LONGER STATEMENTS HERE

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• LONGER STATEMENTS
• Two separate, large, retrospective studies of patients treated for early Lyme disease found a surprisingly high incidence of continued signs and symptoms, especially if treatment was delayed.
• 34 percent of patients in a suburban area of highly endemic disease just north of Boston who had been treated for early Lyme disease had long-term sequelae, including arthritis, arthralgia, cognitive impairment, and neuropathy
• 114 of the 215 patients studied (53 percent) had persistent signs and symptoms, including neurologic, cardiac, and musculoskeletal disorders. Of the 114 patients with ongoing problems, 35 (31 percent) had clinically important fatigue and arthralgia as their chief symptoms. These retrospective studies suggest that perhaps more attention should be paid to minor post-treatment symptoms.
• One year after treatment with cefuroxime axetil or doxycycline, approximately 10 percent of patients reported the persistence of mild-to-severe fatigue, arthralgia, and myalgia.
• 58 percent of ceftriaxone-treated patients and 43 percent of doxycycline-treated patients reported drug-related adverse events- these events were generally mild; serious events were uncommon.
• Most frequently adverse events during ceftriaxone treatment- diarrhea (37 percent)
• Doxycycline-treated patients most frequently reported photosensitivity and rash (13 percent)
• Children in Brazil- Signs and symptoms with statistical significance were itching; absence of lip notch and ocular pain; irritability and good clinical condition- pruritus (90%), irritability (80%) and fever (38 masculineC) (58.3%) with a duration of 1 to 3 days. Erythema was maculo-papular (40%), urticaria-like (25%) and scarlatiniform (16.7%), occurring predominately on the trunk (60%).
• Treatments for secondary and tertiary Lyme borreliosis are more poorly documented, and antibiotics are not always effective. This is due to the unique pathophysiology of late Lymeborreliosis, which involves not only bacterial infection, but also immunological response.
• Borrelial lymphocytoma (BL)- Borrelia afzelii was identified in three cases, B. garinii and B. burgdorferi sensu stricto in one case each
• Patients with LM (Lyme meningitis) had statistically more frequent cranial neuropathy (73% vs. 4%), displayed a longer duration of symptoms before admission (8.8 vs. 1.8 days), had a higher CSF protein (71 vs. 38 mg/d), and had a lower percentage of neutrophil cells in the CSF (3.4% vs. 51%) than patients with NLAM (Non-Lyme aseptic meningitis).
• Lyme arthritis shares features with both septic and nonseptic non-Lyme arthritis. This overlap prevents the creation of a clinically useful predictive model for Lyme arthritis.
• Early diagnosis is important to prevent prolonged suffering from chronic joint swelling with probable joint damages, unnecessary treatment procedures and as well school and sports absenteeism.
• Acropapular dermatitis is a symmetric self-limited papulovesicular exanthem- classically occurs on cheeks, extensor extremities, and buttocks in young children- workup revealed an acute Lyme infection.
• "Borrelia-associated early onset morphea" is characterized by a combination of disease onset at younger age, infection with B burgdorferi, and autoimmune phenomena as reflected by high-titer antinuclear antibodies- it may take a particularly severe course and require treatment of both infection and skin inflammation.
• The clinical manifestation of LD were usual and unusual from patient to patient. They included four cases of facial nerve paralysis (with bilateral paralysis in one case), in three cases transverse myelitis and in a single case, hemiparesis, and oculomotor nerve paresis. In 9/13 children motoric disturbances of neuroboreliosis was diagnosed indeed. The antibiotic treatment was successful in 6 patients and only partially effective in 3 children with facial nerve paralysis.
• Lyme disease caused by the spirochete Borrelia burgdorferi is the most common tick-borne illness in the world today
• Although prompt diagnosis and treatment results in a favourable outcome in most patients with B. burgdorferi infection, tick exposure and acute infection with the Lyme spirochete often go unrecognized, and patients with untreated infection may go on to develop a chronic debilitating multisystem illness that is difficult to diagnose and treat.
• Lyme patients with predominant musculoskeletal symptoms had significantly longer duration of disease compared to Lyme patients with predominant neurologic symptoms (42 ± 21 versus 27 ± 13 months, P = 0.01).
• Many individuals who contract Lyme disease do not know that they are infected because they are unaware of a tickbite and/or they do not have the characteristic erythema migrans Lyme rash. Subsequently these individuals develop a multisystem illness that can be difficult to diagnose and treat.
• To date, the only clinically useful immunologic marker of chronic Lyme disease is the CD57 NK cell level.
• C4a appears to be a useful marker for both clinical diagnosis and response to treatment in patients with chronic Lyme disease.
• Patients with predominant neurologic symptoms of Lyme disease had normal levels of C4a despite the presence of chronic fatigue in most of these patients.
• Borrelia lusitaniae may be pathogenic in humans, highlighting that patients may be seronegative or present with minimal positive antibody titres and clinical signs that are not specific for Lyme borreliosis.
• 200 patients- Average length of intravenous antibiotic treatment was 118 days (range, 7-750 days)- Seven (3.5%) experienced allergic reactions to medication- Two (1.0%) had gallbladder toxicity- Intravascular devices (IVDs) complications occurred in 15 patients (7.5%) with only one confirmed- None of the IVD complications were fatal.
• All patients with chronic Lyme disease and AIDS had normal C3a levels compared to controls, whereas patients with SLE had significantly increased levels of this marker. Patients with predominant musculoskeletal symptoms of Lyme disease and AIDS patients had significantly increased levels of C4a compared to either controls, patients with predominant neurologic symptoms of Lyme disease or SLE patients.
• Response to antibiotic therapy in chronic Lyme disease was associated with a significant decrease in the C4a level, whereas lack of response was associated with a significant increase in this marker.
• Lyme patients with positive single-photon emission computed tomographic (SPECT) scans had significantly lower C4a levels compared to Lyme patients with normal SPECT scan results. Patients with predominant musculoskeletal symptoms of Lyme disease have normal C3a and increased C4a levels. This pattern differs from the increase in both markers seen in acute Lyme disease, and C4a changes correlate with the response to therapy in chronic Lyme disease. C4a appears to be a valuable immunologic marker in patients with persistent symptoms of Lyme disease.
• Erythema annulare centrifugum (EAC), considered an inflammatory skin disease, is a clinical reaction pattern and should be considered in some cases of cutaneous Lyme disease.
• Histological, histochemical, and immunohistochemical detection of microorganisms has turned out to be difficult, frequently unreliable, and almost always extremely time consuming. Cultures with specific media can detect Borrelia species in all clinical forms, but these techniques are not generally available and are unreliable, with less than 50% sensitivity for classic borreliosis.
• The diagnosis of chronic Lyme disease and its treatment differ substantively from the diagnosis and treatment of recognized infectious diseases. The diagnosis is often based solely on clinical judgment rather than on well-defined clinical criteria and validated laboratory studies, and it is often made regardless of whether patients have been in areas where Lyme disease is endemic.
• Negative results of serologic tests are often attributed to previous antibiotic therapy or to the theory that chronic infection with B. burgdorferi suppresses humoral immune responses.
• No other spirochetal infection, including the neurologic complications of tertiary syphilis, is managed in an analogous fashion.2,23 The duration of treatment commonly prescribed for chronic Lyme disease often far surpasses even the conventional 6-month course of therapy successfully used for most cases of tuberculosis.
• Patients with category 1 disease [chronic Lyme disease] do not have objective clinical manifestations or laboratory evidence of B. burgdorferi infection, and they receive a diagnosis on the basis of the presence of nonspecific symptoms such as fatigue, night sweats, sore throat, swollen glands, stiff neck, arthralgia, myalgia, palpitations, abdominal pain, nausea, diarrhea, sleep disturbance, poor concentration, irritability, depression, back pain, headache, and dizziness.
• In prospective studies of patients with erythema migrans, subjective symptoms of unknown cause were present 1 year or more after treatment in 0.5 to 13.1% of patients.
• DNA of B. burgdorferi was detected by means of PCR in urine specimens from nearly three quarters of 97 patients who had received the diagnosis of chronic Lyme disease.
• Physicians and laypeople who believe in the existence of chronic Lyme disease have formed societies, created charitable foundations, started numerous support groups (even in locations in which B. burgdorferi infection is not endemic), and developed their own management guidelines.
• The choice of antibiotics depends on many factors such as the stage of the disease, the drug efficacy, adverse effects, type of delivery, duration of treatment, and cost.
• Education about the stereotypical presentations of Lyme neuroborreliosis is necessary, allowing cases to be identified and treated earlier and without the need to wait for the results of serology tests.
• Diagnostic assessment by TMS [transcranial magnetic stimulation] failed to provide a reliable diagnostic criterion for distinguishing between iFNP [idiopathic facial nerve palsy] and bFNP [facial nerve palsy due to borreliosis] in children and adolescents.
• Chronic infectious diseases, including tick-borne infections such as Borrelia burgdorferi may have direct effects, promote other infections and create a weakened, sensitized and immunologically vulnerable state during fetal development and infancy leading to increased vulnerability for developing autism spectrum disorders.
• Multiple cases of mothers with Lyme disease and children with autism spectrum disorders
• Similarities between tick-borne diseases and autism spectrum disorder regarding symptoms, pathophysiology, immune reactivity, temporal lobe pathology, and brain imaging data; positive reactivity in several studies with autistic spectrum disorder patients for Borrelia burgdorferi (22%, 26% and 20-30%).
• It is imperative to research these [Lyme and tick borne diseases] and all possible causes of autism spectrum disorders in order to prevent every preventable case and treat every treatable case until this disease has been eliminated from humanity.
• Diagnosis of Lyme borreliosis by urine polymerase chain reaction (PCR) has been recognized as having better diagnostic sensitivity in patients with erythema migrans than serological methods.
• A recent World Health Organization report indicated that infectious diseases are now the world's biggest killer of children and young adults.
• Recently, it is reported that infectious diseases are responsible for more than 17 million deaths worldwide each year, most of which are associated with bacterial infections.
• In developed countries, the emergence of new, rare or already-forgotten infectious diseases, such as HIV/AIDS, Lyme disease and tuberculosis, has stimulated public interest and inspired commitments to surveillance and control.
• Urine PCR can serve as a diagnostic method in early Lyme borreliosis and also in seropositive patients with unclear clinical symptoms.
• When unexplained nonspecific systemic symptoms such as myalgia, fatigue, and paresthesias have persisted for a long time in a person from an endemic area, serologic testing should be performed
• (50)
• A tight regulation therefore needs to take place in order not only to eradicate the pathogen, but also to prevent excessive inflammatory responses leading to tissue destruction
• Children with NB had both significantly higher Borrelia-specific secretion and unstimulated secretion of IL-4 in the CSF, as compared with adults
• This commercially available laboratory test (CFS for Lyme) is not generally helpful for identifying Lyme meningitis because of its low sensitivity.
• 5 treatment failures in the 14 day group- 80 patients (IV ceftriaxone); none in the 28 day group- 63 patients (IV ceftriaxone)
• Co-infected patients commonly present with a prolonged influenza-like illness that fails to respond to antiborrelial therapy.
• False-negative results often are attributable to tests taken too early in the course of infection.
• Antibiotics also can influence the results of serologic tests when given early in the course of infection, and have been shown to abort seroconversion, even if inadequate therapy is provided.
• Overdiagnosis most commonly is attributable to incorrect interpretation of Western blot test results, misidentification of rashes as erythema migrans, or ascribing nonspecific symptoms to Lyme disease.
• Antibiotic therapy in these patients is useful in preventing progression to late-stage disseminated disease where response to treatment is less favorable.
• Approximately one-half of the patients with reported subjective symptoms of residual facial palsy had signs of slight dysfunction in the clinical examination.
• The assumption is not true that all children who had neuroborreliosis with facial palsy will heal 100%
• Prompt diagnosis and treatment are important to prevent progression of disease and extracutaneous complications.
• Acrodermatitis chronica atrophicans that had been misdiagnosed as chronic venous insufficiency for 6 years
• Long-standing disease course- skin changes expanded and progressed to marked atrophy
• Chronic, tertiary Lyme disease, a vector-borne infection most accurately designated neuroborreliosis, is often misdiagnosed.
• Infectors of the human brain, Lyme borrelial spirochetes are neurotropic, similar to the spirochetes of syphilis.
• Symptoms of either disease may be stable and persistent, transient and inconsistent or severe yet fleeting.
• Characteristics may be incompatible with established knowledge of neurological dermatomes, appearing to conventional medical eyes as anatomically impossible, thus creating confusion for doctors, parents and child patients.
• Physicians unfamiliar with Lyme patients' shifting, seemingly vague, emotional, and/or bizarre-sounding complaints, frequently know little about late-stage spirochetal disease.
• Doctors may accuse mothers of fabricating their children's symptoms--the so-called Munchausen's by proxy (MBP) "diagnoses."
• Modern medicine's tendency to trivialize women's "offbeat" concerns and the fact that today's hurried physicians of both genders tend to seek easy panaceas, frequently result in the misogyny of mother-devaluation, especially by doctors who are spirochetally naïve.
• Thousands of children, sick from complex diseases, have been forcibly removed from mothers who insist, contrary to customary evaluations, that their children are ill.
• Charges against mothers of children with Lyme relate to the idea they believe their children sick to satisfy warped internal agendas of their own-- "MBP mothers" are then vilified, frequently jailed and publicly shamed for the "sins" of advocating for their children.
• Many cases of Munchausen's by Proxy involve an unrecognized Lyme borreliosis causation that mothers may insist is valid despite negative tests.
• Doctors who have utilized MBP tactics against mothers are likely to be unaware that in advanced borreliosis, seronegativity is often the rule, a principle disagreed upon by its two extant, published, peer-reviewed, Standards of Care.
• These are guidelines for Lyme disease management--the older system questioning the existence of persistent Lyme and the newer system relying on established clinical criteria.
• Mothers must be free to obtain the family's preferred medical care by choosing between physicians practicing within either system without fear of reprisal.
• Doctors and mothers together may explore medical options with renewed mutual respect toward the best interest of children's health.
• Oligoarthritis is the most common manifestation of late Lyme disease in children.
• Lyme borreliosis is a multi-organ infection with dermatological, rheumatological, neurological, and cardiac manifestations.
• The list of possible symptoms for Lyme disease is long, and symptoms can affect every part of the body.
• Over the past nine years, we have treated over three hundred children for Lyme Disease in the hospital because they had significant neurologic manifestations of Lyme Disease or, in the minority of cases, an arthritis necessitating hospitalization for intravenous antibiotics.
• Sixty percent of the ticks are carrying the Borrelia spirochete so the chance for an infection is very high.
• Many children are not diagnosed initially because their complaints are vague and thought to be all functional.
• Children can develop neurologic symptoms within a few weeks after a tick bite. Others will not develop symptoms for one year or more.
• Less than fifty percent of the children even remember being bitten by a tick and even a smaller percentage than that remember any ECM rash.
• After this "flu-like illness," the child never was well again.
• In the majority of cases the headache comes on gradually, becomes quite persistent and does not respond to over-the-counter analgesics.
• We treat patients with negative serologies without hesitation if they truly have a number of the symptoms and are incapacitated by them
• Children have been out of school for an entire year because they have been too sick to leave the house
• Children have had to give up all extracurricular activities, sports, etc. because they are too sick and too weak to participate
• Every patient we have treated with the diagnosis of Neurologic Lyme Disease has had persistent complaints.
• The diagnosis of Neurologic Lyme Disease is a clinical one, not a laboratory one.
• If the patient's symptoms are compatible with the diagnosis, the patient is ill, the disease is having a significant effect on the person's ability to function, then they deserve treatment.
• I believe it is safer to be aggressive and treat someone than to allow them to continue suffering indefinitely.
• Treatment consists of intravenous antibiotics, ceftriaxone, cefotaxime, ampicillin given for as long as is necessary, minimum of four-six weeks initially.
• Since I have seen patients do better after receiving more than one course of treatment, I am willing to retreat rather than just let them live with their symptoms. It is impossible to know for how long a person should be treated although I am beginning to feel that we were probably undertreating when we only gave fourteen or twenty-four days so I am now recommending four-six weeks and, in some cases, even a longer course than that.
• Many patients are treated for months if they continue to be clinically ill.
• About twenty-five percent of the patients we have treated have had to be re-treated and of these re-treated, the vast majority then do well.
• Her vision returned and she then relapsed again and required a much longer course of treatment
• (100)
• Following the longer course of treatment during which time she received intravenous Claforan, she gradually improved. Her visual acuity went back to 20/20.
• Patients, again, may require anywhere from four-six weeks or longer of treatment depending upon how they are responding.
• After completing a course of intravenous antibiotics, the patient should then be placed on antibiotics by mouth for as long as it is necessary.
• She was essentially asymptomatic and doing so well that she was able to do cartwheels- then relapsed again about six months later with, again, a complaint of vision loss, headache and some joint pain.
• Once the patients have these neurologic complaints and, in some cases the positive neurologic findings, they truly deserve a course of aggressive intravenous antibiotic treatment, perhaps more than one time.
• Again, at the parents' insistence, a titer was done which was positive
• Has been treated now three times, initially with ceftriaxone for two courses, fourteen days each, and then a course of cefotaxime, twenty-one days. Modest improvement- still complains of weakness and still has brisk reflexes and probably will require further treatment.
• LD may be difficult to diagnose because the symptoms may resemble other conditions.
• Infants can be infected with Borrelia transplacentally in any stage of pregnancy and/or via mother’s breast milk.
• Diagnosis of Lyme disease must be made by an experienced physician.
• Gestational Borreliosis can be associated with repeated miscarriages
• The co-infections: Babesia, Bartonella,Mycoplasma and perhaps even theEhrlichias can be transmittedtransplacentally to the developing fetus.
• Maternal antibiotic treatment during pregnancydoes not guarantee that the fetus will be free ofinfection
• Infants infected congenitally can have small windpipes (tracheomalacia)
• Teens need to be aware that Borrelia may besexually transmitted and that a fetus canacquire the infection from the mother during pregnancy
• Borrelia spirochetes have been found at autopsyin fetal brain, liver, adrenal glands, spleen, bonemarrow, heart and placenta
• Ocular Lymeborreliosis is an underdiagnosed disorder, because it is often unrecognised by ophthalmologists and due to weak seropositivity and seronegativity in the late ocular Lyme borreliosis.
• Lyme disease is a tick-transmitted infection with disabling sequelae and important occupational health implications for a military workforce (and family).. who during 2002--2003 required hospital inpatient treatment for Lyme disease.
• Children with acute peripheral facial palsy have often suffered tick bites and/or erythema migrans in the head/neck region on the same side.
• Oligoarticular juvenile idiopathic arthritis in remission- Five months later patient relapsed with arthritis in the same knee.
• 167 children that reached our unit for a tick bite; they were 92 males (mean age four years) and 75 females (mean age five years)
• 5-year-old boy showing nine erythemas with central pallor on his face, trunk, arms and legs
• One year after treatment, four patients with acute neuroborreliosis still suffered from facial palsy and five with chronic neuroborreliosis still had moderate spastic ataxic gait disturbance.
• We tested sera from 152 [Lyme] vaccine recipients by using in-house and commercial Western blot assays and found that vaccination caused interference in up to 25% of recipients and can persist for over 6 years.
• At least half of the children with PFP as a result of Lyme borreliosis show other signs or symptoms suggesting this disease.
• Lyme borreliosis has become a serious diagnostic and therapeutic problem of modern medicine.
• Diagnostic problems with Borrelia burgdorferi infection result from non-characteristic course of the disease in children, without the 1 st stage of the disease (erythema migrans), negative history forwards tick bite, lack of seasonal changes in occurrence and difficulties with interpretation of serological tests results.
• Direct laboratory investigations are also of little relevance.
• Vaccine- The low demand undoubtedly was the result of limited efficacy, need for frequent boosters, the high price of the vaccine, exclusion of children, fear of vaccine-induced musculoskeletal symptoms and litigation surrounding the vaccine.
• In 6 (21%) patients there was evidence for infection with more than 1 tick-borne agent
• The most common identified illnesses were tick-borne encephalitis and Lyme borreliosis
• Only 16% of the neuroborreliosis patients and 32% of the arthritis patients remembered having had an EM.
• Fifty-nine children (aged between 14 months to 16 years) were hospitalized or ambulatory treated due to borreliosis during 5 years between 1997 and 2001.
• Erythema migrans was observed in 50 cases; the main localisations of erythema were: face, neck and chest.
• Erythema migrans returned in two cases after therapy with Amoxicillin in one case at 6 months, in the other one 12 months later.
• Admission to hospital was the result of leucopaenia (2800/mm3), bradycardia, headache and fatigue.
• In the acute stage Elisa assay was positive in 33% only.
• Isolated intracranial hypertension- must be diagnosed early in order to avoid serious complications such as optic nerve atrophia in the absence of an appropriate treatment.
• The articular syndrome manifested itself through arthralgia (53 patients) and arthritis (104 patients), which set on quite often in the tick-attack area.
• Another major problem is the high frequency of misdiagnosis of Lyme disease.
• Refractory cases may require intravenous therapy, and occasionally surgery.
• Antibacterial prophylaxis, using doxycycline, for tick bites has been shown to be an effective approach to prevention.
• In six out of 27 children (22%), the facial nerve function was mildly or moderately impaired at 2 year follow-up.
• Among patients with fever after a tick-bite, Lyme borreliosis was most frequently found.
• Patients with positive IgM-antibodies showed more often low frequency hearing loss than IgG-positive patients.
• The younger the child, the more difficult it is to diagnose Lyme disease.
• Children under the age of 19 are at high risk for Lyme disease because of the amount of time spent in outdoor activities during the late spring and summer.
• Early recognition of concurrent Lyme disease and HGE is important because amoxicillin, an antibiotic of choice for young children with early Lyme disease, is ineffective for HGE.
• A consecutive case series of 10 children with acute arthritis consistent with septic arthritis who ultimately were diagnosed with Lyme disease.
• Seven [Lyme] patients underwent emergent joint irrigation and debridement for presumed septic arthritis- they were misdiagnosed.
• (150)
• Cerebrospinal fluid pleocytosis was detected in 25.7% of children with multiple erythema migrans.
• The appearance of "Herxheimer's reaction" at the beginning of treatment was recorded.
• Side effects of treatment were observed in 5.3% of patients treated with azithromycin and in 6% treated with phenoxymethylpenicillin.
• The CSF numbers of CD4+, CD8+, HLA-DR+ and total-T lymphocytes, B lymphocytes, and NK cells were all greater in neuroborreliosis patients than in TBE patients.
• Increased CSF pressure in the absence of an intracranial mass or obstruction to the circulation of CSF.
• Acrodermatitis chronica atrophicans affecting all four limbs and parts of the trunk- 11 year old girl.
• 25% of the patients suffered from residual neurological symptoms 5 year post-treatment.
• Erythema migrans rash may go undetected in children and in the dark skin of African Americans, leading to delayed treatment and a relatively increased incidence in LA.
• Subjective cognitive difficulty during or soon after LD, which persists despite antibiotic treatment.
• The early stages of the disease, with their paucity of symptoms or wide variability of the clinical symptomatology, often present a diagnostic challenge.
• There was no history of tick bites, skin rashes, or recent travel. She lived in an urban community in Pennsylvania.
• An initial diagnosis of a pseudotumor syndrome was entertained.
• Tick bite and infection with Borrelia burgdorferi should be considered in the differential diagnosis of necrotic arachnidism in regions endemic for Lyme disease.
• Serious neurologic complications in children from either frequent or excessive application of repellents containing DEET have been reported, but these are rare and the risk is low when these products are used according to their labeling.
• The Lyme disease vaccine does not protect all recipients from infection with B. burgdorferi and provides no protection against other tick-bome diseases.
• In some of the original reports of Lyme disease, the proportions of patients who also had nonspecific symptoms such as arthralgia, myalgia, headache, or fatigue were substantial.
• It is well documented that the sensitivity and specificity of antibody tests for Lyme disease vary substantially.
• Moreover, a recent study suggested that even at the subspecies level, certain strains, on the basis of genetic diversity of ospC genes, might cause more invasive or severe disease than other strains.
• Cognitive deficits were still found after controlling for anxiety, depression, and fatigue. Lyme disease in children may be accompanied by long-term neuropsychiatric disturbances, resulting in psychosocial and academic impairments.
• Children below the age of 9 are at a high risk for Bb infection, with many new cases of Lyme occurring among persons younger than 14 years.
• Our preliminary data using symptom-driven reports suggest that children who develop chronic LYD have psychiatric and cognitive difficulties in the area of attention and memory.
• All initially benefited from antibiotic therapy, but improvement was sustained in only 10% (2/20) after oral antibiotics and in 36% (4/11) after IV antibiotics.
• The LYD group had significantly lower scores: Full Scale IQ; Performance IQ; the Perceptual/Organization and Freedom from Distractibility indices of the WISC-III; and the General Memory, Verbal Memory, and Visual Memory indices of the WRAML.
• The LYD group had significantly lower scores on the digit span, picture completion, coding, and block design subtests of the WISC-III.
• The LYD group had significantly lower scores on the design memory, story memory, finger windows, sentence memory, and number/letter subtests of the WRAML.
• The LYD group had significantly greater difficulty maintaining set on the WCST.
• There was a strong trend for the LYD group to have greater attentional difficulties.
• There was a significantly greater frequency of definite attention problems in the LYD group than in the control subjects (9:1; P=0.007). After correction for multiple comparisons, Performance IQ, General Memory Index, Verbal Memory Index, and finger windows remained significant.
• Regarding depression, parents indicated that 41% (7/17) of children with LYD had suicidal thoughts and 11% (2/18) had made a suicide gesture.
• On the child rating (CDI), 40% (8/20) had suicidal thoughts.
• The LYD group scored far worse on measures of learning problems and hyperactivity: almost 7 SD above the control subjects' mean on the CPRS Learning Problems scale, and 5 SD above the controls' mean on the Hyperactivity Index scale.
• Our results indicated that compared with control subjects, the Lyme sample had significantly more psychopathology and more objective cognitive deficits.
• Children with chronic LYD had higher rates of anxiety, mood, and behavioral disorders than children without LYD.
• Children with LYD had significantly higher rates of psychopathology than control subjects across various domains.
• Learning and attention problems, feelings of ineffectiveness, and mood problems were significantly greater for the LYD group compared with the control group.
• Children with LYD who present with psychiatric problems may be misdiagnosed as having a primary psychiatric problem such as an affective disorder, oppositional defiant disorder, or attention deficit disorder.
• On the standardized measure of intellectual functioning (WISC-III), the deficit in Performance IQ suggests a problem in overall perceptual and organizational abilities, and the lower Freedom from Distractibility score suggests a problem with attention and concentration. Visual and auditory tracking or scanning difficulties could account for these results.
• On standardized tests of memory, deficits were noted in both visual and auditory primary processing as well as visual memory.
• Our study demonstrated that a group of children with LYD had a pattern of cognitive deficits, as defined by both objective measures of cognitive functioning and self-report measures.
• These types of deficits may be incorrectly perceived by the patients and others as memory impairments.
• Children whose diagnosis and treatment are delayed may suffer considerable impairment.
• Children with chronic neurologic LYD can have significant neuropsychiatric problems.
• Identification of children with persistent neuroborreliosis is imperative so that these children can receive the most appropriate medical, psychological, and educational assistance.
• Chronic Lyme arthritis is a model of chronic arthritis resembling forms of arthritis of unknown cause, such as rheumatoid arthritis and juvenile idiopathic arthritis.
• Patients with a history of neuroborreliosis who have incomplete resolution of symptoms should be evaluated for B henselae infection.
• Especially in the absence ofcranial nerve palsy, the possible diagnosis of Lyme borreliosis is not being considered often enough.
• A number of different diagnoses have been considered, including multiple sclerosis, Guillain– Barré syndrome, pseudotumor cerebri, and cerebral vasculitis.
• The clinical presentation may be varying, includingheadache, lethargy, irritability, and focal neurological signs.
• In the case of newly appearing arthritis, a borrelial serologyshould be obtained, especially in mono- or oligoarthritis,including the knee joint.
• The interpretation of results of serology for B. burgdorferi may be difficult and sometimes is indeterminate.
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• Headache and diplopia early in the infection due to increased intracranial pressure associated with Lyme meningitis.
• Headache and visual loss attributable to increased intracranial pressure and perhaps also to optic neuritis.
• Clinicians should be aware that neuro-ophthalmologic involvement of Lyme disease may have significant consequences.
• If increased intracranial pressure persists despite antibiotic therapy, measures must be taken quickly to reduce the pressure.
• Vaccine in Children- Solicited reactogenicity data revealed a higher incidence of local injection site reactions and general symptoms (fever, headache, fatigue, and arthralgia) in vaccine than placebo recipients.
• Lyme infection can spread haematogenously to involve the heart, nervous system or the joints. After months to years, the spirochete may persist in these organs causing a chronic form of illness.
• B. burgdorferi detected in a bioptic sample of the heart muscle which was positive on immunohistochemical examination.
• Tickborne infections are an important cause of nonspecific febrile illness.
• Our study confirm that borreliosis should be considered in every case of peripheral facial palsy.
• Younger individuals practiced fewer preventive behaviors than older individuals.
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• LD clinical symptoms differed in the age groups. Patients of group 1 had more prevalent infectious syndrome with fever but they had no radiculoneuritis and polyneuritis. Patients of group 2 more frequently suffered of carditis and secondary erythema. Groups 3 and 4 were characterized by infectious syndrome, secondary erythema and aseptic meningitis, joint lesions being more frequent in group 3, nervous system lesions--in group 4.
• Clinical manifestations might vary, depending on the part of the world, i.e. type of Borrelia involved.
• Imaging techniques ruled out space occupying lesions, whereas CSF cytology indicated CNS involvement of a non-Hodgkin lymphoma in the form of abnormal lymphocytic pleocytosis with malignancy criteria fulfilling lymphoid cells.
• Symptomatology of neuroborreliosis is rich and various.
• Any headache and psychiatric disorder in the course of Lyme disease could be an early manifestation of invasion of the CNS by the spirochaetes. Each part of neurologic system could be involved.
• Encephalopathy is due to neuroimmunomodulators, like lymphokines and by toxico-metabolic effect could be connected with each form of systemic borreliosis. Spheroplast L-form of borrelia could be responsible for difficulties with their eradication.
• Although erythema migrans is the main clinical manifestation, symptoms of stage II and III indicate that Lyme borreliosis is also responsible for relatively major systemic morbidity.
• Patients who had received intraarticular steroids prior to antibiotic treatment required significantly more courses of antibiotic treatment and the time required for disappearance of the arthritis was longer.
• Of 51 patients followed for at least 12 months after initiation of antibiotic treatment, 24% retained manifestations of the disease including arthritis (8 patients) and arthralgias (4 patients).
• Pediatric Lyme arthritis is more benign in younger children. Lyme arthritis should be excluded as a possible cause of arthritis prior to the administration of intraarticular steroids.
• Older patients [teens] were more likely to have chronic arthritis, higher levels of IgG antibodies to B. burgdorferi (by ELISA and immunoblot), and a longer interval between antibiotic treatment and the disappearance of arthritis.
• Erythema migrans was reported in 41% of patients; arthritis in 4%; musculoskeletal symptoms in 18%; and neuroborreliosis in 15%.
• Vaccination is not recommended for persons with treatment-resistant Lyme arthritis or pregnant women.
• The areas where EM appeared were lower limbs and the perineal region (60%), chest (24%), head and neck (10%) and upper limbs (6%).
• Children remain seropositive more than 1 year with or without clinical symptoms.
• 225
• 1999 or before
  • The reliability of methods for direct detection of borrelial infection other than culture to ascertain spirochetes in tissue specimens is open to question.
  • For the majority of manifestations the most effective antibiotic, the optimal dosage, and the most appropriate duration of treatment have not been exactly determined.
  • An increased frequency of symptoms (eg, pain, fatigue) or of difficulty with daily activities (eg, performing housework, exercising) was reported by 69% of the patients.
  • Many patients reported increases in symptoms and/or increased difficulties with typical daily activities between 1 and 11 years after diagnosis of Lyme disease.
  • Fifteen percent of adults and 5% of children believed they were not cured of Lyme disease.
  • Patients who met the case definition reported increased symptoms (26.4%).
  • Patients who did not meet the case definition and reported increased symptoms (34.6%).
  • Many patients who had been diagnosed as having Lyme disease reported increased symptoms or increased difficulties with typical daily activities.
  • Lyme patients reported increased joint or muscle pain and difficulties in their abilities to formulate ideas more frequently than did matched controls.
  • Delays in diagnosis and treatment can lead to adverse outcomes.
  • 235
  • Lyme disease is also an important problem in children.
  • Peripherally inserted central catheter-associated complication: 8% had an infectious complication
  • Children were more likely than adults to have manifestations other than erythema migrans alone.
  • A recombinant lipoprotein vaccine against Lyme disease, containing 30 microg of Borrelia burgdorferi outer surface protein A (OspA) with aluminum adjuvant, has been shown in a large US field trial of subjects >/=15 years of age to offer 76% efficacy against clinical Lyme disease after 3 injections given at 0, 1, and 12 months.
  • Local pain at the injection site was reported by approximately 76% of the 250 children. Headaches (after 5% to 18% of the injections) and malaise (after 2% to 16% of the injections) were the most frequently reported general symptoms.
  • 240
  • The national surveillance case definition was developed for standardized national reporting of LD and was not intended to be used in clinical diagnosis.
  • The diagnosis of LD remains a clinical diagnosis by the attending physician.
  • The most frequent late manifestation is Lymearthritis presenting as episodic arthritis whichmay become chronic.
  • The eye may be affectedin the course of neuroborreliosis involving the2nd, 3rd, 4th, 6th, and 7th cranial nerves or asocular borreliosis that may occur during theearly and late stages of Lyme borreliosis.
  • Mostpatients have CSF abnormalities with lymphocytic pleocytosisand an increased number of plasma cells, increased CSF proteinconcentrations indicating blood-CSF barrier damage, intrathecal Ig production, and increased levels of a CSF glial proteinmarker (glial fibrillary acidic protein).
  • Overall, underdiagnosis of Lyme disease may actually be more of a problem than overdiagnosis in the ED setting.
  • Lyme arthritis is caused by all 3 human pathogenetic genospecies which are actually known.
  • Uniquely hard to diagnose, including the complexity and unreliability of serologic tests.
  • Presentations of this disease that mimic attention deficit hyperactivity disorder (ADHD), depression, and multiple sclerosis.
  • Up to seven years after treatment- ongoing musculoskeletal complaints resulting in mild to moderate impairment of school or sports activities.
  • 250
  • These results indicate that the transmission rate from infected ticks in Europe is higher than previously assumed.
  • Lone Star ticks are associated with rashes that are similar, if not identical, to erythema migrans associated with borrelial infection.
  • Lone Star ticks containing Borrelia -appearing spirochetes variably reactive to H5332 were found in the counties of 16 case patients (Missouri).
  • Along with or months after erythema migrans, cranial neuropathy or Lyme arthritis, the five children developed behavioral changes, forgetfulness, declining school performance, headache or fatigue and in two cases a partial complex seizure disorder.
  • Difficulties in diagnosis of late stages of Lyme disease include low sensitivity of serological testing and late inclusion of Lyme disease in the differential diagnosis.
  • Despite normal intellectual functioning the five children had mild to moderate deficits in auditory or visual sequential processing.
  • Children may develop neurocognitive symptoms along with or after classic manifestations of Lyme disease. This may represent an infectious or postinfectious encephalopathy related to B. burgdorferi infection.
  • All patients with Lyme uveitis had manifestations of the posterior segment of the eye, such as vitritis, retinal vasculitis, neuroretinitis, chorioretinitis, or optic neuropathy.
  • Tick borne relapsing fever- A Jarisch-Herxheimer reaction was reported in 33 (54.1%) of 61 cases for which this information was available.
  • Cerebrospinal fluid white blood cell count, protein level, or both were abnormal in 27 (68%) of the children. Thirty-six (90%) of the 40 children had a CSF abnormality consistent with central nervous system infection or immune involvement by B burgdorferi. Of the 22 children with CSF pleocytosis, only 7 (32%) had headache and none had meningeal signs.
  • 260
  • Both regimens were well tolerated; only four patients (6 percent) in each group withdrew because of adverse events.
  • In northern California, the risk of infection with these emerging tickborne diseases, particularly in children, may be greater than previously recognized.
  • In children who do not have a rash and who go untreated, Lyme disease can progress to later stages and cause serious illness.
  • Inflammatory changes in CNS bloodvessels, such as diffuse or focal vasculitis or cerebrovascularinjury, may be an important factor in the development of theCNS lesions and dysfunction in LNB.
  • Lyme borreliosis may also causevascular damage in the CNS, because it is known to causevasculitis and perivascular inflammation in several otherorgans outside the CNS.
  • It is evident that the spirochaete occurs in very low numbersespecially in the CNS, since its presence in brain tissue hasbeen a rare finding (MacDonald and Miranda, 1987).
  • One recent study showed that B. burgdorferi is capable of direct activation of vascular endothelium promoting recruitment of
  • leucocytes to perivascular tissues
  • Parents reading this report may conclude that Lyme disease is easily treatable, and they may not practice prevention. They may also be told by their physicians that they are overreacting to “Lyme hysteria.”
  • A Th1-type cytokine pattern was found in the joints of patients with Lyme arthritis.
  • 270
  • Borrelia burgdorferiis able to adhere to and penetrate through the endotheliumof CNS blood vessels and then adhere to the glial cells. This invasion can already occurat early stages of the infection, even without signs ofinflammation in the CSF.
  • After invasion of the CNS, the spirochaete maycause direct damage to oligodendroglial cells, which maylead to demyelination.
  • MRI of the brain showed enlarged ventricles, cortical atrophy, and marked degenerative changes in the periventricular areas.
  • Neuropathological examinationshowed a chronic left-sided subdural haematoma. Its structurewas compatible with the haemorrhages occurring 6 and 2months before death.
  • An increased number of plasma cellswere present within the organizing connective tissue of thehaematoma. In subcortical and periventricular white matter,diffuse demyelination with mild perivascular inflammationwas seen.
  • MRI of the brain showed three smallfrontal lesions at the bottom of the left frontal lobe near themeninges.
  • During the antibiotic treatment, MRI of the brainshowed new lesions: one enhancing lesion (2 cm in diameter),suggestive of focal vasculitis, located medially from the.postoperative area, and later, enhancing lesions at the bottomof the right frontal lobe and a frontal lobe sulcus.
  • Standing on the right leg alone was difficult,and walking was slightly impaired.
  • CT of the brain showed a periventricular low density enhancing lesion, 10X6 mm2 in diameter, andlocated in left parietal lobe white matter. The lesion wassuggestive of a neoplasm.
  • Our observations support results from both experimental and clinical investigations suggesting that thenumber of B. burgdorferi spirochaetes in the CNS is verylow.
  • 280
  • In a newborn whose mother had suffered from Lyme borreliosis in early pregnancy and who died during the first dayafter birth, B. burgdorferi could be demonstrated by stainingand immunocytochemistry in the brain and liver.
  • One child with a history of severe arthritis forseveral months died during a protracted seizure which washer first neurological manifestation of the disease; histological studies of brain tissue showed general vasculitis, andB. burgdorferi was demonstrated by silver staining.
  • In the peripheralnervous system, inflammatory vascular changes or vasculitisseem to cause axonal degeneration in Lyme borreliosis.
  • Studieson experimental borrelia infections have also shownprominent lymphoplasmacellular infiltration in themicrovasculature, endarteritis obliterans, and spirochaetes inand around blood vessels of synovial and myocardial tissues.
  • Our study supports a sporadic causative role for B. burgdorferi infection in stroke-like diseases or vasculitis inagreement with previous studies.
  • B. burgdorferimay occasionally cause pronounced demyelination, possiblyvia damage to microvasculature, similar to that seen inneurosyphilis.
  • Direct damageto oligodendroglial cells may cause demyelination becauseB. burgdorferi very actively binds to them (Baig et al., 1991).This binding may partly explain the long-term persistence ofB. burgdorferi in the CNS and explain why the spirochaeteis seldom isolated from the CSF.
  • Brain lesions in Patient 2 developed in previously intact areas during or after treatment, the last one of them 16months after onset of prolonged antibiotic therapy. Severalreports have been published on the occurrence of new fociand paradoxical enlargement of CNS lesions during thetreatment of mycobacterial CNS infections.
  • DNA of B. burgdorferiin the plasma of the patient over 16 months after the onsetof first antibiotic treatment suggests the presence of ongoinginfection.
  • Our experience with this patient suggests that, inrare cases, extended or repeated antibiotic treatments may benecessary to eradicate the spirochaete from sites where it hasaquired a latent state.
  • 290
  • The CNS can be consideredan immunoprivileged site where the spirochaete can lie latentout of reach of the host immune system.
  • Average number of joints with arthritis during 1st year of illness- 2.59
  • Sensory polyneuropathy with electrophysiologic evidence of anaxonal polyneuropathy.
  • B. burgdorferi DNA was detected in CSF samples (PCR) in 6 (38%) of the 16 patients with acute neuroborreliosis andin 11 (25%) of the 44 patients with chronic neuroborreliosis.
  • In those with chronic neuroborreliosis, the median duration of disease before testing was 7.3 years among PCR-positive patients and 5 years among PCR- negative patients.
  • Patients may develop chronic neuroborreliosis years afterearly manifestations of Lyme disease.
  • B. burgdorferi DNA was detected in patients (CSF) a medianof 7.3 years and as long as 27 years after disease onset.
  • This provides the best evidence to date that the Lyme disease spirochete may persist actively or latently in the nervous system for years. This prolonged disease course, with long periods of active and latent infection, is reminiscent of tertiary neurosyphilis.
  • Multisystem disease (two or more organ systems involved)
  • Vasculitis is one ofthe mechanisms that can be an underlying cause of organdamage in LB.
  • 300
  • Besides autoimmune reactions, chronic infection is anotherpossible explanation for the persistent symptoms of LB.
  • Imported- Child had a recent contact with hamsters brought from Germany.
  • Lyme borreliosis can present as facial palsy alone.
  • Bell’s palsy is often treated with steroids, which may be deleterious in cases of infection.
  • Neurological check-up seems to be advised.
  • Many patients had had symptoms for several years.
  • This study shows that patients with late LB who have livespirochetes or borrelial DNA in their body fluids may have lowor negative levels of borrelial antibodies in their sera.
  • Musculoskeletal manifestations in three-fourths of patients- most of these manifestations were long-lived.
  • Low or even undetectable antibody levels in late LB may becaused by formation of circulating immune complexes.
  • If serological means alone are used, a considerable proportion of LB patients may not be diagnosed and treated.
  • 310
  • It might be possible that LB patients with weak or no humoral immune responses against the spirochete develop even more seriousdisease than the patients with strong antibody responses.
  • Antibodies to B. burgdorferi often arepresent in only low levels or are even absent in culture- or PCR-positive patients who have been suffering for years fromsymptoms compatible with LB.
  • 13 cases erythema migrans was misdiagnosed- pitfalls in diagnosis.
  • Late stages of borrelia Lyme disease infections may be difficult to diagnose because of unspecific symptoms and unreliable laboratory tests.
  • 27% of children with neurologic abnormalities due to LD had a history of EM or arthritis.
  • Lyme arthritis was defined as recurrent, brief attacks of visible swelling in one or a few joints, possibly followed by chronic arthritis.
  • Children more often had lymphocytoma and neuroborreliosis.
  • The most common site for a tick bite in children was the ears.
  • Altogether, 49 percent of the bites in children were located in the head and neck region, as compared with 2 percent among the adults. (Adults were most commonly bitten in the popliteal fossa area- behind the knee.)
  • We found cranial MRI far superior to cranial CT.
  • Among those with neurologic involvement, boys outnumbered girls two to one.
  • Borrelial lymphocytoma- 22 on the ear lobe and 43 on the breast.
  • Patients not meeting the surveillance case definition were significantly more likely to have influenza-like symptoms, a smaller rash, and arthralgia.
  • Bites in the head and neck region were more common among children than among adults and were associated with an increased risk of neuroborreliosis.
  • Better clinical guidelines are needed to identify the diagnostic and management decisions that benefit patient outcome.
  • Implications of this observation [Babesia phylogenetically related to Theileria] may include the possible existence of an exoerythrocytic stage of parasite development and attendant features of chronicity, immune suppression, and perhaps lymphoproliferation.
  • Physicians in Maryland are treating many patients for LD who are clinically diagnosed as having LD (e.g., febrile patients with flulike symptoms, patients with arthralgias or erythematous rashes < 5 cm in size) and who have positive serologic test results but who do not meet the CDC surveillance case definition.
  • Positive serologic results were more likely (OR: 2.2; CI: 1.2 to 4.2) in those not meeting the case definition.
  • The optimal agent, dosage and duration of therapy for borrelial lymphocytoma have not been determined.
  • One patient died because of cardiac infarction.
  • In no patient had treatment to be discontinued because of adverse reactions to antibiotics.
  • Nine individuals developed an erythema migrans, despite a previously treated Lyme borreliosis.
  • 2 of them had mixed infection with tick-borne viral encephalitis.
  • PCR testing in CSF is not suitable for routine application in the diagnosis of Lyme neuroborreliosis.
  • Pregnancy- 1 ended with a missed abortion and 5 with preterm birth; 1 of the preterm babies had heart abnormalities. One child born at term was found to have urologic abnormalities at 7 months of age.
  • Coinfected patients experienced fatigue, headache, sweats, chills, anorexia, emotional lability, nausea, conjunctivitis, and splenomegaly more frequently than those with Lyme disease alone.
  • Patients coinfected with Lyme disease experienced more symptoms and a more persistent episode of illness than did those experiencing babesial infection alone.
  • Circulating spirochetal DNA was detected more than 3 times as often in coinfected patients as in those with Lyme disease alone.
  • Within days or weeks spirochetes may spread hematogenouslyor lymphogenously from the skin to other organs, leading toearly disseminated infection with dermatologic, neurological,cardiac, arthritic, or musculoskeletal symptoms.
  • Late infectionmay evolve a year or more after initial infection, with chronic manifestations involving the skin, joints, and nervous system.
  • During gestation B. burgdorferi may spread transplacentallyto the fetus, causing adverse outcome of pregnancy, including various congenital abnormalities, premature birth, and even fetal death.
  • EM disappeared completely within a range of 2-100 days(median, 11days) following the institution of treatment.
  • For 51 of the 58 women (87.9%), the pregnancies werenormal and the infants were born at term, were found to beclinically healthy, and had normal psychomotor development.
  • Of the 5 babies (8.6%) who were born preterm (1 at 14weeks, 2 at 4 weeks, and 2 at 3 weeks preterm), 2 had complications soon after birth.
  • Three days after birth, respiratory distress syndromedeveloped in the baby.
  • At 36 weeks' gestation she gave birth to a boy weighing 2,940 g, who had respiratory distress within 1 hour and was admitted to the intensive care unit.
  • Newborn- Wet lung was noted, and on the second day pneumothorax and atelectasis developed also.
  • Newborn- At the end of the first week of life a systolic murmur was heard, and anechocardiogram showed an atrial and ventricular septum defect.The infant was able to leave the intensive care unit after 2weeks. His later development was normal.
  • Bilateral stenosis of the ureter with hydronephrosis was found at 7 months of age.
  • A normal-appearingboy was born at term, but 7 months later he was found to have urologic abnormalities.
  • When spirochetemia occurs during pregnancy, the placenta may be involved andthe fetus infected.
  • Transplacental transmission of B. burgdorferi has been well documented and may result in variousforms of fetal involvement.
  • Among the infants of untreated women who had symptoms and/or signs of Lyme borreliosis during pregnancy, researchers have noted cardiovascular malformations, prematurity, stillbirth, and neonatal rash.
  • In cases in which patients were treated for EM acquired during pregnancy, intrauterine fetal death, neonatal death, syndactyly, hydrocephaluswith spina bifida, and cortical blindness have been reported.
  • Recently, cheilognathopalatoschisis, cavernoushemangioma, and dysplasia coxae have also been associated with borrelial infection during pregnancy.
  • In some cases spirochetes were culturedfrom multiple organs of infants on autopsy and/or fromplacenta, with no evidence of inflammation in the affected tissues.
  • Recommendations for "proper"treatment are merely arbitrary and the efficacy of therapy isdifficult to assess.
  • Which antibiotic is the most efficacious has not yet been established, and failureshave been reported with all antibiotic regimens used.
  • The causative agent of Lyme borreliosis may alsopersist for a long time in the skin or other tissues of untreatedand even antibiotically treated patients, with the potential for dissemination.
  • These data suggest that the usual treatment of EM with oralantibiotics may not be adequate for some patients.
  • It seems important to treat at least some groups of patients with EM as effectively as possible: particular attention and concern must be devoted to pregnant women.
  • The optimal mode of treatmentduring pregnancy has not yet been established, and recommendations have evolved over time.
  • In patients with LA the test may turn positive after antibiotic therapy. The test does not aid in prognosis or follow up.
  • Many physicians in Canada were not sufficiently interested in Lyme disease to come to a conference.
  • The correction of the erroneous conclusion by the British Columbia Centre for Disease Control that there was no Lyme disease in British Columbia and the establishment of British Columbia as an endemic area for Lyme disease, came about only two years ago through the persistence of patients, rather than as a result of any actions taken by physicians.
  • Immunoblot, fluorescence EIA, and P39 EIA lack the sensitivity to reliably diagnose EM.
  • Although the disease evidently was a late manifestation of Lyme borreliosis, antibodies to B. burgdorferi were low in titer and were restricted to the IgM class.
  • The distribution of osteomyelitic lesions in multiple bones and the positive PCR results obtained with serum argue for hematogenous spread of the spirochetes.
  • Infection due to B. burgdorferi must be considered a possible cause of subacute pediatric osteomyelitis.
  • Indeed, there is a seronegative NB (neuroborreliosis) also in children.
  • A positive serum antibody titer cannot confirm, and a negative one cannot exclude a recent NB (neuroborreliosis).
  • In view of the difficulties in interpreting serological results the early diagnosis of Lyme borreliosis sometimes may be problematic.
  • Both acute and chronic borreliosis can be seropositive or seronegative.
  • Affection of locomotor system manifested with acute arthritis episodes or pains in major joints.
  • The disease duration and severity were often substantial.
  • Peripheral neuropathies occurred most frequently (80%).
  • High titers of the specific antibodies- rare finding.
  • Informative value of II and ELA in Lyme's disease diagnosis is equal because ELA is more sensitive, while II is more specific. They are both of little help in atypical borreliosis presentation.
  • If pseudotumor cerebri is the only symptom, it is recommended that testing for Lyme borreliosis should be carried out.
  • Seven year-old girl with six weeks of headache, vomiting nausea and fatigue as the only symptoms was shown to suffer from pseudotumor cerebri with papilloedema and increased intracranial pressure caused Borrelia burgdorferi.
  • In addition to urine, breast milk from two lactating women with erythema migrans was tested and also found reactive.
  • With the exception of an allergic reaction in one patient treated with ceftriaxone, no significant adverse effects of therapy were noticed.
  • One or a few brief episodes of joint swelling or pain in one large joint at a time.
  • Arthritis or arthralgia were a common feature of the illness.
  • Serologic tests may be found negative in the early stages of disease.
  • Among 62 children and adolescents with Lyme arthritis, only 1 had a preceding erythema migrans.
  • Arthritis was episodic in 62% and was chronic at onset in 18%.
  • The clinical presentation of Lyme arthritis in children is different from that in adults.
  • Neurological involvement was also described with the skin signs.
  • "Lyme disease" is a rheumatological disorder commonly associated with erythema chronicum migrans and sometimes with multiple organ involvement.
  • Clinical picture and serology were compatible with both arthritis reactive to infection with Yersinia or Salmonella and with Lyme arthritis.
  • Regional lymphadenopathy may serve a clinical marker of early Lime borreliosis.
  • The specificity of serological tests for Lyme borreliosis is impaired by several phenomena including cross-reacting antibodies.
  • There is considerable debate regarding treatment of the many patients with chronic complaints not meeting the CDC's case definition, particularly those with fibromyalgia and positive tests for Lyme.
  • Most commercially available tests are unreliable for diagnosing Lyme disease.
  • Tests have poor specificity in those suspected of having chronic infections.
  • The third generation cephalosporin, cefatriaxone, is a very potent, broad spectrum antibiotic indicated in meningitis, osteomyelitis, pyelonephritis, Lymedisease and many other severe infectious diseases. Up to 46% of those receiving this antibiotic develop gallbladder sludge.
  • Most patients with gallbladder sludge are asymptomatic, but a small proportion may develop right upper quadrant pain, nausea, vomiting and even cholecystitis.
  • Gallbladder sludge- Ultrasonography may demonstrate many, small, echogenic particles within the gallbladder, as well as larger echogenic foci casting acoustic shadows. However, it can not differentiate these pseudostones from real stones.
  • There are reports of surgical intervention in children treated with ceftriaxone for meningitis after gallbladder sludge was identified by ultrasonography.
  • Follow-up ultrasonography after the drug ceftriaxone was stopped showed no evidence of pseudostones in either case. Awareness of this phenomena might save many unnecessary operations.
  • IgG immunoblotting of selected high titered sera to either borrelia species confirmed the lack of specificity of the IFA assay.
    • Serological tests for borreliosis should be cautiously interpreted in children with chronic arthritis.
    • Clinical history turned out to be a more powerful diagnostic tool than Lyme serology.
    • Frequently manifests itself with joint involvement without characteristic dermatologic signs or history of tick bite.
    • Serologic testing remains unreliable.
    • Multiple focal areas of increased signal intensity in white matter on long TR images.
    • ELISA and immunoblot were not helpful for identifying these nine patients [with persistent or recurrent symptoms].
    • In this study, infectious diseases including recently described diseases--such as AIDS (three cases) and Lyme disease (one case)--caused FUO in 28 patients.
    • Newborn- Umbilical blood for serological examination was collected: elevated IgG antibody levels against Borrelia burgdorferi was detected.
    • Electromyographic and clinical findings in the regions of the tick suction correlated.
    • Multiple lesions of the nervous system may be considered as meningoencephalomyeloradiculoneuropathy as well as subclinical multiple mononeuropathy.
    • Nearly half of the patients with Erythema migrans did not known that they had a tick bite (42.5%).
    • In 87% of patients skin lesions lasted less than three weeks.
    • Seropositivity to Borrelia burgdorferi has been found in 10.2% of patients, mostly three weeks after the tick bite.
    • Seropositivity found in sera of 11% of patients tested.
    • Some cases of lyme disease remain unrecognized as the result of poor knowledge about the disease.
    • Acute Lyme arthritis may mimic acute pyogenic arthritis.
    • EM may be subtle, atypical, or gounnoticed.
    • The disease maybe rapidly progressive or evolve more slowly as a chronicprocess.
    • B. burgdorferi is a cultivable spirochete,but it is difficult to isolate with any degree of regularityfrom blood, joint fluid, and cerebrospinal fluid.
    • Cases [of Lyme disease] were identified in a military community in West Germany.
    • Subclinical hepatitis is a common finding in early Lyme disease.
    • Twenty patients (27%) had liver function abnormalities [prior to Lyme treatment]. Elevation of gamma-glutamyltransferase was the most common finding.
    • Only seven [Lyme] patients (9%) had a positive titer in response to the enzyme-linked immunosorbent assay for Lyme disease.
    • A negative result (PCR) does not rule out neuroborreliosis.
    • PCR is an adjunct, but no substitute for clinical judgement and serology.
    • Healing was less favorable in the Borrelia group despite an equal rate of palsy at onset and adequate antibiotic treatment.
    • Corticosteroid treatment used in 44% of the patients did not significantly improve the functional outcome.
    • BB (Lyme) is responsible for cases of JCA (juvenile chronic arthritis) in which no symptomatic infection preceded.
    • Lyme neuroborreliosis proved a main cause of acute peripheral facial palsy and aseptic meningitis in children.
    • Complete atrioventricular block in a nine year old girl in whom Borrelia burgdorferi was confirmed by serological testing; no other symptoms or cutaneous manifestations of the disease.
    • Neurological, articular and muscular symptoms and signs dominate.
    • Pregnancy- Tick bites within 3 years preceding conception were significantly associated with congenital malformations.
    • Pregnancy- Preventive measures are being taken by obstetricians and patients.
    • Importance of early diagnosis and therapy in order to prevent severe complications.
    • The ocular manifestations begin as conjunctivitis, and then as uveitis, choroidoretinitis, keratitis and vitritis.
    • Prolonged systemic corticosteroids may predispose the patient to antibiotic failure.
    • Newborns- One child was operated at the age of one year on account of a patent ductus arteriosus, another child was treated at the age of two years on account of cryptorchism, two children were treated on account of hypoplastic enamel, in one infant at the age of 10 months the psychomotor development was retarded by two months.
    • Approximately every fifth local tick (Ixodes ricinus) is infected.
    • Misdiagnosis- The diagnosis of Guillain-Barré syndrome was confirmed by electrophysiological studies. High antibody titres against Borrelia burgdorferi in the serum and specific antibodies in the CSF were demonstrable by ELISA and immunoblotting. B. burgdorferi specific DNA fragments were demonstrated in urine and CSF by means of a nested polymerase chain reaction (PCR), thus providing the borrelial aetiology and indicating B. burgdorferi infection.
    • Misdiagnosis of Guillain- Barré Syndrome- Complete recovery was observed after treatment with high dose immunoglobulin and ceftriaxone and control urine specimens were PCR negative.
    • Child suffered from rapidly evolving motor weakness with paresthesia and radicular pain in both legs, accompanied by an isolated elevation of protein levels in CSF.
    • Immunoblot, fluorescence EIA, and P39 EIA lack the sensitivity to reliably diagnose EM.
    • Although the disease evidently was a late manifestation of Lyme borreliosis, antibodies to B. burgdorferi were low in titer and were restricted to the IgM class.
    • The distribution of osteomyelitic lesions in multiple bones and the positive PCR results obtained with serum argue for hematogenous spread of the spirochetes.
    • Infection due to B. burgdorferi must be considered a possible cause of subacute pediatric osteomyelitis.
    • Indeed, there is a seronegative NB (neuroborreliosis) also in children.
    • A positive serum antibody titer cannot confirm, and a negative one cannot exclude a recent NB (neuroborreliosis).
    • In view of the difficulties in interpreting serological results the early diagnosis of Lyme borreliosis sometimes may be problematic.
    • Both acute and chronic borreliosis can be seropositive or seronegative.
    • Affection of locomotor system manifested with acute arthritis episodes or pains in major joints.
    • The disease duration and severity were often substantial.
    • Peripheral neuropathies occurred most frequently (80%).
    • High titers of the specific antibodies- rare finding.
    • Informative value of II and ELA in Lyme's disease diagnosis is equal because ELA is more sensitive, while II is more specific. They are both of little help in atypical borreliosis presentation.
    • If pseudotumor cerebri is the only symptom, it is recommended that testing for Lyme borreliosis should be carried out.
    • Seven year-old girl with six weeks of headache, vomiting nausea and fatigue as the only symptoms was shown to suffer from pseudotumor cerebri with papilloedema and increased intracranial pressure caused Borrelia burgdorferi.
    • In addition to urine, breast milk from two lactating women with erythema migrans was tested and also found reactive.
    • With the exception of an allergic reaction in one patient treated with ceftriaxone, no significant adverse effects of therapy were noticed.
    • One or a few brief episodes of joint swelling or pain in one large joint at a time.
    • Arthritis or arthralgia were a common feature of the illness.
    • Serologic tests may be found negative in the early stages of disease.
    • Among 62 children and adolescents with Lyme arthritis, only 1 had a preceding erythema migrans.
    • Arthritis was episodic in 62% and was chronic at onset in 18%.
    • The clinical presentation of Lyme arthritis in children is different from that in adults.
    • Neurological involvement was also described with the skin signs.
    • "Lyme disease" is a rheumatological disorder commonly associated with erythema chronicum migrans and sometimes with multiple organ involvement.
    • Clinical picture and serology were compatible with both arthritis reactive to infection with Yersinia or Salmonella and with Lyme arthritis.
    • Regional lymphadenopathy may serve a clinical marker of early Lime borreliosis.
    • The specificity of serological tests for Lyme borreliosis is impaired by several phenomena including cross-reacting antibodies.
    • There is considerable debate regarding treatment of the many patients with chronic complaints not meeting the CDC's case definition, particularly those with fibromyalgia and positive tests for Lyme.
    • Most commercially available tests are unreliable for diagnosing Lyme disease.
    • Tests have poor specificity in those suspected of having chronic infections.
    • The third generation cephalosporin, cefatriaxone, is a very potent, broad spectrum antibiotic indicated in meningitis, osteomyelitis, pyelonephritis, Lymedisease and many other severe infectious diseases. Up to 46% of those receiving this antibiotic develop gallbladder sludge.
    • Most patients with gallbladder sludge are asymptomatic, but a small proportion may develop right upper quadrant pain, nausea, vomiting and even cholecystitis.
    • Gallbladder sludge- Ultrasonography may demonstrate many, small, echogenic particles within the gallbladder, as well as larger echogenic foci casting acoustic shadows. However, it can not differentiate these pseudostones from real stones.
    • There are reports of surgical intervention in children treated with ceftriaxone for meningitis after gallbladder sludge was identified by ultrasonography.
    • Follow-up ultrasonography after the drug ceftriaxone was stopped showed no evidence of pseudostones in either case. Awareness of this phenomena might save many unnecessary operations.
    • Lyme arthritis in children may mimic other pediatric arthritides.
    • A history of relapse with major organ involvement had occurred in 28%.
    • At followup, 82 (38%) patients were asymptomatic and clinically active Lyme disease was found in 19 (9%).
    • Persistent symptoms of arthralgia, arthritis, cardiac or neurologic involvement with or without fatigue were present in 114 (53%) patients.
    • Persistent symptoms correlated with a history of major organ involvement or relapse but not the continued presence of anti-Borrelial antibodies.
    • Thirty-five of the 114 (31%) patients with persistent symptoms had predominantly arthralgia and fatigue.
    • Neurological involvement in 29% of patients, objective cardiac problems in 6%, arthralgia in 78% and arthritis in 41%.
    • Penicillin or ceftriaxone was used to treat the patients, and the effective rates were 64% and 88%, respectively.
    • We wish to emphasize the frequency of alterations of the liver function in this group of people.
    • Borrelia burgdorferi is difficult to detect in synovial fluid.
    • Joint Fluid Samples- Of 73 patients with Lyme arthritis that was untreated or treated with only short courses of oral antibiotics, 70 (96 percent) had positive PCR results.
    • PCR testing can detect B. burgdorferi DNA in synovial fluid.. and may be able to show whether Lyme arthritis that persists after antibiotic treatment is due to persistence of the spirochete.
    • B. burgdorferi DNA was detected in the initial sample (joint fluid) from 75 of 88 patients with Lyme arthritis.
    • The detection of OspA DNA in joint fluid indicates the presence of viable spirochetes.
    • Of the patients with persistent effusions after one month of oral antibiotics or two weeks of intravenous antibiotics, approximately one third still had positive PCR results, suggesting that the spirochete may not have been eradicated.
    • None of the patients with positive PCR results after treatment had received more than two months of oral antibiotics or three weeks of intravenous antibiotics.
    • The antibody response in Bb infection develops slowly.
    • Two clinicoimmunological LD variants were verified: seropositive and seronegative mite-borne Borrelia infection with typical clinical manifestations.
    • Patients with LNB can be antibody negative in blood up to 6-8 weeks after onset of neurological symptoms.
    • The titers in the older age group (over 30) were slightly higher than those of the younger age group (under 30).
    • Arthralgia was the single most common complaint.
    • Lyme serology should be interpreted with caution and within the clinical context.
  • The second and third stages may occur without the clinicalmanifestations of the earlier stage.
  • Cross-reactivity occurs with tick-borne relapsing fever,louse-borne relapsingfever, syphilis, yaws, and Rocky Mountain spotted fever.
  • Arthralgia frequently occurs in early Lyme disease when the serology is often negative.
  • Because as many asthree serum samples were submitted for some patients,persons were considered to havea positive serologic test result if any sample was positive.
  • Children aged five to 14 years had the highest incidence.
  • Persons less than 20 years old were almost twice as likely to have arthritis than older persons.
  • Of persons with arthritis, 92 percent of those less than 20 years of age, compared to 68 percent of older persons, did not have antecedent erythema migrans.
  • Of those with Lyme disease, children may be more likely than adults to develop arthritis and have it as their first major disease manifestation.
  • Lyme disease is a multisystem infectious, inflammatory, and immune-related disorder.
  • Subsequent manifestations are protean. This is particularly true concerning the nervous system.
  • Nervous system manifestations of Lyme disease can occur from weeks to many years following the primary infection and can be quite devastating.
  • Subsequent neurologic manifestations are not unlike those seen with many other diseases.
  • When the nervous system has been affected by Lyme disease, aggressive antibiotic treatment is usually necessary, often using IV preparations.
  • Some patients will continue to have persistent, probably irreversible, nervous system abnormalities.
  • None had selective concentration of specific antibody in the cerebrospinal fluid.
  • All six patients were treated with high-dose intravenous penicillin; four had complete recoveries and two did not.
  • Lyme disease may affect the central nervous system causing organic brain disease or syndromes suggestive of demyelination.
  • A brain biopsy specimen showed microgliosis without an inflammatory infiltrate and spirochetes morphologically compatible with Borrelia burgdorferi.
  • Cases of Lyme keratitis characterized by multiple focal, nebular opacities at varying levels of the stroma which may progress to edema, neovascularization, and scarring.
  • Late stage Lyme borreliosis can occur in children without a history of tick bite or ECM.
  • The arthritis syndrome can mimic oligoarticular juvenile rheumatoid arthritis.
  • The diagnosis of Lyme borreliosis depends upon clinical recognition.
  • The incidence of Lyme borreliosis was 3% in this study in a non endemic area.
  • 14% remembered having been bitten by a deer tick.
  • Western blot was more sensitive than ELISA.
  • This progredient [progressive] infectious disease is to be treated by intravenous penicillin therapy in order to avoid future complications.
  • By performance of the orbicularis oculi reflex in all four cases peripheral damage of the facial nerve could be demonstrated. This simple electromyographic method seems to be a valuable tool in the differentiation of central and peripheral facial nerve palsy in childhood, preserving the affected children from painful electrodiagnostic procedure or useless search for supranuclear lesions.
  • Antibiotic therapy may abrogate the antibody response to the infection.
  • B. burgdorferi may persist as shown by positive culture in MKP-medium.
  • Patients may have subclinical or clinical disease without diagnostic antibody titers to B. burgdorferi.
  • The early stage of the disease as well as chronic Lyme disease with persistence of B. burgdorferi after antibiotic therapy cannot be excluded when the serum is negative for antibodies against B. burgdorferi.
  • Pediatricians should become familiar with the different clinical syndromes caused by the Borrelia burgdorferi.
  • Appropriate antibiotic therapy must be initiated and follow-up of these children should be a part of the management as some may develop (tertiary) chronic borreliosis.
  • Lyme disease should be considered in the diagnostic work-up of heart block, childhood arthritis and in undiagnosed peripheral and central nervous system disease.
  • A syndrome resembling pars planitis with atypical features such as granulomatous keratic precipitates and posterior synechiae should prompt a search for Lyme borreliosis.
  • Lyme disease diagnosis is usually made on clinical grounds alone because serologic tests are often negative.
  • Tick bites were recalled by less than half (49%) of the children or parents.
  • The CSF abnormalities quickly improved but improvement of the neurologic symptoms was gradual and to date still incomplete.
  • Isolation of spirochetes from cerebrospinal fluid is not suitable as a routine method [for diagnosis] but might prove successful in clinically selected cases of Lymeborreliosis.
  • Erythema migrans (Afzelius), Meningopolyneuritis [Garin-Bujadoux, Bannwarth (MPN)] are now generally subsumed under the name Lyme borreliosis.
  • MR examinations were abnormal in 43%. Areas of abnormal signal were identified within the cerebral white matter as well as within the brainstem.
  • The real prevalence of arthritis in LD is complicated by the possible existence of seronegative LD and by the effect of early antibiotic treatment.
  • Lyme carditis may be the only manifestation of the disease. Temporary cardiac pacing may be necessary.
  • Younger age groups, particularly children less than ten years old, appear to be at increased risk.
  • Early recognition by physician and patient is necessary for prompt treatment to reduce complications.
  • PNS [peripheral nervous system] abnormalities occur in one-third of our patients with late Lyme borreliosis.
  • The pattern of electrophysiological abnormalities is indicative of widespread axonal damage.
  • The seropositivity rate ranged from 15 to 20% with 88 to 93% agreement among laboratories.
  • Borrelia burgdorferi, the etiologic agent of Lyme disease, is a spirochete that, not unlike the treponema of syphilis, can cause a spectrum of disease from the initial skin lesion, through widely varied symptoms and signs, to chronic neurologic and arthritic disability.
  • Lyme disease presenting as hepatitis and jaundice in a child.
  • Literature review suggests that this disorder is ubiquitous in its manifestations.
  • The diagnosis should be remembered in unexplained neurologic disorders, particularly in cranial and peripheral neuropathies.
  • Lyme borreliosis is a multisystem disorder common in childhood.
  • Diagnosis is established mainly by history and clinical manifestations.
  • The optimal drug has not yet been found.
  • 342 (64.6%) patients reported contact with a tick, another 108 patients reported contact with other arthropods.
  • Among the affected systems the skin and nervous system predominated.
  • Lyme borreliosis is currently suspected to be capable of mimicking nearly all known neurologic symptomsand disease entities.
  • Only 1 of the 35 patients presented an elevated titre of IgG and IgM in the cerebrospinal fluid as well as elevated IgG and IgM titres in the serum.
  • There were difficulties in relating serological results to clinical features and management of some patients.
  • Episodes of arthritis often become longer during the second or third years of illness, lasting months rather than weeks, and in about 10% of patients, chronic arthritis begins during this period.
  • In adults, Lyme arthritis is most like Reiter's syndrome or reactive arthritis, and in children, it is most similar to the pauciarticular form of juvenile rheumatoid arthritis.
  • Borrelia burgdorferi was isolated from the cerebrospinal fluid (CSF) 7.5 months after ceftriaxone therapy.
  • A prolongation of therapy may be necessary.
  • The skin diseases Erythema (chronicum) migrans (ECM, EM), Lymphadenosis benigna cutis (LABC), and Acrodermatitis chronica atrophicans (ACA) have long been described in northern Europe, and successfully treated with penicillin for about 40 years without the causative agent being known.
  • Certain neurologic symptoms could be linked to tickbites during the 1920's and later also to EM.
  • It has proven to be a great imitator disease, mainly through its involvement of the neurological system, and to be far more widespread than previously thought.
  • The full course of the disease is not yet known.
  • Manifestations involve mainly the skin, the joints, the nervous system (Neuroborreliosis), and the heart.
  • Lyme disease can be classified using the terminology of syphilis.
  • Antibacterial therapy in early, primary cases caused Jarisch-Herxheimer reaction 7% of the time.
  • Despite longer and more frequent parenteral therapy, late Lyme disease frequently required retreatment, owing to poor clinical response.
  • Acute transverse myelopathy following adenovirus and Borrelia Burgdorferi infections.
  • The cerebrospinal fluid examination showed a highly increased myelin basic protein concentration, indicating demyelination.
  • Neither can seronegativity exclude nor can seropositivity confirm the diagnosis of neuroborreliosis (CFS fluid) as in only 71% of group I serum B. burgdorferi antibodies were detected.
  • Serious neurological and arthritic complications.
  • Some manifestations are the result of persistent infection, whereas other symptoms are a consequence of immunologic changes secondary to the infection.
  • Isolation of Bb (Lyme) from specimens is notoriously slow and difficult.
  • Borrelia infection during pregnancy can cause infection of the fetus.
  • Two infants of mothers infected during the first trimester died in the first week of life; autopsy confirmed spirochetes in a variety of tissues.
  • Serology tests are not standardized and results vary depending on the laboratory.
  • Jarisch-Herxheimer with chills, malaise, fever, pain or anaphylaxis may be seen when therapy is started.
  • If symptoms persist continued therapy is necessary until they have resolved.
  • Relapses can occur, requiring re-treatment with the same or other antibiotics.
  • Without evidence of erythema chronicum migrans, diagnostic confirmation of Lyme disease may be difficult, particularly if there are conflicting laboratory results.
  • Mild functional limitation at long-term followup after arthroscopic synovectomy for refractory chronic Lyme arthritis.
  • Duration of arthritis was generally longer in older children.
  • More than 10 years after the onset of disease, a subtle encephalopathy developed.
  • Persistent or recurrent synovitis after arthroscopic synovectomy for refractory chronic Lyme arthritis.
  • The T-cell proliferative assay may be a helpful diagnostic test in the small subset of patients with late Lyme disease who have negative or indeterminant antibody responses by ELISA.
  • In spite of significant advances in immunologically based testing, accurate diagnosis of Lymeborreliosis remains problematic.
  • Treatment failure rates of 50% have been reported.
  • Jarisch-Herxheimer reactions are encountered in 14% of early cases and are more common in severe disease.
  • Lyme disease is a serious disorder with potential immediate and long term morbidity and mortality.
  • The use of corticosteroids increases the risk of antibiotic failure and are best avoided.
  • Recovery from meningitis can have remaining radicular signs for two years.
  • Symptoms after treatment such as fatigue, headache and arthralgia developed and persisted.
  • Some patients develop major late complications.
  • Borreliae have been isolated from one stillbirth and one newborn infant.
  • Encephalitis indistinguishable from herpes simplex encephalitis may occur.
  • ACA Lyme resembles scleroderma.
  • The differentiation from Guillain-Barre syndrome may be difficult.
  • Lymphocyte infiltrates at the base of the brain in Lyme borreliosis have been misdiagnosed as B-cell lymphomas.
  • Central nervous involvement is common.
  • Features of late Lyme disease may develop without any history of early disease.
  • About 3 years after antibiotic therapy none of the children [4] had arthritis, but one suffered from fibromyalgia.
  • The clinical presentation could not distinguish these 4 children from 4 other children with monarthritis of the knee of unknown origin.
  • The incidence of electrocardiographic abnormalities in the definite group [children] was 29% (4/14), including two patients with 1 degree atrioventricular block, one with left axis deviation, and one with ventricular ectopy.
  • Thirty percent (3/10) of the probable group [children] had abnormal ECGs, including one with ST-T wave abnormalities, one with prominent sinus arrhythmia, sinus bradycardia, and wandering atrial pacemaker, and one with ectopic atrial bradycardia.
  • When the diagnosis of LD is highly suspected, an electrocardiogram may be a useful screening test for cardiac involvement.
  • It may be very difficult to diagnose a disease as L.D. because of its various clinical symptoms expressions. This is why it is often called "the great imitator".
  • Diagnostic problems come from the fact that early phases are often lacking.
  • The disease may begin with any symptom of any stage.
  • Borrelia infection is capable of imitating rheumatic diseases.
  • In view of the wide clinical spectrum and the difficulties in interpreting serological results the early diagnosis of Lyme borreliosis is still problematic at present.
  • In case of late diagnosis therapeutic failure and/or partial recovery may result.
  • Early diagnosis of neuroborreliosis can only be ameliorated when a careful synopsis of all specific and nonspecific laboratory parameters available is done.
  • Chronic stages of the disease, lasting longer than one year.
  • Disabling sequelae were reported in nine patients, mainly those with previous CNS involvement.
  • We conclude that neuroborreliosis is a common and characteristic neurological disorder.
  • Six percent of the patients [children] suffered a chronic course with a disease duration between 6 mths and 6 yrs either as chronic lymphocytic meningitis (1.6%) or as third stage chronic encephalomyelitis (4.3%).
  • Lyme neuroborreliosis is one of the chronic manifestations of Lyme disease.
  • Two of the three stages of Lyme disease potentially involve the central nervous system: a second stage that may manifest as meningitis, cranial neuritis, or radiculoneuritis; and a third stage, or chronic neuroborreliosis, with parenchymal involvement.
  • The tertiary stage may mimic many conditions, including multiple sclerosis, polyneuropathy, viral encephalitis, brain tumor, vasculitis, encephalopathy, psychiatric illness, and myelopathy.
  • Unilateral nonpalpable enlarged lymph nodes in the caudal portion of the parotid gland around the stylomastoid foramen.
  • Ninety-four percent of the patients had early (second stage) neuroborreliosis. The most common manifestation was a painful lymphocytic meningoradiculitis (Bannwarth's syndrome) either with paresis (61%) or as a radicular pain syndrome only (25%).
  • Borrelial lymphocytoma located on the ear lobe.
  • 10-year-old child with signs, symptoms, and radiological manifestations of intracranial mass lesions, without previously recognized manifestations of Lyme disease.
  • Erythema migrans preceded or accompanied borrelial lymphocytoma in eight cases.
  • In 15 cases, eight female and seven male, borrelial lymphocytoma was localized on the mamilla.
  • Borrelial lymphocytoma was localized on the nose, scrotum, upper arm and shoulder.
  • HLA antigens as risk factors for B. burgdorferi infections to become manifest or chronic.
  • Involvement of the nervous system.
  • Although babesiosis had not been diagnosed in any of the Babesia-seropositive subjects, 25% of the children and 20% of the adults reported symptomscompatible with this infection during the previous year.
  • Of the 6 children and 45 adults seropositive for B burgdorferi, 17% and 14%, respectively, were also seropositive for B microti.
  • It is concluded that children are infected with B microti no less frequently than are adults and that this infection is underdiagnosed in all age groups.
  • Physicians who practice where Lyme disease is endemic should become familiar with the clinical presentation and diagnosis of babesiosis, both in adults and children.
  • Arthritis (defined in terms of heat, redness and effusion) was noted in 34.3% of the seropositive patients, but in only 9.3% of seronegative patients.
  • Complaints of arthralgia were noted in 23.4% of seropositive patients and 13.3% of seronegative patients.

• Medication side effects
• Ceftriaxone-induced autoimmune hemolytic anemia
• Ceftriaxone- Sonographical evidence for ceftriaxone induced cholelithiasis after a treatment of at least 10 days
• Doxycycline was associated with more photo-sensitivity reactions and cefuroxime axetil with more diarrhea and Jarisch-Herxheimer reactions.