Diagnostic Challenges of Lyme Neuroborreliosis in Inpatient Neurology: A Case Series
Kaitlyn Palmer1, Maria Sokola1, Sanem Uysal1, Jessica Cooperrider1, Anthony Leung5, Alejandro Torres-Trejo2, Yuebing Li3, Justin Abbatemarco4
1Neurologic Institute, 2Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, 3Neuromuscular Center, 4Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, 5Infectious Disease, Cleveland Clinic Akron General
Objective:
We aim to increase awareness of the diagnostic challenges of Lyme neuroborreliosis (LNB) in order to decrease treatment delays due to unfamiliarity of unique clinical manifestations in the setting of rising Lyme disease incidence.
Background:
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 setting of climate change. Approximately 10-15% of untreated Lyme disease cases will develop neurologic manifestations of LNB. Due to varying manifestations, LNB presents diagnostic challenges and is associated with a delay to treatment.
Results:
Three patients from low-incidence areas with prior extensive diagnostic evaluations presented to our referral center in a traditionally low-incidence state in August with neurologic manifestations of radiculoneuritis, cranial neuropathies, and/or lymphocytic meningitis. One patient reported a preceding rash on admission. Two patients disclosed prior tick exposure and possible rash at the end of their hospitalization. MRI findings included cranial nerve, nerve root, and leptomeningeal enhancement leading to broad differential diagnoses. Cerebrospinal fluid demonstrated lymphocytic pleocytosis (range 85-753 cells/uL) and elevated protein (range 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 healthcare presentation (mean 20 days) and a delay to diagnosis and treatment (mean 54 days) due to under-recognition and ongoing evaluation. After completion of antibiotics, symptoms completely resolved.
Conclusions:
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 patient 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.