Diagnostic challenges of early Lyme disease: Lessons from a community case series

Abstract Objectives The purpose of this study was to investigate the characteristics of physician diagnosed Neurological Lyme disease (NLD) using Quantitative EEG and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We hypothesize that findings would include more slow wave (Delta/Theta) activity that is consistent with the severity reported dysfunction. Methods Subjects consisted of four adult females with a physician provided diagnosis of NLD. EEG was recorded from 21 sites during an eyes open and eyes-closed resting conditions. Raw EEG data was made quantifiable (qEEG) through Fourier transformation to determine z-score derived cortical and subcortical slow wave activity. The RBANS was used to assess each subject’s functioning. Results (See Imaging). Subject 1. Theta: 3.7. Alpha: 2.3. Theta: 3.2. Alpha: 2.5. RBANS - 96. Subject 2. Theta: 1.9. Alpha: 3.1. Theta: 2.3. Alpha: 4.4. RBANS - 76. Subject 3. Theta: 3.4. Alpha: 2.8. Theta: 3.5. Alpha: 2.1. RBANS - 110. Subject 4. Theta: 3.6. Alpha: 3.0. Theta: 3.3. Alpha: 2.8. RBANS - 100. Conclusions NLD subjects within this study all demonstrated elevated subcortical frontal and frontotemporal theta and alpha. Elevation in cortical slow wave activity was found for subjects with greater reported symptomatology and may suggest either less severe course of disease or serve as a recovery marker. RBANS assessment variables were not completely sensitive in detection of subject reported challenges. Implications for conceptualization, treatment, and disease monitoring are highlighted. Directions for future research will also be discussed.

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Characterising DSCATT: A case series of Australian patients with debilitating symptom complexes attributed to ticks

Australian & New Zealand Journal of Psychiatry ◽

10.1177/00048674211043788 ◽

2021 ◽

pp. 000486742110437

Author(s):

Jesse Schnall ◽

Georgina Oliver ◽

Sabine Braat ◽

Richard Macdonell ◽

Katherine B Gibney ◽

...

Keyword(s):

Chronic Fatigue Syndrome ◽

Lyme Disease ◽

Case Series ◽

Disease Process ◽

Chronic Fatigue ◽

Retrospective Case ◽

Medical Diagnoses ◽

Fatigue Syndrome ◽

First Case ◽

Medically Unexplained

Objectives(s): To characterise the clinical profile, aetiology and treatment responsiveness of ‘Australian Lyme’, or Debilitating Symptom Complexes Attributed to Ticks. Methods: Single-centre retrospective case analysis of patients referred to the Infectious Diseases Unit at Austin Health – a tertiary health service in Heidelberg, Australia – between 2014 and 2020 for investigation and treatment of suspected Debilitating Symptom Complexes Attributed to Ticks. Patients were included if they had debilitating symptoms suggested by either themselves or the referring clinician as being attributed to ticks. Results: Twenty-nine Debilitating Symptom Complexes Attributed to Ticks cases were included in the analysis. Other than Lyme disease (83%), the most common prior medical diagnoses were Epstein–Barr virus (38%), chronic fatigue syndrome (28%) and fibromyalgia (24%). Prior histories of anxiety (48%) and depression (41%) were common. The most frequently reported symptoms included fatigue (83%), headache (72%) and arthralgia (69%). National Association of Testing Authorities/Royal College of Pathologists of Australasia–accredited serology was not diagnostic of acute infective causes, including Lyme disease, in any patient. Of 25 cases with available data, 23 (92%) had previously been prescribed antimicrobials, with 53% reporting benefit from them. The most common diagnoses made by our hospital were chronic fatigue syndrome (31%), migraines (28%) and fibromyalgia (21%). Only one patient’s symptoms were not accounted for by other diagnoses. Conclusion: This is the first case series of patients with Debilitating Symptom Complexes Attributed to Ticks. They had high rates of other medically unexplained syndromes, and no evidence of acute Lyme disease, or any common organic disease process. Debilitating Symptom Complexes Attributed to Ticks remains medically unexplained, and may therefore be due to an as yet unidentified cause, or may be considered a medically unexplained syndrome similar to conditions such as chronic fatigue syndrome.

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Lyme borreliosis in southern United Kingdom and a case for a new syndrome, chronic arthropod-borne neuropathy

Epidemiology and Infection ◽

10.1017/s0950268814001071 ◽

2014 ◽

Vol 143 (3) ◽

pp. 561-572 ◽

Cited By ~ 13

Author(s):

M. S. DRYDEN ◽

K. SAEED ◽

S. OGBORN ◽

P. SWALES

Keyword(s):

Lyme Disease ◽

Clinical Symptoms ◽

Case Series ◽

Case Definition ◽

Tick Bite ◽

Cognitive Changes ◽

Cranial Nerve Palsies ◽

Tiered System ◽

The Uk ◽

Research Initiatives

SUMMARYThis series of serologically confirmed Lyme disease is the largest reported in the UK and represents 508 patients who presented to one hospital in the South of England between 1992 and 2012. The mean rate of borreliosis throughout this period was 9·8/100 000 population, much higher than the reported national rate of 1·7/100 000. The actual rate increased each year until 2009 when it levelled off. Patients clinically presented with rash (71%), neurological symptoms (16%, of whom half had VII cranial nerve palsies), arthropathy (8%), pyrexia (5%), cardiac abnormalities (1%) or other manifestations (<1%). Twenty percent of patients had additional non-specific symptoms of fatigue, myalgia, and cognitive changes. Serological diagnosis was with a two-tiered system of ELISA and immunoblot. There was a marked seasonal presentation in the summer months and in the first and sixth decades of life. A third of patients gave a clear history of a tick bite. The median interval between tick bite and clinical symptoms was 15 days [interquartile range (IQR) 9–28 days], with a further interval of 14 days to clinical diagnosis/treatment (IQR 2–31 days). Most cases were acquired locally and only 5% abroad. Patients responded to standard antibiotic therapy and recurrence or persistence was extremely rare. A second group of patients, not included in the clinical case series, were those who believed they had Lyme disease based on a probable tick bite but were seronegative by currently available validated tests and presented with subjective symptoms. This condition is often labelled chronic Lyme disease. These patients have a different disease from Lyme disease and therefore an alternative name, chronic arthropod-borne neuropathy (CAN), and case definition for this condition is proposed. We suggest that this chronic condition needs to be distinguished from Lyme disease, as calling the chronic illness ‘Lyme disease’ causes confusion to patients and physicians. We recommend research initiatives to investigate the aetiology, diagnosis and therapy of CAN.

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Lyme Carditis in Hospitalized Children and Adults, a Case Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab140 ◽

2021 ◽

Author(s):

Richard V Shen ◽

Carol A McCarthy ◽

Robert P Smith

Keyword(s):

Lyme Disease ◽

Heart Block ◽

Early Recognition ◽

Erythema Migrans ◽

Case Series ◽

Outpatient Setting ◽

Temporary Pacing ◽

Lyme Carditis ◽

Viral Illness ◽

History Presentation

Abstract Background Lyme carditis is an uncommon manifestation of Lyme disease. This report compares Lyme carditis presentation, management, and outcomes in pediatric and adult populations. Methods Charts of pediatric and adult patients with heart block (PR >300ms) and positive Lyme serologies hospitalized in Portland, Maine between January 2010 and December 2018 were analyzed. Data on medical history, presentation, treatment, and outcomes are described. Results Ten children and 20 adults were admitted for Lyme carditis between June and October. Ninety percent were male, and 87% had no prior cardiac history. Seventeen had outpatient evaluation prior to admission. Of these, a minority (41%) had Lyme disease suspected in the outpatient setting, and fewer (12%) were initiated on Lyme disease treatment. The most common alternate diagnoses were viral illness and erythema multiforme. More children than adults had disseminated erythema migrans and fever. First-degree heart block was more prevalent in children, and Mobitz type 2 heart block was more prevalent in adults. Ten patients presented with syncope. Proportionately more adults needed temporary pacing. Children had shorter antibiotic durations compared to adults. Of the 30 cases, twenty-seven had improved heart block, while 3 adults required a pacemaker at discharge. Nine children and 14 adults were discharged with a PR 200-300ms. There was a single death in this series. Conclusion Cases tended to be younger males. Most patients had some heart block on discharge. Of patients evaluated as outpatients, Lyme disease was suspected in 41%. Improved early recognition and treatment of Lyme disease may decrease Lyme carditis.

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Symptom heterogeneity and patient subgroup classification among US patients with post-treatment Lyme disease: an observational study

BMJ Open ◽

10.1136/bmjopen-2020-040399 ◽

2021 ◽

Vol 11 (1) ◽

pp. e040399

Author(s):

Alison W Rebman ◽

Ting Yang ◽

John N Aucott

Keyword(s):

Lyme Disease ◽

Musculoskeletal Pain ◽

Latent Profile Analysis ◽

Clinical Laboratory ◽

Infection Type ◽

Case Series ◽

Post Treatment ◽

Related Factor ◽

Symptom Profiles ◽

Symptom Heterogeneity

ObjectivesTo identify underlying subgroups with distinct symptom profiles, and to characterise and compare these subgroups across a range of demographic, clinical and psychosocial factors, within a heterogeneous group of patients with well-defined post-treatment Lyme disease (PTLD).DesignA clinical case series of patents.SettingParticipants were recruited from a single-site, Lyme disease referral clinic patient population and were evaluated by physical exam, clinical laboratory testing and standardised questionnaires.ParticipantsTwo hundred and twelve participants met study criteria for PTLD, with medical record-confirmed prior Lyme disease as well as current symptoms and functional impact.ResultsExploratory factor analysis classified 30 self-reported symptoms into 6 factors: ‘Fatigue Cognitive’, ‘Ocular Disequilibrium’, ‘Infection-Type’, ‘Mood-Related’, ‘Musculoskeletal Pain’ and ‘Neurologic’. A final latent profile analysis was conducted using ‘Fatigue Cognitive’, ‘Musculoskeletal Pain’ and ‘Mood-Related’ factor-based scores, which produced three emergent symptom profiles, and participants were classified into corresponding subgroups with 59.0%, 18.9% and 22.2% of the sample, respectively. Compared with the other two groups, subgroup 1 had similarly low levels across all factors relative to the sample as a whole, and reported lower rates of disability (1.6% vs 10.0%, 12.8%; q=0.126, 0.035) and higher self-efficacy (median: 7.5 vs 6.0, 5.3; q=0.068,<0.001). Subgroup 2 had the highest ‘Musculoskeletal Pain’ factor-based scores (q≤0.001). Subgroup 3 was characterised overall by higher symptom factor-based scores, and reported higher depression (q≤0.001).ConclusionsThis analysis identified six symptom factors and three potentially clinically relevant subgroups among patients with well-characterised PTLD. We found that these subgroups were differentiated not only by symptom phenotype, but also by a range of other factors. This may serve as an initial step towards engaging with the symptom heterogeneity that has long been observed among patients with this condition.

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A Case Series on Neuroborreliosis- An Emerging Infection in India

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/47140.14670 ◽

2021 ◽

Author(s):

Rachna Sehgal ◽

Meenakshi Bhatt

Keyword(s):

Lyme Disease ◽

Short Term Memory ◽

Case Series ◽

Disease Spread ◽

Penicillin G ◽

Lyme Carditis ◽

Cranial Nerve Palsies ◽

Ixodes Ticks ◽

Sporadic Cases ◽

Disseminated Disease

Lyme disease is a zoonotic disease spread by the bite of Ixodes ticks. These ticks are known to be found in wooded or grassy areas. The disease manifestations can be divided into early Lyme disease and late Lyme disease. The manifestations of late Lyme disease may include arthritis, cranial nerve palsies, short-term memory deficits and Lyme carditis. The disease is diagnosed by a two-step process of Enzyme immunoassay followed by Western blot Test. Disseminated disease is treated with Intravenous (IV) ceftriaxone, cefotaxime or penicillin G, or a combination of oral and IV regimens or in some cases, only oral drugs for up to 28 days. Lyme disease is endemic in temperate regions, especially in America. However, over the years the disease has been reported from various countries of Asia including in India, where there have been sporadic cases. Hereby, the author presents three paediatric cases with varied presentations. The neurological symptoms ranged from Lower Motor Neuron (LMN) facial nerve palsy to acute encephalitis. One patient also had non-erosive arthritis.

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A new Borrelia on the block: Borrelia miyamotoi – a human health risk?

Eurosurveillance ◽

10.2807/1560-7917.es.2019.24.18.1800170 ◽

2019 ◽

Vol 24 (18) ◽

Cited By ~ 15

Author(s):

Sally Cutler ◽

Muriel Vayssier-Taussat ◽

Agustín Estrada-Peña ◽

Aleksandar Potkonjak ◽

Andrei Daniel Mihalca ◽

...

Keyword(s):

Lyme Disease ◽

Human Health Risk ◽

Case Series ◽

Human Infection ◽

Future Research ◽

Borrelia Miyamotoi ◽

Relapsing Fever ◽

Pathogenic Potential ◽

In Vivo Models

Background Borrelia miyamotoi clusters phylogenetically among relapsing fever borreliae, but is transmitted by hard ticks. Recent recognition as a human pathogen has intensified research into its ecology and pathogenic potential. Aims We aimed to provide a timely critical integrative evaluation of our knowledge on B. miyamotoi, to assess its public health relevance and guide future research. Methods This narrative review used peer-reviewed literature in English from January 1994 to December 2018. Results Borrelia miyamotoi occurs in the world’s northern hemisphere where it co-circulates with B. burgdorferi sensu lato, which causes Lyme disease. The two borreliae have overlapping vertebrate and tick hosts. While ticks serve as vectors for both species, they are also reservoirs for B. miyamotoi. Three B. miyamotoi genotypes are described, but further diversity is being recognised. The lack of sufficient cultivable isolates and vertebrate models compromise investigation of human infection and its consequences. Our understanding mainly originates from limited case series. In these, human infections mostly present as influenza-like illness, with relapsing fever in sporadic cases and neurological disease reported in immunocompromised patients. Unspecific clinical presentation, also occasionally resulting from Lyme- or other co-infections, complicates diagnosis, likely contributing to under-reporting. Diagnostics mainly employ PCR and serology. Borrelia miyamotoi infections are treated with antimicrobials according to regimes used for Lyme disease. Conclusions With co-infection of tick-borne pathogens being commonplace, diagnostic improvements remain important. Developing in vivo models might allow more insight into human pathogenesis. Continued ecological and human case studies are key to better epidemiological understanding, guiding intervention strategies.

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134. A Comparison of Lyme Carditis in Children and Adults, a Case Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.209 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S95-S95

Author(s):

Richard V Shen ◽

Carol A McCarthy ◽

Robert P Smith

Keyword(s):

Lyme Disease ◽

Heart Block ◽

Erythema Migrans ◽

Case Series ◽

Adult Patients ◽

Male Predominance ◽

Temporary Pacing ◽

Lyme Carditis ◽

Viral Illness ◽

History Presentation

Abstract Background Lyme disease is a common entity in Maine, and Lyme carditis is an uncommon manifestation of this disease. This case series describes and compares the presentation, management, and outcomes of Lyme carditis in pediatric and adult populations. Methods Charts of pediatric and adult patients with heart block and positive Lyme serologies hospitalized in Portland, Maine between January 2010 and December 2018 were analyzed. Data on medical history, presentation, treatment, and outcomes are described. Results Ten children (range 7–17, mean 12.4 years) and 20 adults (range 22–81, mean 41.4 years) were admitted for Lyme carditis in the examined period. All cases presented between June and October. Twenty-seven (90%) were male, and 26 (87%) had no prior cardiac history. Of the adults, 1 (5%) reported using cocaine, 4 (20%) opioids, and 6 (30%) marijuana. Seventeen (57%) had outpatient evaluation prior to admission. Ten patients (59%) were not recognized as having Lyme disease. One case suspected to have Lyme was not initially treated with doxycycline. The most common alternative diagnoses were a viral illness and erythema multiforme. No coinfections were noted. Proportionately more children than adults had disseminated erythema migrans (40% vs. 20%) and fever (60% vs. 35%). First degree heart block was more prevalent in children (40%), and Mobitz type 2 heart block was more prevalent in adults (55%). Ten patients (30%) presented with syncope. More adults than children needed temporary pacing, 9 (45%) vs. 2 (20%). Children had shorter antibiotic durations compared with adults (mean 19.8 days vs. 23.6 days) Twenty-seven (90%) had improved heart block. Three adult patients (10%) required a pacemaker following hospitalization. Nine (90%) children and 14 (70%) adults were discharged with a PR 200-300ms. There was a single death in this series, which occurred after discharge to another state. Conclusion Cases tended to be in younger patients with male predominance. Most patients still had some degree of heart block on discharge. The majority of patients were evaluated prior to hospitalization but Lyme disease was suspected in only 41%. Improved recognition of early Lyme disease and more prompt treatment may lead to decreased complications of Lyme carditis. Disclosures All authors: No reported disclosures.

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Hospitalisation Due To Lyme Disease: Case Series In British Forces Germany

Journal of the Royal Army Medical Corps ◽

10.1136/jramc-150-03-05 ◽

2004 ◽

Vol 150 (3) ◽

pp. 182-186 ◽

Cited By ~ 2

Author(s):

B. C. Baker ◽

A. M. Croft ◽

C. R. Winfield

Keyword(s):

Lyme Disease ◽

Case Series ◽

Disease Case

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