Epidemiology and Clinical Manifestations of Lyme Borreliosis in Childhood

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Abstract
Lyme borreliosis is a tick‐borne infection caused by the spirocheteBorrelia burgdorferi, whose discovery in 1982 solved an aetiological mystery involving a variety of dcrmatological and neurological disorders and explained their association with Lyme disease. Lyme borreliosis occurs frequently and is readily treatable with antibiotics.Along with its discovery, however, came the realization that it is difficult to diagnose accurately, especially antibody diagnosis. False‐positive antibody results in particular led to gradual widening of the clinical spectrum, and differential diagnosis became increasingly difficult.This prospective, multicentre study presents a systematic description of Lyme borreliosis in childhood, emphasizing epidemiological and clinical issues. Because, predominantly, inpatients were examined, Lyme neuroborreliosis was the focus of the study, with the chief concern being to minimize false‐positive results. To this end, we chose to narrow the diagnostic criteria, using the presence of specific antibodies in the cerebrospinal fluid as the determining factor.The epidemiological investigation was focused on the incidence of Lyme neuroborreliosis in childhood in southern Lower Saxony as well as on the prevalence of Lyme neuroborreliosis among acute‐inflammatory neurological illnesses in children. The clinical part of the study aimed at establishing criteria for differential diagnosis in addition to the detection of specific antibodies. The detection of specific IgM antibodies using an IgM capture ELISA confirmed the presence of acute Lyme borreliosis.The study examined 208 children with Lyme borreliosis, of whom 169 had Lyme neuroborreliosis, from mid‐1986 until the end of 1989. The yearly incidence of Lyme neuroborreliosis in Lower Saxony was 5.8 cases/100,000 children aged 1 to 13. The manifestation index was 0.16, or one case of Lyme neuroborreliosis per 620 infected children, compared with the presence of specific antibodies againstB. burgdorferifor children in the same age group and region. Both the seasonal distribution of Lyme borreliosis, which peaked in summer and autumn, as well as the information about when the tick bites took place point to an incubation period of a few weeks.The most frequent manifestation of Lyme neuroborreliosis in childhood was acute peripheral facial palsy, found in 55% of all cases (n = 93). Lyme borreliosis proved to be the most frequently verifiable cause of acute peripheral facial palsy in children, causing every second case of this disorder in summer and autumn. Bilateral facial palsy was, without exception, found to be caused by Lyme borreliosis; thus it can be considered a specific neurological sign of this infection.The second most common manifestation of Lyme neuroborreliosis in childhood was aseptic meningitis (27.2%, n = 46). Lyme borreliosis was the third most common cause of aseptic meningitis in childhood (11.8%).Meningoradiculoneuritis with peripheral nerve involvement (Bannwarth syndrome) was diagnosed in only 3.6% of the children (n = 6), although this is the most common symptom of Lyme neuroborreliosis in adult patients.The head and neck region proved to be the predominant site of tick bites in children; adults experience most bites on their extremities. The difference in the site of the infection, as well as the short duration of the illness in children and the early treatment, may partially explain the profound differences in the clinical spectrum of Lyme neuroborreliosis in children and adults.Nearly all cases with a positive history of tick bite and/or erythema migrans in the head and neck region showed ipsilateral facial palsy suggesting a direct invasion via the affected nerve byB. burgdorferi.Inflammatory changes in the cerebrospinal fluid along with the presence of specific antibodies are the conditio sine qua non for a diagnosis of Lyme neuroborreliosis. The presence of IgM antibodies in the cerebrospinal fluid has proved to be the most reliable diagnostic criterion, and is responsible for the early diagnosis of acute Lyme neuroborreliosis in children. The IgM capture ELISA facilitated the simple and reliable detection of intrathecal antibody synthesis which could be successfully demonstrated in three‐quarters of the cases with Lyme neuroborreliosis. Specific IgG testing was negative in most cases because of the relatively short duration of the illness in children, and is therefore of less importance here than in the diagnosis of cases of Lyme neuroborreliosis in adults.Acute Epstein‐Barr and varicella‐zoster viral infections both caused false‐positive findings in the IgM capture ELISA.High dose intravenous penicillin G proved to be highly effective in paediatric cases of Lyme neuroborreliosis. Although the rate of spontaneous remission may be very high, it is not possible to predict on a patient‐by patient basis just when this will occur. Thus consistent antibiotic therapy is indicated.

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