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43-YEAR-OLD MAN WITH MENINGITIS AND RADICULITIS DUE TO LYME DISEASE

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Hello, and welcome to another Inside Lyme Podcast. I am your host Dr. Daniel Cameron. In this episode, I will be discussing a unique case involving a 43-year-old man with neurological manifestations of Lyme disease including both meningitis and radiculitis.

The case was published in the journal Neurology International. [1] According to Dabiri and colleagues, the patient had a history of “scaly erythematous macular rash on his proximal medial upper and lower extremities.”

Within two weeks he presented with a broad range of symptoms “including cough, fever, anorexia, malaise, fatigue, myalgias, cervicalgia/neck stiffness with flexion and extension, mild photophobia, headache,”  the authors wrote.

The patient had extensive lab testing which revealed a mild abnormal liver function but no evidence of Lyme disease.  At the onset of symptoms, the patient refused to have a spinal tap.

Doctors presumed the man suffered from viral meningitis.

One month later, the patient developed progressive weakness, severe radicular lancinating pain, emotional lability along with depression and anxiety, an occasional action tremor in hands interfering with fine motor tasks, and tremor in his legs causing imbalance and instability.

Manifestations of the central nervous system (i.e, meningitis), as well as peripheral nervous system presentations (i.e., radiculitis) can occur in isolation or together.

Radiculitis or inflammation of the nerve root involving the peripheral nervous system (PNS) can lead to intractable pain, muscle denervation, and areflexia over one or a few adjacent dermatomes, wrote the authors.

At this point, results from a spinal tap were consistent with Lyme disease.  “A lumbar puncture was performed, and the patient’s cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis with white blood cell count of 225 and elevated protein of 77 and decreased glucose 38,” the authors wrote.

The patient was treated with a 5-day course of doxycycline, followed by a month of intravenous ceftriaxone.

Approximately two weeks after starting treatment, the patient “noted his symptoms were significantly improved including resolution of the pain, weakness, constitutional and affective symptoms, while he still had some ambulatory difficulties.”

This podcast addresses the following questions:

  1. What is Lyme meningitis?
  2. What is Lyme radiculitis?
  3. Why is this case considered “unique”?
  4. CNS and PNS manifestations can occur in isolation or together?
  5. Can you discuss the patient’s symptoms of emotional lability, depression and anxiety?
  6. What is the significance of the rash?
  7. Initial testing for Lyme disease was inconclusive but follow-up tests were positive?
  8. Any significance to MRI and spinal tap results?
  9. What if the significance of a diagnosis of viral meningitis?
  10. What were the other symptoms that might have helped the diagnosis?
  11. Would clinical judgment to treat with antibiotics have been helpful?
  12. What are your thoughts regarding the course of treatment?
  13. Would it have been helpful to consider additional treatment for the remaining ambulatory difficulties?
    1. Thanks for listening to another Inside Lyme Podcast. You can read more about these cases in my show notes and on my website @DanielCameronMD.com. As always, it is your likes, comments, reviews, and shares that help spread the word about Lyme disease. Until next time on Inside Lyme.

Please remember that the advice given is general and not intended as specific advice as to any particular patient. If you require specific advice, then please seek that advice from an experienced professional.

Inside Lyme Podcast Series

This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube.  As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts.

References:
  1. Dabiri I, Calvo N, Nauman F, Pahlavanzadeh M, Burakgazi AZ. Atypical presentation of Lyme neuroborreliosis related meningitis and radiculitis. Neurol Int. 2019 Dec 2;11(4):8318.
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https://madisonarealymesupportgroup.com/2019/03/17/first-case-of-b-corocidurae-in-native-european-presenting-as-meningitis-with-cranial-polyneuritis-cavernous-sinus-thrombosis/  European cases of B. crocidurae infection have been reported in travelers returning from endemic areas. We report the first autochthonous case in Europe of B. crocidurae infection, presenting as meningitis…..