Large Cerebral Vessel Occlusive Disease in Lyme Neuroborreliosis

Abstract

We report on a 12-year-old, previously healthy girl with an acute hemiparesis as the predominant clinical manifestation of Lyme neuroborreliosis (LNB). The diagnosis of LNB was based on cerebrospinal fluid (CSF) studies, laboratory findings and the clinical course whereas the patient's history and the lack of characteristic skin lesions obscured the diagnosis in the beginning. After four weeks of antibiotic and physiotherapeutic treatment, the hemiparetic symptoms had completely resolved. Although evidence of vasculitic and perivascular inflammation in LNB has been described in the literature, large cerebral vessel occlusive disease represents a rare finding. Appropriate treatment strategies can lead to good clinical rehabilitation, as shown in this case, making the timely diagnosis a crucial issue. We conclude that LNB should be considered in every stroke-like episode of unknown origin in children, even in the absence of a history of a tick bite or typical skin lesions.

Key words

Neuroborreliosis - Stroke - Stroke-like Episodes

References

• 1 Burns M J, Sellati T J, Teng E I, Furie M B. Production of interleukin-8 (IL-8) by cultured endothelial cells in response to Borrelia burgdorferi occurs independently of secreted IL-1 and tumor necrosis factor alpha and is required for subsequent transendothelial migration of neutrophils.  Infect Immun. 1997;  65 1217-1222
• 2 Czub S, Duray P H, Thomas R E, Schwan T G. Cystitis induced by infection with the Lyme disease spirochete, Borrelia burgdorferi, in mice.  Am J Pathol. 1992;  141 1173-1179
• 3 Deloizy M, Devos P, Stekelorom T, Testard D, Belhadia A. Left sided sudden hemiparesis linked to a central form of Lyme disease.  Rev Neurol (Paris). 2000;  156 1154-1156
• 4 Deltombe T, Hanson P, Boutsen Y, Laloux P, Clerin M. Lyme borreliosis neuropathy. A case report.  Am J Phys Med Rehabil. 1996;  75 314-316
• 5 deLuise V P, O'Leary M J. Peripheral ulcerative keratitis related to Lyme disease.  Am J Ophthalmol. 1991;  111 244-245
• 6 Ebnet K, Brown K D, Siebenlist U K, Simon M M, Shaw S. Borrelia burgdorferi activates nuclear factor-kappa B and is a potent inducer of chemokine and adhesion molecule gene expression in endothelial cells and fibroblasts.  J Immunol. 1997;  158 3285-3292
• 7 Kruger H, Heim E, Schuknecht B, Scholz S. Acute and chronic neuroborreliosis with and without CNS involvement: a clinical, MRI, and HLA study of 27 cases.  J Neurol. 1991;  238 271-280
• 8 Laroche C, Lienhardt A, Boulesteix J. Ischemic stroke caused by neuroborreliosis.  Arch Pediatr. 1999;  6 1302-1305
• 9 Lebech A M, Hansen K, Brandrup F, Clemmensen O, Halkier-Sorensen L. Diagnostic value of PCR for detection of Borrelia burgdorferi DNA in clinical specimens from patients with erythema migrans and Lyme neuroborreliosis.  Mol Diagn. 2000;  5 139-150
• 10 Leong J M, Wang H, Magoun L, Field J A, Morrissey P E, Robbins D, Tatro J B, Coburn J, Parveen N. Different classes of proteoglycans contribute to the attachment of Borrelia burgdorferi to cultured endothelial and brain cells.  Infect Immun. 1998;  66 994-999
• 11 Michalova K, Rihova E, Poch T. Ocular involvement in Lyme disease.  Cesk Oftalmol. 1993;  49 101-104
• 12 Nanagara R, Duray P H, Schumacher H R. Ultrastructural demonstration of spirochetal antigens in synovial fluid and synovial membrane in chronic Lyme disease: possible factors contributing to persistence of organisms.  Hum Pathol. 1996;  27 1025-1034
• 13 Oksi J, Kalimo H, Marttila R J, Marjamaki M, Sonninen P, Nikoskelainen J, Viljanen M K. Inflammatory brain changes in Lyme borreliosis. A report on three patients and review of literature.  Brain. 1996;  119 2143-2154
• 14 Oksi J, Kalimo H, Marttila R J, Marjamaki M, Sonninen P, Nikoskelainen J, Viljanen M K. Intracranial aneurysms in three patients with disseminated Lyme borreliosis: cause or chance association?.  J Neurol Neurosurg Psychiatry. 1998;  64 636-642
• 15 Schmitt A B, Kuker W, Nacimiento W. Neuroborreliosis with extensive cerebral vasculitis and multiple cerebral infarcts.  Nervenarzt. 1999;  70 167-171
• 16 Scott T F. Diseases that mimic multiple sclerosis.  Postgrad Med. 1991;  89 187-191
• 17 Tezzon F, Corradini C, Huber R, Egarter Vigl E, Simeoni J, Stanek G, Ferrari G. Vasculitic mononeuritis multiplex in patient with Lyme disease.  Ital J Neurol Sci. 1991;  12 229-232
• 18 Till S H, Snaith M L. Assessment, investigation, and management of acute monoarthritis.  J Accid Emerg Med. 1999;  16 355-361
• 19 Wilke M, Eiffert H, Christen H J, Hanefeld F. Primarily chronic and cerebrovascular course of Lyme neuroborreliosis: case reports and literature review.  Arch Dis Child. 2000;  83 67-71
• 20 Wooten R M, Morrison T B, Weis J H, Wright S D, Thieringer R, Weis J J. The role of CD14 in signaling mediated by outer membrane lipoproteins of Borrelia burgdorferi.  J Immunol. 1998;  160 5485-5492
• 21 Zhang Y, Lafontant G, Bonner F J. Lyme neuroborreliosis mimics stroke: a case report.  Arch Phys Med Rehabil. 2000;  81 519-521