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Szanyi J, Kremlacek J, Kubova Z, Kuba M, Vit F, Langrova J, Gebousky P, Szanyi J. Optic nerve involvement in patients with Lyme neuroborreliosis: an electrophysiological study. Doc Ophthalmol 2024:10.1007/s10633-024-09975-w. [PMID: 38622306 DOI: 10.1007/s10633-024-09975-w] [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: 09/08/2023] [Accepted: 03/28/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE The aim of this neurophysiological study was to retrospectively analyze visual evoked potentials (VEPs) acquired during an examination for diagnosing optic nerve involvement in patients with Lyme neuroborreliosis (LNB). Attention was focused on LNB patients with peripheral facial palsy (PFP) and optic nerve involvement. METHODS A total of 241 Czech patients were classified as having probable/definite LNB (193/48); of these, 57 were younger than 40 years, with a median age of 26.3 years, and 184 were older than 40 years, with a median age of 58.8 years. All patients underwent pattern-reversal (PVEP) and motion-onset (MVEP) VEP examinations. RESULTS Abnormal VEP results were observed in 150/241 patients and were noted more often in patients over 40 years (p = 0.008). Muscle/joint problems and paresthesia were observed to be significantly more common in patients older than 40 years (p = 0.002, p = 0.030), in contrast to headache and decreased visual acuity, which were seen more often in patients younger than 40 years (p = 0.001, p = 0.033). Peripheral facial palsy was diagnosed in 26/241 LNB patients. Among patients with PFP, VEP peak times above the laboratory limit was observed in 22 (84.6%) individuals. Monitoring of patients with PFP and pathological VEP showed that the adjustment of visual system function occurred in half of the patients in one to more years, in contrast to faster recovery from peripheral facial palsy within months in most patients. CONCLUSION In LNB patients, VEP helps to increase sensitivity of an early diagnostic process.
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Affiliation(s)
- Jana Szanyi
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic.
| | - Jan Kremlacek
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Zuzana Kubova
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Miroslav Kuba
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Frantisek Vit
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Jana Langrova
- Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 500 03, Hradec Kralove, Czech Republic
| | - Pavel Gebousky
- Department of Infectious Diseases, Faculty Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Juraj Szanyi
- Department of Infectious Diseases, Faculty Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
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De Larochellière E, Langley JM, Bata BM. Unilateral ptosis and mydriasis secondary to presumed Lyme neuroborreliosis. J AAPOS 2022; 26:278-280. [PMID: 36108883 DOI: 10.1016/j.jaapos.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/11/2022] [Accepted: 07/17/2022] [Indexed: 11/25/2022]
Abstract
We report a case of unilateral acute-onset ptosis and mydriasis in a girl 2 years and 7 months of age from an area endemic for Lyme disease. She lacked other signs of oculomotor nerve palsy. She tested positive for Borrelia burgdorferi and negative for Bartonella henselae on serology and was diagnosed with Lyme neuroborreliosis. The ptosis and mydriasis resolved after 1 week of oral doxycycline.
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Affiliation(s)
- Elianne De Larochellière
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia; Department of Ophthalmology, Université Laval, Québec, Quebec
| | - Joanne M Langley
- Departments of Pediatrics and Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia
| | - Bashar M Bata
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia.
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Lu Y, Zand R. Characteristics of Lyme optic neuritis: a case report of Lyme associated bilateral optic neuritis and systematic review of the literature. BMC Neurol 2022; 22:113. [PMID: 35321665 PMCID: PMC8941763 DOI: 10.1186/s12883-022-02627-z] [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: 10/06/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
Optic Neuritis is rare in Lyme borreliosis. The current knowledge of optic nerve involvement in Lyme borreliosis relies solely on case reports. The aim of this systematic review was to characterize and investigate the associated factors of optic neuritis in Lyme borreliosis. We further presented a very rare case of isolated bilateral optic neuritis in a Lyme seropositive patient.
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Affiliation(s)
- Yezhong Lu
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Ramin Zand
- Department of Neurology, Neuroscience Institute, Geisinger Health System, Danville, PA, USA.
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Miller NR, Johnson LN, Bakaeva T, Van Stavern GP, Lee AG. Is Neuroretinitis Associated With Multiple Sclerosis? J Neuroophthalmol 2022; 42:126-130. [PMID: 34873139 DOI: 10.1097/wno.0000000000001374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Neil R Miller
- Wilmer Eye Institute (NRM), Johns Hopkins University School of Medicine, Baltimore, Maryland; Neuro-Ophthalmology Unit (LNJ, TB), Warren Alpert Medical School of Brown University, Lifespan, Rhode Island Hospital, Providence, Rhode Island; Department of Ophthalmology and Visual Sciences (GPVS), Washington University in St. Louis School of Medicine, St. Louis, Missouri; and Chair, Blanton Eye Institute (AGL), Houston Methodist Hospital, Houston, Texas
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Papilledema Secondary to Neurologic Lyme Borreliosis: A Meta-Case Series. J Neuroophthalmol 2021; 41:e498-e508. [PMID: 34788244 DOI: 10.1097/wno.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Rebman AW, Yang T, Aucott JN, Mihm EA, West SK. Contrast Sensitivity Loss in Patients With Posttreatment Lyme Disease. Transl Vis Sci Technol 2021; 10:27. [PMID: 34003960 PMCID: PMC7995915 DOI: 10.1167/tvst.10.3.27] [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] [Indexed: 11/24/2022] Open
Abstract
Purpose Posttreatment Lyme disease (PTLD) is marked by neurologic symptoms, cognitive impairment, and significant symptom burden, including fatigue and ocular complaints. The purpose of this study was to determine whether contrast sensitivity (CS) is altered in patients with PTLD compared with healthy controls and, second, whether CS is associated with cognitive and/or neurologic deficits. Methods CS was measured using a Pelli-Robson chart with forced-choice procedures, and the total number of letters read was recorded for each eye. CS impairment was defined for age <60 years as logCS of 1.80 (36 letters or fewer) and for those age ≥60 years as logCS of 1.65 (33 letters or fewer). Participants self-administered a questionnaire to assess presence of ocular symptoms and underwent a neurologic exam and battery of neurocognitive tests. Results CS impairment was associated with an increased odds of being in the PTLD group that was 2.6 times as high as those without CS impairment (odds ratio, 2.6; 95% confidence interval, 1.3-5.2). Neither cases nor controls had significant distance acuity impairment. CS impairment was not associated with any of the ocular complaints in cases but was borderline associated with neurologic abnormalities and cognitive impairment. Conclusions CS impairment in patients with PTLD is linked to signs of cognitive and neurologic impairment and may be a marker of illness severity. Translational Relevance Further investigation into the value of testing CS impairment in PTLD cases is warranted, especially if it is an indicator of cognitive or neurologic manifestations.
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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, USA
| | - Ting Yang
- Lyme Disease Research Center, Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John N Aucott
- Lyme Disease Research Center, Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erica A Mihm
- Lyme Disease Research Center, Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sheila K West
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Dabiri I, Burakgazi AZ. Simultaneous involvement of optic and abducens nerves by Lyme disease: Case report with review of the literature. Neurol Int 2019; 11:8241. [PMID: 31579143 PMCID: PMC6763746 DOI: 10.4081/ni.2019.8241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/22/2019] [Indexed: 11/23/2022] Open
Abstract
Ocular manifestations of Lyme disease (LD) remain a rare feature of the disease, but it may present a wide range of clinical presentations with different combinations. LD related optic neuritis or cranial nerve (CN) six palsy have been reported in the literature. However, this is the first case report of simultaneous involvement of CN 2 and CN 6 in a patient with LD. The diagnosis of LD can be challenging and initial laboratory tests can be a false negative. It is paramount important to repeat the diagnostic test if clinical suspicious is ongoing. With this case, we aim to increase awareness of clinicians for possible ocular manifestations of LD and its complex diagnostic process.
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Affiliation(s)
- Iman Dabiri
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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Gunzenhauser RC, Rubino SM, John V, Greven MA. The development and spontaneous resolution of a full-thickness macular hole in bartonella henselae neuroretinitis in a 12-year-old boy. Am J Ophthalmol Case Rep 2019; 15:100515. [PMID: 31341998 PMCID: PMC6630014 DOI: 10.1016/j.ajoc.2019.100515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/16/2019] [Accepted: 07/08/2019] [Indexed: 11/04/2022] Open
Abstract
Purpose To describe an unusual case of Bartonella henselae neuroretinitis complicated by macular hole (MH) development. Observations A full-thickness macular hole developed in a 12-year-old boy in association with serology-confirmed Bartonella henselae neuroretinitis. Following a period of observation, the MH closed without intervention. Conclusion and importance MH may occur as a complication of neuroretinitis secondary to Cat-Scratch Disease.
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Affiliation(s)
- Robert C Gunzenhauser
- Department of Ophthalmology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Margaret A Greven
- Department of Ophthalmology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Guliani BP, Kumar S, Chawla N, Mehta A. Neuroretinitis as presenting and the only presentation of Lyme disease: Diagnosis and management. Indian J Ophthalmol 2017; 65:250-252. [PMID: 28440258 PMCID: PMC5426134 DOI: 10.4103/ijo.ijo_151_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We present a case of neuroretinitis as presenting and the only presentation of Lyme disease in a 25-year-old female who visited hilly areas in the Himalayas of North India. She presented with right eye sudden and painless blurring of vision. Her vision at presentation was 20/60. She had fundus examination; fundus fluorescein angiography (FFA) and optical coherence tomography (OCT) imaging showed classical features of neuroretinitis. No other organ was involved. Oral steroids were prescribed and relevant investigations sent for noninfective and infective causes. Worsened visual acuity (VA) to hand movement and positive IgM titers for Borrelia burgdorferi led to the diagnosis of Lyme disease-associated neuroretinitis. Treatment with oral doxycycline plus oral steroids for 4 weeks revealed VA of 20/20 and resolution of fundus and OCT changes. Neuroretinitis as presenting and the only presentation of Lyme disease will be discussed with serial fundus, FFA, and OCT pictures.
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Affiliation(s)
| | - Sandeep Kumar
- Department of Ophthalmology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Neha Chawla
- Department of Ophthalmology, Sanjay Gandhi Memorial Hospital, New Delhi, India
| | - Anuj Mehta
- Department of Ophthalmology, VMMC and Safdarjung Hospital, New Delhi, India
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Lin YH, Yeung L, Sun CC, Ku WC, Yang JW. Contact dermatitis on the lower eyelid related to tick infestation: A case report in Taiwan. Taiwan J Ophthalmol 2016; 6:201-203. [PMID: 29018743 PMCID: PMC5525628 DOI: 10.1016/j.tjo.2016.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 11/29/2022] Open
Abstract
Tick bite on the lower eyelid is a rare condition. We reported a case of contact dermatitis on the lower eyelid related to the tick infestation. Ticks are vectors for disease transmission. Symptoms and treatments for tick-borne diseases were reviewed.
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Affiliation(s)
- Yun-Hsuan Lin
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ling Yeung
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - Chi-Chin Sun
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - Wan-Chen Ku
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ju-Wen Yang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
- Corresponding author. Department of Ophthalmology, Chang Gung Memorial Hospital, 6F., No. 222, Maijin Rd., Anle Dist., Keelung City 204, Taiwan. E-mail address: (J.-W. Yang)
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Kahloun R, Abroug N, Ksiaa I, Mahmoud A, Zeghidi H, Zaouali S, Khairallah M. Infectious optic neuropathies: a clinical update. Eye Brain 2015; 7:59-81. [PMID: 28539795 PMCID: PMC5398737 DOI: 10.2147/eb.s69173] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.
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Affiliation(s)
- Rim Kahloun
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Nesrine Abroug
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Imen Ksiaa
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Anis Mahmoud
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Hatem Zeghidi
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Sonia Zaouali
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Moncef Khairallah
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
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Correll MH, Datta N, Arvidsson HSS, Melsom HA, Thielberg AK, Bjerager M, Brodsky MC, Saunte JP. Lyme neuroborreliosis: a treatable cause of acute ocular motor disturbances in children. Br J Ophthalmol 2015; 99:1401-4. [PMID: 25868792 DOI: 10.1136/bjophthalmol-2015-306855] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/20/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Lyme neuroborreliosis (LNB) designates central nervous system involvement caused by the tick-borne spirochaete Borrelia burgdorferi (Bb). The present study describes a spectrum of acquired ocular motor disorders in children with LNB. METHODS Six paediatric patients (age 3-15 years) with ocular motor symptoms as first manifestations of LNB evaluated by a paediatrician and ophthalmologist are presented. Diagnosis was based on new onset ocular motor disturbances and detection of cerebrospinal fluid (CSF) pleocytosis and intrathecal synthesis of Bb IgM and/or IgG antibodies by lumbar puncture. The children were evaluated before and after antibiotic treatment with a follow-up time of 1-7 months. Videos were obtained both pre and post treatment in four patients. RESULTS Two children presented with acquired nystagmus, one with combined nystagmus and partial sixth nerve palsy, one with partial sixth nerve palsy, one with ptosis and one with Adie's pupil. Five of the patients presented with severe fatigue, malaise, nausea, headache and fever. Four had recognised a tick bite recently, and two developed erythema migrans. Intrathecal synthesis of IgM and/or IgG antibodies specific for Bb was positive in all children, and five showed CSF pleocytosis. Cerebral MRI or CT of the brain were normal. Treatment with intravenous or oral antibiotics produced rapid clinical improvement in five of the six children. CONCLUSIONS LNB can present as acute ocular motor disorders in conjunction with fatigue and other clinical manifestations. In endemic areas, children with unexplained, acquired ocular motor abnormalities should be evaluated for LNB, a treatable medical condition.
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Affiliation(s)
- M H Correll
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark Department of Ophthalmology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - N Datta
- Department of Ophthalmology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - H S S Arvidsson
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - H A Melsom
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - A K Thielberg
- Department of Pediatrics, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - M Bjerager
- Department of Pediatrics, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - M C Brodsky
- Departments of Ophthalmology and Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - J P Saunte
- Department of Ophthalmology, Nordsjællands Hospital Hillerød, Hillerød, Denmark Department of Ophthalmology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
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Portmann A, Gueudry J, Lebas A, Michelet I, Lefaucheur R, Marguet C, Muraine M. Hypertension intracrânienne isolée révélatrice d’une maladie de Lyme. J Fr Ophtalmol 2012; 35:720.e1-4. [DOI: 10.1016/j.jfo.2011.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 12/12/2011] [Accepted: 12/19/2011] [Indexed: 11/27/2022]
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[Ocular Lyme disease occurring during childhood: five case reports]. J Fr Ophtalmol 2011; 35:17-22. [PMID: 21696850 DOI: 10.1016/j.jfo.2011.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/17/2011] [Accepted: 03/28/2011] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Lyme borreliosis (LB) is the most common human tick-borne disease in the Northern hemisphere. The various ophthalmologic manifestations of Lyme borreliosis (LB) during childhood are discussed in this paper. PATIENTS AND METHODS Six children with LB-associated ocular manifestations were treated between 2000 and 2010 in the ophthalmology department of Strasbourg University Hospital (an endemic area). Medical history, ocular and systemic clinical findings, determinations of antibodies related to Borrelia, as well as exclusion of other causes were the diagnosis criteria. RESULTS Two cases of uveitis, two cases of abducens palsies, one case of optical neuropathy, and one case of orbital myositis associated with LB were diagnosed. Systemic findings, such as arthritis, rash, or erythema migrans were mentioned in all cases. Two children also complained of severe knee arthritis. Determination of antibodies was positive in all patients. They were all treated with antibiotics adjusted to individual circumstances and some of them (two cases of uveitis and one of optic neuropathy) also had anti-inflammatory treatment. Resolution of ocular signs, with no relapse, was observed in all patients within two to 12 weeks. CONCLUSION For any unexplained ocular symptom, even in children, LB should be taken into account, especially in endemic areas. Such patients should undergo serological testing. If the clinical presentation is suggestive of LB, a course of oral antibiotics should be used. All in all, permanent defects are extremely rare during the childhood period, even following long-term manifestation at an early age.
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Berbos ZJ, Krachmer JH. Infectious Disease. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00073-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lee AG. Optic atrophy: a diagnostic sign but not a diagnosis. EXPERT REVIEW OF OPHTHALMOLOGY 2010. [DOI: 10.1586/eop.10.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Liu GT, Volpe NJ, Galetta SL. Optic disc swelling. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
A wide variety of infectious agents are known to cause optic neuropathy. This article will consider the bacteria, spirochetes, fungi, and viruses that most commonly affect the optic nerve. Clinical presentation is variable, but some pathogens often produce a characteristic funduscopic pattern. Diagnosis is usually made on the basis of clinical suspicion and serologic testing. Polymerase chain reaction is also increasingly utilized. Most infectious agents can be effectively treated but visual recovery is highly variable.
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Affiliation(s)
- Karl C Golnik
- Department of Ophthalmology, University of Cincinnati and The Cincinnati Eye Institute, Cincinnati, OH, USA.
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Abstract
Benign recurrent abducens nerve palsy is rare. Twenty-three cases in children have been reported in the literature and many of these cases followed immunization or were associated with viral illness. Most of the reported patients share the following features: spontaneous recovery within 6 months, ipsilateral recurrence, and painless palsy. The authors describe a Turkish child with recurrent abducens nerve palsy with no obvious etiology.
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Affiliation(s)
- Vedat Okutan
- Gülhane Military Medical Academy, Department of Pediatrics, Ankara 06018, Turkey
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Tsai JH, Chao JR, Rao NA. Syphilitic and Other Spirochetal Uveitis. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Chapter 7 Inflammatory Optic Neuropathies Not Associated with Multiple Sclerosis. Neuroophthalmology 2008. [DOI: 10.1016/s1877-184x(09)70037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Boyé T. Sur quels éléments cliniques, épidémiologiques et biologiques faut-il évoquer la maladie de Lyme? Aspects dermatologiques et ophtalmologiques au cours de la maladie de Lyme. Med Mal Infect 2007; 37 Suppl 3:S175-88. [DOI: 10.1016/j.medmal.2007.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Accepted: 10/03/2007] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- Patrick Sibony
- Department of Ophthalmology and Neurology, State University of New York at Stony Brook, Stony Brook, NY 11794, USA.
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27
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Abstract
Despite the wide spectrum of clinical entities, eye involvement remains a rare event in patients with Lyme borreliosis. Most of ocular manifestations occur during the late phase of the disease. The infection needs to be considered along with more conventional causes of ocular inflammation, particularly in regions where Lyme disease is common. The pathogenesis of this condition remains controversial. Direct ocular infection and a delayed hypersensitivity mechanism may be involved at different disease stages. Uveitis and optic neuritis are the most common ocular complications. Serological testing lacks sensitivity and specificity. In atypical cases, ocular fluids sampling and analysis may be proposed. PCR seems to be an interesting diagnostic tool, allowing genotypic analysis. In the majority of cases, therapeutic strategy should be based on the association of antibiotics and corticosteroids. A new course of antibiotics may be prescribed to patients with chronic or relapsing inflammation due to bacterial persistence in ocular tissues.
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Affiliation(s)
- B Bodaghi
- Service d'ophtalmologie, université Paris-VI, CHU de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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Mishra SK, Murjaneh S, Morgan MS, Simcock PR, Glover S. Papillitis, Lyme disease, and cats. Eye (Lond) 2007; 21:850-1. [PMID: 17237753 DOI: 10.1038/sj.eye.6702705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Kubová Z, Szanyi J, Langrová J, Kremlácek J, Kuba M, Honegr K. Motion-onset and pattern-reversal visual evoked potentials in diagnostics of neuroborreliosis. J Clin Neurophysiol 2006; 23:416-20. [PMID: 17016151 DOI: 10.1097/01.wnp.0000218241.95542.4f] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Neuroborreliosis is a form of borreliosis that affects the central and/or peripheral nervous system. Although it can mimic neurologic and ophthalmologic disorders such as multiple sclerosis and optic neuritis, visual evoked potential (VEP) examination is usually not used in neuroborreliosis diagnostics. Combined VEP testing (pattern-reversal VEPs and VEPs produced in response to linear and radial motion) was performed in 81 patients with neuroborreliosis verified by laboratory results (positive polymerase chain reaction or intrathecal antibodies production). Thirty-four patients reported diplopia or blurred vision related to borreliosis. In 33 (40%) patients the VEPs were delayed: motion-onset VEPs were pathologic in 22 (27%) patients, reversal VEPs in 5 (6%) patients, and both VEP types in 6 (7%) patients. The findings suggest that VEP testing (especially the motion-onset VEP testing) can confirm CNS involvement. Much higher sensitivity of motion-onset VEPs in comparison with reversal VEPs can result from rather selective (earlier) involvement of the magnocellular system or the dorsal stream of the visual pathway.
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Affiliation(s)
- Zuzana Kubová
- Department of Pathophysiology, Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic.
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30
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Abstract
A man with orbital myositis and optic neuritis tested positive serologically for multiple tick-borne diseases. Erlichiosis, babesiosis, and Lyme disease may occur together and affect the eye or orbit.
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Affiliation(s)
- Sagun Pendse
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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31
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Abstract
Uveitis remains an important cause of visual impairment, particularly in young patients. Idiopathic forms of intraocular inflammation should no longer be regarded as a presumed clinical entity, and the ophthalmologist must reconsider the specific etiology of primary uveitis when the clinical examination does not yield a definitive diagnosis or when the course of the disease on corticosteroids remains atypical. Laboratory tests based on serum analysis have limited value and should not be considered as diagnostic proof in different clinical presentations. The diagnostic management of infectious uveitis has been greatly improved by the use of molecular techniques applied to ocular fluids and tissues. Polymerase chain reaction (PCR) technology is a powerful tool that should be proposed in atypical cases of uveitis or retinitis of unclear but potentially infectious origin. This strategy is a major step before using unconventional and new immunomodulatory agents such as anti-TNF-alpha molecules. Under strict experimental conditions including adequate testing to rule out a possible contamination, PCR and its variants have changed our practical approach to intraocular inflammatory disorders and have provided new details for the understanding of infectious uveitis. The concept of pathogen-induced intraocular inflammation can be revisited in the light of molecular data obtained after anterior chamber paracentesis or diagnostic vitrectomy.
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Affiliation(s)
- B Bodaghi
- Service d'Ophtalmologie, Hôpital de la Pitié-Salpétrière, Paris
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32
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Abstract
Lyme borreliosis in humans is an inflammatory disease affecting multiple organ systems, including the nervous system, cardiovascular system, joints and muscles. The causative agent, the spirochaete Borrelia burgdorferi, is transmitted to the host by a tick bite. The pathogenesis of the disease in its early stages is associated largely with the presence of viable bacteria at the site of inflammation, whereas in the later stages of disease, autoimmune features seem to contribute significantly. In addition, it has been suggested that chronic persistence of B. burgdorferi in affected tissues is of pathogenic relevance. Long-term exposure of the host immune system to spirochaetes and/or borrelial compounds may induce chronic autoimmune disease. The study of bacterium-host interactions has revealed a variety of proinflammatory and also immunomodulatory-immunosuppressive features caused by the pathogen. Therapeutic strategies using antibiotics are generally successful, but chronic disease may require immunosuppressive treatment. Effective and safe vaccines using recombinant outer surface protein A have been developed, but have not been propagated because of fears that autoimmunity might be induced. Nevertheless, new insights into the modes of transmission of B. burgdorferi to the warm-blooded host have been generated by studying the action of these vaccines.
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Affiliation(s)
- S K Singh
- Paediatric Rheumatology, Children's Hospital, University of Würzburg, Würzburg, Germany
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33
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Stadtbäumer K, Leschnik MW, Nell B. Tick-borne encephalitis virus as a possible cause of optic neuritis in a dog. Vet Ophthalmol 2004; 7:271-7. [PMID: 15200624 DOI: 10.1111/j.1463-5224.2004.04030.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 3-year-old spayed female Siberian Husky was presented due to acute vision loss. Examination revealed bilateral optic neuritis and lymphocytic meningoencephalitis. The serum (1:800) and cerebrospinal fluid (CSF; 1:200) immunoglobulin (Ig)G titers for tick-borne encephalitis virus (TBEV) were elevated as were the serum IgG titer for Anaplasma phagocytophilum (1:640) and serum IgM titer for Toxoplasma gondii (1:20). Intracytoplasmic inclusion bodies such as ehrlichial or anaplasmal morulae were not observed in the CSF or blood smear. The dog was treated with methylprednisone and doxycycline. The left eye regained vision; the right eye remained blind. Anti-inflammatory therapy was stopped on day 18 after diagnosis. Four days later the dog showed evidence of hyperesthesia in the cervical region. Analysis of CSF showed no abnormalities and CSF IgG titers for TBEV and A. phagocytophilum were negative. Funduscopic evidence of active papillitis was absent on day 22 in the left eye and on day 86 in the right eye. On day 243, the dog was presented again with lethargy, ataxia, disorientation and temporary head tilt. The IgG titer for TBEV was again elevated in the CSF (1:800) and in serum (1:400). After interpretation of all findings, we assume that meningoencephalitis and optic neuritis in this patient was caused by TBEV and associated immune-mediated inflammation. In endemic areas, TBEV should be considered as cause of optic neuritis in dogs.
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Affiliation(s)
- K Stadtbäumer
- Clinic for Surgery and Ophthalmology, University of Veterinary Medicine, Veterinärplatz 1, 1210 Vienna, Austria.
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Williams KE, Johnson LN. Neuroretinitis in patients with multiple sclerosis. Ophthalmology 2004; 111:335-40; discussion 340-1. [PMID: 15019385 DOI: 10.1016/s0161-6420(03)00663-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2002] [Accepted: 02/21/2003] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To present a case series of three patients with neuroretinitis associated with multiple sclerosis. DESIGN Retrospective, noncomparative, consecutive, interventional case series. PARTICIPANTS Thirty-five consecutive patients with neuroretinitis. METHODS The records of 35 consecutive patients with neuroretinitis were reviewed for prior, concurrent, or subsequent development of multiple sclerosis. MAIN OUTCOME MEASURES Presentation, clinical course, and diagnosis of multiple sclerosis. RESULTS Three of 35 patients (8.6%) with neuroretinitis were diagnosed with multiple sclerosis by the McDonald criteria. One of the three patients underwent brain biopsy that further confirmed multiple sclerosis. Neuroretinitis in the three patients occurred after the diagnosis of multiple sclerosis. All three patients with multiple sclerosis had been treated with interferon beta before or concurrently with the development of neuroretinitis. CONCLUSIONS Neuroretinitis can be an associated manifestation of multiple sclerosis. The possible association between neuroretinitis and interferon beta warrants further investigation.
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Affiliation(s)
- Kyle E Williams
- Neuro-Ophthalmology Unit, Mason Eye Institute, University of Missouri-Columbia, Columbia, Missouri 65212, USA.
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35
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Guyomard JL, Jacob H, Roche O, Pierre-Kahn V, Charlin JF. Présentation d’un cas atypique de rétinopathie hypertensive maligne chez une fillette. J Fr Ophtalmol 2004; 27:57-62. [PMID: 14968079 DOI: 10.1016/s0181-5512(04)96093-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Stage IV hypertensive retinopathies in children have been described, but their incidence appears to be rare. Most etiologies are nephropathies. The authors present a clinical case of malignant high blood pressure in a young girl whose ophthalmological tests detected an unusual nephropathy, the Ask-Upmark kidney, illustrating the importance of determining high blood pressure chronicity and using Kirkendall's classification. Systematic fluorescein angiography and NMR on atypical subjects prevents the diagnosis of Leber neuroretinis, the main differential diagnosis. Early treatment of high blood pressure can avoid complications such as macular exudes.
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Affiliation(s)
- J-L Guyomard
- Service d'Ophtalmologie, CHU Pontchaillou, Rennes.
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36
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Abstract
Increased intracranial pressure in patients with Lyme disease is an uncommon but reported finding. We discuss 2 patients from Lyme endemic areas who initially presented with headache, nausea, and vomiting and were eventually found to have increased intracranial pressure, a mild cerebrospinal fluid pleocytosis, and positive Lyme titers. It has been shown that increased intracranial pressure in association with neuroborreliosis can lead to blindness. In endemic areas, it is important for practitioners to consider Lyme disease when patients present with persistent headache, especially in those who have evidence of increased intracranial pressure.
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Affiliation(s)
- James M Moses
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 32115, USA
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37
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Nachman SA, Pontrelli L. Central nervous system Lyme disease. SEMINARS IN PEDIATRIC INFECTIOUS DISEASES 2003; 14:123-30. [PMID: 12881800 DOI: 10.1053/spid.2003.127229] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Lyme disease is a disease caused by the spirochete, Borrelia burgdorferi. It is transmitted to humans via a bite from an infected tick. It has several classic stages or categories of illness, including early localized disease, early disseminated disease, and late disease. The focus of this article is on the manifestations, diagnosis, and treatment of Lyme disease of the central nervous system.
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Affiliation(s)
- Sharon A Nachman
- Stony Brook University, Department of Pediatrics, Stony Brook, NY 11794-8111, USA.
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38
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Lastra B, Riaño I, Fernández P, González E. [Neuro-ophthamologic manifestations as unusual presentation of Lyme disease]. Med Clin (Barc) 2002; 119:396. [PMID: 12372174 DOI: 10.1016/s0025-7753(02)73426-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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39
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Cackett P, Weir C. Oculomotor nerve paralysis and bilateral facial nerve paralysis as presenting signs of Lyme disease. Neuroophthalmology 2002. [DOI: 10.1076/noph.27.1.183.14295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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40
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Abstract
Inflammation of the episclera and sclera still represents a diagnostic challenge. Many of these presentations are idiopathic and are managed empirically with the use of anti-inflammatory therapy, usually with a satisfactory response. However, some cases will have a more aggressive nature or will show resistance to conventional therapy, and those potentially are connected to an infectious or underlying disease. In such cases, there is an increased risk of visual loss and severe systemic complications requiring intensive investigations and aggressive therapy. The diseases more commonly associated with these conditions, especially with scleritis, are the connective tissue disorders and systemic vasculitis, but systemic infections and malignancies also must be excluded. Management depends on the specific diagnosis, and every year a new list of potential associations or atypical presentations is reported. For a successful outcome, it is important that these presentations are recognized.
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Affiliation(s)
- C E Pavesio
- Moorfields Eye Hospital, London, United Kingdom.
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41
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Abstract
Involvement of the optic nerve, either because of inflammation or increased intracranial pressure, is a rare manifestation of Lyme disease. Of the 4 children reported here with optic nerve abnormalities, 2 had decreased vision months after disease onset attributable to optic neuritis, and 1 had headache and diplopia early in the infection because of increased intracranial pressure associated with Lyme meningitis. In these 3 children, optic nerve involvement responded well to intravenous ceftriaxone therapy. The fourth child had headache and visual loss attributable to increased intracranial pressure and perhaps also to optic neuritis. Despite treatment with ceftriaxone and steroids, he had persistent increased intracranial pressure leading to permanent bilateral blindness. Clinicians should be aware that neuro-ophthalmologic involvement of Lyme disease may have significant consequences. If increased intracranial pressure persists despite antibiotic therapy, measures must be taken quickly to reduce the pressure.
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Affiliation(s)
- H Rothermel
- Division of Rheumatology/Immunology, Tufts University School of Medicine, New England Medical Center, Boston, MA 02111, USA
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42
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Akura J, Ikeda T, Sato K, Ikeda N. Macular star associated with posterior hyaloid detachment. ACTA OPHTHALMOLOGICA SCANDINAVICA 2001; 79:317-8. [PMID: 11401648 DOI: 10.1034/j.1600-0420.2001.790323.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To report a patient with a Leber's idiopathic stellate neuroretinitis-like lesion that was caused by vitreous traction accompanying a posterior hyaloid detachment. METHODS We present a 49-year-old woman who showed segmental optic disc edema, peripapillary retinal detachment, and a macular star. RESULTS An incomplete posterior hyaloid detachment was present, and the posterior hyaloid membrane was attached to the nasal margin of the optic disc. Fluorescein angiography revealed a bent retinal artery on the upper margin of the optic disc, and leakage of fluorescein was observed from this area. CONCLUSION Vascular damage to the optic disc due to vitreous traction should also be considered as a mechanism for the ophthalmoscopic appearance of the fundus when lesions suggestive of Leber's idiopathic stellate neuroretinitis are present in an adult.
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Affiliation(s)
- J Akura
- Department of Ophthalmology, Kushimoto Rehabilitation Center, Wakayama, Japan
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43
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Burkhard C, Gleichmann M, Wilhelm H. Optic nerve lesion following neuroborreliosis: a case report. Eur J Ophthalmol 2001; 11:203-6. [PMID: 11456029 DOI: 10.1177/112067210101100221] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Neuroborreliosis may cause various neuro-ophthalmological complications. We describe a case with a bilateral optic neuropathy. CASE REPORT A 58-year-old female developed facial paresis six weeks after an insect bite. One week later she developed bilateral optic disc swelling with haemorrhages and nerve fibre bundle defects in the lower visual field of the left eye. In CSF and serum, raised IgM and IgG titres to Borrelia burgdorferi were found. Systemic antibiotic treatment led to improvement of the vision and facial paresis, but not all visual field defects resolved, probably due to ischemic lesions of the optic disc. DISCUSSION/CONCLUSIONS In optic nerve lesions due to neuroborreliosis it is difficult to distinguish between inflammatory and ischemic lesions. This patient demonstrated features of an ischemic optic nerve lesion.
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Abstract
Despite the growing list of agents that can present as neuroretinitis, nearly one-half remain idiopathic. However, many of the candidate etiologies are treatable conditions, and accurate diagnosis can result in visual rehabilitation. A complete workup in patients presenting with acute neuroretinitis should include a thorough history and general medical evaluation. Exposure history should be thoroughly explored, including recent travel, unpasteurized and uncooked foods, sexual experience, and animal contacts. A detailed physical examination should be performed to note hidden rashes and inoculation sites and should include routine measurements of blood pressure and heart rate. Laboratory tests should be tailored to the history and may include complete blood count; erythrocyte sedimentation rate; bacterial, fungal, and viral blood cultures; antinuclear antibody test; angiotensin-converting enzyme; anti-double-stranded DNA; and C3. Serological evaluation should look for syphilis, Lyme disease, histoplasmosis, brucellosis, chlamydia, HIV, toxoplasmosis, Epstein-Barr virus, viral hepatitis B and C, and tuberculin skin test. Neuroretinitis is a clinical entity in which there is inflammation of the retinal architecture and optic nerve. There are numerous entities that can cause a picture of neuroretinitis ranging from vascular to infectious to autoimmune. With regards to the infectious etiologies, it is interesting to note that many of these organisms are obligate intracellular pathogens. The microorganisms B. henselae, T. gondii, R. typhi, T. pallidum, Mycobacterium tuberculosis, Histoplasma capsulatum, and various viruses, such as HIV, mumps, and HSV, are known intracellular agents. Other major infectious agents, such as B. burgdorferi and Leptospirosis spp. are known to remain sequestered within the circulatory system. It is possible that in this way these agents are able to breach the delicate blood-brain barrier. The implication of such findings on the treatment and management of neuroretinitis remains to be explored. Interestingly, the vast majority of infected patients do not develop neuroretinitis or demonstrate CNS involvement. Detailed examination of this variability may provide further insight into the pathogenic properties of these infectious agents, host tissue susceptibility, and mechanisms of blood-retina barrier integrity. A detailed retinal examination can provide an unobstructed view of the CNS. Careful inspection of this delicate interface may reveal subtle findings critical for accurate and rapid diagnosis of underlying systemic pathology. The varied visual and neurological symptoms of neuroretinitis attest to the fact that this is a disease of both the retina and contiguous neuronal elements. Such involvement significantly elevates the risk to the patient and emphasizes the need for early detection and prompt treatment.
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Affiliation(s)
- S Ray
- Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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Abstract
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.
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Affiliation(s)
- F Hamideh
- Department of Medicine, University of California, Irvine, Medical Center, Orange, CA, USA
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46
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Wade NK, Levi L, Jones MR, Bhisitkul R, Fine L, Cunningham ET. Optic disk edema associated with peripapillary serous retinal detachment: an early sign of systemic Bartonella henselae infection. Am J Ophthalmol 2000; 130:327-34. [PMID: 11020412 DOI: 10.1016/s0002-9394(00)00599-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe optic disk edema associated with peripapillary serous retinal detachment as an early sign of systemic Bartonella henselae infection. METHODS Multicentered, retrospective case series. RESULTS Five women and two men presented with optic disk edema producing peripapillary serous retinal detachment. Each patient had a markedly elevated serum anti-B. henselae antibody titer. Patient age ranged from 11 to 44 years, with a mean and median of 26.6 and 28 years, respectively. The time from the onset of systemic symptoms to the onset of visual symptoms varied from 3 days to 1 month. The peripapillary serous retinal detachment resolved within 1 to 3 weeks in each case, producing a macular star in four of seven patients. Initial vision was 20/200 or worse in five of seven patients and improved in four of these five patients to 20/30 or better. CONCLUSIONS Systemic B. henselae infection should be considered in patients who develop optic disk edema associated with a peripapillary serous retinal detachment, even in the absence of classic neuroretinitis with a macular star.
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Affiliation(s)
- N K Wade
- Francis I. Proctor Foundation, University of California, San Francisco, CA 94143-0944, USA
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47
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Mikkilä HO, Seppälä IJ, Viljanen MK, Peltomaa MP, Karma A. The expanding clinical spectrum of ocular lyme borreliosis. Ophthalmology 2000; 107:581-7. [PMID: 10711899 DOI: 10.1016/s0161-6420(99)00128-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To delineate the clinical manifestations of ocular Lyme borreliosis, while concentrating on new symptoms and findings and the phase of appearance of ophthalmologic disorders. DESIGN Observational case series. PARTICIPANTS Ten patients with Lyme borreliosis-associated ophthalmologic findings previously reported from the Helsinki University Central Hospital in addition to 10 new cases that have since been diagnosed. INTERVENTION/TESTING: The patients underwent medical and ophthalmologic evaluation. The diagnosis of Lyme borreliosis was based on medical history, clinical ocular and systemic findings, determinations of antibodies to Borrelia burgdorferi by enzyme-linked immunosorbent assay and immunoblot analysis, the detection of DNA of B. burgdorferi by polymerase chain reaction, and exclusion of other infectious and inflammatory causes. MAIN OUTCOME MEASURES Ocular complaints, presenting ophthalmologic findings, and the stage of Lyme borreliosis were recorded. RESULTS Four patients presented with a neuro-ophthalmologic disorder, five had external ocular inflammation, 10 patients had uveitis, and one had branch retinal vein occlusion. One patient developed episcleritis and one patient developed abducens palsy within 2 months of the infection incident. In the remaining 14 patients in whom the time of infection was traced, the ocular manifestations appeared in the late stage of Lyme borreliosis. Two patients with a neuro-ophthalmologic disorder and one with external ocular inflammation experienced severe photophobia, whereas the main reported symptom of the patients with uveitis was decreased visual acuity. Four patients with external ocular disease and one with a neuro-ophthalmologic disorder experienced severe periodic ocular or facial pain. Retinal vasculitis developed in seven patients with uveitis. CONCLUSIONS Lyme borreliosis can cause a variety of ocular manifestations, which develop mainly in the late stage of the disease. Photophobia and severe periodic ocular pain can be characteristic symptoms of Lyme borreliosis. In the differential diagnosis of retinal vasculitis, Lyme borreliosis should be taken into account, especially in endemic areas.
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Affiliation(s)
- H O Mikkilä
- Department of Ophthalmology, Helsinki University Central Hospital, Finland
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48
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Huppertz HI, Münchmeier D, Lieb W. Ocular manifestations in children and adolescents with Lyme arthritis. Br J Ophthalmol 1999; 83:1149-52. [PMID: 10502576 PMCID: PMC1722824 DOI: 10.1136/bjo.83.10.1149] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lyme arthritis is the most frequent late manifestation of Lyme borreliosis and has been associated with ocular inflammation. METHODS A group of 153 children and adolescents with arthritis, 84 of whom had Lyme arthritis and 69 other causes of arthritis, were followed prospectively for 22-73 (median 44) months in the course of a national study. RESULTS Three of 84 patients with Lyme arthritis had ocular inflammation (4%), including keratitis, anterior uveitis, and uveitis intermedia. All three had symptoms of decreased visual acuity. Whereas anterior uveitis disappeared without sequelae, a corneal scar and a permanent loss of visual acuity in the patients with keratitis and intermediate uveitis remained. Systematic examination of all patients revealed no further ocular involvement. Of 69 patients with other causes of arthritis who were followed in parallel as a control group, four of 15 patients with early onset pauciarticular juvenile rheumatoid arthritis had chronic anterior uveitis and two of 12 patients with juvenile spondyloarthropathy had acute anterior uveitis. CONCLUSIONS Ocular involvement with keratitis, anterior uveitis, and intermediate uveitis may occur in children and adolescents with Lyme arthritis. Visual loss appears to be symptomatic, making regular ocular screening of such patients unnecessary.
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Affiliation(s)
- H I Huppertz
- Children's Hospital, University of Würzburg, Würzburg, Germany
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49
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 6-1999. A 17 1/2-year-old girl with a thoracoabdominal aneurysm. N Engl J Med 1999; 340:635-41. [PMID: 10049073 DOI: 10.1056/nejm199902253400808] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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50
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Miller RW, Lee AG, Schiffman JS, Prager TC, Garza R, Jenkins PF, Sforza P, Verm A, Kaufman D, Robinson W, Eggenberger E, Tang RA. A practice pathway for the initial diagnostic evaluation of isolated sixth cranial nerve palsies. Med Decis Making 1999; 19:42-8. [PMID: 9917019 DOI: 10.1177/0272989x9901900106] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To define a practice pathway for the evaluation of sixth-nerve palsies (SNPs) and to determine its cost-effectiveness and validity in a retrospective chart review. METHODS A Medline search of the English-language literature from 1966 to 1995 was performed to define the available clinical evidence and develop the practice pathway. The authors retrospectively reviewed 407 charts with the diagnosis of SNP seen at three centers. Information obtained included: etiologic diagnosis if known; development of new neurologic or ophthalmologic findings; and results and costs of neuroimaging studies, if performed. RESULTS Of the 407 patients, 98 underwent computed tomography scans and 212 underwent magnetic resonance imaging of the head. Eighty cases were non-isolated, 317 were isolated SNP, and ten could not be classified from chart information. Of the 317 cases of isolated SNP, 49 were classified as traumatic; 5, congenital; 158, vasculopathic; 63, nonvasculopathic; and 42, progressive or unresolved. Following the recommendations of the practice pathway, the 158 patients classified as having vasculopathic SNP would not have undergone neuroimaging studies, realizing a savings of $100,000 in this study population of 407 patients. CONCLUSION The recommendations of the practice pathway are supported by review of the literature and the retrospective review of these cases. However, a prospective study with a matched control group is needed to demonstrate regional and specialty-specific variations in care and to strengthen the clinical certainty of the pathway recommendations.
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Affiliation(s)
- R W Miller
- Department of Ophthalmology at the University of Texas Medical School at Houston, USA
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