Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 534  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,675 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Case Report
 » Discussion
 »  References
 »  Article Figures

 Article Access Statistics
    Viewed495    
    Printed12    
    Emailed0    
    PDF Downloaded33    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 68  |  Issue : 4  |  Page : 916-918

A Case Report of Early Disseminated Lyme Disease


1 Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Neurology, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Radiodiagnosis and Imaging, Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication26-Aug-2020

Correspondence Address:
Dr. Preema Sinha
Department of Dermatology, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.293476

Rights and Permissions

 » Abstract 


Lyme disease is a multi-organ infectious disease caused by the spirochete “Borrelia burgdorferi,” and transmitted by the “Ixodes” tick. Early disseminated Lyme disease can have varied central nervous system manifestations ranging from meningitis to radiculopathy and cranial neuropathy. If not suspected, misdiagnosis or delayed diagnosis can prove to be fatal. Erythema migrans is the most common clinical presentation, thereby, making dermatological examination extremely crucial in early diagnosis and treatment.


Keywords: Early disseminated Lyme, erythema chronicum migrans, neuroborreliosis
Key Messages: Patients with cutaneous lesions of Lyme disease like erythema migrans should be monitored and kept under observation for picking up early the serious complications and sequelae of Lyme disease like neuroborreliosis.


How to cite this article:
Sinha P, Oberoi B, Sirohi YS, Sood A, Bhattacharjee S. A Case Report of Early Disseminated Lyme Disease. Neurol India 2020;68:916-8

How to cite this URL:
Sinha P, Oberoi B, Sirohi YS, Sood A, Bhattacharjee S. A Case Report of Early Disseminated Lyme Disease. Neurol India [serial online] 2020 [cited 2020 Oct 24];68:916-8. Available from: https://www.neurologyindia.com/text.asp?2020/68/4/916/293476




Lyme disease is a tick-borne multisystem disease which occurs in three stages with protean clinical manifestations depending upon the stage. These include the stage of early localized infection, early disseminated infection, and late infection.[1],[2],[3] Lyme neuroborreliosis can be seen both in the early disseminated and late stages.[4] The classic triad of early disseminated Lyme neuroborreliosis is called meningoradiculoneuropathy, which includes aseptic meningitis, cranial neuropathy, and painful radiculoneuritis occurring in isolation or combination.[4] The most common symptoms reported by such patients include back pain (radiculitis), headache (meningitis), and finally cranial nerve palsy.[5]

Here we present a case of early disseminated Lyme disease where the cutaneous symptoms played a significant role in maintaining a high index of suspicion and reaching an early diagnosis which helped in preventing the potential long-term complications of neuroborreliosis.


 » Case Report Top


A 26-years-old male presented with a red raised progressive circular rash associated with burning and itching of 7 days, fever of 2 days, and severe global headache of 3 days duration. The rash initially started over the inner aspect of his left arm and gradually over the next 2–3 days similar-looking rashes appeared to involve his trunk, left thigh, neck, and left leg [Figure 1] and [Figure 2]. There was no history of any swelling over the body, joint pains, neck stiffness, vomiting, pain abdomen, or chest pain. The patient gave no history of any insect bite or any history of travel in the last 2 months. But due to strong clinical suspicion of Lyme disease in view of his clinical presentation of erythema migrans and endemicity in his area of residence which was near a forest area in Maharashtra, he was thoroughly investigated. A skin biopsy was done which revealed a nonspecific superficial and deep lymphocytic inflammatory infiltrate in the dermis [Figure 3]. Serology was sent for Borrelia antibodies in which Borrelia IgM came out to be raised 3.6 U/mL (>1.1 is positive). The patient was worked up for other systemic involvement including ECG, 2D echocardiography, and nerve conduction studies which were normal.
Figure 1: Oval erythematous macules seen over right arm and trunk

Click here to view
Figure 2: Annular erythematous macule seen over the left shoulder with interspersed hyperpigmented streaks

Click here to view
Figure 3: Histopathology revealed a nonspecific superficial and deep lymphocytic inflammatory infiltrate in the dermis (H&E, 200×)

Click here to view


The patient was clinically, serologically, and histopathologically diagnosed as a case of Lyme disease and managed with Cap doxycycline 100 mg twice daily to which he responded well with a resolution of fever and near resolution of rash in two weeks [Figure 4]. However, despite treatment he had persistent headache, developed low backache and also developed features of meningism for which a non-contrast computed tomography (NCCT) of the head was done which was normal and cerebrospinal fluid (CSF) analysis was done which revealed a protein count of 170 mg/dL (increased), sugar level was 59 mg/dL, and lymphocyte count was 110 (suggestive of aseptic meningitis), CSF Borrelia antibodies were, however, negative. The patient was managed for neuroborreliosis with injection ceftriaxone for 14 days to which he responded well with near resolution of headache and backache. The patient has been kept under follow-up for any systemic complications or further manifestations of chronic Lyme disease.
Figure 4: Regression of the erythema migrans lesions over 2 weeks

Click here to view



 » Discussion Top


Lyme neuroborreliosis can present with Lyme meningitis, myelopathies, radiculopathies, and late neurologic Lyme disease.[6] If untreated, these patients might go on to develop progressive encephalomyelitis or cerebrovascular neuroborreliosis, which can lead to parenchymal or meningovascular involvement.[7] The criteria for Lyme neuroborreliosis include neurological symptoms, CSF pleocytosis, and Borrelia-specific antibodies intrathecally. All three are a definite diagnosis while two out of three give a probable diagnosis.[8] The intrathecal production of antibodies is the gold standard but has very low sensitivity in the early stages. The CSF in Lyme's meningitis generally presents with mononuclear cell predominance, a high level of proteins, and nearly normal sugar; hypoglycorrhachia, a rare feature has been reported in the case report by Farmania et al.[8] Patients with central nervous system manifestations should be treated with parenteral ceftriaxone (2 g daily) for 14 days and with late involvement for three weeks.[9]

The dermatological manifestations provide great help in providing a diagnostic clue and the typical erythema migrans present in almost 40–60% of the patients is usually sufficient to make a diagnosis in the absence of a corroboratory laboratory test.[10] The rash is generally of two types, either an expansive lesion with various hues of erythema or a target-like lesion. The surface is smooth and the lesion may be associated with burning sensation or pain. Centers for Disease Control and Prevention (CDC) guidelines state that the diameter of the rash must be at least 5 cm to qualify as erythema migrans, however, in special clinical situations, smaller lesions may be considered.[11] In our patient, the skin manifestations played a pivotal role in the initial diagnosis of the patient and the case also highlights the importance of knowing the complications and sequelae of the disease which prompted us to further evaluate and manage the patient on the lines of neuroborreliosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Hildenbrand P, Craven DE, Jones R, Nemeskal P. Lyme neuroborreliosis: Manifestations of a rapidly emerging zoonosis. Am J Neuroradiol 2009;30:1079-87.  Back to cited text no. 1
    
2.
Baymakova M, Tsachev I, Popov G, Andonova R, Pepovich R, Zaekov N, et al. Lyme borreliosis. Gen Med 2019;21:72-9.  Back to cited text no. 2
    
3.
Baǧcı IS, Ruzicka T. Keneler, Borrelia burgdorferi ve Lyme hastalıǧı. Turk Dermatoloji Derg 2016;10:116-21.  Back to cited text no. 3
    
4.
Prasad A, Sankar D. Classic diseases revisited: Overdiagnosis and overtreatment of Lyme neuroborreliosis are preventable. Postgrad Med J 1999;75:650-6.  Back to cited text no. 4
    
5.
Schwenkenbecher P, Pul R, Wurster U, Conzen J, Pars K, Hartmann H, et al. Common and uncommon neurological manifestations of neuroborreliosis leading to hospitalization. BMC Infect Dis 2017;17:1-10.  Back to cited text no. 5
    
6.
Pachner AR. Early disseminated Lyme disease: Lyme meningitis. Am J Med 1995;98:30S-43S.  Back to cited text no. 6
    
7.
Stages and syndromes of neuroborreliosis. J Neurol 1998;245:262-72.  Back to cited text no. 7
    
8.
Farmania R, Jauhari P, Chakrabarty B, Gulati S. Chronic meningitis with persistent hypoglycorrhachia: An unusual presentation of Lyme's disease. Neurol India 2019;67:563-5.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Mygland Š, Ljøstad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I. EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Eur J Neurol 2010;17:8-16.  Back to cited text no. 9
    
10.
Kaiser R. Neuroborreliosis. J Neurol 1998;245:247-55.  Back to cited text no. 10
    
11.
Vasudevan B, Chatterjee M. Lyme borreliosis and skin. Indian J Dermatol 2013;58:167-74.  Back to cited text no. 11
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow