Epidemiological characteristics and clinical manifestations of Lyme borreliosis in Croatia

OBJECTIVE: The goal was to show the epidemiological characteristics and clinical manifestations of Lyme borreliosis in Croatia. METHODS: Data on registered Lyme borreliosis cases were analyzed and the most common clinical manifestations of the disease, based on meta-analysis of the data collected, are described. RESULTS: A total of 3,317 cases were reported from 1987 to the end of 2003. Northwestern Croatia is an area in which Lyme borreliosis is endemic, but the disease has also been recorded in the other parts of the country, with the exception of the area south of Zadar. The clinical picture of Lyme borreliosis in Croatia is dominated by erythema migrans, followed by neurological manifestations. The diversified clinical picture is consistent with reports from other European countries, as is the isolation of Borrelia afzelii and Borrelia garinii, which are causally related to these forms of the disease. CONCLUSION: Tick density and tick infection rates of Borrelia burgdorferi have not yet been investigated in the part of Croatia free from the occurrence of Lyme borreliosis.     

MRI features of Lyme arthritis in children

OBJECTIVE: Oligoarthritis is the most common manifestation of late Lyme disease in children. Considerable overlap can occur in the clinical presentation of Lyme arthritis and acute septic arthritis. Early differentiation is critical, given the disparate therapeutic implications; Lyme arthritis is treated with outpatient oral antibiotics, while septic arthritis requires hospitalization, IV antibiotics, and, often, surgical drainage. We wanted to identify MRI features that may distinguish Lyme arthritis from septic arthritis in children. MATERIALS AND METHODS: Knee MR images in 11 children with Lyme arthritis and 7 with septic arthritis, with a mean age 10.6 years old and 11.7 years old, respectively, were reviewed by a radiologist blinded to the final diagnosis. Joint effusion size, synovial thickness, adenopathy, subcutaneous, marrow, and muscle edema on MRI; and clinical parameters including age, sex, fever, WBC, erythrocyte sedimentation rate, C-reactive protein, and joint fluid WBC in the two patient groups were compared using univariate and multivariate analyses. RESULTS: Subcutaneous edema was seen in all septic arthritis patients but in only one of 11 patients with Lyme arthritis (p < 0.01). Myositis and adenopathy were present in all Lyme arthritis patients and two of seven patients with septic arthritis (both p < 0.01). No significant difference was present in synovial thickness, marrow edema, or joint fluid size. There were no statistically significant differences in the clinical parameters assessed. CONCLUSION: Our results identified three MRI features, specifically, myositis, adenopathy, and lack of subcutaneous edema, that strongly suggest the diagnosis of Lyme arthritis rather than septic arthritis in children with acute inflammation of the knee. Awareness of these characteristic MRI features may avoid unnecessary invasive procedures and cost.     

Lyme disease of the brainstem

Lyme disease is a multisystem infectious disease caused by the tick-borne spirochete, Borrelia burgdorferi. Central nervous system (CNS) involvement typically causes local inflammation, most commonly meningitis, but rarely parenchymal brain involvement. We describe a patient who presented with clinical findings suggesting a brainstem process. Magnetic resonance imaging (MRI) and positron emission tomography (PET) suggested a brainstem neoplasm. Prior to biopsy, laboratory evaluation led to the diagnosis of Lyme disease. Clinical and imaging abnormalities improved markedly following antimicrobial therapy. We describe Lyme disease involvement of the cerebellar peduncles with hypermetabolism on PET. Although MRI is the primary imaging modality for most suspected CNS pathology, the practical applications of PET continue to expand.     

MRI in Lyme disease of the spinal cord

We report a case of Lyme myelitis in a 31-year-old man, presenting with a conus medullaris syndrome. MRI demonstrated contrast enhancement on the pial surface of the lower thoracic cord and conus medullaris. Elevated blood immunoglobulins and IgM antibodies against Borrelia burgdorferi in the cerebrospinal fluid (CSF) were found. Leptomeningitis may be the first stage of spinal infection in Lyme disease, preceding parenchymal infection leading to myelitis. Vasculitis is probably the major mechanism. MRI findings are nonspecific and the diagnosis is given by serum and CSF analyses. Early treatment with antibiotics and high doses steroids may result in complete recovery, as in this case. Received: 29 December 1999 Accepted: 31 January 2000     

Lyme disease reporting for Navy and Marine Corps (1997-2000)

Reported cases of Lyme disease for Navy and Marine Corps personnel during 1997-2000 are presented from data collected in the Naval Disease Reporting System and the Defense Medical Epidemiological Database. Naval Disease Reporting System identified 210 case subjects; 60% were men, 49% were family members, and 37% were active duty, and most originated in the second quarter of the calendar year. States reporting the greatest number of reports were Connecticut (44%), North Carolina (16%), Rhode Island (10%), and Virginia (10%), which was generally consistent with national figures and the concentration of military populations. Incidence rates from Defense Medical Epidemiological Database for Lyme disease were generally higher for active duty personnel than reported civilian rates. Areas for improvement for Naval Disease Reporting System are identified and include additional emphasis on complete reporting on patient history and on Lyme disease antibody testing results. These findings suggest that Lyme disease is an important disease in military medicine, particularly in the eastern United States.     

Triple-phase bone image abnormalities in Lyme arthritis

Arthritis is a frequent manifestation of Lyme disease. Limited triple-phase Tc-99m MDP bone imaging of the wrists and hands with delayed whole-body images was performed in a patient with Lyme arthritis. This demonstrated abnormal joint uptake in the wrists and hands in all three phases, with increased activity seen in other affected joints on delayed whole-body images. These findings are nonspecific and have been previously described in a variety of rheumatologic conditions, but not in Lyme disease. Lyme disease should be considered in the differential diagnosis of articular and periarticular bone scan abnormalities.     

Orbital Lyme disease: MR imaging before and after treatment: case report

Lyme disease is a multi-system organ disease caused by Borrelia burgdorferi. Although ocular manifestations have been reported, these remain a rare feature of the disease. To our knowledge, the radiology literature has not documented orbital Lyme disease both before and after treatment. We present the MR imaging findings of florid Lyme disease affecting the extraocular muscles in a 46-year-old man. A follow-up MR imaging study performed 6 months after a course of antibiotic therapy revealed complete resolution of the myositic changes.     

Lyme disease in childhood presenting as primary leptomeningeal enhancement without parenchymal findings on MR.

We report the MR appearance of a rare case of Lyme disease presenting as diffuse leptomeningeal enhancement in the absence of parenchymal lesions. In the appropriate clinical setting, one should consider Lyme disease in the differential diagnosis of meningeal enhancement.     

Scintigraphic evaluation of Lyme disease: gallium-67 imaging of Lyme myositis

A patient suffering from Lyme disease had cardiac conduction abnormalities, symptoms of arthritis, and myalgia. A Ga-67 image showed evidence of endomyocarditis, but intense skeletal muscle uptake pointed to Lyme myositis. Reference is made to two other case reports of Lyme myositis.     

Lyme myocarditis diagnosed by indium-111-antimyosin antibody scintigraphy

We report a new case of Lyme disease with cardiac manifestations, which has been possible to follow during the long period of 12 years. We have detected the usual ECG abnormalities, and concentric hypertrophic myocardiopathy, by echocardiography. The acute myocarditis was demonstrated by ¹¹¹In-antimyosin scintigraphy, which showed global myocardial uptake of the tracer, constituting the first report, to our knowledge, of Lyme myocarditis diagnosed by this method.     

Lyme disease of the CNS: MR imaging findings in 14 cases

The MR images of 14 patients with clinical diagnoses of Lyme disease, CNS complaints, and positive Lyme titers were reviewed. MR examinations were abnormal in 43%. Areas of abnormal signal were identified within the cerebral white matter as well as within the brainstem.     

Facial palsy, enhancement of cranial nerves and Lyme disease

Lyme disease involves multiple organ systems including in 10-15% of cases, the nervous system. Cranial neuropathies are observed in the second stage of the disease. The facial nerve is the most frequently affected nerve (20-30%). Facial nerve enhancement may be associated with cochleovestibular nerve abnormalities and can mimick an intracanalicular pseudomass. We present post-gadolinium enhancement of multiple cranial nerves associated to an intracanicular enhancement illustrated in a patient referred for a facial nerve palsy and presenting a Lyme disease. We discuss the differential diagnosis.     

Cases from the aerospace medicine residents' teaching file. Case #42. An aviator with concentration deficit, Lyme disease organic diagnostic evaluation, and a somatoform disorder

An aviator with concentration deficit, Lyme disease organic diagnostic evaluation, and a somatoform disorder. The clinical presentation, evaluation and diagnosis of an aviator being evaluated for vague cognitive deficits of episodic and long duration with a history of rigid ideation concerning Lyme disease. The patient was diagnosed as having an atypical somatoform disorder. The aeromedical disposition of this patient is also presented.     

Cerebral metabolic changes associated with Lyme disease

There are no positron emission tomography (PET) studies reported in the literature with regards to brain metabolism and function in patients with Lyme disease. These patients frequently present with various neurological symptoms, including memory problems. We used [(18)F]fluorodeoxyglucose (FDG) PET to determine the metabolic landscape in 23 patients with Lyme disease. Images were evaluated for cortical and subcortical abnormalities by two experienced reviewers blinded to the clinical information. The most striking finding was hypometabolism in the temporal lobes in 17/23 (74%) patients. Of these, 12 had bilateral temporal lobe hypometabolism, two had left temporal lobe, and three had right temporal lobe hypometabolism. Seven of the patients with temporal lobe hypometabolism had diffuse cortical hypometabolism that included the frontal and parietal lobes. Lyme disease appears to have two primary patterns of brain involvement on FDG PET scans, specific temporal lobe hypometabolism or a diffuse cortical hypometabolism. The involvement of the temporal lobes in both patterns is likely associated with the memory disturbances described in many of these patients. Although there was no clear diagnostic pattern, and many of the defects were mild, FDG PET imaging may provide important information regarding the areas of the brain affected in patients with neurological symptoms associated with Lyme disease.     

Lyme disease and radiologic findings in Lyme arthritis.

Lyme disease typically begins in the spring or summer months, with a pathognomonic skin lesion and associated flulike or meningitislike symptoms. If the patient is not treated during this early stage, cardiac, neurologic, or musculoskeletal manifestations may occur weeks to months later. Although the clinical picture of Lyme disease is extremely variable, the diagnosis can be made in most cases by recognizing the typical patterns of organ involvement and associated immunologic abnormalities.     

Childhood neuroborreliosis: clinicoradiological correlation

We report the cranial CT and MRI findings in three children with Lyme disease (neuroborreliosis). The neuroimaging findings in children have been rarely reported. We found cranial MRI far superior to cranial CT. Ring-enhancing lesions have been described in acute disseminating encephalomyelitis and multiple sclerosis but not in neuroborreliosis. Although orther infectious and inflammatory diseases cannot be excluded, Lyme disease should be included in the differential diagnosis and put forward as being the most likely diagnosis in the appropriate clinical setting. Gadopentetate dimeglumine is helpful in assessing the response to antibiotic treatment.     

How to Detect Lyme Disease

If patients lack the characteristic sign of Lyme disease—a red rash with a pale center—diagnosing the disease can be challenging. A thorough workup and history should alert physicians when patients' flulike symptoms are the result of this tick-borne infection.     

Hospitalisation due to Lyme disease: case series in British Forces Germany

Lyme disease is a tick-transmitted infection with disabling sequelae and important occupational health implications for a military workforce. It is likely that some military patients with typical clinical signs remain undiagnosed and untreated. Prompt treatment with an antibiotic is essential, besides targeted education on preventing infection through avoiding exposure to tick bites. We describe four British Forces Germany personnel (two serving military personnel, one adult civilian, one child) who during 2002--2003 required hospital inpatient treatment for Lyme disease. The epidemiology, pathogenesis, clinical features, diagnosis and treatment of the disease are discussed.     

Lyme myocarditis diagnosed by indium-111-antimyosin antibody scintigraphy

We report a new case of Lyme disease with cardiac manifestations, which has been possible to follow during the long period of 12 years. We have detected the usual ECG abnormalities, and concentric hypertrophic myocardiopathy, by echocardiography. The acute myocarditis was demonstrated by 111In-antimyosin scintigraphy, which showed global myocardial uptake of the tracer, constituting the first report, to our knowledge, of Lyme myocarditis diagnosed by this method.     

MR imaging in neuroborreliosis of the cervical spinal cord

The central nervous system is involved in 10–20% of cases in Lyme disease. The neurological symptoms, time course of the disease and imaging findings are multifaceted. We report two patients with cervical radiculitis. Magnetic resonance imaging revealed strong enhancement of the cervical nerve roots on contrast-enhanced T1-weighted images. These imaging patterns of borrelia-associated radiculitis have not been reported before. Knowledge of these imaging features may help to diagnose neuroborreliosis, which presents with non-specific symptoms.