Thirty-two patients with the onset of erythema chronicum migrans, Lyme arthritis, or both in mid-1976 were studied prospectively. The skin lesion (24 patients) typically lasted about 3 weeks, beginning as a red macule or papule that expanded to form a large ring with central clearing. Associated symptoms ranged from none to malaise, fatigue, chills and fever, headache, stiff neck, backache, myalgias, nausea, vomiting, and sore throat. Three patients had been bitten by ticks at the site of the initial lesion 4 to 20 days before its onset. Nineteen patients suddenly developed a monoarticular or oligoarticular arthritis 4 days to 22 weeks (median, 4 weeks) after onset of the skin lesion; eight developed arthritis without a preceding skin lesion. Seven of these 27 experienced migratory joint pains. Arthritis attacks, most commonly in the knee, were typically short (median, 8 days) but sometimes persisted for months. Other manifestations included neurologic abnormalties, myocardial conduction abnormalities, serum cryoprecipitates, elevated serum IgM levels, and elevated erythrocyte sedimentation rates. The diagnostic marker is the skin lesion; without it, geographic clustering is the most important clue.

Erythema chronicum migrans and lyme arthritis. The enlarging clinical spectrum

During 1980 and 1981, we compared antibiotic regimens in 108 adult patients with early Lyme disease. Erythema chronicum migrans and its associated symptoms resolved faster in penicillin- or tetracycline-treated patients than in those given erythromycin (mean duration, 5.4 and 5.7 versus 9.2 days, F = 3.38, p less than 0.05). None of 39 patients given tetracycline developed major late complications (meningoencephalitis, myocarditis, or recurrent attacks of arthritis) compared with 3 of 40 penicillin-treated patients and 4 of 29 given erythromycin (chi square with 2 degrees of freedom = 5.33, p = 0.07). In 1982, all 49 adult patients were given tetracycline; again, none of them developed major complications. However, with all three antibiotic agents nearly half of the patients had minor late symptoms such as headache, musculoskeletal pain, and lethargy. These complications correlated significantly with the initial severity of illness. For patients with early Lyme disease, tetracycline appears to be the most effective drug, then penicillin, and finally erythromycin.

Treatment of the early manifestations of Lyme disease

Objective: To provide evidence-based recommendations on the treatment of nervous sys- tem Lyme disease and post-Lyme syndrome. Three questions were addressed: 1) Which antimicrobial agents are effective? 2) Are different regimens preferred for different manifestations of nervous sys- tem Lyme disease? 3) What duration of therapy is needed? Methods: The authors analyzed published studies (1983-2003) using a structured review process to classify the evidence related to the ques- tions posed. Results: The panel reviewed 353 abstracts which yielded 112 potentially relevant arti- cles that were reviewed, from which 37 articles were identified that were included in the analysis. Conclusions: There are sufficient data to conclude that, in both adults and children, this nervous sys- tem infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline (Level B recommen- dation). Although most studies have used parenteral regimens for neuroborreliosis, several European studies support use of oral doxycycline in adults with meningitis, cranial neuritis, and radiculitis (Level B), reserving parenteral regimens for patients with parenchymal CNS involvement, other severe neu- rologic symptomatology, or failure to respond to oral regimens. The number of children (8 years of age) enrolled in rigorous studies of oral vs parenteral regimens has been smaller, making conclusions less statistically compelling. However, all available data indicate results are comparable to those ob- served in adults. In contrast, there is no compelling evidence that prolonged treatment with antibiotics has any beneficial effect in post-Lyme syndrome (Level A). NEUROLOGY 2007;69:1-1 STATEMENT OF PURPOSE The Quality Stan- dards Subcommittee (QSS) develops scientifically sound, clinically relevant practice parameters to aid in the practice of neurology. This article addresses the use of antibiotic treatments in patients with ner- vous system Lyme disease and post-Lyme syn- drome. These recommendations address the needs of medical providers caring for patients with these conditions. Lyme disease is a multisystem infectious disease

/pdf/practice-parameter-treatment-of-nervous-system-lyme-disease-40jh8vujzg.pdf

Practice parameter: treatment of nervous system lyme disease (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology

The epidemiology of lyme borreliosis

. Lyme borreliosis is a tick-borne infection caused by the spirochete Borrelia burgdorferi, whose discovery in 1982 solved an aetiological mystery involving a variety of dcrmatological and neurological disorders and explained their association with Lyme disease. Lyme borreliosis occurs frequently and is readily treatable with antibiotics.



Along with its discovery, however, came the realization that it is difficult to diagnose accurately, especially antibody diagnosis. False-positive antibody results in particular led to gradual widening of the clinical spectrum, and differential diagnosis became increasingly difficult.



This prospective, multicentre study presents a systematic description of Lyme borreliosis in childhood, emphasizing epidemiological and clinical issues. Because, predominantly, inpatients were examined, Lyme neuroborreliosis was the focus of the study, with the chief concern being to minimize false-positive results. To this end, we chose to narrow the diagnostic criteria, using the presence of specific antibodies in the cerebrospinal fluid as the determining factor.



The epidemiological investigation was focused on the incidence of Lyme neuroborreliosis in childhood in southern Lower Saxony as well as on the prevalence of Lyme neuroborreliosis among acute-inflammatory neurological illnesses in children. The clinical part of the study aimed at establishing criteria for differential diagnosis in addition to the detection of specific antibodies. The detection of specific IgM antibodies using an IgM capture ELISA confirmed the presence of acute Lyme borreliosis.



The study examined 208 children with Lyme borreliosis, of whom 169 had Lyme neuroborreliosis, from mid-1986 until the end of 1989. The yearly incidence of Lyme neuroborreliosis in Lower Saxony was 5.8 cases/100,000 children aged 1 to 13. The manifestation index was 0.16, or one case of Lyme neuroborreliosis per 620 infected children, compared with the presence of specific antibodies against B. burgdorferi for children in the same age group and region. Both the seasonal distribution of Lyme borreliosis, which peaked in summer and autumn, as well as the information about when the tick bites took place point to an incubation period of a few weeks.



The most frequent manifestation of Lyme neuroborreliosis in childhood was acute peripheral facial palsy, found in 55% of all cases (n = 93). Lyme borreliosis proved to be the most frequently verifiable cause of acute peripheral facial palsy in children, causing every second case of this disorder in summer and autumn. Bilateral facial palsy was, without exception, found to be caused by Lyme borreliosis; thus it can be considered a specific neurological sign of this infection.



The second most common manifestation of Lyme neuroborreliosis in childhood was aseptic meningitis (27.2%, n = 46). Lyme borreliosis was the third most common cause of aseptic meningitis in childhood (11.8%).



Meningoradiculoneuritis with peripheral nerve involvement (Bannwarth syndrome) was diagnosed in only 3.6% of the children (n = 6), although this is the most common symptom of Lyme neuroborreliosis in adult patients.



The head and neck region proved to be the predominant site of tick bites in children; adults experience most bites on their extremities. The difference in the site of the infection, as well as the short duration of the illness in children and the early treatment, may partially explain the profound differences in the clinical spectrum of Lyme neuroborreliosis in children and adults.



Nearly all cases with a positive history of tick bite and/or erythema migrans in the head and neck region showed ipsilateral facial palsy suggesting a direct invasion via the affected nerve by B. burgdorferi.



Inflammatory changes in the cerebrospinal fluid along with the presence of specific antibodies are the conditio sine qua non for a diagnosis of Lyme neuroborreliosis. The presence of IgM antibodies in the cerebrospinal fluid has proved to be the most reliable diagnostic criterion, and is responsible for the early diagnosis of acute Lyme neuroborreliosis in children. The IgM capture ELISA facilitated the simple and reliable detection of intrathecal antibody synthesis which could be successfully demonstrated in three-quarters of the cases with Lyme neuroborreliosis. Specific IgG testing was negative in most cases because of the relatively short duration of the illness in children, and is therefore of less importance here than in the diagnosis of cases of Lyme neuroborreliosis in adults.



Acute Epstein-Barr and varicella-zoster viral infections both caused false-positive findings in the IgM capture ELISA.



High dose intravenous penicillin G proved to be highly effective in paediatric cases of Lyme neuroborreliosis. Although the rate of spontaneous remission may be very high, it is not possible to predict on a patient-by patient basis just when this will occur. Thus consistent antibiotic therapy is indicated.

Epidemiology and clinical manifestations of lyme borreliosis in childhood : a prospective multicentre study with special regard to neuroborreliosis

Successful treatment of erythema migrans Afzelius.

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Successful treatment of erythema migrans Afzelius.