Symptoms & Signs

Part 4

• Because of the limitations of laboratory testing for Lyme disease, diagnosis is based primarily on clinical findings.
• Myopericarditis
• ... pre-neurologic symptoms (stage one) consisting of erythema chronicummigrans (ECM), fever, arthralgias, myalgias, malaise, and fatigue.
• ...[headaches] usually frontal or occipital, and itcharacteristically fluctuated in intensity over a period of weeks.
• ...signs often present inpurulent meningitis were absent.
• It should be stressed that meningitis may be the first manifestation of Lyme disease.
• ... mild encephalitic symptoms - lethargy, difficulty in concentrating, fatigue, emotional lability, irritability, and poor memory.
• Symptoms also varied from day to day but did not necessarilycorrelate with the severity of headache and stiff neck.
• Although a few patients madeoccasional mistakes in their mental status testing,none had a definite organic brainsyndrome, obtundation,or coma.
• Neither the CT scan nor the EEG was helpful insupporting the diagnosis of encephalitis.
• ... patients with encephalitic symptoms had abnormalelectroencephalograms, which showed mild generalized slowing or some sharp activity.
• LP consistently revealed a lymphocytic pleocytosis with normal opening pressure.
• Median CSF white count was 166 with a range of 5-700.
• Median protein was 79 with a range of 8-400.
• CSF glucose was usually normal.
• Intermittent diplopia without clinicaly evident extra ocular movement palsy.
• Intense pain or pressure within the distribution of dermatomes.
• Radiculoneuritis involved more than one extremity.
• Mononeuritis multiplex- different sites became affected days to weeks apart.
• Peripheral nerve lesions may occur at the root,plexus, or distal nerve.
• Denervation changes in the infraspinatus muscle.
• Neurological involvement may be confused with a number of other disorders.
• Most common misdiagnosis is viral meningitis which rarelyruns the protracted and relapsing course of Lyme meningitis.
• In Lyme radiculoneuritis,the Guillain-Barre syndrome has been considered.
• Three major types of lesions comprise the neurological manifestations of Lymedisease: meningitis, cranial neuropathy, and radiculoneuritis [1]. These three mayoccur alone or in combination.
• We believe that this constellation of symptoms is unique among neurological diseases. (Yale)
• Half of the patients also had facial palsies, which were unilateral in 12 and bilateral in seven.
• In addition, 12 patients had motor and/or sensory radiculoneuropathies; asymmetric weakness of extremities was the most common finding.
• Although incomplete presentations of neurologic involvement of Lyme disease may be confused with other entities, the typical constellation of neurologic symptoms represents a unique clinical picture.
• Other relapsing-remittingdiseases like multiple sclerosis sometimes appear in the differential diagnosis.
• Headache and mild neck stiffness, which fluctuated in intensity, and lymphocytic pleocytosis were the common findings.
• Other relapsing-remittingdiseases like multiple sclerosis sometimes appear in the differential diagnosis.
• Lyme disease- nerve involvement is rarely ascending or symmetrical.
• In Lyme radiculoneuritis,the Guillain-Barre syndrome has been considered.
• Lyme disease- nerve involvement is rarely ascending or symmetrical.
• Meningitis, frequently accompanied by cranial and/orperipheral radiculoneuritis
• With all three antibiotic agents, nearly half of patients had minor late symptoms.
• Seven of the 20 penicillin-treated patients (35%) were apparently cured.
• Of 20 arthritis patients treated with intravenous penicillin G, 11 (55%) were apparently cured.
• All 3 stages of Lyme disease can be treated with antibiotic therapy, but some patients with late disease may not respond.
• Infectious-toxic nature of the condition.
• 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
• Lyme keratitis characterized by multiple focal, nebular opacities at varying levels of the stroma which may progress to edema, neovascularization, and scarring.
• 10
• Brain biopsy specimen showed microgliosis without an inflammatory infiltrate and spirochetes morphologically compatible with Borrelia burgdorferi.
• All six patients had elevated antibody titers to B burgdorferi in serum, but 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.
• Lyme disease is a multisystem infectious, inflammatory, and immune-related disorder.
• Neurological symptoms can occur from weeks to many years following the primary infection and can be quite devastating.
• The majority of patients will not recall a tick bite or characteristic rash.
• When the nervous system has been affected by Lyme disease, aggressive antibiotic treatment is usually necessary, often using IV preparations.
• Usually, there will be significant improvement following the use of antibiotics, but there are some patients who will continue to have persistent, probably irreversible, nervous system abnormalities.
• Children aged five to 14 years had the highest incidence.
• 20
• 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.
• Affected joints were the knee (89 percent), hip (9 percent), shoulder (9 percent), ankle (7 percent),and elbow (2 percent).
• The positivity rate for the first serum specimen for those with erythema migrans was only 30 percent by IFA and 24 percent by ELISA.
• In view of the low sensitivities of serologic testsduring early Lyme disease, it is particularly important for physicians to re-evaluateclinical data when antibodies are not detected.
• Seropositive children with aseptic meningitis and without initial signs of an infectious aetiology should be checked for a neuroborreliosis even when CSF negative in the first lumbar puncture.
• A 3-year-old boy with typical clinical features of Lyme disease, including erythema chronicum migrans and arthritis... the clinical picture evolved into juvenile chronic myelocytic leukemia.
• Lyme borreliosis is the main cause of peripheral facial palsy in childhood.
• All cases of facial palsy with a tick bite and/or an erythema migrans in the head-neck region showed ipsilateral neurological affection suggesting direct invasion via the affected nerve by Borrelia burgdorferi.
• Only about 50% of patients with longstanding (1 to 12 months) untreated EM were IgG seropositive.
• Lyme disease during pregnancy- the child was born with a ventricular septal defect.
• Of six affected children, two had hyperbilirubinaemia, one muscular hypotonia, one was underweight for gestational age, one was macrocephalic, and one had supra ventricular extrasystoles.
• Acute hemorrhagic leukoencephalitis with renal insufficiency that had been diagnosed at the terminal stage.
• Convulsions, hemiplegia and consciousness disorders... detection of IgM and IgG specific serum antibodies raised against Borrelia burgdorferi.
• Tick-borne annular erythema (TAE) are much like those of Laim disease.
• Lyme borreliosis affecting the central nervous system does exist.
• Early diagnosis of children with Lyme is difficult- the bite of the ixodid tick often goes unnoticed.
• Erythema chronicum migrans occurs in less than 50% of cases.
• Brief intermittent attacks of swelling and pain in one or more joints.
• In most cases, pain is not severe enough to debilitate the patient or prevent weight-bearing activity.
• An elevated sedimentation rate is the only consistently abnormal routine laboratory finding in Lyme disease.
• 40
• Lyme disease shares symptoms in common with septic arthritis and juvenile rheumatoid arthritis.
• Erythema chronicum migrans (63%), neurological involvement (47%) and arthritis (22%), frequently in combination.
• Lyme disease can also involve the brain parenchyma.
• First manifestation was an acute, focal meningoencephalitis with signs and symptoms such as fever, headache, slurred speech, hemiparesis, seizure, and CSF pleocytosis.
• 17 patients presented with acute Lyme disease and received prompt treatment with oral antibiotics, but chronic Lyme disease subsequently developed.
• Clinically active disease- none had diagnostic levels of antibodies to B. burgdorferi.
• On Western blot analysis reactivity against B. burgdorferi from chronic Lyme patients was no greater than that in serum from normal controls.
• Presence of chronic Lyme disease cannot be excluded by absence of antibodies against B. burgdorferi.
• 58 (64%) developed neurological abnormalities and four (4%) patients developed monoarticular or oligoarticular arthritis.
• Lyme disease is now recognized as an infectious process capable of involving multiple organs including the cardiovascular system.
• 50
• Symptomatic heart block may be the sole presenting complaint of Lyme Disease in children.
• Oligoarthritis appearing in part of the leg where the cutaneous or neurological complications, or both, of Lyme disease developed before arthritis.
• Twenty nine patients had neurological disorders as the only manifestation of Lyme disease.
• Patients with neuropsychiatric manifestations, focal CNS lesions, or profound fatigue appearing in the third stage of Lymedisease, many months to years after the initial infection.
• Arthritis was the presenting feature in more than half of the children.
• Half of the children had initially consulted an orthopaedic surgeon, none of whom made the correct diagnosis.
• Sweden- Skin lesions were of longer duration (median 5-6 weeks), but less often multiple (8%) than in the USA.
• 72 patients with erythema migrans disease (EMD) had 1 to 10 constitutional symptoms besides the erythema migrans.
• Patients with ACA developed signs and symptoms consistent with neurologic, cardiac and joint involvement, and 2 had a history of erythema migrans disease (EMD).
• 60
• Borreliae were found in brain and liver of a newborn.
• Early erythema migrans disease (EMD) appears to be quite similar to early Lyme disease.
• Spirochetes were localized in dermal papilles and subepidermal zones of skin sections of ECMA, in lymph vessels and collagen fibres.
• In synovia of patients with arthritis spirochetes were found beneath the synovial lining cells and perivascularly.
• In the lymphnode of patient with arthritis and lymphadenitis spirochetes were localized in and round the blood vessels and in the lymph vessels.
• (52%) children had no history of erythema chronicum migrans or other rash.
• Temperatures as high as 41 degrees C (105.8 F) for up to 2 months before the onset of arthritis.
• Ten (40%) children, seven had no rash, were hospitalized for presumed septic arthritis.
• Four had diagnoses of pauciarticular juvenile rheumatoid arthritis for as long as 3 years.
• Seven patients had less acute, recurrent episodes of synovitis.
• 70
• Two children had seventh nerve palsies 2 months before onset of arthritis.
• Lyme arthritis may be confused with acute bacterial septic arthritis or recurrent "pauciarticular juvenile rheumatoid arthritis".
• Individuals with ECM rash who are treatedimmediately develop Lyme diseaseantibody only 40 per cent to 50 per cent of the time.
• In many instances the diagnosis is a clinical rather than a serologic one.
• Clinical expressions of the disease vary widely.
• Some patients have very mild disease and others develop severe and prolonged illness.
• Different subtypes of this organism may infect man.
• Most commonly affecting the brain or meninges, other skin sites, lymph nodes, or joints.
• Of 40 blood cultures, only one, from a patient with disseminated infection, yielded spirochetes.
• Due to low yield of cultures and delay in antibody response, recognition of clinical picture remains very important in diagnosing early Lyme disease.
• 80
• Spirochetes were seen in and around blood vessels.
• Lyme spirochete may survive for years in affected synovium and may be directly responsible for the microvascular injury.
• Nonspecific villous hypertrophy, synovial cell hyperplasia, prominent microvasculature, lymphoplasmacellular infiltration, and sometimes lymphoid follicles.
• Larger surgically obtained specimens also showed striking deposition of fibrin in synovial stroma and a form of endarteritis obliterans.
• Joint involvement is typically intermittent and oligoarticular.
• Lyme may become chronic, with erosion of cartilage and bone.
• Lyme synovia often showed greater proliferative changes in arterioles.
• Spirochetes were seen near these vessels (arterioles).
• Joint involvement was intermittent, but became chronic (>6 months) in the knees.
• Vascular microangiopathy, which resembled lupus"onion-skinning"inspleens,was seen.
• 90
• Spirochetes were seen within edematous vascular beds and in vessel walls.
• This finding implies that that the Lyme spirochete may survive for years in affected synovium.
• Chronic, with erosion of cartilage and bone.
• The importance of a sufficient antibiotic therapy to prevent late manifestations is stressed.
• Although there are many similarities between erythema chronicum migrans Afzelius and Lyme disease, the results of the present study also point to differences.
• Decreased suppression may permit damage to tissues because of autoimmune phenomena or a heightened response to the Lyme spirochete.
• (75%) had single EM lesions, 13 patients (25%) had multiple lesions.
• Meningitis, cranial neuropathy, and radiculoneuritis, alone or in combination, lasting for months.

CONTINUED HERE- PART 2

https://sites.google.com/view/symptoms-of-lyme/childrens-symptoms/childrens-symptoms-part-2?authuser=0

PART 3 IS HERE

https://sites.google.com/view/symptoms-of-lyme/childrens-symptoms/childrens-symptoms-part-3?authuser=0

PART 4 IS HERE

https://sites.google.com/view/symptoms-of-lyme/childrens-symptoms/symptom-descriptions-children

PART 5 IS HERE

https://sites.google.com/view/symptoms-of-lyme/childrens-symptoms/childrens-symptom-statements

Last Updated- April 2019

Lucy Barnes

AfterTheBite@gmail.com