may be a therapeutic strategy for controlling relapsing fever neuroborreliosis.

Relapsing fever due to Borrelia hermsii is characterized by recurrent bacteremia episodes. However, infection of B. hermsii, if not treated early, can spread to various organs including the central nervous system (CNS). CNS disease manifestations are commonly referred to as relapsing fever neuroborreliosis (RFNB). In the mouse model of B. hermsii infection, we have previously shown that the development of RFNB requires innate immune cells as well as T cells. Here, we found that prior to the onset of RFNB, an increase in the systemic proinflammatory cytokine response followed by sustained levels of IP-10 concurrent with the CNS disease phase. RNA sequencing analysis of the spinal cord tissue during the disease phase revealed an association of the interleukin (IL)-17 signaling pathway in RFNB. To test a possible role for IL-17 in RFNB, we compared B. hermsii infection in wild-type and IL-17A^−/− mice. Although the onset of bacteremia and protective anti-B. hermsii antibody responses occurred similarly, the blood-brain barrier permeability, proinflammatory cytokine levels, immune cell infiltration in the spinal cord, and RFNB manifestations were significantly diminished in IL-17A^−/− mice compared to wild-type mice. Treatment of B. hermsii-infected wild-type mice with anti-IL-17A antibody ameliorated the severity of spinal cord inflammation, microglial cell activation, and RFNB. These data suggest that the IL-17 signaling pathway plays a major role in the pathogenesis of RFNB, and IL-17A blockade may be a therapeutic modality for controlling neuroborreliosis.

Lyme neuroborreliosis as a cause of sudden sensorineural hearing loss and facial palsy

We present a case of sudden sensorineural hearing loss and rapidly progressive facial palsy in a female patient in her 40s with no, apparently, notable past medical or surgical history. Investigations revealed a positive serology for B. burgdoferi and the MRI allowed us to identify suggestive signs of Lyme meningitis with multiple cranial nerve involvement. After diagnosis, the patient was treated with intravenous ceftriaxone with a full recovery of sensorineural deafness and facial palsy. This case report highlights the importance of collecting a complete medical history in all cases of facial palsy and sudden hearing loss while presenting an infrequent clinical presentation of early disseminated Lyme disease with neuroborreliosis.

Fatigue and cognitive impairment in neuroborreliosis patients posttreatment-A neuropsychological retrospective cohort study

BACKGROUND

The aim of this study was to determine the prevalence of fatigue and cognitive impairment in patients with neuroborreliosis (NB) posttreatment and to determine whether delayed treatment initiation led to higher levels of fatigue and cognitive impairment.

METHODS

The study population consisted of 88 patients with NB included between October 10, 2014, and August 21, 2020, at the Clinical Center for Emerging and Vector-borne Infections at Odense University Hospital, Denmark. The Symbol Digit Modalities Test (SDMT) was used as a cognitive screening test, and the Modified Fatigue Impact Scale (MFIS) was used to assess the patients' level of fatigue over the course of a year.

RESULTS

Overall, 14.3% of patients had an SDMT score indicative of cognitive impairment, and 38.8% of patients reported experiencing fatigue 12 months posttreatment. We found no statistically significant differences in fatigue or cognitive impairment when comparing the patients who had a treatment delay of ≤14 days and those with a treatment delay of >14 days (p > .05) 12 months posttreatment. A random effects regression model showed a significant positive correlation between longer treatment delay and higher MFIS scores, indicating higher levels of fatigue.

CONCLUSIONS

The results of this study show that both the early and late treatment groups improved significantly over a 12-month period in terms of both cognitive symptoms and fatigue. However, it also showed that a substantial subgroup of patients with NB still suffer from fatigue and cognitive impairment 12 months posttreatment.

Genomic hybrid capture assay to detect Borrelia burgdorferi: an application to diagnose neuroborreliosis in horses

Antemortem diagnosis of neuroborreliosis in horses has been hindered by both the low sensitivity of PCR testing for Borrelia burgdorferi in CSF and the low specificity of serum:CSF ELISA ratios used to determine intrathecal antibody production against the bacterium. PCR testing of the CSF of an adult horse with acute neurologic disease for the B. burgdorferi flagellin gene was negative. However, we enriched B. burgdorferi DNA through nucleic acid hybrid capture, followed by next-generation sequencing, and identified B. burgdorferi in the CSF of the horse, confirming a diagnosis of neuroborreliosis.

Lyme neuroborreliosis: known knowns, known unknowns

Lyme borreliosis affects the nervous system in three principal ways-mononuclear cell meningitis, cranial neuropathies and radiculoneuropathies-the last a broad term encompassing painful radiculopathy, unifocal and multifocal peripheral nerve involvement. Diagnostic tools have been significantly refined-including improved peripheral blood and CSF serodiagnostics-and much has been learned about the interactions between the causative pathogen and the nervous system. Despite these advances in our understanding of this disease, a broad range of other disorders continue to be misattributed to nervous system Lyme borreliosis, supported by, at best, limited evidence. These misattributions often reflect limited understanding not only of Lyme neuroborreliosis but also of what constitutes nervous system disease generally. Fortunately, a large body of evidence now exists to clarify many of these issues, establishing a clear basis for diagnosing nervous system involvement in this infection and, based on well performed studies, clarifying which clinical disorders are associated with Lyme neuroborreliosis, which with non-neurologic Lyme borreliosis, and which with neither.

Occam vs Hickam

A 23-year-old man presented with new onset horizontal diplopia 5 months after a left orbital floor fracture. Examination revealed bilateral abduction deficits and disc swelling. Urgent MRI and MRI showed no significant abnormalities in the CNS. Lumbar puncture revealed a minimally elevated opening pressure and significant leukocytosis. Additional CSF testing revealed probable Lyme meningitis. The patient responded to a course of oral doxycycline, with rapid resolution of his diplopia, abduction deficits, and disc edema.

Cognitive function in patients with neuroborreliosis: A prospective cohort study from the acute phase to 12 months post treatment

BACKGROUND

Long-term cognitive problems after neuroborreliosis treatment remain a subject of debate. We have previously shown that cognitive problems are not present in the acute phase of neuroborreliosis, although fatigue is common. The aim of this study was to re-assess the same patient cohort and evaluate long-term outcomes.

METHODS

In this follow-up, we re-assessed 58 patients with well-characterized neuroborreliosis 12 months after completing treatment. The same protocol with eight subtests measuring attention and processing speed and the Fatigue Severity Scale (FSS) were used to compare the results from the acute phase to 12 months post treatment.

RESULTS

We found no changes in attention or processing speed but a reduction in the level of fatigue (median score on FSS: 4.9 vs. 3.9, p < .001) from the acute phase to 12 months post treatment.

CONCLUSION

The patient group did not develop problems with attention or processing speed post treatment, while the level of fatigue decreased.

Plasma Proteomic Profile of Patients with Tick-Borne Encephalitis and Co-Infections

Despite the increasing number of patients suffering from tick-borne encephalitis (TBE), Lyme disease, and their co-infection, the mechanisms of the development of these diseases and their effects on the human body are still unknown. Therefore, the aim of this study was to evaluate the changes in the proteomic profile of human plasma induced by the development of TBE and to compare it with changes in TBE patients co-infected with other tick-borne pathogens. The results obtained by proteomic analysis using a nanoLC-Q Exactive HF mass spectrometer showed that the most highly elevated groups of proteins in the plasma of TBE patients with co-infection were involved in the pro-inflammatory response and protein degradation, while the antioxidant proteins and factors responsible for protein biosynthesis were mainly downregulated. These results were accompanied by enhanced GSH- and 4-HNE-protein adducts formation, observed in TBE and co-infected patients at a higher level than in the case of patients with only TBE. In conclusion, the differences in the proteomic profiles between patients with TBE and co-infected patients indicate that these diseases are significantly diverse and, consequently, require different treatment, which is particularly important for further research, including the development of novel diagnostics tools.

Unique Clinical, Immune, and Genetic Signature in Patients with Borrelial Meningoradiculoneuritis1

This form of Lyme neuroborreliosis is a distinct clinical entity with specific signs and symptoms.

Lyme neuroborreliosis (LNB) in Europe may manifest with painful meningoradiculoneuritis (also known as Bannwarth syndrome) or lymphocytic meningitis with or without cranial neuritis (peripheral facial palsy). We assessed host immune responses and the prevalence of TLR1 (toll-like receptor 1)–1805GG polymorphism to gain insights into the pathophysiology of these conditions. Regardless of LNB manifestation, most mediators associated with innate and adaptive immune responses were concentrated in cerebrospinal fluid; serum levels were unremarkable. When stratified by specific clinical manifestation, patients with meningoradiculoneuritis had higher levels of B-cell chemoattractants CXC motif chemokine ligand (CXCL) 12 and CXCL13 and T-cell–associated mediators CXCL9, CXCL10, and interleukin 17, compared with those without radicular pain. Moreover, these patients had a higher frequency of TLR1–1805GG polymorphism and more constitutional symptoms. These findings demonstrate that meningoradiculoneuritis is a distinct clinical entity with unique immune and genetic pathophysiology, providing new considerations for the study of LNB and borrelial meningoradiculitis.

Lyme borreliosis presenting as severe back pain after Shinrin-Yoku (forest bathing) in southern Germany

Since Lyme borreliosis is endemic in the Northern Hemisphere, it is usually not in the spotlight of travel medicine. However, borreliosis is a relevant problem and diagnostic challenge in travelers from the Southern Hemisphere returning from trips to Europe and North America.

To Lumbar Puncture or Not to Lumbar Puncture: A Case of Lyme Neuroborreliosis

Lyme disease is a zoonotic infection increasing in prevalence across the United States. While the recognition of its classic clinical signs is sufficient to establish the diagnosis in the early stages, the diagnosis of Lyme neuroborreliosis (LNB) may be challenging and the diagnostic approaches may have to be tailored. We report a rare case of early disseminated LNB presenting with features of Banwarth syndrome in the form of painful radiculoneuritis, motor weakness, and facial palsy in a middle-aged female who presented to an Upstate New York Hospital during summer. Lyme antibody testing was found to be positive at a level of 11.70 by enzyme immunoassay and Western Blot was IgM positive with three out of three reactive borrelial proteins. Lumbar puncture was not performed per the patient's preference. Otherwise, the laboratory workup along with MRI of the brain and cervical spine were grossly unremarkable. The patient was treated with a four-week course of oral doxycycline with resolution of all her symptoms. The diagnostic value of lumbar puncture in certain presentations of LNB remains controversial and is further discussed in this review.

Lyme Disease and Associated NMDAR Encephalitis: A Case Report and Literature Review

We present a case of a patient with positive N-methyl-D-aspartate receptor (NMDAR) IgG antibodies in their serum and cerebrospinal fluid (CSF) associated with neuroborreliosis. Clinically, the patient presented with symptoms of confusion, as well as behavioral and speech impairments. Regardless of antibacterial treatment, no significant improvement was achieved. Methylprednisolone provided a marked improvement in the patient’s clinical signs and CSF findings. The screening did not reveal any underlying neoplasm. Taking into account the marked clinical improvement after treatment with glucocorticosteroids, we suggest that NMDAR encephalitis is a possible autoimmune complication in neuroborreliosis patients requiring additional immunotherapy.

Relapsing Fever Infection Manifesting as Aseptic Meningitis, Texas, USA

Neuroborreliosis initially misdiagnosed as Lyme disease was discovered to be caused by the relapsing fever spirochete Borrelia turicatae.

Tickborne relapsing fever spirochetes are an overlooked cause of disease around the globe. We report a case of tickborne relapsing fever in a patient in Texas, USA, who had a single febrile episode and gastrointestinal and neurologic symptoms. Immunoblot analysis using recombinant Borrelia immunogenic protein A implicated Borrelia turicatae as the causative agent.

Bilateral Facial Nerve Palsy in a Young Woman From West Bengal: Do Not Forget Lyme Neuroborreliosis

Borrelia burgdorferi can affect the nervous system in various ways, which can generate significant confusion and dilemma regarding diagnosis. From India, a country until recently known to be a nonendemic zone for Lyme disease, several cases and one study of Lyme neuroborreliosis have been published. The aim of this study was to describe a young woman with bilateral facial nerve palsy as the presenting manifestation of Lyme neuroborreliosis. We herein report a case of a lactating woman with acute onset progressive ascending flaccid tetraparesis that was preceded by a misdiagnosed bilateral facial nerve palsy. She was finally diagnosed to be a case of acute Lyme neuroborreliosis, which responded favorably to intravenous and orally administered antibiotics. The possibility of Lyme neuroborreliosis should be considered more often from now on because in the last year four cases with the kindred clinical syndrome have been described from a so-called "nonendemic zone."

Lyme Neuroborreliosis in Children

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.

A Unique Case of Bannwarth Syndrome in Early Disseminated Lyme Disease

Lyme borreliosis is a multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi (B. burgdorferi) and transmitted through the Ixodes tick. Nervous system involvement is known as Lyme neuroborreliosis; it only occurs in disseminated Lyme disease and is manifested by the classic triad of meningitis, cranial neuritis, and radiculoneuritis. Timeline is a significant factor when staging Lyme manifestations. However, certain cases do not follow the typical presentation timelines described in most literature. We report a case of a 66-year-old male who presented with progressively worsening generalized body aches, severe fatigue, and new-onset urine retention for two weeks. Physical examination revealed severe pain with neck flexion and lying supine and diminished deep tendon reflexes bilaterally. Laboratory data revealed a positive Lyme immunoglobulin (Ig) M antibody with lymphocytic pleocytosis on lumbar puncture. He was treated with intravenous (IV) ceftriaxone for early disseminated Lyme disease. His radicular pain responded well to therapy, and he regained full bladder function. Bannwarth syndrome (BWS) is a term applied to the constellation of painful radiculoneuritis characterized as severe, burning, often dermatomal pain. In most cases, BWS affects the limbs, with only a few reported cases of sacral radiculitis causing neurogenic urinary dysfunction. Early recognition of this rare presentation associated with Lyme disease and treatment with antibiotics can prevent disease progression and detrimental neurological sequelae.

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

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

[The state of mental health in people with a diagnosis of neuroborreliosis]

BACKGROUND

In recent years, the number of recorded cases of Borrelia burgdorferi infections causing Lyme borreliosis has been on a steady rise in Poland. A wide spectrum of disorders in the peripheral and central nervous system is observed in the course of such infections. Symptoms which are not clear-cut are reported by approx. 10-25% of all people infected with B. burgdorferi. They may concern both the somatic and mental spheres, which in turn significantly impedes the daily functioning of the patients. The main purpose of the research was to compare the mental health status of people with neuroborreliosis with that of healthy people. An answer was also obtained to the question of whether people with neuroborreliosis experience difficulties in functioning in the following areas: family, social, professional and educational.

MATERIAL AND METHODS

The study included 60 people: 30 people with the diagnosis of neuroborreliosis and 30 healthy people aged 18-47. The mean age in the study group was 28.6 years. As a research tool, the General Health Questionnaire 28 (GHQ-28) by Goldberg was used along with a socio-demographic questionnaire.

RESULTS

The subjects diagnosed with neuroborreliosis obtained higher results in GHQ-28, both on individual scales: Somatic Symptoms, Anxiety, Insomnia, Social Dysfunction, Severe Depression, as well as the overall result, which is an indicator of the mental health status. As much as 70% of the patients experienced difficulties in functioning in the social area, 66% in the professional area, and 60% in the educational area. No impact of the disease on functioning in the family area has been demonstrated.

CONCLUSIONS

The results of the study indicate some significant differences in the mental health status of people diagnosed with neuroborreliosis and that of healthy people. The patients obtained significantly higher results in GHQ-28 than the healthy subjects, which proves the poor mental health of the former. It was also confirmed that people diagnosed with neuroborreliosis experience difficulties in functioning in the social, professional and educational areas. Therefore, it becomes crucial to deepen research into mental health in tick-borne diseases, including neuroborreliosis, and to adapt and implement appropriate preventive and therapeutic measures. Med. Pr. 2021;72(3):259-66.

The many manifestations of a single disease: neuroborreliosis

Lyme disease is a tick-borne illness that occurs in stages, multiple organs and tissue with highly variable clinical presentation. Most commonly, it presents with seventh cranial nerve palsy, often mimicking stroke and atypical rash (erythema migrans). Atypical presentations include abdominal pain, ileus/pseudo-obstruction and constipation thought to be due to autonomic dysfunction. Other less common presentations include Syndrome of Inappropriate Antidiuretic Hormones (SIADH). Lyme disease should be a differential when a patient presents from Lyme endemic areas with abdominal pain, constipation and SIADH in the setting of other causes of gastrointestinal and renal symptoms ruled out. Here we present a case of multisystem involvement in a single patient with Lyme Disease along with neuroborreliosis (neurological manifestation of Lyme disease).

Confirmed cases of Neuroborreliosis with involvement of peripheral nervous system: Description of a cohort

The manifestations of borreliosis in the peripheral nervous system (PNS) remain poorly described. As the symptoms of neuroborreliosis can be reversed with timely introduction of antibiotics, early identification could avoid unnecessary axonal loss. Our aim was to describe the characteristics of confirmed neuroborreliosis cases involving the PNS diagnosed between 2007 and 2017 in our neuromuscular disease center in a nonendemic area (La Pitié-Salpêtrière Hospital, Paris, France).Neuroborreliosis was defined as follows: compatible neurological symptoms without other cause of neuropathy; cerebrospinal fluid and serum analysis (positive serological tests with ELISA, confirmed by Western Blot); and improvement of symptoms with adapted antibiotherapy. All the patients consulting in our center between 2007 and 2017 underwent electrophysiological study.Sixteen confirmed cases of neuroborreliosis involving the PNS were included: 10 cases of meningoradiculoneuritis, 4 of axonal neuropathy, and 2 of demyelinating neuropathy (one acute and one chronic). Only 4 (25%) patients reported tick bites. Meningoradiculoneuritis was characterized by lymphocytic meningitis, intense pain, cranial nerve palsy, and contrast enhancement of nerve roots on imagery. The patients with axonal neuropathy presented sensory symptoms with intense pain but no motor deficit and meningitis was rare. Nerve biopsy of 1 patient revealed lymphocytic vasculitis. Electrophysiological testing showed sensory or sensorimotor axonal neuropathy (3 subacute and 1 chronic) of the lower limbs, with asymmetrical neuropathy in 1 patients, symmetrical neuropathy in one and monomelic sensory mononeuritis multiplex in another. We also found 1 case of acute demyelinating neuropathy, treated with antibiotherapy and immunoglobulins, and 1 chronic demyelinating neuropathy. Overall, diaphragmatic paralysis was frequent (18.6%). Antibiotherapy (mostly ceftriaxone 3-4 weeks) resulted in symptom resolution.This series gives an updated overview of the peripheral complications of neuroborreliosis to help identify this disease so that timely treatment could avoid axonal loss.

Comparative Analysis of the Euroimmun CXCL13 Enzyme-Linked Immunosorbent Assay and the ReaScan Lateral Flow Immunoassay for Diagnosis of Lyme Neuroborreliosis

Diagnosis of Lyme neuroborreliosis (LNB) is challenging, as long as Borrelia-specific intrathecal antibodies are not yet detectable. The chemokine CXCL13 is elevated in the cerebrospinal fluid (CSF) of LNB patients. Here, we compared the performances of the Euroimmun CXCL13 enzyme-linked immunosorbent assay (CXCL13 ELISA) and the ReaScan CXCL13 lateral flow immunoassay (CXCL13 LFA), a rapid point-of-care test, to support the diagnosis of LNB. In a dual-center case-control study, CSF samples from 90 patients (34 with definite LNB, 10 with possible LNB, and 46 with other central nervous system [CNS] diseases [non-LNB group]) were analyzed with the CXCL13 ELISA and the CXCL13 LFA. Classification of patients followed the European Federation of Neurological Societies (EFNS) guidelines on LNB. The CXCL13 ELISA detected elevated CXCL13 levels in all patients with definite LNB (median, 1,409 pg/ml) compared to the non-LNB controls (median, 20.7 pg/ml; P < 0.0001), with a sensitivity of 100% and a specificity of 84.8% (cutoff value, 78.6 pg/ml; area under the receiver operating characteristic [ROC] curve, 0.93). Similarly, the CXCL13 LFA yielded elevated CXCL13 levels in 31 patients with definite LNB (median arbitrary value, 223.5) compared to the non-LNB control patients (median arbitrary value, 0; P < 0.0001) and had a sensitivity and specificity of 91.2% and 93.5%, respectively (cutoff arbitrary value, 22.5; area under the ROC curve, 0.94). The correlation between the CXCL13 levels obtained by ELISA and LFA was strong (Spearman correlation coefficient r = 0.89; P < 0.0001). The CXCL13 ELISA and the CXCL13 LFA are comparable diagnostic tools for the detection of CXCL13 in the CSF of patients with definite LNB. The advantage of the CXCL13 LFA is the shorter time to result.

Lyme neuroborreliosis epidemiology in Sweden 2010 to 2014: clinical microbiology laboratories are a better data source than the hospital discharge diagnosis register

BackgroundIn a study from 2013 that prioritised communicable diseases for surveillance in Sweden, we identified Lyme borreliosis as one of the diseases with highest priority. In 2014, when the present study was designed, there were also plans to make neuroborreliosis notifiable within the European Union.AimWe compared possibilities of surveillance of neuroborreliosis in Sweden through two different sources: the hospital discharge register and reporting from the clinical microbiology laboratories.MethodsWe examined the validity of ICD-10 codes in the hospital discharge register by extracting personal identification numbers for all cases of neuroborreliosis, defined by a positive cerebrospinal fluid-serum anti-Borrelia antibody index, who were diagnosed at the largest clinical microbiology laboratory in Sweden during 2014. We conducted a retrospective observational study with a questionnaire sent to all clinical microbiology laboratories in Sweden requesting information on yearly number of cases, age group and sex for the period 2010 to 2014.ResultsAmong 150 neuroborreliosis cases, 67 (45%) had received the ICD-10 code A69.2 (Lyme borreliosis) in combination with G01.9 (meningitis in bacterial diseases classified elsewhere), the combination that the Swedish National Board of Health and Welfare recommends for neuroborreliosis. All 22 clinical laboratories replied to our questionnaire. Based on laboratory reporting, the annual incidence of neuroborreliosis in Sweden was 6.3 cases per 100,000 in 2014.ConclusionThe hospital discharge register was unsuitable for surveillance of neuroborreliosis, whereas laboratory-based reporting was a feasible alternative. In 2018, the European Commission included Lyme neuroborreliosis on the list of diseases under epidemiological surveillance.

The potential for CXCL13 in CSF as a differential diagnostic tool in central nervous system infection

Introduction: Central nervous system (CNS) infections can be life-threatening and are often associated with disabling sequelae. One important factor in most CNS infections is a timely pathogen-specific treatment. The diagnostic methods available, however, do not always reach a satisfying sensitivity and specificity. In these cases, there is need for additional diagnostic biomarkers. Chemokines represent potential candidates as biomarkers, since they are an important pillar of the host immune response. The aim of this review is to discuss the diagnostic potential of cerebrospinal fluid (CSF) CXCL13 in patients with CNS infections. Areas covered: Data were obtained from a literature search in PubMed up to October 2019. This review focusses on articles on the potential of CXCL13 as a diagnostic tool. The majority of identified studies aimed to characterize its role in two diseases, namely Lyme neuroborreliosis and neurosyphilis. Expert opinion: CSF CXCL13 has a significant potential as a diagnostic and monitoring add-on marker in Lyme neuroborreliosis. Differences in study design, control groups and clinical parameters between studies, however, affect sensitivity, specificity and cutoff values, underlining the need of further studies to address these issues and pave the way for a generalized clinical practice.

Peripheral facial nerve palsy in children in a Borrelia high-endemic area, a retrospective follow-up study

AIM

To identify the incidence, aetiology and prognosis of acute peripheral facial nerve palsy (FNP) in children in the Borrelia high-endemic region of Stockholm.

METHODS

The present study identified children from 0 to 18 years of age who visited a paediatric emergency department for acute peripheral FNP during a 1-year period from 2014 to 2015. Data were collected retrospectively. The Sunnybrook and House-Brackmann facial grading systems were used to measure clinical outcome.

RESULTS

A total of 77 children were identified with FNP, an estimated incidence of 30 per 100 000 children/year. Forty-five children (58%) were diagnosed with neuroborreliosis, 28 (36%) with idiopathic FNP and four (6%) with other rarer causes. Neuroborreliosis was common from June to November and mainly seen in children below 10 years of age. Six patients (8%) had remaining symptoms at least 3 months after onset; three had idiopathic facial palsy (IFP) and were all older than 10 years, one had neuroborreliosis and two had other causes.

CONCLUSION

Neuroborreliosis and IFP were the major causes of FNP during the study period. Neuroborreliosis-associated facial palsy had a seasonal variation and dominated in younger ages.

Neuroborreliosis – clinical presentation – Current state of knowledge

Neuroborreliosis is one of the manifestations of Lyme disease involving central and peripheral nervous system. It is caused by infection with Borrelia burgdorferi spirochete which is transmitted by tick bites. Neuroborreliosis can affect both adults and children. The clinical course in children is often different than in adults. The article discusses the most common clinical symptoms, complications, diagnostics and treatment of neuroborreliosis in children.

Guillain-Barre Syndrome, Neuroborreliosis, or Both

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

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

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

Chemokine Ligand 13 (CXCL13) in Neuroborreliosis and Neurosyphilis as Selected Spirochetal Neurological Diseases: A Review of Its Diagnostic Significance

Neuroborreliosis (NB) and neurosyphilis (NS) are abnormal conditions caused by spirochetal bacteria which affect the nervous system. Diagnosis of neuroborreliosis and neurosyphilis is determined by clinical examination of visible symptoms, serum and cerebrospinal fluid (CSF) analysis, and serological detection of antibodies against Borrelia burgdorferi sensu lato and Treponema pallidum, respectively. Establishing a diagnosis may sometimes pose a number of diagnostic difficulties. A potential role of chemokine ligand 13 (CXCL13) as an accurate diagnostic biomarker of intrathecal inflammation has been suggested. In this review, we focused on changes in serum and cerebrospinal fluid concentration of chemokine ligand 13 in selected spirochetal neurological diseases neuroborreliosis and neurosyphilis reported in the available literature. We performed an extensive search of the literature relevant to our investigation via the MEDLINE/PubMed database. It has been proven that CXCL13 determination can provide rapid information regarding central nervous system inflammation in patients with selected spirochetosis. We described that neuroborreliosis and neurosyphilis are associated with an elevated CXCL13 concentration, mainly in the cerebrospinal fluid. Moreover, literature data suggest that CXCL13 determination is the most interesting additional marker for diagnosis and monitoring of neuroborreliosis and neurosyphilis thanks to its high sensitivity. Based on these published findings, we suggest that CXCL13 has high diagnostic utility and may be applied in laboratory diagnostics as a potential diagnostic marker in human spirochetal neurologic diseases.

Patient-reported outcome after treatment for definite Lyme neuroborreliosis

OBJECTIVE

To chart patient-reported outcome measures (PROMs) in Norwegian patients treated for definite neuroborreliosis (NB).

MATERIAL AND METHODS

Adult patients treated for definite NB 1-10 years earlier supplied demographics, symptoms and treatment during NB, and answered validated questionnaires; Fatigue Severity Scale (FSS), Hospital Anxiety and Depression Scale (HADS), health-related quality of life questionnaire (RAND-36), and Patient Health Questionnaire (PHQ-15).

RESULTS

A higher proportion of NB-treated persons reported severe fatigue, defined as FSS score ≥ 5, than in Norwegian normative data, but when removing persons with confounding fatigue associated comorbidities (n = 69) from the analyses, there was no difference between groups. Physical health-related quality of life (RAND-36 PCS), mean FSS score, proportions of persons reporting moderate or severe somatic symptom burden (PHQ-15 score ≥ 10), anxiety (HADS-A ≥ 8), or depression (HADS-D ≥ 8) did not differ between NB-treated persons and reference scores. Mental health-related quality of life (RAND-36 MCS) was poorer than in normative data (47.1 vs. 53.3), but associated with anxiety, depression and current moderate or severe somatic symptom burden, and not with NB characteristics.

CONCLUSIONS

Results on validated PROM questionnaires measuring fatigue, anxiety, depression, self-reported somatic symptom burden, and physical health-related quality did not differ between persons treated for definite NB 1-10 years earlier and reference scores. NB-treated persons tended to report a slightly poorer mental health-related quality of life than found in normative data, but when adjusting for confounders the causative connection is questionable. Overall, the long-term prognosis of definite NB seems to be good.

ALS or ALS mimic by neuroborreliosis-A case report

Comprehensive investigation in motor neuron disease is vital not to miss a treatable differential diagnosis. Neuroborreliosis should be considered during an ALS work-up. However, false-positive CSF results do occur, and thus, results should be interpreted carefully in context of all clinical test results.

Chronic Lyme Disease: An Evidence-Based Definition by the ILADS Working Group

Objective: Chronic Lyme disease has been a poorly defined term and often dismissed as a fictitious entity. In this paper, the International Lyme and Associated Diseases Society (ILADS) provides its evidence-based definition of chronic Lyme disease. Definition: ILADS defines chronic Lyme disease (CLD) as a multisystem illness with a wide range of symptoms and/or signs that are either continuously or intermittently present for a minimum of six months. The illness is the result of an active and ongoing infection by any of several pathogenic members of the Borrelia burgdorferi sensu lato complex (Bbsl). The infection has variable latency periods and signs and symptoms may wax, wane and migrate. CLD has two subcategories, CLD, untreated (CLD-U) and CLD, previously treated (CLD-PT). The latter requires that CLD manifestations persist or recur following treatment and are present continuously or in a relapsing/remitting pattern for a duration of six months or more. Methods: Systematic review of over 250 peer reviewed papers in the international literature to characterize the clinical spectrum of CLD-U and CLD-PT. Conclusion: This evidence-based definition of chronic Lyme disease clarifies the term's meaning and the literature review validates that chronic and ongoing Bbsl infections can result in chronic disease. Use of this CLD definition will promote a better understanding of the infection and facilitate future research of this infection.

Vertigo and Severe Balance Instability as Symptoms of Lyme Disease-Literature Review and Case Report

Lyme disease is caused by a tick-borne bacterium Borrelia sp. This zoonotic infection is common in the Northern Hemisphere, e.g., Europe. Clinical presentation may involve multisystem symptoms and depends on the stage of the disease. The involvement of nervous system in Lyme disease is commonly referred to as neuroborreliosis. Neuroborreliosis may involve meningitis, mononeuritis multiplex, or cranial neuritis including the inflammation of vestibulocochlear nerve. In the late or chronic stage of Lyme disease, vestibular involvement may be the sole presentation, although such cases are rare. Our study was designed to present our own case and review the available literature reporting cases of neuroborreliosis with vertigo/dizziness and severe balance instability as a main disease symptom. The studies were obtained by searching the following databases: PubMed, Medline, and Embase. We included case reports of Lyme disease presenting with vertigo or gait disorders as the main symptom, written in the English language. Initially, 60 papers were identified. After analyzing the abstracts, seven manuscripts focusing on 13 clinical cases were included in this review. We conclude that the patients with neuroborreliosis sometimes present vertigo/dizziness, but rarely gait ataxia as a sole symptom. These complaints are usually accompanied by a hearing loss. Antibiotic treatment is usually effective. Balance instability in the patients with neuroborreliosis may persist but it responds well to vestibular rehabilitation.

Neuroborreliosis with Unusual Presentation: A Case Report

Lyme disease is the most common vector-borne disease in the northern hemisphere. Neurological complications usually manifest in patients who do not receive treatment for Lyme disease. Neurological involvement may be early or late, depending on the duration of the symptoms. Early neuroborreliosis presents with symptoms such as headache and meningism; late neuroborreliosis can present with signs and symptoms of encephalopathy and stroke-like symptoms. The diagnosis is based on clinical manifestations and lumbar puncture finding. Treatment consists of intravenous antibiotics for a period of three to four weeks. Patients who receive early treatment usually have an excellent prognosis, with very few patients developing post-treatment Lyme disease syndrome. Here, we report an unusual case of Lyme disease with extremely high cerebrospinal fluid protein level and devastating neurological sequelae. The diagnosis of neuroborreliosis is based on neurological symptoms and lumbar puncture findings.

Assessment of TLR-2 concentration in tick-borne encephalitis and neuroborreliosis

The aim of the study was to check whether measurement of TLR-2 in serum or cerebrospinal fluid (CSF) can help differentiate between neuroborreliosis (NB) and tick-borne encephalitis (TBE). Eighty patients with meningitis and meningoencephalitis were divided into two groups: Group I - patients with NB (n = 40) and Group II - patients with TBE (n = 40). Diagnosis was based on the clinical picture, CSF examination and presence of specific antibodies in serum and CSF. The control group (CG) consisted of healthy blood donors (n = 25) and patients in whom inflammatory process in central nervous system was excluded (n = 25). Concentration of TLR-2 was measured using a commercial kit [TLR-2 Elisa Kit (EIAab, China)]. The serum and CSF TLR-2 concentration of NB patients was significantly higher than in CG. The serum and CSF TLR-2 concentration in TBE patients was significantly higher than in the CG. Receiver operating characteristic analysis of the serum TLR-2 concentration showed significant differences between the group of patients with NB and a group of patients with TBE. TLR-2 is involved in the development of inflammatory process in the CNS caused by both tick-borne pathogens: viral and bacterial as TLR-2 concentration in both CSF and serum differentiates these groups from healthy patients. Although TLR-2 cannot be used as a sole and reliable biomarker differentiating NB from TBE, results of our study are a step forward toward discovering such biomarker in the future.

Geographic Range of Lyme Borreliosis in Mongolia

Introduction: In Asia, Borrelia garinii, B. afzelii, and B. bavariensis are transmitted by Ixodes persulcatus ticks and clinically present with a wide range of neurological and arthritic symptoms. This report aims to provide details on the geographic distribution of suspected cases of Lyme borreliosis (LB), reported to local Mongolian hospitals between 2007 and 2017. Methods: This report examines 150 reported cases of suspected LB from 13 aimags (provinces) in Mongolia from April 2007 to August 2017, including date and location of infection, method of diagnosis (indirect immunofluorescent assay and/or enzyme-linked immunosorbent assay test), frequency of specific symptoms, and case demographics. Information was gathered through collaboration with the National Center of Communicable Disease and the National Center for Zoonotic Diseases. Results: Zavkhan and Selenge, located in northern Mongolia, had the highest percentage of reported suspected cases, with 25% and 20%, respectively. Ages ranged from 1 to 78 years, with a mean age of 26 years, however, 37% of individuals were younger than 10. More than twice as many women sought treatment as men, and the distribution of men who sought treatment was skewed toward children and the elderly. Most frequently reported symptoms include fever, rash, headache, and enlarged lymph glands. Furthermore, peak months of tick bite and treatment seeking occurred between April and June. Conclusions: Based on these preliminary findings, syndromic surveillance should be expanded across northern Mongolia, with LB considered in differential diagnosis for patients reporting a recent tick bite.

Atypical papillitis: An isolated manifestation of Lyme disease

Lyme disease is a rare condition caused by the bacterium Borrelia burgdorferi. Despite typical symptoms including fever, headache, fatigue, and a characteristic skin rash, sometimes we cannot find those due to the lack of physician consultation in those early stages. If this disease is left untreated, infection could spread to the nervous system causing neuroborreliosis, an atypical and complicated manifestation of this disease. We present the case of an atypical papillitis, probably caused by this bacterium. We suspected this because of the results on the indirect test bloods and the improvement of the symptoms after treatment. This entity should be considered as a possible diagnosis of atypical optical neuropathies, particularly if it occurs in an endemic area.

Disulfiram (Tetraethylthiuram Disulfide) in the Treatment of Lyme Disease and Babesiosis: Report of Experience in Three Cases

Three patients, each of whom had required intensive open-ended antimicrobial therapy for control of the symptoms of chronic relapsing neurological Lyme disease and relapsing babesiosis, were able to discontinue treatment and remain clinically well for periods of observation of 6–23 months following the completion of a finite course of treatment solely with disulfiram. One patient relapsed at six months and is being re-treated with disulfiram.