Teenager with stroke symptoms actually had Lyme

Source-https://www.sciencedaily.com/releases/2015/03/150302182428.htm

A Swiss teenager, recently returned home from a discotheque, came to the emergency department with classic sudden symptoms of stroke, only to be diagnosed with . The highly unusual case presentation was published online in Annals of Emergency Medicine.

"Everything about her symptoms indicated stroke: speech deficits, poor comprehension and right-sided face and arm weakness, so we considered treating her with clot-busting drugs" said lead study author Arseny Sokolov, MD, of the Department of Clinical Neuroscience, Centre Hospitalier Universitaire Vaudois in Lausanne, Switzerland. "But a 16 year-old having a stroke, while not unheard of, would be quite rare so we looked at other possibilities and found Lyme."

Brain imaging was not suggestive of stroke either, but revealed circumscribed brain dysfunction. The treatment team performed a spinal tap. The patient's spinal fluid showed elevated white blood cell counts and Lyme neuroborreliosis was diagnosed, so the treatment team began a course of antibacterial and antiviral agents. The patient improved immediately after treatment began.

"The imaging findings for the first time demonstrate acute brain dysfunction that appears to be directly related to neuroborreliosis" said senior co-author Renaud Du Pasquier, MD, neurology chairman at the Centre Hospitalier Universitaire Vaudois in Lausanne. "It may point out future perspectives for research on the underlying mechanisms."

Lyme disease is caused by burgdorferi bacteria, and is known as "the great imitator," as its symptoms can mimic so many other . Many patients have Lyme for a long time before a proper diagnosis is rendered. When that happens, serious long-term complications are the result.

"The uncommon set of symptoms our patient had show why Lyme is a 'chameleon disease' of the emergency department," said Dr. Sokolov. "Furthermore, the patient had no history of tick bite. This curious case just shows the careful detective work that is involved in such a large portion of emergency medicine."

Reference:

Acute Lyme Neuroborreliosis With Transient Hemiparesis and Aphasia

Arseny A. Sokolov, MD, Reto Lienhard, MSc, Renaud Du Pasquier, MD, Véronique Erard, MD DOI: http://dx.doi.org/10.1016/j.annemergmed.2015.01.011

ABSTRACT involvement in Lyme disease often mimics other conditions and thus represents a diagnostic challenge, especially in an emergency department setting. We report a case of a female teenager presenting with sudden-onset aphasia and transient right-sided faciobrachial hemiplegia, along with and agitation. Ischemia, vasculitis, or another structural lesion was excluded by brain imaging. Toxicologic evaluation results were negative. Cerebral perfusion computed tomography and electroencephalography showed left parietotemporal brain dysfunction. Lumbar puncture result, although atypical, suggested bacterial and intravenous was initiated. Finally, microbiological analysis revealed Lyme neuroborreliosis, showing specific intrathecal antibody production and high level of C-X-C motif chemokine 13. The patient rapidly recovered. To our knowledge, this report for the first time illustrates that acute-onset language and motor symptoms may be directly related to Lyme neuroborreliosis. Neuroborreliosis may mimic other acute neurologic events such as stroke and should be taken into diagnostic consideration even in the absence of classic symptoms and evolution.

Further scientific literature

Pediatr Neurol. 2015 Jan;52(1):107-9. doi: 10.1016/j.pediatrneurol.2014.10.009. Epub 2014 Oct 16. A unique case of adolescent neuroborreliosis presenting with multiple cranial neuritis and cochlear on magnetic resonance imaging. Ewers EC1, Dennison DH2, Stagliano DR3. Author information Abstract BACKGROUND: Lyme disease is the most common vector-borne disease in the United States and is caused by infection with the spirochete . In children, neuroborreliosis usually presents as peripheral facial nerve palsy and lymphocytic and only rarely is associated with cranial polyneuritis. PATIENT DESCRIPTION: We present a 15-year-old with tinnitus, hearing loss, and facial nerve palsy in the setting of acute, severe right arm pain and a several week history of malaise and headache. Lumbar puncture was notable for lymphocytic pleocytosis. Serologic testing demonstrated positive Lyme antibody and a positive immunoglobulin M Western blot. Immunofluorescent assay of cerebrospinal fluid was also positive for anti-Lyme immunoglobulin M. Audiologic testing revealed mixed, right-sided hearing loss. Neuroimaging demonstrated cranial polyneuritis and right-sided cochlear inflammation. The patient was treated with parenteral ceftriaxone with resolution of his symptoms at close follow-up. DISCUSSION: Neuroborreliosis with radiculopathy, lymphocytic meningitis, and cranial polyneuritis is a rare presentation of pediatric Lyme disease. Additionally, cochlear inflammation along with cranial nerve VIII inflammation may contribute to hearing loss in patients with neuroborreliosis.

Wien Klin Wochenschr. 2015 Jan;127(1-2):65-7. doi: 10.1007/s00508-014-0622-5. Epub 2014 Oct 24. Cerebral sinuvenous thrombosis: a rare complication of Lyme neuroborreliosis. Blažina K1, Miletić V, Relja M, Bažadona D. Author information Abstract Association between neuroborreliosis and cerebral sinuvenous thrombosis is rare, and it can be made only when other, more common predisposing conditions are excluded. In the case of increased and confirmed neuroborreliosis, early magnetic resonance venography and combination of antibacterial therapy with anticoagulation provide better long-term outcome. We present a case of a patient with cerebral sinuvenous thrombosis who was first treated for neuroborreliosis. Infect Dis (Lond). 2015 Jan;47(1):1-6. doi: 10.3109/00365548.2014.961544. Epub 2014 Oct 24. Vasculitis and stroke due to Lyme neuroborreliosis - a review. Zajkowska J1, Garkowski A, Moniuszko A, Czupryna P, Ptaszyńska-Sarosiek I, Tarasów E, Ustymowicz A, Łebkowski W, Pancewicz S. Author information Erratum in • Corrigendum. [Infect Dis (Lond). 2015] Abstract 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.

J Child Neurol. 2015 Aug;30(9):1226-9. doi: 10.1177/0883073814552104. Epub 2014 Oct 14. Stroke-like Phenomena Revealing Multifocal Cerebral Vasculitis in Pediatric Lyme Neuroborreliosis. Kurian M1, Pereira VM2, Vargas MI2, Fluss J3. Author information Abstract Stroke-like presentation in Lyme neuroborreliosis is rare in the pediatric age group. We report a previously healthy 12- year-old boy who presented with acute left hemiparesis and meningeal signs. Neuroimaging failed to reveal any cerebral infarction but demonstrated a multifocal cerebral vasculitis involving small, medium and large-sized vessels affecting both the anterior and posterior circulation. Concentric contrast enhancement of the basilar artery was also observed. Further investigations and laboratory findings were consistent with Lyme neuroborreliosis. A rapidly favorable clinical outcome was obtained with appropriate antibiotic treatment along with antiaggregants and steroids. Lyme neuroborreliosis should be considered in the diagnostic differential, not only in adults but also among children, especially in the context of an unexplained cerebral vasculitis.

Cerebrovasc Dis. 2013;35(2):184-5. doi: 10.1159/000346597. Epub 2013 Feb 21. Transient ischaemic attack in a 5-year-old girl due to focal vasculitis in neuroborreliosis. Kohns M1, Karenfort M, Schaper J, Laws HJ, Mayatepek E, Distelmaier F. J Pediatr. 2016 Mar;170:334-334.e1. doi: 10.1016/j.jpeds.2015.11.077. Epub 2016 Jan 6. Lyme Neuroborreliosis: A Potentially Preventable Cause of Stroke. Allen NM1, Jungbluth H1.

Cerebrovasc Dis. 2008;26(5):455-61. doi: 10.1159/000155982. Epub 2008 Sep 23. Cerebral vasculitis and stroke in Lyme neuroborreliosis. Two case reports and review of current knowledge. Topakian R1, Stieglbauer K, Nussbaumer K, Aichner FT. Author information Abstract We report on 2 patients with cerebral vasculitis and stroke due to Lyme neuroborreliosis (LNB). Both patients had a prodromal stage involving , and showed meningeal enhancement in addition to ischemic infarctions on brain magnetic resonance imaging and diffuse vasculitis on vascular imaging. Serological and cerebrospinal (CSF) fluid studies confirmed the diagnosis of active LNB. Ceftriaxone for 3 weeks led to an excellent recovery and improvements in the CSF examination findings. Stroke physicians should be aware of this rare presentation of LNB. A review of the current knowledge on cerebral vasculitis due to LNB is provided.

Acta Neurol Belg. 2008 Sep;108(3):103-6. Acute ischaemic pontine stroke revealing lyme neuroborreliosis in a young adult. Van Snick S1, Duprez TP, Kabamba B, Van De Wyngaert FA, Sindic CJ. Author information Abstract We report the case of a 23-year-old male patient who suddenly developed right hemiparesis, cerebellar , dysarthria, and bilateral dysmetria. Brain magnetic resonance (MR) examination demonstrated hyperacute ischaemic lesions within the pons. CSF analysis revealed a high protein content, lymphocytic pleocytosis, and oligoclonal IgG bands not present in the serum. Elevated IgM and IgG anti-Borrelia burgdorferi antibodies were shown in both serum and CSF samples, associated with an intrathecal synthesis of these antibodies. Ischaemic CNS lesions have been rarely observed as the first manifestation of Lyme neuroborreliosis. The putative mechanism for parenchymal ischaemia is the local extension of inflammatory changes from meninges to the wall of penetrating arterioles.

Arch Pediatr. 2008 Jan;15(1):41-4. Epub 2007 Dec 26. [Acute hemiparesis revealing a neuroborreliosis in a child]. Rénard C1, Marignier S, Gillet Y, Roure-Sobas C, Guibaud L, Des Portes V, Lion-François L. Author information Abstract We report on a 11-year-old boy who had 2 acute hemiparesis episodes over a period of 1 month. He suffered from headache and fatigue since 1 year. He could not remember neither a tick bite nor a local erythematous skin lesion. The diagnosis of neuroborreliosis was based on intrathecal production of specifics antibodies. Furthermore, the CSF/blood glucose ratio was decreased (0.14), which was rarely described. Cranial MRI showed left capsulothalamic inflammation and a vasculitis. The patient was successfully treated by ceftriaxone. Neuroborreliosis should be considered in all children with stroke-like episode, even in the absence of a history of a tick bite.

Eur Neurol. 2004;51(1):49-50. Epub 2003 Nov 21. Neuroborreliosis with vasculitis causing stroke-like manifestations. Romi F1, Kråkenes J, Aarli JA, Tysnes OB. J Neuroimaging. 2012 Apr;22(2):210-2. doi: 10.1111/j.1552-6569.2010.00550.x. Epub 2010 Dec 1. Stroke due to lyme neuroborreliosis: changes in vessel wall contrast enhancement. Lebas A1, Toulgoat F, Saliou G, Husson B, Tardieu M. Author information Abstract BACKGROUND AND PURPOSE: Neuroborreliosis is a rare cause of stroke in children. We aim here to demonstrate the diagnostic value of gadolinium- enhanced magnetic resonance imaging (MRI) for demonstrating vessel wall abnormality in a child with brainstem stroke. RESULTS: We report here the case of an 8-year-old boy with cerebral vasculitis and stroke due to Lyme neuroborreliosis. Imaging studies revealed the presence of ischemic lesions in the pons and cerebellum, with focal stenosis of the basilar artery on magnetic resonance angiography and focal gadolinium enhancement of the basilar artery wall. Nine months after treatment, clinical outcome was favorable, with no enhancement of the basilar artery. CONCLUSIONS: Gadolinium-enhanced MRI provided additional information facilitating the diagnosis of vasculitis in a child with Lyme neuroborreliosis and stroke. The location of vessel wall enhancement was correlated with the topography of the acute infarct, and the lack of vessel lumen obstruction supported the diagnosis of vasculitis rather than any other cause

Arch Phys Med Rehabil. 2000 Apr;81(4):519-21. Lyme neuroborreliosis mimics stroke: a case report. Zhang Y1, Lafontant G, Bonner FJ Jr. Author information Abstract 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 , and mild 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.

Arch Dis Child. 2000 Jul;83(1):67-71. Primarily chronic and cerebrovascular course of Lyme neuroborreliosis: case reports and literature review. Wilke M1, Eiffert H, Christen HJ, Hanefeld F. Author information Abstract As part of an ongoing study aiming to define the clinical spectrum of neuroborreliosis in childhood, we have identified four patients with unusual clinical manifestations. Two patients suffered from a primarily chronic form of neuroborreliosis and displayed only non-specific symptoms. An 11 year old boy presented with long standing symptoms of severe weight loss and chronic headache, while the other patient had pre-existing mental and motor retardation and developed and failure to thrive. Two further children who presented with acute hemiparesis as a result of cerebral ischaemic infarction had a cerebrovascular course of neuroborreliosis. One was a 15 year old girl; the other, a 5 year old boy, is to our knowledge the youngest patient described with this course of illness. Following adequate antibiotic treatment, all patients showed substantial improvement of their respective symptoms. Laboratory and magnetic resonance imaging findings as well as clinical course are discussed and the relevant literature is reviewed.

Rev Neurol (Paris). 2000 Dec;156(12):1154-6. [Left sided sudden hemiparesis linked to a central form of Lyme disease]. [Article in French] Deloizy M1, Devos P, Stekelorom T, Testard D, Belhadia A. Author information Abstract Lyme disease is known for its numerous neurological manifestations. Cerebral ischemic lesions are more rarely reported. We describe the case of a 27 - year old man - presenting with a left-sided hemiparesis when waking up. We first thought of a stroke, due to the presence of a light right capsulo-thalamic hypodensity on C.T. scan and the spontaneous regression of the hemiparesis within a few days. However, the lumbar puncture performed on the patient due to a fever running 38 degrees C and some drowziness showed a lymphocytic pleocytosis with a very inflammatory face of the spinal fluid. The M. R.I. revealed a right capsular and thalamic image with edema of the front part of the thalamus showing either a vascular or an inflammatory origin. The Lyme serodiagnosis in the blood and in the spinal fluid was positive, and we demonstrated an intrathecal Borrelia burgdorferi specific antibody synthesis. This case is interesting because it shows a central form of neuroborreliosis through cerebral infarct and its regressive evolution under treatment. The possible pathophysiology mechanisms have been discussed.

Nervenarzt. 1999 Feb;70(2):167-71. [Neuroborreliosis with extensive cerebral vasculitis and multiple cerebral infarcts]. [Article in German] Schmitt AB1, Küker W, Nacimiento W. Author information Abstract We report on a patient who suffered from borreliosis-induced severe cerebral vasculitis accompanied by multiple cerebral infarctions leading to hemiparesis, hemianopsia and reduced consciousness. Despite antibiotic and immunosuppressive therapy with ceftriaxon and prednisolone the patients condition deteriorated. Cerebral angiography showed multiple stenoses of large arteries of the posterior circulation and ubiquitous irregularities of small vessel wails. General reduced perfusion reflected an increased peripheral resistance. After 4 weeks of additional immunosuppressive treatment with cyclophosphamide the neurological status and angiographic findings improved dramatically.

Arch Pediatr. 1999 Dec;6(12):1302-5. [Ischemic stroke caused by neuroborreliosis]. [Article in French] Laroche C1, Lienhardt A, Boulesteix J. Author information Abstract 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.

Neurology. 1993 Dec;43(12):2705-7. Stroke due to Lyme disease. Reik L Jr1. Author information Abstract A 56-year-old Connecticut woman suffered multiple 18 months after antibiotic treatment for early Lyme disease with facial palsy. Pleocytosis, intrathecal synthesis of anti-Borrelia burgdorferi antibody, and the response to antibiotic treatment substantiated the diagnosis of neuroborreliosis. This is the first report of stroke caused by Lyme disease acquired in North America.

Stroke. 1993 Sep;24(9):1393-6. Screening for neuroborreliosis in patients with stroke. Hammers-Berggren S1, Gröndahl A, Karlsson M, von Arbin M, Carlsson A, Stiernstedt G. Author information Abstract BACKGROUND AND PURPOSE: Borrelia burgdorferi, the etiologic agent of Lyme disease, can cause different neurological manifestations. We studied the prevalence of Lyme neuroborreliosis in patients with stroke. METHODS: During a 1-year period, sera from patients with cerebral thrombosis or transient ischemic attack without cardioembolism were investigated for antibodies against B burgdorferi. RESULTS: One of 281 patients had a positive serum immunoglobulin M titer and 23 of 281 (8%) had positive serum immunoglobulin G titers against B burgdorferi. One of the 24 seropositive patients, with a diagnosis of transient ischemic attack due to dysphasia, had a lymphocytic pleocytosis and intrathecal antibody production against B burgdorferi. The medical history revealed a 9-month period of general and neurological symptoms compatible with Lyme neuroborreliosis before the strokelike incidents. CONCLUSIONS: We conclude that Lyme neuroborreliosis may imitate stroke, but screening for antibodies against B burgdorferi seems to be of little value and may be replaced by a careful medical history.

Neuroradiology. 1993;35(7):529-31. Lyme disease presenting as a stroke in the vertebrobasilar territory: MRI. Defer G1, Levy R, Brugiéres P, Postic D, Degos JD. Author information Abstract A 28-year-old female farmer, without vascular risk factors, developed a limited infarct of the pons, associated with a lymphocytic cerebrospinal fluid (CSF) pleocytosis. Titres of specific antibodies against Borrelia burgdorferi were high in serum and CSF. MRI confirmed an infarct in the territory of the medial pontine arteries, but angiography showed no evidence of cerebral angiopathy. Antibiotic therapy rapidly led to a return to normal of CSF cytology and serology. We suggest that Lyme disease is a possible cause of cerebral ischaemia.

Ann Emerg Med. 1990 May;19(5):572-6. The enlarging clinical spectrum of Lyme disease: Lyme cerebral vasculitis, a new disease entity. Brogan GX1, Homan CS, Viccellio P. Author information Abstract The case of a patient with cerebral vasculitis with a right thalamic infarct associated with cerebral spinal fluid Lyme disease is presented. This entity has not been described in the United States, and only one similar case in the world literature could be found. The patient presented with a progressive headache and subsequent development of grand mal activity. Lyme disease has been associated with cranial nerve palsies, peripheral and cranial radiculopathies, aseptic meningitis, encephalitic symptoms, , and demyelinating polyneuropathy presenting like Guillain-Barré syndrome. These syndromes can occur separately or in combination. Stroke and strokelike syndromes have been attributed to Lyme disease. The literature concerning the neurologic manifestations of Lyme disease is reviewed.

Rinsho Shinkeigaku. 1990 Jan;30(1):50-4. [A case of cerebral thrombosis presenting global aphasia without hemiparesis]. [Article in Japanese] Hirano T1, Hashimoto Y, Watanabe S, Araki S, Makino H. Author information Abstract We reported a 62-year-old male with cerebral thrombosis presenting global aphasia without hemiparesis. The patient had an episode of aphasia 15 years ago, but recovered within 6 months. This time he had transient right sided mild hemiparesis, then he became aphasia next morning. When we examined at day 10 and day 15, his consciousness was clear, nothing he could speech, he could not understand or repeat. We diagnosed him global aphasia, but he had no hemiparesis except for right facial mild paresis and was able to walk. CT scan showed low density area in left and right posterior, left anterior watershed and left terminal zone. Cerebral angiography disclosed thrombotic occlusion of main trunk of left middle cerebral artery, and ambient segment of right posterior cerebral artery. Global aphasia without hemiparesis has been said a sign of embolic encephalopathy. This case was considered a very rare case, because he revealed global aphasia without hemiparesis by thrombotic occlusion.