Excerpt:

INTRODUCTION: Acute transverse myelitis (ATM) is a rare disorder
(1-8 new cases per million of population per year), with 20% of
all cases occurring in patients younger than 18 years of age.
Diagnosis requires clinical symptoms and evidence of inflammation
within the spinal cord (cerebrospinal fluid and/or magnetic
resonance imaging). ATM due to neuroborreliosis typically
presents with impressive clinical manifestations.
CASE PRESENTATION: Here we present a case of Lyme
neuroborreliosis-associated ATM with severe MRI and CSF findings,
but surprisingly few clinical manifestations and late conversion
of the immunoglobulin G CSF/blood index of Borrelia burgdorferi
sensu lato.
CONCLUSION:
Clinical symptoms and signs of neuroborrelial ATM may be minimal,
even in cases with severe involvement of the spine, as shown by
imaging studies. The CSF/blood index can be negative in the early
stages and does not exclude Lyme neuroborreliosis; if there is
strong clinical suspicion of Lyme neuroborreliosis, appropriate
treatment should be started and the CSF/blood index repeated to
confirm the diagnosis.

OBJECTIVE: Children often develop arthritis secondary to Lyme
disease; however, optimal treatment of Lyme arthritis in
pediatric patients remains ill-defined.
We sought to characterize the outcomes of a large cohort of
children with Lyme arthritis treated using the approach
recommended by the American Academy of Pediatrics and the
Infectious Diseases Society of America. METHODS: Medical records
of patients with Lyme arthritis seen by rheumatologists at a
tertiary care children’s hospital from 1997 to 2007 were
reviewed. Patients were classified with antibiotic responsive or
refractory arthritis based on absence or presence of persisting
joint involvement 3 months after antibiotic initiation. Treatment
regimens and outcomes in patients with refractory arthritis were
analyzed.

RESULTS: Of 99 children with Lyme arthritis, 76 had arthritis
that responded fully to antibiotics, while 23 developed
refractory arthritis. Most patients with refractory arthritis
were successfully treated with nonsteroidal antiinflammatory
drugs (6 patients), intraarticular steroid injections (4), or
disease-modifying antirheumatic drugs (DMARD) (2). Five were lost
to followup. Six patients with refractory arthritis were
initially treated elsewhere and received additional antibiotic
therapy, with no apparent benefit.
Three subsequently required DMARD, while 3 had gradual resolution
of arthritis without further therapy. Antibiotic responsiveness
could not be predicted from our clinical or laboratory data.

CONCLUSION: Lyme arthritis in children has an excellent
prognosis. More than 75% of referred cases resolved with
antibiotic therapy. Of patients with antibiotic refractory
arthritis, none in whom followup data were available developed
chronic arthritis, joint deformities, or recurrence of infection,
supporting current treatment guidelines.

NEW YORK (Reuters Health) May 01 – Manifestations of Lyme carditis in children can range from asymptomatic first-degree heart block to fulminant myocarditis, physicians at Harvard Medical School report in the May issue of Pediatrics. Data from their case series indicate that older age, arthralgia, and cardiopulmonary symptoms were independent predictors of carditis in pediatric patients with early disseminated Lyme disease.

In untreated Lyme disease, signs and symptoms of early dissemination may manifest within weeks to months of a tick bite, Dr. John M. Costello and co-investigators note. To characterize the clinical course of Lyme carditis in children, they reviewed cases of 207 children treated between 1994 and 2008 for early disseminated Lyme disease.

November 13, 2009 (Washington, DC) — The odds that a child living in a Lyme-endemic area of the United States who presents with a joint effusion will be diagnosed as having Lyme arthritis is 29%. The odds are even higher (44%) if the affected joint is the knee. The leukocyte count is useful in distinguishing between septic and Lyme arthritis, researchers announced here.

“There was an increase in the number of cases in the United States by 101% over the past 15 years, possibly due to increased recognition of Lyme disease,” said Aristides I. Cruz Jr., MD, resident in the Department of Orthopedics and Rehabilitation at Yale University in New Haven, Connecticut. During his presentation, he noted that 93% of all Lyme disease cases arise from 10 states, most in the Northeast United States.

“There was an increase in the number of cases in the United States by 101% over the past 15 years, possibly due to increased recognition of Lyme disease,” said Aristides I. Cruz Jr., MD, resident in the Department of Orthopedics and Rehabilitation at Yale University in New Haven, Connecticut. During his presentation, he noted that 93% of all Lyme disease cases arise from 10 states, most in the Northeast United States.

“Children are more likely to present with arthritis as initial manifestation of Lyme disease,” Dr. Cruz told the audience.

“Children with Lyme arthritis presenting with a limp and a swollen joint will typically have a lower peripheral white blood cell count,” Dr. Cruz added. “They are less likely to have complete non-weight-bearing on the affected limb, less likely to have a fever, and [arthritis symptoms are] more likely to involve the knee joint compared with children with septic arthritis.”

The findings were reported here at the American Academy of Pediatrics 2009 National Conference & Exhibition.

Basic Diagnostic Tools Help Distinguish Lyme From Septic Arthritis

“In the Northeast, we see a lot of Lyme disease,” said Yi-Meng Yen, MD, PhD, instructor in orthopaedic surgery, Harvard Medical School, Children’s Hospital Boston in Massachusetts. “It is hard to distinguish whether [it] is Lyme disease or whether [it] is septic arthritis,” Dr. Yen agreed.

“Septic arthritis mandates that we take the patient to the operating room and do a surgery, whereas Lyme arthritis theoretically can be treated with antibiotics,” he told Medscape Pediatrics in an interview. For instance, he said, “Our institution has been looking at MRIs [magnetic resonance images] as a way to reliably distinguish between the two, because it takes several days sometimes for the lab tests to come back to definitely tell you whether you have Lyme disease or not. So, in those few days, if you have septic arthritis, that’s a bad thing.”

“To reliably, quickly diagnose what the patient has can help us determine the treatment quickly,” added Dr. Yen, who was not involved in this study.

“If you are clinically susceptible for septic arthritis, it pays to go to the operating room,” Dr. Cruz said in answer to a question from the audience. “In the past, almost all these patients automatically went to the operating room.”

However, if the clinical presentation is consistent with Lyme arthritis, treatment with antibiotics should suffice, he added. “The point of this study was to come up with some clinically useful criteria to arm ourselves with more tools to diagnose the disease.”

Dr. Cruz and his team sought to evaluate clinical parameters that could eventually be used to differentiate Lyme arthritis from septic arthritis in children and help with diagnosis and subsequent treatment.

In this retrospective analysis, the investigators reviewed data from children who underwent lower-extremity joint aspiration at Yale University Medical Center, a tertiary care children’s hospital in a Lyme disease endemic area.

Between August 2002 and August 2008, more than 200 children underwent a total of 212 aspirations for a joint effusion. Cell count, culture, hematologic inflammatory markers, and subsequent surgical intervention were available for 170 of the 212 aspirates.

Dr. Cruz’s team compared findings from 50 children with serologically confirmed Lyme disease with data from 21 patients with culture-positive septic arthritis.

They found statistically significant differences between the 2 cohorts. For instance, the peripheral white blood cell count was 9.5 x 1000/μL (range, 3.0 – 14.9 x 1000/μL) in the aspirates from children with Lyme disease vs 12.5 (range, 5.5 – 30.1) in children with septic arthritis (P = .002).

Other parameters, such as joint fluid cell count, erythrocyte sedimentation rate, and C-reactive protein levels, were not significantly different between the 2 groups and could not be used to differentiate between septic and Lyme arthritis.

Interestingly, said Dr. Cruz, of all the children presenting with a joint effusion at their hospital, 29% were likely to be diagnosed as having Lyme arthritis overall compared with 44% if the aspirate was a knee aspirate.

“Is it worthwhile to develop something that’s very reliable? Absolutely!” said Dr. Yen. “Especially in the Northeast centers. It is a growing healthcare problem and a lot more study should be put into it.”

Dr. Cruz and Dr. Yen have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2009 National Conference & Exhibition (NCE): Abstract 5806. Presented October 17, 2009.

Journalist

Crina Frincu-Mallos, PhD

Crina Frincu-Mallos is a freelance writer for Medscape Medical News.

• American Academy of Pediatrics (AAP) 2009 National Conference and Exhibition

This coverage is not sanctioned by, nor a part of, the American Academy of Pediatrics.

From Medscape Medical New

In untreated Lyme disease, signs and symptoms of early dissemination may manifest within weeks to months of a tick bite, Dr. John M. Costello and co-investigators note. To characterize the clinical course of Lyme carditis in children, they reviewed cases of 207 children treated between 1994 and 2008 for early disseminated Lyme disease.

Records showed that 33 (16%) had carditis, along with a wide range of systemic involvement. According to the Boston-based research team, only one patient presented with isolated carditis and no erythema migrans or noncardiac systemic manifestations. Duration of hospitalization ranged from 1 to 13 days, and there were no deaths.

Fourteen patients had advanced heart block, including 9 with complete block, but recovery of sinus rhythm took no more than 7 days.

In addition, among the 33 patients with carditis, 4 had depressed ventricular systolic function and 3 of them required mechanical ventilation, temporary pacing, and inotropic support.

Analysis showed that significant independent predictors of Lyme carditis were age over 10 years (adjusted odds ratio 8.3), arthralgias (OR 5.8), and cardiopulmonary symptoms (OR 76.8). Sensitivity and specificity of cardiopulmonary symptoms for Lyme carditis were 42% and 99%, respectively.

Of 27 patients for whom follow-up data were available, complete recovery occurred in 24. One patient had ongoing second-degree atriventricular block at 2.7 years. The other 2 patients had improved but still had mildly prolonged PR intervals at short-term follow-up.

Thus, Dr. Costello’s group states, “A full recovery should be expected with supportive care and antibiotic therapy.” However, they point out that 6 patients had prolonged corrected QT intervals and advise physicians “to avoid drugs that prolong the QT interval in these patients until the electrocardiogram has normalized.”

From Reuters Health Information  http://www.medscape.com/viewarticle/702223

Pediatrics 2009;123:e835-e841.