Transient ischemic attack in a 5-year-old girl due to focal vasculitis in neuroborreliosis

Neuroborreliosis has been described as a rare cause of stroke and stroke-like symptoms. So far, there is no general consensus about treatment of these patients.

We report on a 5-year-old girl with a complete right-sided hemiparesis for a duration of approximately 20 minutes and an ongoing hyp- and paraesthesia in the right leg for the following hour, 5 hours before admission to our hospital. In the interval to presentation at our hospital, she complained about recurrent short episodes of vertigo.

Upon neurological examination in our ward, clinical symptoms had subsided completely. Based on the above-mentioned history, brain MRI was performed, which revealed a thrombus in the left middle cerebral artery (MCA) and circumscript areas of malperfusion in the territory of this artery as well as arterial wall signal enhancement. Lumbar puncture showed a cell count of 25 per µL. Immunoglobulin levels against B. burgdorferi were strongly elevated in blood and CSF.

We initiated an intravenous treatment with ceftriaxone. To prevent thromboembolic events, we started anticoagulant therapy.

Although the initial symptoms did not reoccur under treatment, a follow-up MRI scan 12 days after onset of ceftriaxone showed a new stenosis in the left posterior cerebral artery (PCA) that was consistent with vasculitic inflammation. MCA lesions remained unchanged. To inhibit eventual progression and spread of the vasculitic lesions, we administered methylprednisolone in a daily dose of 20 mg/kg/day for 3 days.

Follow-up MRI 3 months after discharge demonstrated disappearance of the PCA stenosis but persistence of the MCA lesions. Clinical examination of the girl was completely normal.

In conclusion, the case reported here demonstrates that neuroborreliosis constitutes an important differential diagnosis of pediatric stroke and central nervous system (CNS) vasculitis. Therapy includes antibiotic treatment and anticoagulant therapy. Moreover, corticosteroids might be required if initial therapy is not sufficient.