Severe encephalopathy associated with Lyme disease

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thieme Atlas of Anatomy: Head and Neuroanatomy

BACKGROUND

Establishing a causal relationship between optic neuritis and Lyme disease (LD) has been hampered by technical limitations in serologic diagnosis of LD. Even so, there is a general impression that optic neuritis is a common manifestation of LD.

METHODS

Retrospective case analysis of Lyme serology in 440 patients with optic neuritis examined between 1993 and 2003 in a single neuro-ophthalmic practice at Stony Brook University Medical Center, Suffolk County, New York, a region hyper-endemic for LD.

RESULTS

Lyme enzyme-linked immunosorbent assay (ELISA) was positive in 28 (6.4%) patients with optic neuritis, three of whom had syphilis with cross-reactive antibodies. Among the remaining 25 ELISA-positive patients, optic neuritis could be confidently attributed to LD in only one case, a patient with papillitis. The other 24 cases had reactive Lyme serologies related to a history of LD years earlier, asymptomatic exposure, false-positive results, or non-specific humoral expansion. The ELISA in these 24 cases were weakly positive and the Western blots were negative by Centers for Disease Control criteria. There were no significant clinical differences between the 25 seropositive optic neuritis cases and 50 seronegative optic neuritis cases.

CONCLUSIONS

Based on these cases and a review of the literature, there is insufficient evidence for a causal link between LD and retrobulbar optic neuritis or neuroretinitis. There is sufficient evidence to establish a causal link between LD and papillitis and posterior uveitis.

Ophthalmologic manifestations of rheumatic diseases

OBJECTIVES

Detailed review of the manifestations of eye involvement in the context of rheumatic diseases.

METHODS

An OVID Medline search of the rheumatology and ophthalmology English literature related to the eye manifestations of human rheumatic diseases from 1966 to the present was conducted by the authors.

RESULTS

Analysis of 300 recent and consecutive rheumatology consultations from a large Veterans Administration Healthcare System shows that 4% are referred for eye manifestations of suspected rheumatic diseases, most commonly, anterior uveitis and keratoconjunctivitis sicca (KCS). Ocular involvement is common in the rheumatic diseases but varies among the different disorders. A literature review indicated that the most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, anterior uveitis, and scleritis. The most serious eye complications of the inherited connective tissue disorders are lens involvement with cataract formation or subluxation. The most significant side effects of the drugs used to treat rheumatic diseases are the maculopathy associated with anti-malarial agents and cataracts and glaucoma associated with corticosteroid use. Although many of the eye manifestations are easily recognizable, consultation with an ophthalmologist is usually necessary for optimal treatment and prevention of complications.

CONCLUSIONS

The rheumatologist, in coordination with the ophthalmologist, can play a major role in detecting and managing the eye involvement in his patients to save this important sense. Understanding the varied manifestations of eye disease will permit the rheumatologist to better evaluate the activity of the rheumatic disease.

Penicillin G sodium and ceftriaxone in the treatment of neuroborreliosis in children--a prospective study

A controlled clinical study was set up to examine whether penicillin G sodium (PG) or ceftriaxone (C) is superior in the treatment of acute neuroborreliosis in childhood. Within a time period of 18 months 77 children with symptoms indicative of Lyme borreliosis of the central nervous system (CNS) were seen. In 23 of these children Borrelia burgdorferi specific cerebrospinal fluid (CSF) parameters confirmed the diagnosis of a neuroborreliosis. These children were treated at random with intravenous (i.v.) PG 400,000-500,000 I.U./kg/day for 14 days (group I) or with i.v. ceftriaxone 75-93 mg/kg/day for 14 days (group II), respectively. Clinical examination and a set of diagnostic laboratory parameters were done at admission, right after therapy, three, six and partly 12 months after therapy. The general condition of all children in both groups improved dramatically during antibiotic therapy, and no relapse occurred within the observation period. Considering the clear and comparable decrease of B. burgdorferi serum titres and the clinical outcome (duration of disease and follow-up for at least six months) in children of both groups no difference between both antibiotic drugs can be demonstrated.

Lyme disease: neurologic and ophthalmic manifestations

Lyme disease is tick-borne infection which produces early and late manifestations in many organ systems. Prominent symptoms and signs occur in skin, heart, joints and nervous system. Many ocular and neuro-ophthalmic abnormalities recently have been attributed to Lyme disease, but some cases have not been well established as direct sequelae. This review of the contemporary state of knowledge about Lyme disease was undertaken so that more rigorous criteria can be applied in future diagnosis.

Lyme disease

Neurological problems form an important part of the clinical spectrum of Lyme disease. A triad of aseptic meningoencephalitis, cranial neuritis and peripheral neuritis is unique to the disease. However, the list of neurological manifestations described includes pseudotumour cerebri, hemiparesis, demyelinating disorders, optic atrophy, recurrent laryngeal nerve palsy and purulent meningitis so that Lyme disease must now be considered in the differential diagnosis of a wide range of neurological disorders.

Borrelia burgdorferi antibodies in patients with relapsing/remitting form and chronic progressive form of multiple sclerosis

Sera of 106 multiple sclerosis patients and 103 closely matched controls were examined for Borrelia burgdorferi antibodies. The prevalence rate in multiple sclerosis patients was 14.2%, in controls 25.2%. Overall prevalence was 20.1%. Mean IgG antibody level was insignificantly higher in controls than in multiple sclerosis patients. Patients with a chronic progressive course of multiple sclerosis had an insignificantly higher mean borrelia antibody level, when compared with those suffering from relapsing/remitting form of disease.

CNS-borreliosis selectively affecting central motor neurons

A patient is described having Borrelia burgdorferi spirochetal infection clinically affecting central motor neurons selectively and without any sensory impairment. Diagnosis was based on elevated B. burgdorferi IgG antibody titers in cerebrospinal fluid (CSF) and titer normalization at clinical recovery. This occurred promptly and was complete after penicillin treatment despite 14 months of progressive central nervous system (CNS) dysfunction, favouring the hypothesis of the presence of the organism within the CNS. CSF findings characteristic of neuroborreliosis were registered, including parallel occurrence of mononuclear pleocytosis, severe blood-brain barrier damage and marked CSF IgM index elevation of prolonged duration. Some earlier reports of CNS manifestations related to B. burgdorferi are reviewed.