Screening for neuroborreliosis in patients with stroke

Lyme neuroborreliosis-associated cerebrovascular events in the Finnish endemic area

OBJECTIVES

Neuroborreliosis is a rare cause of cerebral vasculitis and stroke. The incidence of Lyme borreliosis in Finland has been increasing in the last 20 years, so we expect that Lyme neuroborreliosis-associated vasculitis can be a more common cause of stroke in the future.

MATERIALS & METHODS

We have retrospectively identified all adult patients (>16 years old) diagnosed with borreliosis (A69.2 Lyme borreliosis), transient ischemic attack (TIA, G45), and ischemic stroke (I63) at Helsinki University Hospital during 1.1.2014-31.10.2019 at our neurological emergency department. Medical data and follow-up data were retrospectively collected from medical records. Neuroborreliosis was diagnosed according to the European Federation of Neurological Societies guidelines.

RESULTS

We have identified 10 cases of neuroborreliosis-associated stroke or TIA and/or vasculitis. Vasculitis as a manifestation of borreliosis was diagnosed in six patients of 1454 (0.4%) and stroke or TIA in nine (0.6%) of all borreliosis patients at Helsinki University Hospital. Clinical outcomes for all our patients were good with a modified Rankin scale (mRS) 0-2.

CONCLUSIONS

Lyme neuroborreliosis-associated vasculopathy and cerebrovascular events still remain rare but should be considered especially in Lyme borreliosis endemic areas. Prognosis is good with appropriate antibiotic treatment, but additional immunosupressive treatment is sometimes needed.

Cerebrovascular Manifestations of Lyme Neuroborreliosis-A Systematic Review of Published Cases

BACKGROUND

Lyme neuroborreliosis (LNB) is a disease caused by spirochete Borrelia burgdorferi, involving the nervous system. It usually manifests as lymphocytic meningoradiculitis, but in rare cases, it can also lead to cerebrovascular complications. We aimed to perform a systematic review of all reported cases of LNB complicated by central nervous system vasculitis and stroke or transient ischemic attack (TIA).

MATERIALS AND METHODS

We conducted a systematic review of literature between May 1987 and December 2016 with patients who presented with cerebrovascular course of LNB.

RESULTS

This study included 88 patients with a median age of 46 years. The median interval from onset of symptoms suggesting Lyme disease to first symptoms of cerebrovascular manifestations of LNB was 3.5 months. The most common cerebrovascular manifestation of LNB was ischemic stroke (76.1%), followed by TIA (11.4%). The posterior circulation was affected alone in 37.8% of patients, the anterior circulation in 24.4% of patients, and in 37.8% of cases, posterior and anterior circulations were affected simultaneously. The most common affected vessels were middle cerebral artery-in 19 cases, basilar artery-in 17 cases, and anterior cerebral artery-in 16 cases. A good response to antibiotic treatment was achieved in the vast number of patients (75.3%). The overall mortality rate was 4.7%.

CONCLUSION

Cerebral vasculitis and stroke due to LNB should be considered, especially in patients who live in or have come from areas with high prevalence of tick-borne diseases, as well as in those without cardiovascular risk factors, but with stroke-like symptoms of unknown cause.

Common and uncommon neurological manifestations of neuroborreliosis leading to hospitalization

BACKGROUND

Neuroborreliosis represents a relevant infectious disease and can cause a variety of neurological manifestations. Different stages and syndromes are described and atypical symptoms can result in diagnostic delay or misdiagnosis. The aim of this retrospective study was to define the pivotal neurological deficits in patients with neuroborreliosis that were the reason for admission in a hospital.

METHODS

We retrospectively evaluated data of patients with neuroborreliosis. Only patients who fulfilled the diagnostic criteria of an intrathecal antibody production against Borrelia burgdorferi were included in the study.

RESULTS

Sixty-eight patients were identified with neuroborreliosis. Cranial nerve palsy was the most frequent deficit (50%) which caused admission to a hospital followed by painful radiculitis (25%), encephalitis (12%), myelitis (7%), and meningitis/headache (6%). In patients with a combination of deficits, back pain was the first symptom, followed by headache, and finally by cranial nerve palsy. Indeed, signs of meningitis were often found in patients with neuroborreliosis, but usually did not cause admission to a hospital. Unusual cases included patients with sudden onset paresis that were initially misdiagnosed as stroke and one patient with acute delirium. Cerebrospinal fluid (CSF) analysis revealed typical changes including elevated CSF cell count in all but one patient, a blood-CSF barrier dysfunction (87%), CSF oligoclonal bands (90%), and quantitative intrathecal synthesis of immunoglobulins (IgM in 74%, IgG in 47%, and IgA in 32% patients). Importantly, 6% of patients did not show Borrelia specific antibodies in the blood.

CONCLUSION

In conclusion, the majority of patients presented with typical neurological deficits. However, unusual cases such as acute delirium indicate that neuroborreliosis has to be considered in a wide spectrum of neurological diseases. CSF analysis is essential for a reliable diagnosis of neuroborreliosis.

Vasculitis and stroke due to Lyme neuroborreliosis - a review

Abstract Lyme neuroborreliosis (LNB) is a rare cause of vasculitis and stroke. It may manifest as subarachnoid hemorrhage, intracerebral hemorrhage, and most often ischemic stroke due to cerebral vasculitis. The vast majority of reported cases have been described by European authors. A high index of suspicion is required in patients who live or have traveled to areas with high prevalence of tick-borne diseases, and in the case of stroke-like symptoms of unknown cause in patients without cardiovascular risk factors. In this review, we also present four illustrative cases of vasculitis and stroke-like manifestations of LNB.

Chronic or late lyme neuroborreliosis: analysis of evidence compared to chronic or late neurosyphilis

Whether spirochetes persist in affected host tissues and cause the late/chronic manifestations of neurosyphilis was the subject of long-lasting debate. Detection of Treponema pallidum in the brains of patients with general paresis established a direct link between persisting infection and tertiary manifestations of neurosyphilis. Today, the same question is in the center of debate with respect to Lyme disease. The goal of this review was to compare the established pathological features of neurosyphilis with those available for Lyme neuroborreliosis. If the main tertiary forms of neurosyphilis also occur in Lyme neuroborreliosis and Borrelia burgdorferi can be detected in brain lesions would indicate that the spirochete is responsible for the neuropsychiatric manifestations of late/chronic Lyme neuroborreliosis. The substantial amounts of data available in the literature show that the major forms of late/chronic Lyme neuroborreliosis (meningovascular and meningoencephalitis) are clinically and pathologically confirmed. Borrelia burgdorferi was detected in association with tertiary brain lesions and cultivated from the affected brain or cerebrospinal fluid. The accumulated data also indicate that Borrelia burgdorferi is able to evade from destruction by the host immune reactions, persist in host tissues and sustain chronic infection and inflammation. These observations represent evidences that Borrelia burgdorferi in an analogous way to Treponema pallidum is responsible for the chronic/late manifestations of Lyme neuroborreliosis.Late Lyme neuroborreliosis is accepted by all existing guidelines in Europe, US and Canada. The terms chronic and late are synonymous and both define tertiary neurosyphilis or tertiary Lyme neuroborreliosis. The use of chronic and late Lyme neuroborreliosis as different entities is inaccurate and can be confusing. Further pathological investigations and the detection of spirochetes in infected tissues and body fluids are strongly needed.

Neuroborreliose bei einer Patientin mit vermeintlich kryptogenen zerebralen Infarkten

Es handelt sich um den Fall einer 55-jährigen Patientin, welche zweimal einen zerebralen Infarkt erlitt, ohne dass primär eine Ursache festgestellt werden konnte. Durch eine Lumbalpunktion wurde eine aktive Neuroborreliose diagnostiziert. Eine zweiwöchige antibiotische Therapie mit Ceftriaxon führte zu einem klaren Rückgang der entzündlichen Liquorveränderungen. Ein neuerlicher Insult trat bis zum heutigen Tag nicht auf.

Entzündliche Erkrankungen

Unter einer Meningitis versteht man eine Entzündung von Pia mater und Arachnoidea. Das Erregerspektrum ist weit und reicht von Bakterien, die hämatogen-metastatisch, fortgeleitet oder durch offene Hirnverletzung zur eitrigen Meningitis führen, über Viren zu Pilzen und Parasiten. Insbesondere bei den unbehandelt häufig letal verlaufenden eitrigen Meningitiden ist eine rasche Diagnose mit Erregernachweis notwendig. Unverzüglich ist daraufhin eine spezifische, der regionalen Resistenzentwicklung angepasste Therapie einzuleiten. Die meningeale Affektion im Rahmen einer Listeriose oder Tuberkulose verdient aufgrund des klinischen Bildes, des Verlaufs und der spezifischen Therapie besondere Beachtung. Die fungalen Infektionen werden, da klinisch häufig als Meningoenzephalitis imponierend, in Abschn. 33.3 abgehandelt.

[Vasculitis of the nervous system in infectious diseases]

Vasculitis and vasculopathies of the central and peripheral nervous system can be caused by infectious diseases. Vasculitis can lead to stenosis, occlusion and aneurysm formation of blood vessels which may result in stroke or cerebral haemorrhage. In cases of peripheral nervous system involvement mononeuritis multiplex and symmetric peripheral neuropathy are possible. The diagnosis is based on clinical presentation, serology, cerebrospinal fluid analysis and neuroradiologic examinations. In cases of peripheral neuropathy neurophysiologic examinations and biopsy of the sural nerve can lead to the diagnosis. A fast and efficient antimicrobial therapy is the most important treatment option. In cases of peripheral neuropathies short-term treatment with corticosteroids and plasma exchange may be helpful.

Lyme neuroborreliosis: manifestations of a rapidly emerging zoonosis

Lyme disease has a worldwide distribution and is the most common vector-borne disease in the United States. Incidence, clinical manifestations, and presentations vary by geography, season, and recreational habits. Lyme neuroborreliosis (LNB) is neurologic involvement secondary to systemic infection by the spirochete Borrelia burgdorferi in the United States and by Borrelia garinii or Borrelia afzelii species in Europe. Enhanced awareness of the clinical presentation of Lyme disease allows inclusion of LNB in the imaging differential diagnosis of facial neuritis, multiple enhancing cranial nerves, enhancing noncompressive radiculitis, and pediatric leptomeningitis with white matter hyperintensities on MR imaging. The MR imaging white matter appearance of successfully treated LNB and multiple sclerosis display sufficient similarity to suggest a common autoimmune pathogenesis for both. This review highlights differences in the epidemiology, clinical manifestations, diagnosis, and management of Lyme disease in the United States, Europe, and Asia, with an emphasis on neurologic manifestations and neuroimaging.

[Recurrent ischemic strokes revealing Lyme meningovascularitis]

INTRODUCTION

Infectious vascularitis is an unusual cause of ischemic stroke (IS). We report a case of Lyme meningovascularitis complicated with multiple IS.

CASE REPORT

A 64-year-old man, without any cardiovascular risk factor, was admitted for a right hemiparesia with a left thalamic hypodensity on the initial cerebral CT scan. No cause for this presumed IS could be identified. Later, the patient developed cognitive impairment and a bilateral cerebellar syndrome. Multiple infarcts and multiple intracranial stenosis were seen on cerebral MRI with magnetic resonance angiography (MRA). Cerebrospinal fluid tests showed meningitis and positive Lyme serology with an intrathecal specific anti-Borrelia antibody index. Antibiotic treatment was followed by good biological and partial clinicoradiological outcome.

CONCLUSION

The diagnosis of Lyme neuroborreliosis should be entertained as a possible cause of IS in highly endemic zones.

Sur quels éléments cliniques et épidémiologiques faut-il évoquer le diagnostic de la borréliose de Lyme? Aspects neurologiques et psychiatriques au cours de la maladie de Lyme

Lyme disease is associated with various systemic and neurological manifestations. The neurological and psychiatric manifestations of Lyme disease are more frequently observed during its secondary phase (stage 2) than during its late tertiary phase (stage 3). In stage 2, cerebrospinal fluid and bacterial tests are consistent with the ongoing infection. Painful meningoradiculitis, encephalomyelitis and encephalitis, and symptoms of depression are the most characteristic at this stage. The diagnosis should be based on the association of clinical, epidemiological, and biological features. Adequate treatment usually leads to recovery. In stage 3 of the disease, the link between neurological manifestations and initial infection is uncertain. Distal axonal polyneuropathy and chronic encephalopathy are the most frequently reported presentations.

Lyme neuroborreliosis mimics stroke: a case report

Lyme neuroborreliosis is diagnostically challenging because of its diverse manifestations. The well-documented neurologic spectrum includes lymphocytic meningitis, cranial neuropathy, and radiculoneuritis in the early disseminated stage; and peripheral neuropathy, chronic encephalomyelitis, and mild encephalopathy in the late persistent stage. This case report describes a 74-year-old man who developed progressive left hemiparesis and facial palsy. The patient was hospitalized to rule out a cerebral vascular accident. The diagnosis of Lyme borreliosis was established with serologic studies. The patient was treated with intravenous ceftriaxone and responded with rapid clinical and functional recovery. Lyme neuroborreliosis presenting as hemiparesis has rarely been reported. Prompt diagnosis and treatment appear to facilitate symptomatic relief and prevent persistent neurologic deficits.

[Ischemic stroke caused by neuroborreliosis]

Ischemic stroke in children is rare and its etiology is frequently unknown.

CASE REPORT

We report the case of a nine-year-old boy who presented a right ischemic lenticular stroke due to neuroborreliosis, with a good outcome after antibiotic treatment.

CONCLUSION

We suggest that it is important to search for neuroborreliosis in case of an ischemic stroke in children; the study of cerebral spinal fluid is a good diagnostic marker.

Nervous system Lyme disease

Lyme disease is a multisystem infectious disease caused by tick-borne spirochetes of the Borrelia burgdorferi group. The disease occurs primarily in specific areas of North America, Europe and Asia, reflecting the distribution of the hard-shelled Ixodes ticks that are required for disease transmission. Diagnosis of this infection can be somewhat problematic, although in clinically appropriate settings, serologic testing can be highly useful, particularly if Western blots are used to confirm borderline or positive results. The organism has several specific organotropisms-involvement of the heart, joints and nervous system being particularly common. The nervous system can be involved in one or more ways. Early in infection, patients tend to get a lymphocytic meningitis, cranial neuritis (particularly the facial nerves) or a painful radiculitis. Rarely, an encephalomyelitis can occur. In patients with more protracted and indolent involvement, a more disseminated mononeuropathy multiplex may occur, or a mild, non-focal alteration of cognitive function and memory, i.e. an encephalopathy. In patients with central nervous system involvement, the most sensitive diagnostic test is the demonstration of intrathecal production of anti-Borrelia burgdorferi antibody. Culture, polymerase chain reaction and other techniques appear to be less specific. In most instances, the disease is quite responsive to antimicrobial therapy. Oral treatment with doxycycline has been shown to be effective in meningitis. In more serious cases two to four week courses of parenteral ceffriaxone or cefotaxime are effective in the vast majority of patients.

An epidemiologic study of Lyme disease in southern Sweden

BACKGROUND

Lyme disease is the most common vector-borne infection in some temperate regions of the Northern Hemisphere. However, for most areas of endemic disease reliable epidemiologic data are sparse.

METHODS

Over a one-year period, we conducted a prospective, population-based survey of cases of Lyme disease in southern Sweden. The diagnosis was made on the basis of the presence of erythema migrans at least 5 cm in diameter or characteristic clinical manifestations such as arthritis, neuroborreliosis, and carditis.

RESULTS

We identified 1471 patients with Lyme disease, for an overall annual incidence of 69 cases per 100,000 inhabitants. The incidence varied markedly according to geographic region, and there were several areas where disease was widely prevalent. The incidence varied according to age, with the highest rates among people 5 to 9 and 60 to 74 years of age, but not according to sex. The most frequent clinical manifestation was erythema migrans (seen in 77 percent of all cases), followed by neuroborreliosis (16 percent) and arthritis (7 percent). Carditis was rare. A preceding tick bite was reported by 79 percent of the patients. Bites in the head and neck region were more common among children than among adults and were associated with an increased risk of neuroborreliosis.

CONCLUSIONS

Lyme disease is very common in southern Sweden, with a relatively high frequency of neurologic complications and arthritis. With the exception of the low incidence of carditis, the pattern of disease we found in Sweden was similar to that reported in the United States.