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Volk T, Urbach H, Fingerle V, Bardutzky J, Rauer S, Dersch R. Spectrum of MRI findings in central nervous system affection in Lyme neuroborreliosis. Sci Rep 2024; 14:12486. [PMID: 38816506 PMCID: PMC11139962 DOI: 10.1038/s41598-024-63006-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/23/2024] [Indexed: 06/01/2024] Open
Abstract
Affections of the central nervous system (CNS) rarely occur in Lyme neuroborreliosis (LNB). CNS manifestations can have residual neurological symptoms despite antibiotic treatment. We explored the spectrum of CNS affections in patients with LNB in a tertiary care center in a region endemic for Lyme borreliosis. We retrospectively included patients treated at a tertiary care center from January 2020-December 2021 fulfilling the case criteria for LNB as stated in the current German guideline on LNB. Clinical data, cerebrospinal fluid (CSF) findings and MRI imaging were collected. We included 35 patients with LNB, 24 with early manifestations and 11 with CNS-LNB. CNS-LNB patients had encephalomyelitis (n = 6) or cerebral vasculitis (n = 5). Patients with early LNB and CNS-LNB differed regarding albumin CSF/serum quotient and total protein in CSF. Duration from onset of symptoms until diagnosis was statistically significantly longer in patients with encephalomyelitis. MRI findings were heterogeneous and showed longitudinal extensive myelitis, perimedullar leptomeningeal enhancement, pontomesencephalic lesions or cerebral vasculitis. CNS-LNB can present with a variety of clinical syndromes and MRI changes. No clear pattern of MRI findings in CNS-LNB could be identified. The role of MRI consists in ruling out other causes of neurological symptoms.
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Affiliation(s)
- T Volk
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - H Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - V Fingerle
- National Reference Center for Borrelia, Bavarian Health and Food Safety Authority, 85764, Oberschleissheim, Germany
| | - J Bardutzky
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - S Rauer
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
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2
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Bransfield RC, Goud Gadila SK, Kursawe LJ, Dwork AJ, Rosoklija G, Horn EJ, Cook MJ, Embers ME. Late-stage borreliosis and substance abuse. Heliyon 2024; 10:e31159. [PMID: 38779029 PMCID: PMC11108998 DOI: 10.1016/j.heliyon.2024.e31159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Background Infectious diseases can contribute to substance abuse. Here, a fatal case of borreliosis and substance abuse is reported. This patient had a history of multiple tick bites and increasing multisystem symptoms, yet diagnosis and treatment were delayed. He experimented with multiple substances including phencyclidine (PCP), an N-methyl-d-aspartate (NMDA) receptor antagonist that opposes NMDA agonism caused by Borrelia infection. During PCP withdrawal, he committed one homicide, two assaults, and suicide. Methods Brain tissue was obtained from autopsy and stained for microglial activation and quinolinic acid (QA). Immunoflouresence (IFA) and fluorescence in situ hybridization (FISH) were used to identify the presence of pathogens in autopsy tissue. Results Autopsy tissue evaluation demonstrated Borrelia in the pancreas by IFA and heart by IFA and FISH. Activated microglia and QA were found in the brain, indicating neuroinflammation. It is postulated that PCP withdrawal may exacerbate symptoms produced by Borrelia-induced biochemical imbalances in the brain. This combination may have greatly increased his acute homicidal and suicidal risk. Patient databases also demonstrated the risk of homicide or suicide in patients diagnosed with borreliosis and confirmed multiple symptoms in these patients, including chronic pain, anxiety, and anhedonia. Conclusions Late-stage borreliosis is associated with multiple symptoms that may contribute to an increased risk of substance abuse and addictive disorders. More effective diagnosis and treatment of borreliosis, and attention to substance abuse potential may help reduce associated morbidity and mortality in patients with borreliosis, particularly in endemic areas.
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Affiliation(s)
- Robert C. Bransfield
- Rutgers-RWJ Medical School, Piscataway, NJ, USA. Hackensack Meridian Health-School of Medicine, Nutley, NJ, USA
| | - Shiva Kumar Goud Gadila
- Division of Immunology, Tulane National Primate Research Center, Tulane University Health Sciences, Covington, LA, USA
| | - Laura J. Kursawe
- Charité – Universitatsmedizin Berlin, Corporate Member of Freie Universitat Berlin and Humboldt-Universitat zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andrew J. Dwork
- Department of Psychiatry, Columbia University, New York, NY, United States. Division of Molecular Imaging and Neuropathology, New York, USA
- State Psychiatric Institute, New York, NY, USA
- Macedonian Academy of Sciences and Arts, Skopje, Macedonia
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Gorazd Rosoklija
- State Psychiatric Institute, New York, NY, USA
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | | | | | - Monica E. Embers
- Division of Immunology, Tulane National Primate Research Center, Tulane University Health Sciences, Covington, LA, USA
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3
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David Ruban S, Skaarup Andersen N, Svatkova A, Fischer CP. Neuroborreliosis Presenting as Encephalitis: A Case Report. Cureus 2024; 16:e57882. [PMID: 38725777 PMCID: PMC11081406 DOI: 10.7759/cureus.57882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/12/2024] Open
Abstract
Infection with Borrelia burgdorferi spirochetes can cause Lyme neuroborreliosis (LNB). Neuroborreliosis presenting as encephalitis is a rare manifestation. We present a 72-year-old male patient hospitalized after three days of confusion and altered mental status. Initial computerized tomography (CT) and magnetic resonance imaging (MRI) of the brain were both unremarkable. Lumbar puncture showed an elevated number of white blood cells, elevated protein, and normal glucose levels in the cerebrospinal fluid (CSF), normal electroencephalogram (EEG), and negative tests for common microorganisms in the CSF. The patient received treatment with acyclovir and ceftriaxone. Lumbar puncture repeated on day 16 showed a decreasing number of white blood cells. A repeated MRI showed white matter edema, interpreted as encephalitis, while a repeated EEG showed signs of a non-specific cerebral lesion. The first lumbar puncture revealed intrathecal immunoglobulin M (IgM) antibodies against Borrelia and was positive for Borrelia DNA using real-time PCR, and the following lumbar puncture showed both IgM and IgG intrathecal antibody production. These results thus confirmed the diagnosis of Lyme Borrelia encephalitis. The patient improved clinically and was discharged after treatment with ceftriaxone for three weeks. Encephalitis due to LNB should be considered as a differential diagnosis in cases with unexplained neurological symptoms. Changes in MRI and/or EEG might occur late in the course of the disease, underlining the need for repeated tests in unresolved cases.
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Affiliation(s)
- Sabina David Ruban
- Department of Infectious Diseases, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, DNK
| | - Nanna Skaarup Andersen
- Clinical Centre for Emerging and Vector-Borne Infections, Department of Clinical Microbiology, Odense University Hospital, Denmark, Odense, DNK
- Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, DNK
| | - Alena Svatkova
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, DNK
- Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, DNK
| | - Christian Philip Fischer
- Department of Infectious Diseases, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, DNK
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4
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Lannoo L, Termote B, Delmotte K. A case of neuroborreliosis with striking abnormalities on brain MRI. Acta Neurol Belg 2024; 124:367-369. [PMID: 37495824 DOI: 10.1007/s13760-023-02337-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/10/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Laura Lannoo
- Department of Neurology, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Bruno Termote
- Department of Radiology, Jessa Hospital, Hasselt, Belgium
| | - Koen Delmotte
- Department of Neurology, Jessa Hospital, Hasselt, Belgium
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5
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Radzišauskienė D, Urbonienė J, Jasionis A, Klimašauskienė A, Malickaitė R, Petrulionienė A, Vitkauskaitė M, Kaubrys G. Clinical and epidemiological features of Lyme neuroborreliosis in adults and factors associated with polyradiculitis, facial palsy and encephalitis or myelitis. Sci Rep 2023; 13:19881. [PMID: 37964035 PMCID: PMC10646085 DOI: 10.1038/s41598-023-47312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/12/2023] [Indexed: 11/16/2023] Open
Abstract
The clinical course of Lyme neuroborreliosis (LNB) is highly variable. Delayed diagnosis and treatment still remain actual challenges. Moreover, there is a lack of studies analyzing the factors associated with different LNB syndromes. We aimed to analyze clinical and epidemiological features of LNB in hospitalized adults in eastern Lithuania. A retrospective study was performed for patients presenting in the years 2010-2021. A total of 103 patients were included in the study, 100 with early, and three with late LNB. Patients with early LNB most often presented polyradiculitis [75/100, (75%)], which was also the most common initial neurological syndrome. Peripheral facial palsy was diagnosed in 53/100 (53%) patients, in 16/53 (30.2%) cases both facial nerves were affected. Encephalitis or myelitis was diagnosed in 14% of patients with LNB. A total of 76/103 (73.8%) patients were discharged with residual symptoms or signs. One patient presenting encephalomyelitis died because of bacterial complications. The absence of observed erythema migrans (EM) was the predictor of peripheral facial palsy, while female sex and EM untreated with antibiotics were predictors of isolated polyradiculitis. A fever of ≥ 38 ° °C and pleocytosis of ≥ 300 × 106/l were associated with the development of encephalitis or myelitis in patients with early LNB.
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Affiliation(s)
- Daiva Radzišauskienė
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Jurgita Urbonienė
- Center of Infectious Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arminas Jasionis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Aušra Klimašauskienė
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Radvilė Malickaitė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Monika Vitkauskaitė
- Center of Infectious Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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6
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Rosendahl SB, Ravn P, Lebech AM, Midtgaard Stenør CP. Lyme neuroborreliosis with encephalitis: A rare case. IDCases 2023; 31:e01704. [PMID: 36845907 PMCID: PMC9947094 DOI: 10.1016/j.idcr.2023.e01704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Encephalitis caused by Borrelia burgdorferi sensu lato is a rare clinical manifestation of Lyme neuroborreliosis and only in few cases have brain parenchymal inflammation been documented. Here, we present a case of Lyme neuroborreliosis with encephalitis with significant parenchymal inflammation on magnetic resonance imaging (MRI) in an immunosuppressed patient.
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Affiliation(s)
- Simone Bruhn Rosendahl
- Department of Internal Medicine, Infectious Diseases Section, Copenhagen University Hospital - Herlev-Gentofte, Herlev, Denmark,Corresponding author.
| | - Pernille Ravn
- Department of Internal Medicine, Infectious Diseases Section, Copenhagen University Hospital - Herlev-Gentofte, Herlev, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian Peter Midtgaard Stenør
- Department of Neurology, Copenhagen University Hospital Herlev-Gentofte, Herlev, Denmark,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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7
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Kashyap M, Kashyap PV. Neuroborreliosis: Unusual clinical presentation and imaging features. J Neurosci Rural Pract 2023; 14:132-136. [PMID: 36891091 PMCID: PMC9945291 DOI: 10.25259/jnrp-2022-7-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/20/2022] [Indexed: 12/30/2022] Open
Abstract
Lyme disease is a tick-borne infectious disease caused by Borrelia burgdorferi which causes a multi-organ involvement. It is endemic in North America and Europe, but not very commonly seen in India. Neurological manifestations (Lyme's Neuroborreliosis,) can occur in both the early and late disseminated stages, and the classic triad consists of aseptic meningitis, painful radiculoneuritis, and cranial neuropathy. If untreated, it can be fatal and may lead to significant morbidity. We report a case with neuroborreliosis who developed acute onset and rapidly progressive bilateral vision loss, and we also report characteristic features on neuroimaging, including a characteristic "rounded M sign." This unusual presentation, along with the characteristic imaging features, should be borne in mind to avoid misdiagnosis.
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Affiliation(s)
- Manshi Kashyap
- Department of Neurology, AIIMS, Bhopal, Madhya Pradesh, India
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8
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Kalaszi M, Donlon E, Ahmad MW, Mohamed AS, Boers P. Case report: Dueling etiologies: Longitudinally extensive spinal cord lesion mimicking spinal cord infarct with simultaneous positive Lyme serology and amphiphysin antibody. Front Neurol 2022; 13:905283. [PMID: 36176565 PMCID: PMC9513320 DOI: 10.3389/fneur.2022.905283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Longitudinally extensive spinal cord lesions are challenging diagnostic entities as they are uncommon, but various etiologies can cause them. Case report We report a case of a 55-year-old man with a past medical history of hypertension. He is an ex-smoker. He presented with chest pain, followed by right lower limb weakness, preceded by 2 weeks of constipation and voiding dysfunction. The examination revealed right lower limb mild flaccid paresis, absent reflexes, reduced anal tone, and urinary retention. His symptoms deteriorated over 24 h, and he developed severe flaccid paraparesis with impaired pinprick sensation below the T4 level. MRI spine showed an abnormal, non-enhancing signal in the anterior aspect of the spinal cord extending from the T4 level to the conus without associated edema. He was commenced on intravenous steroids and had significant improvement after one dose. The imaging was felt to be consistent with spinal cord infarction, and aspirin was started. The cerebrospinal fluid analysis showed elevated protein (0.8 mg/ml). Investigations for stroke and autoimmune pathologies were negative. The Lyme immunoblot confirmed intrathecal production of IgG to Borrelia antigens. The patient was started on ceftriaxone. The paraneoplastic screen identified amphiphysin antibodies. CT-TAP and PET-CT did not identify occult malignancy. The patient had a significant improvement over 2 months, strength was almost fully recovered, and autonomic functions returned to normal. Conclusion We describe an unusual steroid-responsive, longitudinally extensive spinal cord lesion with radiological features of spinal cord infarct and a simultaneous finding of intrathecal Lyme antibodies and serum amphiphysin antibodies.
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9
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Early Disseminated Lyme Disease: Cranial Neuropathy, Meningitis, and Polyradiculopathy. Infect Dis Clin North Am 2022; 36:541-551. [PMID: 36116833 DOI: 10.1016/j.idc.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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10
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Halperin JJ, Eikeland R, Branda JA, Dersch R. Lyme neuroborreliosis: known knowns, known unknowns. Brain 2022; 145:2635-2647. [PMID: 35848861 DOI: 10.1093/brain/awac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, 99 Beauvoir Ave., Summit, NJ 07901, USA.,Department of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.,Department of Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Randi Eikeland
- National Advisory on Tick-borne Diseases, Sørlandet Hospital Trust, Egvsveien 100, 4615 Kristiansand, Norway.,Faculty of Health and Sport Sciences, University of Agder, 4879 Grimstad, Norway
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA.,Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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11
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Gunio D, Babaa A, Bencardino JT. Imaging of Nerve Disorders in the Elbow. Semin Musculoskelet Radiol 2022; 26:123-139. [PMID: 35609574 DOI: 10.1055/s-0042-1743407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Neuropathies of the elbow represent a spectrum of disorders that involve more frequently the ulnar, radial, and median nerves. Reported multiple pathogenic factors include mechanical compression, trauma, inflammatory conditions, infections, as well as tumor-like and neoplastic processes. A thorough understanding of the anatomy of these peripheral nerves is crucial because clinical symptoms and imaging findings depend on which components of the affected nerve are involved. Correlating clinical history with the imaging manifestations of these disorders requires familiarity across all diagnostic modalities. This understanding allows for a targeted imaging work-up that can lead to a prompt and accurate diagnosis.
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Affiliation(s)
- Drew Gunio
- Division of Clinical Radiology, Department of Radiology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Ahmad Babaa
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jenny T Bencardino
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Lindland ES, Solheim AM, Dareez MN, Eikeland R, Ljøstad U, Mygland Å, Reiso H, Lorentzen ÅR, Harbo HF, Beyer MK. Enhancement of cranial nerves in Lyme neuroborreliosis: incidence and correlation with clinical symptoms and prognosis. Neuroradiology 2022; 64:2323-2333. [PMID: 35608630 DOI: 10.1007/s00234-022-02957-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/08/2022] [Indexed: 01/17/2023]
Abstract
PURPOSE Symptoms of cranial neuritis are a common presentation of Lyme neuroborreliosis (LNB). Imaging studies are scarce and report contradictory low prevalence of enhancement compared to clinical studies of cranial neuropathy. We hypothesized that MRI enhancement of cranial nerves in LNB is underreported, and aimed to assess the prevalence and clinical impact of cranial nerve enhancement in early LNB. METHODS In this prospective, longitudinal cohort study, 69 patients with acute LNB were examined with MRI of the brain. Enhancement of cranial nerves III-XII was rated. MRI enhancement was correlated to clinical findings of neuropathy in the acute phase and after 6 months. RESULTS Thirty-nine of 69 patients (57%) had pathological cranial nerve enhancement. Facial and oculomotor nerves were most frequently affected. There was a strong correlation between enhancement in the distal internal auditory canal and parotid segments of the facial nerve and degree of facial palsy (gamma = 0.95, p < .01, and gamma = 0.93, p < .01), despite that 19/37 nerves with mild-moderate enhancement in the distal internal auditory canal segment showed no clinically evident palsy. Oculomotor and abducens nerve enhancement did not correlate with eye movement palsy (gamma = 1.00 and 0.97, p = .31 for both). Sixteen of 17 patients with oculomotor and/or abducens nerve enhancement had no evident eye movement palsy. CONCLUSIONS MRI cranial nerve enhancement is common in LNB patients, but it can be clinically occult. Facial and oculomotor nerves are most often affected. Enhancement of the facial nerve distal internal auditory canal and parotid segments correlate with degree of facial palsy.
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Affiliation(s)
- Elisabeth S Lindland
- Department of Radiology, Sorlandet Hospital, Sykehusveien 1, N-4809, Arendal, Norway.
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.
| | - Anne Marit Solheim
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Randi Eikeland
- The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital, Kristiansand, Norway
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Unn Ljøstad
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Habilitation, Sorlandet Hospital, Kristiansand, Norway
| | - Harald Reiso
- The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital, Kristiansand, Norway
| | - Åslaug R Lorentzen
- Department of Neurology, Sorlandet Hospital, Kristiansand, Norway
- The Norwegian National Advisory Unit on Tick-borne Diseases, Sorlandet Hospital, Kristiansand, Norway
| | - Hanne F Harbo
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mona K Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway
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13
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Neuroborreliosis with involvement of rhombencephalon: A case report. IDCases 2022; 28:e01472. [PMID: 35330755 PMCID: PMC8938859 DOI: 10.1016/j.idcr.2022.e01472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/21/2022] Open
Abstract
We describe a case of a 52 year-old woman who was hospitalized with rhombencephalitis caused by Borrelia burgdorferi sensu lato. The patient presented with intermittent fever, dry cough, fatigue, global headache, night sweats, unintentional weight loss, and neurological symptoms like diplopia, tremor, paresthesia and ataxia. Examination of serum and cerebrospinal fluid (CSF) revealed positive Borrelia burgdorferi-specific antibody index and presence of CSF oligoclonal IgG bands, indicating intrathecal synthesis of Borrelia-specific antibodies. The clinical and biochemical picture thus suggested neuroborreliosis. Unexpectedly a magnetic resonance imaging (MRI) scan demonstrated inflammation in rhombencephalon that are extremely rare in patients with neuroborreliosis. The patient was treated with intravenous ceftriaxone with rapid improvement of her symptoms. The MRI findings were in regress six weeks after onset of antibiotic treatment, and normalized after about seven months. Rhombencephalitis refers to inflammatory diseases of the rhombencephalon that include the pons, cerebellum and medulla oblongata. Borrelia burgdorferi sensu lato includes the pathogenic genospecies that causes Lyme disease and is transmitted to humans through the bite of infected ticks in the Ixodidae family, in Europe Ixodes ricinus. To diagnose neuroborreliosis can be challenging; it can cause a wide range of unspecific symptoms, the serological tests can be difficult to interpret, the initial CSF findings can be unspecific, and direct test methods like PCR have low sensitivity. Neuroborreliosis should be considered in all patients with neurological symptoms and findings suggesting inflammation in the CNS, also if normal imaging. If the clinical picture suggests neuroborreliosis, initiate treatment as soon as possible, and simultaneously continue to investigate for differential diagnoses if indicated.
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14
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Skripchenko E, Ivanova G, Skripchenko N, Egorova E. Modern concepts on the pathogenesis of neuroborreliosis. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:27-35. [DOI: 10.17116/jnevro202212207127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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15
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Knudtzen FC, Eikeland R, Bremell D, Quist-Paulsen E, Johansen IS, Solheim AM, Skarphédinsson S. Lyme neuroborreliosis with encephalitis; a systematic literature review and a Scandinavian cohort study. Clin Microbiol Infect 2021; 28:649-656. [PMID: 34768019 DOI: 10.1016/j.cmi.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) presenting with encephalitis is rare and scarcely described. OBJECTIVES To describe the available literature on LNB encephalitis, and to characterize this patient-group through a Scandinavian retrospective cohort study. DATA-SOURCES Medline, Embase, Scopus, Cochrane library. STUDY ELIGIBILITY CRITERIA No discrimination on study-type, time of publication or language. PARTICIPANTS Review: all articles with definite LNB and confirmed/possible encephalitis. Cohort: LNB cohorts from Denmark, Sweden and Norway 1990-2019 screened for patients with encephalitis. METHODS Review: adhering to PRISMA guidelines, two authors extracted and assessed quality of studies. Cohort: data registered on demography, symptoms, CSF-findings, differentialdiagnostic examinations, treatment, residual symptoms, one-year mortality. RESULTS Review: 2330 articles screened on title/abstract, 281 full-texts, yielding 42 articles (case reports/series or cohort studies) including 45 patients from 18 countries spanning 35 years. Altered mental status ranged from personality changes and confusion to unconsciousness. Common focal symptoms were hemiparesis, ataxia and dysarthria, seven patients had seizures. Median time from symptom onset to hospital was 2 weeks (IQR 2-90 days). Of 38 patients with available follow-up after median 12 months (IQR 5-13), 32 had fully or partially recovered, 2 had died. Cohort: 35 patients (median age 67 years,IQR 48-76) were included. The encephalitis prevalence was 3.3%(95%CI 2.2-4.4%) among 1019 screened LNB-patients. Frequent encephalitis symptoms were confusion, personality-changes, aphasia, ataxia. EEGs and neuroimaging showed encephalitis in 93.8% and 20.6%, respectively. Median delay from symptom onset to hospital was 14 days(IQR 7-34), with further 7 days(IQR 3-34) delay until targeted therapy. At follow-up (median 298 days post-treatment(IQR 113-389)), 65.6% had residual symptoms. None had died. CONCLUSIONS This study shows that encephalitis is an uncommon, but likely overlooked clinical manifestation of LNB. As the high frequency of residual symptoms may be related to prolonged treatment delay, prompt LNB testing of patients with encephalitis in B.burgdorferi-endemic areas should be considered.
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Affiliation(s)
- Fredrikke Christie Knudtzen
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark; Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - Randi Eikeland
- The Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Hospital, Arendal, Norway; Faculty of Health & Sport Sciences, University of Agder, Norway
| | - Daniel Bremell
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Else Quist-Paulsen
- Department of Microbiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Anne-Marit Solheim
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Sigurdur Skarphédinsson
- Clinical Center for Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark; Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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16
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Abstract
Lymphocytic meningoradiculitis (Bannwarth syndrome) is a rare manifestation of Lyme neuroborreliosis in children. It is the most common clinical manifestation of early Lyme neuroborreliosis in adults in European countries where the disease is endemic but is rare in children. We report an imported case of Bannwarth syndrome in a pediatric patient and review the literature for other pediatric cases reported.
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17
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Ozgen Mocan B. Imaging Anatomy and Pathology of the Intracranial and Intratemporal Facial Nerve. Neuroimaging Clin N Am 2021; 31:553-570. [PMID: 34689933 DOI: 10.1016/j.nic.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The facial nerve is one of the most complex cranial nerves, with motor, sensory, and parasympathetic fibers. A large spectrum of congenital, inflammatory, vascular, and neoplastic processes may affect one or more segments of the nerve. Customized use of computed tomography and magnetic resonance imaging combined with good understanding of the nerve anatomy and relevant clinical/surgical key points is crucial for appropriate assessment of facial neuropathy. This article reviews the anatomy of the intracranial and intratemporal facial nerve, and the imaging features of the most frequent disorders involving those segments of the nerve.
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Affiliation(s)
- Burce Ozgen Mocan
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL 60612, USA.
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18
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Yeh EA, Yea C, Bitnun A. Infection-Related Myelopathies. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2021; 17:141-158. [PMID: 34637338 DOI: 10.1146/annurev-pathmechdis-040121-022818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent years have seen growing attention to inflammatory and infectious disorders of the spinal cord, not only due to the discovery of autoantibody-mediated disorders of the spinal cord [e.g., aquaporin-4 immunoglobulin G (IgG) antibodies and myelin oligodendrocyte glycoprotein IgG antibodies], but also due to the emergence of clusters of infection-related myelopathy, now known as acute flaccid myelitis. We review the spectrum of infection-related myelopathies and outline a nosological classification system based on association with infection. We describe the epidemiology and definitions of myelopathies, with a discussion of clinical presentation and neuroimaging features, and then turn to specific discussion of myelopathies due to direct pathogen invasion and those considered to be post- or parainfectious. Expected final online publication date for the Annual Review of Pathology: Mechanisms of Disease, Volume 17 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- E Ann Yeh
- Division of Neurology, Department of Pediatrics, and Division of Neuroscience and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; , .,Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1X8, Canada;
| | - Carmen Yea
- Division of Neurology, Department of Pediatrics, and Division of Neuroscience and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; ,
| | - Ari Bitnun
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1X8, Canada;
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19
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Azcona Sáenz J, Herrán de la Gala D, Arnáiz García AM, Salas Venero CA, Marco de Lucas E. Atypical bacterial infections of the central nervous system transmitted by ticks: An unknown threat. RADIOLOGIA 2021; 63:425-435. [PMID: 34625198 DOI: 10.1016/j.rxeng.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/08/2021] [Indexed: 11/16/2022]
Abstract
Infections of the central nervous system caused by atypical bacteria are becoming more common. Borrelia burgdorferi and Rickettsia conorii are microorganisms transmitted by ticks; infection with these bacteria result in a wide spectrum of manifestations on imaging. In areas where these tick-borne microorganisms are endemic, including Spain, these infections must be included in the differential diagnosis of patients with a variety of systemic and neurologic symptoms. The clinical presentation of these infections is nonspecific, and CT is normally the initial imaging technique, although MRI is more sensitive to early changes. On MRI, these infections can manifest as small lesions in the deep supratentorial white matter that are hyperintense on T2-weighted/FLAIR sequences. It is fundamental to know the imaging characteristics of the different atypical bacterial infections and their differential diagnoses. Good history taking combined with complementary tests (blood tests and CSF analysis) and the neuroimaging findings can help reach the right diagnosis and enable appropriate treatment, thereby preventing possible neurological sequelae.
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Affiliation(s)
- J Azcona Sáenz
- Servicio de Radiodiagnóstico, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - D Herrán de la Gala
- Servicio de Radiodiagnóstico, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - A M Arnáiz García
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - C A Salas Venero
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - E Marco de Lucas
- Servicio de Radiodiagnóstico, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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20
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Infecciones bacterianas atípicas del sistema nervioso central transmitidas por garrapatas: una amenaza desconocida. RADIOLOGIA 2021. [DOI: 10.1016/j.rx.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Borreliosi di Lyme e neuroborreliosi. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45319-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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22
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Neuroimaging findings in rheumatologic disorders. J Neurol Sci 2021; 427:117531. [PMID: 34130065 DOI: 10.1016/j.jns.2021.117531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/12/2021] [Accepted: 06/02/2021] [Indexed: 01/06/2023]
Abstract
Patients with rheumatological diseases may present with neurological manifestations of peripheral and/or central nervous system (CNS). Symptoms may be related to underlying rheumatological disease or CNS effects of immune-modulating drugs. Early diagnosis and therapy may help prevent serious complications. Magnetic resonance imaging (MRI), given its excellent soft tissue details, is the preferred imaging modality when evaluating patients with rheumatological disease and suspected CNS involvement. We present a review of the neuroimaging manifestations of various rheumatic diseases with emphasis on the imaging findings on MRI.
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23
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Berg A, Syre H, Ophaug CH, Møller JH, Behzadi GIN. Neuroborreliosis with severe mental confusion and thickening of cranial nerves. IDCases 2021; 24:e01135. [PMID: 33996465 PMCID: PMC8102158 DOI: 10.1016/j.idcr.2021.e01135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Aase Berg
- Stavanger University Hospital, Department of Infectious Diseases, PO Box 8100, 4068, Stavanger, Norway
| | - Heidi Syre
- Stavanger University Hospital, Department of Microbiology, PO Box 8100, 4068, Stavanger, Norway
| | - Christine H Ophaug
- Stavanger University Hospital, Department of Infectious Diseases, PO Box 8100, 4068, Stavanger, Norway
| | - Jannicke H Møller
- Stavanger University Hospital, Department of Intensive Care, PO Box 8100, 4068, Stavanger, Norway
| | - Gry I N Behzadi
- Stavanger University Hospital, Department of Radiology, PO Box 8100, 4068, Stavanger, Norway
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24
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Andreassen S, Lindland EMS, Solheim AM, Beyer MK, Ljøstad U, Mygland Å, Lorentzen ÅR, Reiso H, Harbo HF, Løhaugen GCC, Eikeland R. Cognitive function, fatigue and Fazekas score in patients with acute neuroborreliosis. Ticks Tick Borne Dis 2021; 12:101678. [PMID: 33529985 DOI: 10.1016/j.ttbdis.2021.101678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/12/2021] [Accepted: 01/18/2021] [Indexed: 12/14/2022]
Abstract
Long-term cognitive problems and fatigue after adequately treated neuroborreliosis has caused uncertainty and debate among patients and health care workers for years. Despite several studies, the prevalence, cause and severity of such complaints are still not clarified. More knowledge about cognitive function, fatigue and MRI findings in the acute phase of neuroborreliosis could possibly contribute to clarification. In the current study, we therefore aimed to address this. Patients with well-characterized acute neuroborreliosis (n = 72) and a matched control group (n = 68) were screened with eight subtests from three different neuropsychological test batteries assessing attention, working memory and processing speed, and with Fatigue Severity Scale. Fazekas score was used to grade white matter hyperintensities on MRI. We found no differences in mean scores on the neuropsychological tests between the groups. The patient group reported significantly higher level of fatigue (Fatigue Severity Scale: 4.8 vs. 2.9, p < .001). There was no significant difference in Fazekas score between the groups. Neuroborreliosis does not seem to affect cognitive functions in the acute state of the disease, while fatigue is common.
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Affiliation(s)
- Silje Andreassen
- Department of Pediatrics, Sørlandet Hospital Arendal, Postbox 416, 4604, Kristiansand, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Elisabeth Margrete Stokke Lindland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Radiology, Sørlandet Hospital, Arendal, Norway; Division of Radiology and Nuclear Medicine Oslo University Hospital, Oslo, Norway
| | - Anne Marit Solheim
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Mona Kristiansen Beyer
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Radiology and Nuclear Medicine Oslo University Hospital, Oslo, Norway
| | - Unn Ljøstad
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Åse Mygland
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway; Department of Clinical Medicine, University of Bergen, Norway; Department of Habilitation, Sørlandet Hospital, Norway
| | - Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway; The Norwegian National Advisory Unit on Tick-borne Diseases, Norway
| | - Harald Reiso
- The Norwegian National Advisory Unit on Tick-borne Diseases, Norway
| | - Hanne Flinstad Harbo
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Neurology, Oslo University Hospital, Norway
| | | | - Randi Eikeland
- Department of Pediatrics, Sørlandet Hospital Arendal, Postbox 416, 4604, Kristiansand, Norway; The Norwegian National Advisory Unit on Tick-borne Diseases, Norway
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25
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Myette RL, Webber J, Mikhail H, Leifso K. A 4-year-old boy with ataxia and aphasia. CMAJ 2021; 192:E578-E582. [PMID: 32575060 DOI: 10.1503/cmaj.191279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Robert L Myette
- Departments of Pediatrics (Myette, Leifso) and Public Health (Webber, Mikhail), Queen's University at Kingston Health Sciences Centre, Kingston, Ont
| | - Jenna Webber
- Departments of Pediatrics (Myette, Leifso) and Public Health (Webber, Mikhail), Queen's University at Kingston Health Sciences Centre, Kingston, Ont
| | - Hannah Mikhail
- Departments of Pediatrics (Myette, Leifso) and Public Health (Webber, Mikhail), Queen's University at Kingston Health Sciences Centre, Kingston, Ont
| | - Kirk Leifso
- Departments of Pediatrics (Myette, Leifso) and Public Health (Webber, Mikhail), Queen's University at Kingston Health Sciences Centre, Kingston, Ont.
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26
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Affiliation(s)
- Howard M Heller
- From the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Massachusetts General Hospital, and the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Harvard Medical School - both in Boston
| | - R Gilberto Gonzalez
- From the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Massachusetts General Hospital, and the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Harvard Medical School - both in Boston
| | - Brian L Edlow
- From the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Massachusetts General Hospital, and the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Harvard Medical School - both in Boston
| | - Kevin L Ard
- From the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Massachusetts General Hospital, and the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Harvard Medical School - both in Boston
| | - Tasos Gogakos
- From the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Massachusetts General Hospital, and the Departments of Medicine (H.M.H., K.L.A.), Radiology (R.G.G.), Neurology (B.L.E.), and Pathology (T.G.), Harvard Medical School - both in Boston
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27
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Lyme disease presenting as acute ischemic strokes with an embolic pattern. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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28
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Rubenstein R, Alblaihed L, Dezman Z, Bontempo L. 40-year-old Male with a Headache and Altered Mental Status. Clin Pract Cases Emerg Med 2020; 4:499-504. [PMID: 33217256 PMCID: PMC7676804 DOI: 10.5811/cpcem.2020.10.49546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/05/2020] [Indexed: 11/24/2022] Open
Abstract
A 40-year-old man presents to the emergency department with headache, nausea and paresthesias, with subsequent fever and mental status change. Magnetic resonance imaging showed increased fluid-attenuation inversion recovery signal involving multiple areas of the brain, including the pons. This case takes the reader through the differential diagnosis of rhombencephalitis (inflammation of the hindbrain) with discussion of the unanticipated ultimate diagnosis and its treatment.
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Affiliation(s)
- Rebecca Rubenstein
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Leen Alblaihed
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Zachary Dezman
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Laura Bontempo
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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29
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Ørbæk M, Bodilsen J, Gynthersen RMM, Shekhrajka N, Nordberg CL, Larsen L, Storgaard M, Brandt C, Wiese L, Hansen BR, Luttichau HR, Andersen AB, Mens H, Nielsen H, Lebech AM. CT and MR neuroimaging findings in patients with Lyme neuroborreliosis: A national prospective cohort study. J Neurol Sci 2020; 419:117176. [PMID: 33130434 DOI: 10.1016/j.jns.2020.117176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND We aimed to describe the use and findings of cranial computerized tomography (CT-head), spine and brain magnetic resonance imaging (MRI-spine/MRI-brain) in Lyme neuroborreliose (LNB). METHODS Patients with LNB were identified using a nationwide, population-based prospective cohort of all adults treated for neuroinfections at departments of infectious diseases in Denmark from 2015 to 2019. Multivariate logistic regression analyses assessed associations between clinical characteristics and MRI-findings consistent with LNB. RESULTS We included 368 patients (272 definite LNB and 96 probable LNB), 280 scans were performed in 198 patients. Neuroimaging was associated with older age (59 vs. 57, p = 0.03), suspicion of other diseases (77% vs. 37%, p < 0.0001), no history of tick bites (58% vs. 43%, p = 0.01), physical/cognitive deficits prior to admission (15% vs 5%, p = 0.006), peripheral palsy (10% vs. 2%, p = 0.0008), encephalitis (8% vs. 1%, p = 0.0007) and cognitive impairment (8% vs. 2%, p = 0.03) compared with those without neuroimaging. Normal or incidental findings were common (93/98 CT-head and 154/182 MRI). 1/98 CT-head, 19/131 MRI-brain and 6/51 MRI-spine had findings consistent with LNB. Symptoms ≥45 days was associated with MRI-findings consistent with LNB (adjusted odds ratio (aOR) 4.2, 95%confidence interval 1.2-14.4, p = 0.02). CONCLUSION In this Danish cohort including 368 LNB-patients, use of neuroimaging was common and often performed in older comorbid patients without previous tick-bite intended to investigate alternative diagnoses. The results were in general without pathology and neuroimaging cannot exclude LNB or replace lumbar puncture. MRI is of value when investigating alternative neurological diseases and may support suspicion of LNB in cases with meningeal/leptomeningeal/neural enhancement.
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Affiliation(s)
- Mathilde Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Denmark
| | | | - Nitesh Shekhrajka
- Department of Neuroradiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Lykke Larsen
- Department of Infectious Diseases, Odense University Hospital, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark; Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Sjællands University Hospital, Roskilde, Denmark
| | - Birgitte Rønde Hansen
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark
| | - Hans R Luttichau
- Department of Infectious Diseases, Herlev Gentofte Hospital, Copenhagen, Denmark
| | - Aase Bengaard Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Helene Mens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
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30
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Pfefferkorn T, Röther J, Eckert B, Janssen H. Brainstem encephalitis in neuroborreliosis: typical clinical course and distinct MRI findings. J Neurol 2020; 268:502-505. [PMID: 32857263 DOI: 10.1007/s00415-020-10188-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In this retrospective observational study and referring to a historical case presented in 2009, we searched for typical clinical and imaging features of brainstem encephalitis in neuroborreliosis. METHODS In addition to the historical case we describe five affected patients. RESULTS All patients had a very similar prolonged clinical course with unspecific symptoms such as wasting, fatigue and headache. Brainstem signs were irregularly observed. MRI showed symmetrical brainstem alterations in all patients. In coronary FLAIR imaging these changes formed a figure resembling a Philippine tarsier. CONCLUSIONS A subset of patients with neuroborreliosis develops a brainstem encephalitis with a typical clinical course and distinct MRI findings.
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Affiliation(s)
- Thomas Pfefferkorn
- Department of Neurology, Klinikum Ingolstadt, Krumenauerstrasse 25, 85049, Ingolstadt, Germany.
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Bernd Eckert
- Institute of Radiology and Neuroradiology, Asklepios Klinik Altona, Hamburg, Germany
| | - Hendrik Janssen
- Institute of Radiology and Neuroradiology, Klinikum Ingolstadt, Ingolstadt, Germany
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31
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Carmo RLD, Alves Simão AK, Amaral LLFD, Inada BSY, Silveira CF, Campos CMDS, Freitas LF, Bonadio V, Marussi VHR. Neuroimaging of Emergent and Reemergent Infections. Radiographics 2020; 39:1649-1671. [PMID: 31589575 DOI: 10.1148/rg.2019190020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Infectious diseases emerge and reemerge over the years, and many of them can cause neurologic disease. Several factors contribute to the emergence and reemergence of these conditions, including human population growth, an increase in international travel, the geographic expansion of recognized pathogens to areas where they were previously nonendemic, and greater contact with wild animal reservoirs. The antivaccination social movement has played an important role in the reemergence of infectious diseases, especially some viral conditions. The authors review different viral (arboviruses such as dengue, chikungunya, and Zika virus; enterovirus 71; measles; and influenza), bacterial (syphilis, Lyme disease, and listeriosis), and parasitic (Chagas disease) diseases, focusing primarily on their neurologic complications. Although there are several additional infectious diseases with central nervous system manifestations that could be classified as emergent or reemergent, those listed here are the most relevant from an epidemiologic standpoint and are representative of important public health issues on all continents. The infections caused by these pathogens often show a variety of neuroimaging patterns that can be identified at CT and MRI, and radiology is central to the diagnosis and follow-up of such conditions. Given the increasing relevance of emerging and reemerging infections in clinical practice and public health scenarios, radiologists should be familiar with these infections. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Rafael Lourenço do Carmo
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | - Aylla Keiner Alves Simão
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | - Lázaro Luís Faria do Amaral
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | - Bruno Shigueo Yonekura Inada
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | - Camila Filardi Silveira
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | | | - Leonardo Furtado Freitas
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | - Victor Bonadio
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
| | - Victor Hugo Rocha Marussi
- From the Department of Neuroradiology, A Beneficência Portuguesa de São Paulo, R. Maestro Cardim 769, São Paulo, SP 01323-001, Brazil
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32
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Low Seroprevalence of Lyme Disease Among Multiple Sclerosis Patients in New Brunswick. Can J Neurol Sci 2020; 47:842-844. [PMID: 32594964 DOI: 10.1017/cjn.2020.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The signs and symptoms of Lyme neuroborreliosis can overlap with non-infectious degenerative diseases such as multiple sclerosis (MS). In this study, we assessed a cohort of MS patients in Atlantic Canada for serological evidence of Lyme disease (LD). No positive serology was identified using the recommended two-tiered algorithm.
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Jewells VL, Latchaw RE. CNS Vasculitis-An Overview of This Multiple Sclerosis Mimic: Clinical and MRI Implications. Semin Ultrasound CT MR 2020; 41:296-308. [PMID: 32448486 DOI: 10.1053/j.sult.2020.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This article discusses central nervous system vasculitis, a clinical and MRI mimic of multiple sclerosis (MS). There is a paucity of discussion of vasculitis in the radiology literature, and many MS neurologists believe that vasculitis is underdiagnosed. Therefore, the authors hope that the readers will find this paper increases their knowledge about CNS vasculitis and improves their ability to differentiate MS from vasculitis.
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Rebman AW, Aucott JN. Post-treatment Lyme Disease as a Model for Persistent Symptoms in Lyme Disease. Front Med (Lausanne) 2020; 7:57. [PMID: 32161761 PMCID: PMC7052487 DOI: 10.3389/fmed.2020.00057] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022] Open
Abstract
It has long been observed in clinical practice that a subset of patients with Lyme disease report a constellation of symptoms such as fatigue, cognitive difficulties, and musculoskeletal pain, which may last for a significant period of time. These symptoms, which can range from mild to severe, have been reported throughout the literature in both prospective and population-based studies in Lyme disease endemic regions. The etiology of these symptoms is unknown, however several illness-causing mechanisms have been hypothesized, including microbial persistence, host immune dysregulation through inflammatory or secondary autoimmune pathways, or altered neural networks, as in central sensitization. Evaluation and characterization of persistent symptoms in Lyme disease is complicated by potential independent, repeat exposures to B. burgdorferi, as well as the potential for co-morbid diseases with overlapping symptom profiles. Antibody testing for B. burgdorferi is an insensitive measure after treatment, and no other FDA-approved tests currently exist. As such, diagnosis presents a complex challenge for physicians, while the lived experience for patients is one marked by uncertainty and often illness invalidation. Currently, there are no FDA-approved pharmaceutical therapies, and the safety and efficacy of off-label and/or complementary therapies have not been well studied and are not agreed-upon within the medical community. Post-treatment Lyme disease represents a narrow, defined, mechanistically-neutral subset of this larger, more heterogeneous group of patients, and is a useful definition in research settings as an initial subgroup of study. The aim of this paper is to review the current literature on the diagnosis, etiology, risk factors, and treatment of patients with persistent symptoms in the context of Lyme disease. The meaning and relevance of existing patient subgroups will be discussed, as will future research priorities, including the need to develop illness biomarkers, elucidate the biologic mechanisms of disease, and drive improvements in therapeutic options.
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Affiliation(s)
- Alison W Rebman
- Lyme Disease Research Center, Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - John N Aucott
- Lyme Disease Research Center, Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Bonduelle T, Tang HMA, Marchal C, Thomas B. Severe Lyme neuroborreliosis with bilateral hemorrhagic temporal encephalitis. J Neurol 2020; 267:852-854. [PMID: 31955245 DOI: 10.1007/s00415-020-09706-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/11/2022]
Affiliation(s)
- T Bonduelle
- Department of Neurology, CHU de Bordeaux, University of Bordeaux, Place Amélie Raba Léon, 33000, Bordeaux, France.
| | - Hoang M-A Tang
- Department of Neurology, CHU de Bordeaux, University of Bordeaux, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - C Marchal
- Department of Neurology, CHU de Bordeaux, University of Bordeaux, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - B Thomas
- Department of Neurology, CHU de Bordeaux, University of Bordeaux, Place Amélie Raba Léon, 33000, Bordeaux, France
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Bot JCJ, Mazzai L, Hagenbeek RE, Ingala S, van Oosten B, Sanchez-Aliaga E, Barkhof F. Brain miliary enhancement. Neuroradiology 2020; 62:283-300. [PMID: 31925469 PMCID: PMC7044143 DOI: 10.1007/s00234-019-02335-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/04/2019] [Indexed: 02/07/2023]
Abstract
Purpose Miliary enhancement refers to the presence of multiple small, monomorphic, enhancing foci on T1-weighted post-contrast MRI images. In the absence of a clear clinical presentation, a broad differential diagnosis may result in invasive procedures and possibly brain biopsy for diagnostic purposes. Methods An extensive review of the literature is provided for diseases that may present with miliary enhancement on T1-weighted brain MR images. Additional disease-specific findings, both clinical and radiological, are summarized and categorized by the presence or absence of perivascular space involvement. Results Miliary pattern of enhancement may be due to a variety of underlying causes, including inflammatory, infectious, nutritional or neoplastic processes. The recognition of disease spread along the perivascular spaces in addition to the detection or exclusion of disease-specific features on MRI images, such as leptomeningeal enhancement, presence of haemorrhagic lesions, spinal cord involvement and specific localisation or systemic involvement, allows to narrow the potential differential diagnoses. Conclusion A systematic approach to disease-specific findings from both clinical and radiological perspectives might facilitate diagnostic work-up, and recognition of disease spread along the perivascular spaces may help narrowing down differential diagnoses and may help to minimize the use of invasive diagnostic procedures.
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Affiliation(s)
- Joseph C J Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Linda Mazzai
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands.,Institute of Radiology, Department of Medicine (DiMED), University of Padua, Padua, Italy
| | | | - Silvia Ingala
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands
| | - Bob van Oosten
- Department of Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Esther Sanchez-Aliaga
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands.,Institute of Neurology and Healthcare Engineering, UCL, London, UK
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Ørbæk M, Klausen C, Lebech AM, Mens H. Lyme Neuroborreliosis in a Patient with Breast Cancer: MRI and PET/CT Findings. Diagnostics (Basel) 2020; 10:diagnostics10010036. [PMID: 31936608 PMCID: PMC7169463 DOI: 10.3390/diagnostics10010036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/05/2020] [Accepted: 01/06/2020] [Indexed: 11/16/2022] Open
Abstract
We present a case demonstrating the performance of different radiographical and nuclear medicine imaging modalities in the diagnostic work-up of a patient with Lyme neuroborreliosis. The patient presented in late summer 2019 with radicular pains followed by a foot drop and peripheral facial palsy, both right-sided. Due to a history of breast cancer, disseminated malignant disease was initially suspected. Bone metastasis was ruled out by skeletal scintigraphy. Magnetic resonance imaging (MRI) of the neuroaxis and a whole body 18F-FDG PET-CT was performed within 48 hours. The MRI revealed a strong contrast enhancement of the conus medullaris and fibers of the cauda equina, while the 18F-FDG PET/CT was without pathological findings. Examination of cerebrospinal fluid led to the definitive diagnosis of Lyme neuroborreliosis with monocytic pleocytosis and a positive intrathecal test for Borrelia burgdorferi. The patient became pain-free after 10 days of ceftriaxone, and the paralysis slowly regressed the following month. This case highlights the difficulty of the diagnosis of Lyme neuroborreliosis and discusses the relevant imaging findings.
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Affiliation(s)
- Mathilde Ørbæk
- Department of Infectious Diseases, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark (H.M.)
- Correspondence: ; Tel.: +45-35451498
| | - Camilla Klausen
- Department of Radiology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark;
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark (H.M.)
| | - Helene Mens
- Department of Infectious Diseases, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark (H.M.)
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Valand HA, Goyal A, Melendez DA, Matharu SS, Mangat HS, Tu RK. Lyme Disease: What the Neuroradiologist Needs to Know. AJNR Am J Neuroradiol 2019; 40:1998-2000. [PMID: 31672835 DOI: 10.3174/ajnr.a6301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 11/07/2022]
Abstract
Lyme disease is the most common tick-borne disease in Canada and the United States, caused by Borrelia burgdorferi, which affects multiple organ systems. Epidemiology, clinical presentation, and neuroimaging findings are reviewed.
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Affiliation(s)
- H A Valand
- From the American University of Integrative Sciences (H.A.V.), Brampton, Ontario, Canada
| | - A Goyal
- George Washington University (A.G., D.A.M.), Washington, DC
| | - D A Melendez
- George Washington University (A.G., D.A.M.), Washington, DC
| | - S S Matharu
- The Fischell Department of Bioengineering (S.S.M.), University of Maryland College Park, College Park, Maryland
| | - H S Mangat
- Germantown Medical Center (H.S.M.), Germantown, Maryland
| | - R K Tu
- Progressive Radiology (R.K.T.), George Washington University, United Medical Center, Washington, DC.
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Ramada MA, Kannangara S, Eskarous H. An Unusual Case of Suspected Lyme Neuroborreliosis in a Patient Presenting with Ear Pain. J Glob Infect Dis 2019; 11:160-162. [PMID: 31849437 PMCID: PMC6906891 DOI: 10.4103/jgid.jgid_75_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/11/2019] [Accepted: 10/16/2019] [Indexed: 11/24/2022] Open
Abstract
We report a case of suspected Lyme neuroborreliosis (LNB) where the patient's sole symptom was chronic, intermittent episodes of unilateral ear pain. This case was unusual because this patient did not show any other neurological or extraneurological symptoms of Lyme disease. LNB is a manifestation of infection by Borrelia burgdorferi spirochetes that can manifest in a number of different clinical presentations depending on the nervous system dissemination of the bacteria. Most commonly, these neurological findings present as peripheral nerve radiculopathies, but rarer involvement of the central nervous system (CNS) can occur if a patient goes untreated. Most often, CNS involvement presents as meningitis with increased lymphocytes but can, in rarer cases, involve the spinal cord or brain parenchyma. The diagnosis of LNB was made after the patient was found to have suspicious lesions in the spinal cord and brain parenchyma on magnetic resonance imaging as well as cerebrospinal fluid Borrelia antibody index was consistent with CNS Lyme disease. We discuss this case as a unique clinical presentation of suspected LNB and the diagnostic findings associated with this infection.
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Affiliation(s)
- Michael Anthony Ramada
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Saman Kannangara
- Department of Infectious Disease, Easton Hospital, Wilson, Pennsylvania, USA
| | - Hany Eskarous
- Department of Infectious Disease, Easton Hospital, Wilson, Pennsylvania, USA
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40
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An unusual case of PML in HIV patient presenting with diplopia. Neurol Sci 2018; 40:1081-1082. [PMID: 30515605 DOI: 10.1007/s10072-018-3665-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/28/2018] [Indexed: 01/20/2023]
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