Palmer Kaitlyn N, Sokola Maria, Uysal Sanem P, Cooperrider Jessica, Leung Anthony K, Torres-Trejo Alejandro, Li Yuebing, Abbatemarco Justin R
Department of Neurology, Cleveland Clinic, Cleveland, OH, USA.
Department of Infectious Disease, Cleveland Clinic Akron General, Akron, OH, USA.
Neurohospitalist. 2024 Jul;14(3):301-307. doi: 10.1177/19418744241246308. Epub 2024 Apr 16.
Lyme disease is a multisystem disorder transmitted through the Ixodes tick and is most commonly diagnosed in northeastern and mid-Atlantic states, Wisconsin, and Minnesota, though its disease borders are expanding in the setting of climate change. Approximately 10%-15% of untreated Lyme disease cases will develop neurologic manifestations of Lyme neuroborreliosis (LNB). Due to varying presentations, LNB presents diagnostic challenges and is associated with a delay to treatment. We discuss three cases of LNB admitted to our referral center in a traditionally low-incidence state to highlight clinical pearls in LNB diagnosis. Three patients from low-incidence areas with prior diagnostic evaluations presented in August with neurologic manifestations of radiculoneuritis, cranial neuropathies, and/or lymphocytic meningitis. MRI findings included cranial nerve, nerve root, and leptomeningeal enhancement leading to broad differential diagnoses. Lumbar puncture demonstrated lymphocytic pleocytosis (range 85-753 cells/uL) and elevated protein (87-318 mg/dL). Each patient tested positive for Lyme on two-tiered serum testing and was diagnosed with LNB. All three cases were associated with a delay to health care presentation (mean 20 days) and a delay to diagnosis and treatment (mean 54 days) due to under-recognition and ongoing evaluation. With the geographic expansion of Lyme disease, increasing awareness of LNB manifestations and acquiring detailed travel histories in low-incidence areas is crucial to prompt delivery of care. Clinicians should be aware of two-tiered serum diagnostic requirements and use adjunctive studies such as lumbar puncture and MRI to eliminate other diagnoses. Treatment with an appropriate course of antibiotics leads to robust improvement in neurological symptoms.
莱姆病是一种通过硬蜱传播的多系统疾病，最常见于美国东北部、大西洋中部各州、威斯康星州和明尼苏达州，不过在气候变化的背景下，其疾病边界正在扩大。未经治疗的莱姆病病例中，约10%-15%会出现莱姆神经疏螺旋体病（LNB）的神经学表现。由于临床表现各异，LNB存在诊断挑战，且与治疗延迟相关。我们讨论了三例转诊至我们中心的LNB病例，该中心所在州传统上发病率较低，以突出LNB诊断中的临床要点。三名来自低发病率地区且之前经过诊断评估的患者于8月出现神经根神经炎、颅神经病变和/或淋巴细胞性脑膜炎的神经学表现。MRI检查结果包括颅神经、神经根和软脑膜强化，导致鉴别诊断范围广泛。腰椎穿刺显示淋巴细胞增多（范围为85-753个细胞/微升）和蛋白升高（87-318毫克/分升）。每位患者的两层血清检测莱姆病均呈阳性，被诊断为LNB。所有三例病例均因认识不足和持续评估导致就医延迟（平均20天）以及诊断和治疗延迟（平均54天）。随着莱姆病的地理范围扩大，提高对LNB表现的认识并在低发病率地区获取详细的旅行史对于及时提供治疗至关重要。临床医生应了解两层血清诊断要求，并使用腰椎穿刺和MRI等辅助检查以排除其他诊断。使用适当疗程的抗生素进行治疗可使神经症状显著改善。
