Lyme CNS Infection Mimics Stroke in Teenager

Janis C. Kelly

March 06, 2015

The chameleon qualities of Lyme neuroborreliosis gained another layer with a case report of a teenager with sudden onset of what appeared to be ischemic stroke but turned out to be Borrelia burgdorferi infection. The correct diagnosis was made just in time to avoid the administration of thrombolytic therapy to the teenager.

Arseny A. Sokolov, MD, from the Department of Clinical Neuroscience, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, and colleagues reported in an article published online February 25 in the Annals of Emergency Medicine that the 16-year-old girl presented the morning after a disco party with acute onset of severe headache and confusion. By the time she was evaluated at an urgent care center, she had right-sided face and arm weakness and language deficits. She was transferred by helicopter to a medical center for possible thrombolysis.

"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. 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," Dr Sokolov said in a news release.

By 3 hours after symptom onset, the hemiparesis had resolved, but the patient still displayed agitation, confusion, and aggressiveness. She had reduced ability to speak but no meningismus. Motor and sensory deficits had resolved, and the patient had normal reflexes and other neurological examinations.

"The language deficits with reduced speech production and comprehension but preserved repetition were compatible with transcortical sensory aphasia," the authors write. "Although right-sided face and arm weakness could not be confirmed, both language and motor symptoms pointed to focal left parietotemporal affection, with ischemic stroke and nonconvulsive status epilepticus to be excluded first. Although thrombolytic treatment in pediatric stroke is an evolving area, the patient would have been within the European 4.5-hour window in which thrombolysis has been effective in adults."

Drug intoxication and psychogenic origin were ruled out because the patient had been directly observed for at least 16 hours before hospital admission.

In view of the possible indication for thrombolysis, Dr Sokolov's team conducted contrast-enhanced brain computed tomography with arterial and venous angiographies, which showed no signs of brain lesion, hemorrhagic stroke, vasculitis, or cerebral venous sinus thrombosis but did reveal diffuse brain hyperperfusion with patchy perfusion in the left temporoparietal junction. Given the imaging results, the clinicians concluded that thrombolysis was not indicated. They ruled out nonconvulsive status epilepticus by electroencephalography and drug or other toxicity by extensive toxicologic screening.

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

The next step in the diagnosis was lumbar puncture. Cerebrospinal fluid (CSF) analysis showed elevated leucocyte levels with 45% neutrophils, elevated protein, and elevated lactate, along with reduced CSF glucose. The researchers concluded that despite the relatively low leucocyte counts and unremarkable Gram stain, the patient might have bacterial meningitis.

The patient was quickly treated with an intravenous regimen of ceftriaxone, amoxicillin/clavulanate, and acyclovir and began to improve almost immediately.

Within 24 hours, symptoms had resolved, apart from circumstantial amnesia. Blood immunoassays for B burgdorferi immunoglobulin G, immunoglobulin M, and C6 Lyme immunoglobulin were positive. Intrathecal production of immunoglobulin G was observed using isoelectrofocalization, and highly significant levels of B burgdorferi immunoglobulin M and immunoglobulin G were identified in CSF and serum, yielding an intrathecal antibody index of 7.1 (vs normal <1.5). The CXCL13 chemokine in CSF was nearly double normal levels.

Despite the absence of a history of tick bite, the researchers concluded the patient had acute neuroborreliosis. They continued ceftriaxone alone for 4 weeks, by which time the patient had achieved "excellent clinical evolution."

The authors emphasize that this report "highlights the importance of lumbar puncture and early empiric antimicrobial treatment" to avoid complications such as chronic Lyme encephalopathy with cognitive deficits. They also suggest that CXCL13 might be a particularly useful early marker of Lyme neuroborreliosis before positive tests for intrathecal antibodies because CXCL13 is secreted after Borrelia invasion of the central nervous system and attracts B lymphocytes.

The authors have disclosed no relevant financial relationships.

Annals Emerg Med. Published online February 25, 2015. Full text

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