Abstract Details

Title Diagnostic Challenges of Lyme Neuroborreliosis in Inpatient Neurology: A Case Series

Topic Infectious Disease

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 13-004

Background Lyme disease is a multisystem disorder transmitted through the Ixodes tick and is most commonly diagnosed in northeastern and mid-Atlantic states, Wisconsin, and Minnesota, though its disease borders are expanding in setting of climate change. Approximately 10-15% of untreated Lyme disease cases will develop neurologic manifestations of LNB. Due to varying manifestations, LNB presents diagnostic challenges and is associated with a delay to treatment.

Objective

We aim to increase awareness of the diagnostic challenges of Lyme neuroborreliosis (LNB) in order to decrease treatment delays due to unfamiliarity of unique clinical manifestations in the setting of rising Lyme disease incidence.

Design/Methods NA

Results Three patients from low-incidence areas with prior extensive diagnostic evaluations presented to our referral center in a traditionally low-incidence state in August with neurologic manifestations of radiculoneuritis, cranial neuropathies, and/or lymphocytic meningitis. One patient reported a preceding rash on admission. Two patients disclosed prior tick exposure and possible rash at the end of their hospitalization. MRI findings included cranial nerve, nerve root, and leptomeningeal enhancement leading to broad differential diagnoses. Cerebrospinal fluid demonstrated lymphocytic pleocytosis (range 85-753 cells/uL) and elevated protein (range 87-318 mg/dL). Each patient tested positive for Lyme on two-tiered serum testing and was diagnosed with LNB. All three cases were associated with a delay to healthcare presentation (mean 20 days) and a delay to diagnosis and treatment (mean 54 days) due to under-recognition and ongoing evaluation. After completion of antibiotics, symptoms completely resolved.

Conclusions With the geographic expansion of Lyme disease, increasing awareness of LNB manifestations and acquiring detailed travel histories in low-incidence areas is crucial to prompt delivery of patient care. Clinicians should be aware of two-tiered serum diagnostic requirements and use adjunctive studies such as lumbar puncture and MRI to eliminate other diagnoses. Treatment with an appropriate course of antibiotics leads to robust improvement in neurological symptoms.

Authors/Disclosures
Kaitlyn Palmer, MD (Cleveland Clinic) PRESENTER	Dr. Palmer has nothing to disclose.
Maria Sokola, MD (Cleveland Clinic Main Campus)	Dr. Sokola has nothing to disclose.
Sanem P. Uysal, MD	Dr. Uysal has nothing to disclose.
Jessica Cooperrider, MD	Dr. Cooperrider has nothing to disclose.
Anthony Leung (Cleveland Clinic Akron General)	No disclosure on file
Alejandro Torres-Trejo, MD (Brain Tumor & Neuro-Oncology Center, Taussig Cancer Center, Cleveland Clinic)	Dr. Torres-Trejo has nothing to disclose.
Yuebing Li, MD, PhD, FAAN (Cleveland Clinic)	Dr. Li has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Argenx. Dr. Li has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Catalyst. Dr. Li has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Immunovant. Dr. Li has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Alexion. The institution of Dr. Li has received research support from Argenx.
Justin Abbatemarco, MD (Cleveland Clinic Foundation)	Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for EMD Serono. Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon. Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech . Dr. Abbatemarco has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for TG Therapeutics, Inc.. The institution of Dr. Abbatemarco has received research support from Horizon.