Constipation Heralding Neuroborreliosis
ABSTRACT
This is a report of 2 patients with Lyme disease who initially presented with severe constipation, which progressed to ascending muscular weakness resembling acute idiopathic polyneuritis, with neuropsychiatric symptoms, severe urinary retention, and hyponatremia. These symptoms resolved following proper antibiotic therapy.
COMMENT
Our 2 patients had documented Lyme disease manifesting initially with autonomic symptoms: severe constipation and urinary retention progressing to a syndrome similar to acute idiopathic polyneuritis, with hallucinations and hyponatremia. Both had a history of an atypical rash without central clearing. The presence of an atypical rash in patients with Lyme disease, however, has been described in as many as 50% of the cases.6
In the classic description of the clinical manifestations of Lyme disease, gastrointestinal tract symptoms, excluding constipation, were observed in 10% of patients.3 This is also the case with other spirochetal infections, in which constipation is not a characteristic symptom.7 Within days after starting antibiotic treatment, both patients’ constipation resolved. The pathophysiological features of the constipation in our patients are unclear, but rapid resolution with antibiotics strongly suggests that this symptom was directly produced by the infection.
Neuropsychiatric manifestations of acute neuroborreliosis, including hallucinations, psychoses, and encephalopathy, have been documented,8-9 but their cause is unclear. In case 1, there was no obvious underlying psychiatric history and other organic causes could not explain the hallucinations. They resolved with the start of antibiotic therapy and were thought to be at least temporally associated with the borreliosis. We are unable to explain the cause of the hallucinations, but speculate that neuroborreliosis could be the cause. Lyme psychosis has been reported mainly in Europe, where the genotype, B burgdorferi sensu stricto,10 is associated with Lyme disease. It is likely that this genotypic difference leads to varying phenotypic expressions of the disease.
It is hard to attribute the hallucinations simply to the hyponatremia, because only 0.5% of patients with hyponatremia exhibit hallucinations11 and usually at serum sodium levels below 120 mEq/L (an average of 115 mEq/L).12 Psychiatric manifestations of Lyme disease have been reported for many years. Although exact numbers are not available, depression is reported in 26% to 66% of patients with Lyme disease.13 Multiple neuropsychiatric symptoms have been linked to Lyme disease, including visual hallucinations.13
Urinary retention was once described as an initial presentation of Lyme disease.14 In that patient, serum Lyme titers were high, which likely resulted from tertiary Lyme disease with a history of untreated Bell palsy 5 years earlier. In our patients, the symptom was associated with acute neuroborreliosis, and improved following antibiotic treatment. The constipation and urinary retention may reflect involvement of the autonomic peripheral nervous system.
The hyponatremia exhibited by both patients was considered, following a complete endocrine examination, to be the result of the syndrome of inappropriate antidiuretic hormone. To our knowledge, this has not been reported previously in a patient with Lyme disease, but inflammatory and infectious central nervous system processes have been associated with the syndrome of inappropriate antidiuretic hormone, including acute idiopathic polyneuritis15 and meningitis.16 In the latter, fungal, bacterial, carcinomatous, and tuberculous infections have been implicated. In our patients, fluid restriction was instituted, with a good response.
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