www.thelancet.com/infection Vol 15 June 2015
We read with great interest the excellent Review by Jennifer Fugate and colleagues1 about the infectious causes of stroke. Their Review is useful for daily practice, since physicians often focus excessively on auto immune causes of central nervous system vasculitis causing stroke, while forgetting about infectious causes. However, we think that apart from neurosyphilis, which is mentioned in great detail, an additional comment on stroke caused by another spirochetal disease, Lyme neuroborreliosis, is needed. This rare form of Lyme neuroborreliosis is seldom mentioned in the medical literature.
About 60 cases of vasculitis and subsequent stroke due to Lyme neuroborreliosis have been described. Additionally, we have seen this form of Lyme neuroborreliosis in four patients in our department over the past 7 years. In a study of patients from eastern Saxony (Germany) done by Back and colleagues,2 the same form was seen in 11 patients between 1997 and 2011, with the estimated proportion of cerebral vasculitis in patients with Lyme borreliosis being 0·3%. Almost all cases reported in the literature have been described by European authors, which relates to the higher prevalence of Borrelia garinii in Europe, the most neurotropic genospecies of Borrelia. The most common clinical manifestation of vasculitis due to Lyme neuroborreliosis is ischaemic stroke with pathological changes resembling those occurring in vasculitis induced by infection with Treponema pallidum.2,3 Most patients are relatively young.2 The vasculitis caused by Lyme neuroborreliosis is usually associated with a prodromal clinical course suggesting Lyme neuroborreliosis with symptoms of meningitis, cranial neuritis, or radiculoneuritis weeks to months before the onset of symptoms of stroke. Medical history might also reveal a past history of tick bites or erythema migrans. MRI usually shows multiple and bilateral ischaemic lesions, and sometimes meningeal enhancement.2,4 In this case, cerebral angiography and transcranial Doppler often detect different degrees and location of segmental stenosis suggestive of vasculitis.2,4 Patients with Lyme neuroborreliosis associated vasculitis need immediate diagnosis and antibiotic treatment because the condition is potentially life threatening. 2,5 A high index of suspicion is needed in patients who live in or have come from areas with high prevalence of tick-borne diseases, and in those without cardiovascular risk factors, but with stroke-like symptoms of unknown cause.
We declare no competing interests.
*Adam Garkowski, Joanna Zajkowska, Anna Moniuszko, Piotr Czupryna, Sławomir Pancewicz
Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, 14 E Żurawia Street, 15-540 Białystok, Poland
1 Fugate JE, Lyons JL, Thakur KT, Smith BR, Hedley-Whyte ET, Mateen FJ. Infectious causes of stroke. Lancet Infect Dis 2014; 14: 869–80.
2 Back T, Grünig S, Winter Y, et al. Neuroborreliosis-associated cerebral vasculitis: long-term outcome and health-related quality of life. J Neurol 2013; 260: 1569–75.
3 Miklossy J, Kuntzer T, Bogousslavsky J, et al. Meningovascular form of neuroborreliosis: similarities between neuropathological findings in a case of Lyme disease and those occurring in tertiary neurosyphilis. Acta Neuropathol 1990; 80: 568–72.
4 Topakian R, Stieglbauer K, Nussbaumer K, et al. Cerebral vasculitis and stroke in Lyme neuroborreliosis. Two case reports and review of current knowledge. Cerebrovasc Dis 2008; 26: 455–61.
5 Buchwald F, Abul-Kasim K, Tham J, et al. Fatal course of cerebral vasculitis induced by neuroborreliosis. Neurol India 2010; 5: 139–41.
Medical topics with questions, information and discussion related to Lyme disease and other tick-borne diseases.
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