Field mice carry Lyme disease


CONTENT

 


INTRODUCTION

Lyme disease is transmitted by an arthropod called Ixodes dammini. The spirochete causing the disease is Borrelia burgdorferi.

During the past nine years we have treated over 300 children for Lyme disease in our hospital. They had significant neurological manifestations or, in a minority of cases, arthritis that required hospitalization for intravenous antibiotic treatment.

It is impossible to know how many children in our area have Lyme disease. A pediatrician with a large practice sees at least three ECMs (Erythema Chronicum Migrans) a day and treats such children with amoxicillin or penicillin for 21 days. Apparently, the majority of children who have the reddening of the skin and who are treated early do not develop chronic problems. However, a small percentage are exposed to chronic consequences.

In some of our communities with a population of 20,000-25,000, up to 60% of ticks carry Borrelia spirochetes. So the likelihood of infection is very high.

Since 1982 I have seen large numbers of children with Lyme disease neurological symptoms. Many of these children were initially undiagnosed because their symptoms were obscure and believed to be explainable. I treated a patient who was sick for five years. Others were sick for three or four years before they were diagnosed. We have recently started taking more care of children who suffer from so-called vague symptoms. We diagnose and treat more vigorously.

  • I've seen children develop neurological symptoms after a few weeks. Others take a year or more to develop these symptoms.
  • Less than 50% of children even remember a tick bite, and an even smaller percentage can remember an ECM reddening.
  • Parents recall that their children had a flu-like illness that preceded the persistent symptoms. Usually this flu-like illness appears six or more weeks after the tick bite or contact with ticks. Many parents claim that their child never recovered from the "flu-like illness".
  • The vast majority, over 90% of the children we have treated complain of headaches.
    • In some cases the pain was extremely acute and accompanied by papillary edema.
    • However, the headache usually develops slowly, then becomes persistent and unresponsive to conventional analgesics.
  • In addition to the headache, the children complain
  • School-age children have memory and concentration disorders.
  • Some patients develop progressive weakness.
  • Parents complain that preschoolers have mood swings and become very irritable. You notice a change in personality.
  • Chest pain is a very common complaint among school-age children and adolescents. At least 70% complain of such pain.
  • About 50% complain of stomach pain.
  • Arthralgia affects more than half of children, usually involving the knees and sometimes the wrist.
  • Other complaints are
    • Palpitations,
    • Tingling, numbness,
    • Redness of the skin that comes and goes, mostly malar skin manifestations and
    • severe sore throat.

It is easy to see how extremely unspecific this long list is and therefore it is assumed that the children have functional problems.

Children often show manifestations of the central and peripheral nervous systems. One of the phenomena of the central nervous system is

  • Encephalopathy. These children have memory, concentration, and learning difficulties. You suffer from excessive tiredness and difficulty sleeping (hypersomnia or asomnia).
    We have seldom seen children with encephalitic disease.
  • There have been reports of strokes due to Lyme disease.
  • We had a child with sudden onset of hemiplegia and aphasia.
  • Patients may suffer from involvement of the optic nerve, including papillitis with decreased vision.
  • We also observed peripheral neuropathy with distal paresthesia, subtle weakness, and decreased tendon reflex.

The laboratory results are rather inconspicuous:

  • CBC mostly normal.
  • Sed rates are greater than 30 in only 10% of patients; we only had two patients with sed rates of 100 or more.
  • The EEG is abnormal in a third of the patients, with bilateral sharp waves and some slow waves.
  • The CAT scan is normal, with a number of MRIs abnormal and showing increased signal intensity in the white matter.
  • The decision to take a cerebrospinal fluid must be made on the basis of physical findings.
    • A patient with disc edema will be punctured after CAT scan or NMR images show no mass lesions.
    • In other cases, the decision to puncture is primarily determined by the need for additional diagnostic information. In this way we punctured 25 [sic] patients.
    • The majority had normal CSF findings.
      • Usually they have no elevation in cells.
      • Protein and sugar are normal.
      • Cultures are negative.
      • Interestingly, the CSF pressure is greater than 200, sometimes even greater than 400, in at least fifty percent of patients. Every patient with disc edema has at least 300 or more pressure, with the exception of a girl whose pressure was 260 and who obviously had disc edema with loss of vision in the left eye.
      • Eight of the patients had pleocytosis with a cell count of 60-700, mostly lymphocytes.
      • Only two patients had a positive CSF titer.

Lyme borreliosis is diagnosed clinically.

  • Serum diagnostics, if positive, are helpful. We look at
    • 1: 128 IFA as positive,
    • ELISA if the value is greater than 79.
  • Antigens can also be determined in the urine. However, Lyme urine antigen tests (LUAT) are considered experimental (as tests not yet confirmed).

We have no hesitation in treating seronegative patients if they exhibit a number of debilitating symptoms.

  • We had children who couldn't go to school for a year because they were too sick to leave home.
  • Other children were forced to give up all extracurricular activities, sports, etc. because they were too sick and weak to take part.
  • Every patient we treated for neuroborreliosis had persistent symptoms. The children have headaches and often chest pain.
  • Many have seen numerous doctors without a specific diagnosis being made. Many of them received antibiotics from time to time for various reasons, mainly because of sore throats, otitis media, reddened skin and therefore never developed an antibody reaction against the spirochete infection.
The diagnosis of neuroborreliosis is - as I said - clinical and not based on laboratory values.
  • If the patient's symptoms match the diagnosis, and
  • the disease has a significant impact on the patient's ability to function in life,
he deserves to be treated. I believe it is safer to treat someone too forcefully in such circumstances than to let them suffer indefinitely.
  • Treatment is with intravenous antibiotics, ceftriaxone, cefotaxime, ampicillin, which are taken for as long as necessary. The minimum is 4-6 weeks. Many patients are treated for months if they remain clinically ill.
  • Pruritus can be treated with Benadryl.
  • I recommend that they eat yogurt while on antibiotic treatment to avoid diarrhea.
  • Aspirin is best for treating pain. Due to the historical reluctance of some doctors to give children aspirin, nonsteroidal anti-inflammatory drugs are often prescribed.
  • During and even after treatment, it is necessary that patients get enough rest. The usual activities cannot be resumed immediately after the end of the treatment.
  • Approximately 25% of the patients treated had to be retreated and the majority of them did well afterwards.
  • I usually co-treat initially
    • Ceftriaxone (Rocephin)
      and then either with
    • Ceftriaxone,
    • Cefotaxime or
    • Ampicillin.
    Many children I have seen with these ailments have not been able to get adequate benefit from oral antibiotic treatment. Once patients have neurological symptoms, and in some cases positive neurological findings, they deserve rigorous intravenous antibiotic therapy, perhaps more than once.

SICK STORIES


Some illustrative cases are documented below:

  • In June 1982, a seven-year-old boy who had had a very bad headache for three days, slept around the clock but had no fever, remembered a tick bite three months ago with red skin. No diagnosis was made. At this point he had papillary edema and the CSF pressure was 450 mm. Assuming he had a pseudotumor, he was treated with Decadron. In January 1983 he developed arthritis and was treated with oral antibiotics in combination with NSAIDs. In 1985 he reappeared with a chronic headache that had been around for two years. His neurological exam was completely normal and he had no papilledema. The Lyme titer at that time was 1: 256. He had an increased CSF pressure of 250 without cells. We treated him intravenously with penicillin for 14 days. His headache went away and eventually he had no more bouts of arthritis. This enabled us to successfully treat a patient in 1985 who had been ill for more than three years and who was not diagnosed in 1982, although the tick bite and skin appearance were present. Note that he was treated with steroids in 1982.

  • In 1983, an 11-year-old boy presented with an ECM flush two months prior to his appearance. He suffered from severe pain in both of his thighs. Within days he developed unilateral and then bilateral facial palsy with lively reflexes and upward moving toes. His cerebrospinal fluid showed an increased cell count of 300 and protein of 81. He was treated intravenously with penicillin for 14 days. A dramatic improvement could be achieved with complete resolution of the facial paralysis. There was no longer any pain. His reflexes were all physiological. His Lyme titer was slightly positive. At that time you waited more than seven weeks for a Lyme titer result. Because of his condition, he was treated before the result was received.

  • In 1984 a ten-year-old boy suffered from a sudden headache with a fever. He didn't remember a tick bite or rash. Examination results were normal. There was no papilla edema. Liqor: pressure 190, cell number 7. The Lyme titer was sent to the state laboratory. Seven weeks later the result was a titer of 1: 2048. He was again admitted to the hospital. The CSF now showed a cell count of 100. It was treated with penicillin for 14 days, which caused a dramatic improvement. The headache went away. His Lyme titer was then 1:64. At times he complains of pain in his knees, but otherwise he is fine. During the weeks we waited for his Lyme titer results, he suffered from a very, very severe headache.

  • A nine-year-old girl complained of progressive weakness in her extremities after a flu-like illness. She was examined in May 1988 after she had been sick for two months. The examination showed a very weak child who had to support himself on the walls when entering the practice because of her weakness. She came up with Guillain Barre Syndrome as a clinical diagnosis. The tendon reflexes were absent. The CSF examination showed a protein of 80. Lyme titer 1: 128. She was treated intravenously with ceftriaxone for 14 days, 2g daily. Her condition gradually improved. In November 1988 she was fully active again, she could take part in anything without weakness or discomfort, but her tendon reflexes were still absent. She lives in an area where many ticks can be found.

  • A five-year-old boy had suffered from weakness, arthralgia and fatigue for two years. He was examined in 1988, but had already been bitten by a tick in February 1986. His symptoms were fever, joint pain, abdominal pain, and a rash. As a result, he developed weakness, more on the right than the left, and indeed very mild right-sided hemiparesis was noticeable. The weakness was progressive and his mother, not the doctor, insisted on having a Lyme titer of 1: 1024. Treatment was with ceftriaxone. He had to be treated again so that he was under treatment for a total of 28 days. Therapy ended in the summer of 1988, and by December he was able to run, climb up and down stairs, and climb onto the examination table. He still had hypoactive reflexes, but he was stronger and remarkably better.

  • A two year old girl whose parents noticed that her child had become extremely irritable was examined. She had diaper dermatitis that did not respond to any prescribed treatment from the pediatrician. Because she came into contact with field mice that are tick hosts, the parents insisted on a Lyme titer of 1: 512. Because of her irritability and the rash, she was treated with ceftriaxone for 14 days, which caused a dramatic improvement in her behavior. The rash went away and never came back.

  • A six-year-old girl was examined in September 1987. A very mild left facial weakness was noted. She couldn't remember a tick bite, but she had contact with ticks. She lives in a wooded area. Lyme titer 1: 128. The CSF examination showed a protein of 137 mg. without cells and glucose of 63. She was treated and responded well because of the mild left facial weakness and headache. She received two treatments for a total of 28 days of ceftriaxone.

  • A 16 year old boy who woke up with bilateral facial palsy was examined. He was unable to speak or eat, had a headache, and had been stung by a tick. Lyme titer 1: 128. He was treated intravenously with ceftriaxone for 21 days and showed dramatic improvement. A neurological examination four weeks after starting therapy was normal. In addition to ceftriaxone, he was given prednisone.

  • A nine-year-old girl was examined in 1985 for headache, joint pain, and photophobia. CSF: pressure 230, number of cells 13 and protein 50. Titer 1: 256.
    Initially treated with penicillin. Treated again with ceftriaxone. Therapy again in 1986, 1987 and 1988. She has a persistently abnormal EEG and a significant drop in performance at school. Her EEG is still abnormal and her Lyme titer is consistently positive (1: 256). She will likely need further treatment.

  • A twelve year old boy was examined for a headache in 1987. Liquor, EEG and CAT scan were normal. Lyme titer was negative. Unfortunately, it was decided not to treat him because he had nothing but a headache. During the year, his academic performance deteriorated.He was an exceptionally good student. The following summer his Lyme titer was 1: 256. Other test results were inconspicuous. He received ceftriaxone intravenously for 14 days. His performance improved the following school year, but his headache returned towards the end of the year. Then got severe chest pain and diffuse myalgia. The Lyme titer was increased again (1: 256) and the antibodies in the urine were significantly increased. He was treated intravenously with penicillin in the hospital for 28 days. After the fifth or sixth day, his symptoms improved. Chest pain and headache disappeared.

  • A fourteen-year-old boy was examined for a headache that had persisted for more than two weeks. Then he developed double vision; the headache went away. On examination he showed mild paralysis of the 6th nerve on the left side. He said no to the question about a headache and said that apart from the diplopia, he was feeling fine. Lyme titer 1: 512. CSF examination: 700 lymphocytes. Therapy was carried out with ceftriaxone for 21 days, which caused the diplopia to completely disappear. Since then he's been fine.

  • A nine-year-old girl complained of a headache. The examination revealed papillary edema. CAT scan was normal. Spinal puncture: pressure 280. She was treated with steroids and Diamox. The Lyme titer was 1: 128, after two negative values ​​weeks earlier at the onset of the headache. She is currently receiving 21-day ceftriaxone therapy. Her left eye shows some loss of vision and her papillary edema is healing

  • A 13-year-old girl developed progressive lower extremity weakness with mild spasticity and lively reflexes, back pain and headache, mood swings, and depression. Her parents insisted on having a Lyme test (1: 256), which is consistently positive. CSF: 1: 512. The girl was treated three times, initially twice with ceftriaxone for 14 days each, then with cefotaxime for 21 days. There has been a modest improvement, but she still complains of weakness. The reflexes are still lively. Further treatment will likely be necessary.
  • A twenty month old boy was stung by a tick on the buttocks. The classic ECM was available within 48 hours. An infectious disease doctor explained to the mother that this was a classic symptom of Lyme disease. The child was given amoxil orally. Forty-eight hours later, the patient had a fever and convulsions, became very irritable, and was very pale. He was hospitalized. The CSF examination showed normal pressure, 6 cells and a negative culture.
    The sedimentation was normal. IFA 1: 128. ELISA 1.23. Findings were available less than two weeks after the onset of the disease. The patient is currently being treated intravenously with Rocephin. He speaks slowly, but is still burdened.

  • A young woman contracted Lyme disease at the age of 15. She was treated repeatedly for severe headaches, arthralgias, rashes, weight gain, and slightly positive Lyme titers. An improvement could only be achieved after four intravenous antibiotic treatments. She was treated with Suprax, then ERYC orally, and began her studies. She had an excellent year with only the occasional headache. In the summer she suddenly developed peroneal paralysis and dropped foot while driving. Tests in the hospital showed normal CBC, Chemistry Battery and Sed Rate values. Your Lyme titer was now definitely positive and the number of cells in the CSF was increased. She was treated with Rocephin. The peroneal paralysis improved within 48 hours. The infusions were given for six weeks, then switched to oral medication. She is fine again.

  • A six year old girl was diagnosed with juvenile rheumatoid arthritis and treated appropriately for arthritis. However, there were headaches, abdominal pain and chest pain. The abdominal pain was attributed to gastritis from too much aspirin. Lyme titer was positive. She was given Rocephin for 14 days and then Claforan for 21 days. After that she seemed fine. However, a year later she developed optic neuritis, arthralgias, and chest pain. There was another therapy combined with steroids. Her eyesight returned, but she relapsed and was then treated with Claforan for an extended period of time. There was a gradual improvement. Her visual acuity returned to 20/20. She was essentially symptom free. Six months later she had another relapse with visual disturbances, headache and joint pain. VERS was abnormal. Lyme titer was slightly increased.
    The optic papillae were slightly swollen. During the CSF examination, the pressure was normal and the CSF negative. She was treated with Claforan in combination with steroids. The visual acuity improved again. The EEG is abnormal. Of course, VERS and visual acuity will be checked further.

It is controversial whether patients should be treated more than once. Ever since I've seen improvement after multiple treatments, I've advocated repeated therapy instead of leaving patients to their symptoms. It is not possible to know how long a patient should be treated. I get the impression, however, that we are likely to under-treat for 14-24 days. I now recommend four to six week treatments, more in some cases.



RECOMMENDED LITERATURE


Allen Steere, M.D. has a review article on Lyme Disease in the New England Journal of
Medicine, Vol 321, No. 9, pages 586-596. This article gives you a review of Lyme. Other
articles of interest are:

Pachner, AR, Steere, A: The Triad of Neurologic Manifestations of Lyme Disease.
Neurology, 1985: Vol. 35: 37-53.

Halperin, JJ, et al: Lyme Disease: Cause of a Treatable Peripheral Neuropathy. Neurology,
1987: Vol 37: 1700-1706.

Schechter, SL: Lyme Disease Associated with Optic Neuropathy. The American Journal of
Medicine, July, 1986, Vol. 81: 143-145.

Kohler, J: Chronic Central Nervous System Involvement in Lyme Borreliosis. Neurology,
1988: Vol. 38: 863-866.

Pfister, HW: Latent Lyme Neuro-Borreliosis, Presence of Borrelia Burgdorferi in the Cerebral
Spinal Fluid Without Concurrent Inflammatory Signs. Neurology, August, 1989, Vol 39:
1118-1121.

Benach, Jorje L., et al: Spirochetes Isolated from the Blood of two Patients with Lyme
Disease. New England Journal of Medicine, March, 1983, Vol. 308: 740-742.

Burger, B: Erythema Chronicum Migrans of Lyme Disease, Archives of Dermatology, August,
1984, 120:1017.

Mac Donald, AB, et al: Stillbirth Following Maternal Lyme Disease, New York State Journal
of Medicine, Nov. 1987: 615-616

Logigian, Eric MD, etc: Chronic Neurologic Manifestations of Lyme Disease. New England
Journal of Medicine, Nov. 22, 1990, vol. 323, no. 21: 1438-1444.

Dorward, et al: Immune Capture and Detection of Borrelia Burgdorferi Antigens in Urine,
Blood or Tissues from Infected Ticks, Mice, Dogs, and Humans. Journal of Clinical
Microbiology, June, 1991, vol. 29, no. 26: 1162-1170.

Fernandez, et al: Lyme Disease of the Central Nervous System, MR Imaging Findings in
Fourteen cases. AJNN, May-June 1990, Vol. 11: 479-481.

Rafto et al: Biopsy Confirmed CNS Lyme Disease, MR Appearance at 1.5 T. AJNR 11,
May-June 1990: 482-484.

Rahn: Lyme Disease, Clinical Manifestations, Diagnosis and Treatment. Seminars on Arthritis
and Rheumatism, Feb. 1991, Vol. 20, No. 4: 201-218.

Nadelman, et al: Isolation of Borrelia Burgdorferi from the Blood of Seven Patients with Lyme
Disease. American Journal of Medicine, January 1990, Vol. 88: 21-26.

MacDonald, Allen MD: Gestational Lyme Borreliosis. Rheumatology Clinics of North
America. Nov. 1989, Vol. 15, No. 4th

I hope that these clinical case studies and other information will be of use to you when dealing with this sometimes very frustrating, confusing, and challenging problem that appears as vague ailments.



TREATMENT GUIDELINES - NEUROBORRELIOSIS IN CHILDREN

Intravenous antibiotics

  • I.V. Rocephin (Ceftriaxone): 2g daily, either 2g in one dose or 1g every 12 hours. For children, 1g every 12 hours is preferable. If the child is less than 40 lbs (or less than 20 kg), 100mg per kg. daily in two doses.
  • I.V. Claforan (Cefotaxime): 2g every 8 hours or 180 mg per kilo daily in 3 doses.
  • I.V. Ampicillin: Maximum 2g every 4 hours for a very large child such as a teenager, lower doses for younger children such as 1g every 6 hours or 1g every 4 hours.

Oral antibiotics

  • Amoxil: 1g or 1500 mg once a day. If the patient is taller, up to 2g per day.
  • Suprax: 400 mg daily, up to 600 or even 800 mg.
  • ERYC: 250 mg. per orem qid (take 4 times a day (by mouth), transl.).

Patients may need treatment for four to six weeks or more, depending on how they respond.

After intravenous treatment, the patient should be placed on oral antibiotics for as long as necessary.

  • Amoxil,
  • Suprax, or
  • a combination of Suprax-ERYC can be prescribed.
  • Some doctors prefer combined treatment of Bactrim with ERYC.

Different drugs help different patients. The decision is made based on the patient's clinical response and tolerance to the medication.

In addition to the antibiotics

In addition to the antibiotics should be
  • Vitamin B-6, 25-50 mg daily, may be prescribed depending on size and age.
  • One multivitamin daily.
  • Benedryl or Atarax for itching or rashes caused by the drug.
  • Yogurt or acidophilus (lactic acid bacteria) to prevent diarrhea.
  • Suprax can be given in one dose, the other drugs at different times of the day.
  • Diamox can be given when there is increased pressure in the brain.
  • In unusual cases, steroids may be necessary, but these should only be given with antibiotics. The use of steroids in Lyme borreliosis is very controversial (see e.g. Bleiweiss, d. Trans.). Pain is difficult to treat. Tricyclic medication such as Elavil and of course NSAIDS (nonsteroidal anti-inflammatory drugs) can be tried.


Dorothy M. Pietrucha, M.D., P.A.
Pediatric Neurology
3318 Route 33
Neptune, New Jersey 07753
Telephone: (908) 922-0337
FAX: (908) 922-1631


Version: January 22, 1999