Description, Causes and Risk Factors:
Lyme neuroborreliosis is the most common human tick-borne disease in the Northern hemisphere. Its prevalence is estimated to range between 20 and 100 cases per 100,000 people in the US and about 100 to 130 cases per 100,000 in Europe.
Lyme neuroborreliosis is caused by the tick-borne spirochete Borrelia burgdorferi (Bb) sensu lato. The Bb sensu lato complex consists of at least three human pathogenic species; Bb sensu stricto, B. Garinii, and B. afzelii. All are endemic in Europe, whereas Bb sensu stricto is the only species detected in North America. This may account for clinical differences in American and European neuroborreliosis. In this short review we convey basic facts, our own experience and some new knowledge of clinical manifestations, diagnostics, treatment and prognosis of Lyme neuroborreliosis in European adult patients.
The infection by Bb is a complex process beginning with the translation from the gut to the salivary glands of the tick during the feeding process on the host. After invasion into the skin, Bb can cause a local infection called erythema migrans (EM). During the second stage of Lyme disease, Bb can spread from the tick bite on the skin to various secondary organs throughout the body, including heart, joints, and peripheral and central nervous system (CNS). Major clinical findings of the neurological manifestation of acute Lyme neuroborreliosis (LNB) include painful meningoradiculitis with inflammation of the nerve roots and lancinating, radicular pain (Bannwarth's syndrome), lymphocytic meningitis, and various forms of cranial or peripheral neuritis.
Symptoms associated with Lyme neuroborreliosis that may contribute to increasing risk for aggression include — sensory hyperacusis, significant cognitive impairments, decreased visual memory, impaired ability to recognize faces, depersonalization, derealization, intrusive images and thoughts, horrific nightmares, illusions, hallucinations, decreased or lack of empathy, low frustration tolerance, hypervigilance, acoustic startle, paranoia, irritability, sudden abrupt mood swings, disinhibition, explosive anger, suicidal tendencies, homicidal tendencies and substance abuse. The inability to remember people's faces appeared to be associated with predatory aggression. Patients demonstrating aggressive tendencies often had indications of the presence of other interactive co-pathogens, which included Babesia, Bartonella, Ehrlichia and viral infections.
The diagnosis of early lyme neuroborreliosis is mainly clinical and should be considered in patients with opportunity for tick exposure in an endemic region, who develop an EM rash within weeks of exposure, and then suffer any combination of lymphocytic meningitis, cranial neuropathy, radiculoneuropathy, ataxia, or encephalitis, without any other identifiable cause. Serologic and CSF evidence of antibody response to Borrelia burgdorferi, the causative agent, are helpful to confirm the diagnosis, but should not be used in the absence of a recent and suggestive history for Lyme disease. The most widely used serologic test, the 2-tiered ELISA and Western immunoblot, is only 83% sensitive at the onset of early LNB. Additionally, the ELISA has a high false-positive rate and both tests may remain positive long after treatment of Lyme disease, further invalidating their use as diagnostic tests in patients without a proper history. Tests to identify CSF antibody are specific for early LNB, but these tests are not standardized and also remain positive after successful treatment
All patients with Lyme neuroborreliosis should be treated with antibiotics to achieve rapid resolution of symptoms, and, theoretically, to prevent further dissemination and persistence of the infection. The choice of the best antibiotic, the preferred mode of administration, and the duration of treatment are the still debated issues.
In 1983, two class IV small case series indicated the effect of high dose intravenous (IV) penicillin. Several class III and IV studies have reported response to 10- to 28-day courses of IV penicillin, IV ceftriaxone, IV cefotaxime and oral doxycycline (200 mg daily for 2 days and 100 mg daily for 8 days). IV ceftriaxone, cefotaxime and penicillin seem to have similar efficacy. First-generation cephalosporins were ineffective in vitro against Bb in an American study.
The occurrence of persistent residual symptoms after standard antibiotic therapy has led to speculations about surviving bacteria and an eventual need for longer treatment duration. There are no class I comparisons of different treatment durations. In most European treatment studies, the duration ranged from 10 to 14 days, and few studies for as long as 28 days. A case series reported excellent or good response in 90% of patients with disseminated Lyme.
NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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