Bethany Smeltzer, M.D. PGY3 Dr. Robert Krippendorf Dr. Kurt Pfeifer. Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI.

Transcription

1 Bethany Smeltzer, M.D. PGY3 Dr. Robert Krippendorf Dr. Kurt Pfeifer Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI.

2 Case Presenta*on CC: Low back pain HPI: A 75 yo man presents with 3 week history of low back pain Associated fatigue, upper extremity tremor, double vision Difficulty writing and reading No longer working as substitute teacher Family concerned about word finding difficulty and weight loss

3 Case Presenta*on PMH: Autoimmune hemolytic anemia Ulcerative colitis Hypothyroidism Type 2 diabetes (diet controlled) Hypertension No prior surgeries Medications: levothyroxine, lisinopril, mesalamine

4 Exam Vital signs stable and exam otherwise unremarkable with the exception of: Neurologic: Diminished reflexes bilaterally throughout Vertical diplopia with leftward gaze, no nystagmus Positive Romberg test Bilateral intention tremor with finger- to- nose testing Delayed rapid alternating hand movements on left Wide- based gait

5 Exam Cognition: Fully alert and oriented 13/30 on Montreal cognitive assessment Psych: Flat affect

6 Diagnos*c Studies CBC normal BMP normal TSH 1.8 ANA <1.0 ESR 18 CRP 0.5 UA negative MRI brain negative for acute intracranial abnormality

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8 Procedure Lumbar puncture performed on hospital day 3 CSF analysis revealed: Protein 245 Glucose 70 WBC 322 Negative gram stain & culture CSF Lyme serologies eventually returned positive for IgG and were confirmed by western blot

9 Lyme disease

10 Lyme Disease Most common tick- borne disease in North America and Europe Most common clinical manifestation is the classic target lesion of erythema migrans (EM), which develops 7 to 14 days after tick detachment EM lesions are typically asymptomatic, characteristically exhibit central clearing with surrounding rim of erythema

11 Erythema Migrans Steere AC. The Early Clinical Manifestations of Lyme Disease 4

12 Lyme Disease Localized Timing Days to one month Manifestations Erythema migrans, fatigue, malaise, lethargy, headache, myalgias, arthralgias Early Disseminated Weeks to months Carditis, meningitis,peripheral neuropathy, encephalitis, radiculopathy, lymphadenopathy, iritis, retinitis, hepatitis, proteinuria Late Disseminated Months to years Arthritis, peripheral neuropathy, encephalomyelitis, cutaneous involvement

13 Neuroborreliosis Neuroborreliosis develops in 10-15% of patients Common early manifestations: Lymphocytic meningitis Cranial neuropathies Radiculoneuritis Occur alone or in combination Rarely patients develop inflammation in brain or spinal cord

14 Neuroborreliosis Late disseminated disease: Encephalopathy affecting memory, mood, or sleep Axonal polyneuropathy manifested as either distal paresthesia or radicular pain Encephalomyelitis may include spastic paraparesis, bladder dysfunction, and lesions in the periventricular white matter.

15 Pathogenesis Hematogenous spread Direct injury by spirochete Indirect injury due to infiltration of CSF and tissues Inflammatory cytokines Mononuclear cells

16 Diagnosis Based on clinical appearance of EM lesions Once infection is disseminated, virtually all patients are seropositive Two tiered approach: Screening test with enzyme- lined immunosorbant assay (ELISA) Confirmation test with Western blot

17 Treatment IDSA, CID 2000;31:S1- S14 2

18 Case Follow Up The patient was treated with a 2- week course of ceftriaxone On follow up after completing antibiotic therapy, the patient had residual numbness and tingling in his fingers He was improved in his mental status and level of functioning Planned to return to teaching soon

19 Take Home Points Early recognition of neuroborreliosis has significant impact on quality of life Diagnosis of neuroborreliosis is dependent on: Possible exposure to ticks Features associated with nervous system Lyme disease Positive Lyme serology in CSF Consider a diagnosis of Lyme disease when facing a patient with neurologic complaints

20 References 1. Steere AC. Lyme Borreliosis. In: Longo DL, et al. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw- Hill; Wormser G, et al. Practice Guidelines for the Treatment of Lyme Disease. CID 2000;31:S1- S Halperin, John. Neurologic Manifestations of Lyme Disease. Curr Infect Dis Rep 2011; 13: Steere AC, et al. The Early Clinical Manifestations of Lyme Disease. Annals of Internal Medicine. 1983;99: Garcia- Monco, Juan. Lyme Neuroborreliosis. Annals Of Neurology. 1995; 37, 6:

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