MRI may have normal findings, or show neuritis, meningitis, myelitis, encephalitis or vasculitis. (C) Corresponding hypermetabolic areas on fluorodeoxyglucose-positron emission tomography imaging suggesting inflammation/vasculitis. Independent Department, Laboratory of Molecular Imaging, Medical University of Biaystok, Biaystok, Poland, 3 Clinical practice. This form of LNB has been demonstrated in several case reports that analyzed results of CT angiography (CTA), magnetic resonance angiography (MRA), or conventional angiography. 5. The first MRI exam of the brain was performed, and it showed inflammatory lesion in the brainstem and pathological bilateral contrast enhancement of the facial and abducens nerves (Figure 2CF). Knauth M, Hhnel S. Inflammatory Diseases of the Brain. Antibodies to immunodominant antigens were identified owing to the immunoblot analysis (Virotech, Rsselsheim, Germany). John Wiley & Sons. (A) Fluid-attenuated inversion recovery (FLAIR) image shows focal hyperintense lesion in the white matter of the left frontal lobe. 1 Unable to process the form. Rupprecht TA, Koedel U, Fingerle V, Pfister HW. The basis for these symptoms remains to be defined but may be the result of a vasculitis or The basis for these symptoms remains to be defined but may be the result of a vasculitis or (2013) ISBN:1118484355. Magnetic resonance imaging showing (A) signal abnormality, suggesting inflammatory lesions in a vertebrobasilar distribution; medulla, pons, and cerebellum. In stage 1 (20-30 days after the tick bite), patients have flu-like symptoms and an expanding skin lesion (erythema chronicum migrans). The disease derives its name from the town of Lyme, Connecticut where it was first reported in 1975 2. Lyme borreliosis can be characterized by 3 chronologically overlapping stages: early localized, early disseminated, and late disseminated stage. The patient had a history of erythema migrans. A lumbar puncture was performed, which showed a positive serology for Lyme disease. Garkowski A, Zajkowska J, Zajkowska A, et al. G., El. Other symptoms include meningoencephalitis, encephalomyelitis, peripheral neuropathy, cranial nerve palsies and vasculitis [2-5]. This study retrospectively reviewed the MR imaging findings of all patients seen from 1993 to 2007 in whom neuro-Lyme disease was suspected and who were referred for MR imaging of the brain for the evaluation of neurologic symptoms. The other 2 voxels were also located symmetrically on the opposite sides of brain hemispheres, in the synovial center of the frontal lobes. From our many years of experience we observed this radiological manifestation only in one patient with LNB in the spinal cord (Figure 3). Due to its sensitivity and specificity, magnetic resonance imaging (MRI) may be perceived as preferable to CT regarding examination of lesions in the course of LNB. FLAIR and magnetization transfer imaging of patients Lyme disease. Lyme Disease Infect Dis Clin North Am. Eur J Neurol. 2. MRI makes a crucial contribution in the diagnosis and follow-up of LNB. The same may be stated regarding the posterior region of the lobes (P=.001 and P=.031). (A) Sagittal T2-weighted image, and (B) axial T2-weighted image revealed nonenhancing hyperintense lesion in the pons. 1997;18 (2): 257-61. The clinical course of LB is variable, but the infection typically begins with erythema migrans at the tick bite site (Figure 1), ie, a skin lesion appearing several days or weeks after the bite. This modality offers higher anatomical resolution, better soft tissue contrast, and multiplanar imaging acquisition; it also utilizes nonionizing electromagnetic radiation. Oxford University Press is a department of the University of Oxford. EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Often, multiple parts of the CNS are involved at the same time (e.g. Three disease stages have been proposed manifesting after the tick bite 2: Lyme disease has nonspecific symptoms with multisystemic involvement 1,2:. Lyme borreliosis ([LB] also known as Lyme disease) is a multisystem, multistage, zoonotic inflammatory disease transmitted by tick bite and caused by the Borrelia burgdorferi sensu lato (s.l.) Diagnostic Imaging of Infections and Inflammatory Diseases. 3. It is possible that LNB may also mimic atypical dementia and normal pressure hydrocephalus. Agarwal R, Sze G. Neuro-lyme disease: MR imaging findings. Radiology. The patient reported a several-week history of muscle weakness in the both limbs, and bilateral Babinskis sign was also present. Disease manifestations can be multisystem and nonspecific includes 1,2,4,5: Intracranial MR imaging findings in patients with Lyme disease are rare 2. G., and J. A substantial number of MRI will show no alterations, even with neurological symptoms [2]. Plotkin et al [24] reported a case of a 58-year-old woman who experienced progressive dysesthesia, abasia, and ataxia together with nausea and vomiting. Clinical presentation Typically, symptoms become evident before the age of 2 years, with a presentation in later childhood (juvenile form) or adulthood (adult form) being uncommon. Department of Radiology, Clnica Universidad de Navarra, Spain, 2. CNS: peripheral neuropathy, radiculoneuropathy, myelopathy, encephalitis, meningitis, cardiac: myopericarditis, cardiac arrhythmia, foci of periventricular / subcortical T2 hyperintensity, nerve root enhancement, particularly of the facial nerve. Enhancement after gadolinium chelate administration on T1-weighted images is the common finding (Figure 2CF). In conclusion, Lyme borreliosis should be included in the differential diagnosis if compatible MRI findings (white matter lesions, meningeal and nerve enhancement) are seen in an appropriate clinical context [2,4]. The serum enzyme-linked immunosorbent assay revealed positive high titers of B burgdorferi antibodies (IgM, 50 Biomedica Borrelia units (BBU)/mL and IgG, 68 BBU/mL). Purpose To describe the neuroimaging manifestations of Lyme disease at magnetic resonance (MR) imaging of the brain. Brought to you by the European Society of Radiology (ESR) -, Lyme disease is an infection caused by the spirochete. Clinical symptoms of cranial neuritis usually corresponds with contrast enhancement of the affected nerve [13]. Although US guidelines do not require intrathecal antibody synthesis in all patients, this is expected in central nervous system infection. MRI Materials and methods: Institutional review board approval was obtained and Myelitis is a collective term simply referring to any inflammation of the spinal cord. In the vast majority of cases, the appearance of lesions is nonspecific, and for this reason LNB is included in a broad differential diagnosis. 1). Often, multiple parts of the CNS are involved at the same time (e.g. Z. prepared and developed descriptions of the figures; A. G., wrote the first draft of the manuscript; A. G., U. ., and J. Lyme disease caused by the bacteria Borrelia burgdorferiand is transmitted by the bite of the ticks Ixodes scapularisand Ixodes pacificus. Lumbar puncture showed lymphocytic pleocytosis in cerebrospinal fluid (CSF). In some patients presented with LNB-associated stroke, angiographic showed no features of vasculitis [20]. Murray R, Morawetz R, Kepes J, et al. Inflammatory features revealed in the CSF examination were as follows: pleocytosis, 136 cells/mm3 (91% lymphocytes); and protein, 0.801 g/L. MRI of the spine showed a diffuse enhancement of all nerve roots after contrast administration, without a significant thickening (Fig. The most common neurological manifestations are painful radiculoneuritis and aseptic meningitis. Lyme Disease This modality offers higher anatomical resolution, better soft tissue contrast, and multiplanar imaging acquisition; it also utilizes nonionizing electromagnetic radiation. An example of 1H-MRS spectra in patients with early LNB, together with a healthy control subject, is shown in Figures 9 and 10. BMC Infect Dis. Technique Reveals Brain Inflammation Associated Neurological complications most often occur in early disseminated Lyme disease, with numbness, pain, weakness, facial palsy/droop (paralysis of the facial muscles), visual disturbances, and meningitis symptoms such as fever, stiff neck, and severe headache. Lyme disease is a bacterial infection transmitted to humans through tick bites. CNS infectious diseases The cerebrospinal fluid examination revealed inflammatory features (lymphocytic pleocytosis), and intrathecal synthesis of Borrelia burgdorferi antibodies was confirmed by a positive immunoglobulin G antibody index. This work is licensed under aCreative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Nervous system affectation occurs in up to 15% of untreated patients [3]. 13 articles feature images from this case 149 public playlists include this case Clin. The most common clinical presentation of early LNB in Europe and the United States is facial palsy [6]. The first MRI exam of the brain was performed, and it showed inflammatory lesion in the brainstem and pathological bilateral contrast enhancement of the facial and abducens nerves (Figure 2CF). Agosta F, Rocca MA, Benedetti B, et al. others or those with possible infectious etiologies, hemorrhagic shock and encephalopathy syndrome . {"url":"/signup-modal-props.json?lang=us"}, Di Muzio B, Bell D, Sharma R, et al. Brain MRI in Lyme disease Dis. Arrows indicate areas of abnormality. Clinical presentation Typically, symptoms become evident before the age of 2 years, with a presentation in later childhood (juvenile form) or adulthood (adult form) being uncommon. The feature to emphasize in LNB is that the presence of multiple cranial neuropathies is otherwise unusual and should bring this diagnosis to mind. According to guidelines of the IDSA and the AAN, the diagnosis depends on 3 different elements: the patient may have been exposed to Ixodes ticks in their endemic area, they present clinical symptoms that have been associated with LNB, and diagnostic testing (positive antibodies to B burgdorferi with or without positive B burgdorferi antibodies in the CSF) supports the diagnosis [9, 10]. (B) Corresponding restricted diffusion. They stated that 1H-MRS changes in patients with LNB are not specific, but 1H-MRS may be helpful in therapeutic choices and treatment monitoring by assessing tissue damage of the brain [22]. Department of Infectious Diseases and Neuroinfections, Medical University of Biaystok, Biaystok, Poland. A diagnosis of Lyme neuroborreliosis was confirmed by positive serologic findings of the serum and CSF. Proton MR spectroscopy in neuroborreliosis: a preliminary study. Neuronal loss or dysfunction in patients with early Lyme neuroborreliosis: a proton magnetic resonance spectroscopy study of the brain, Fluorine-18-labeled fluorodeoxyglucose-positron emission tomography studies of acute brainstem Lyme neuroborreliosis [corrected] Case report, Lyme neuroborreliosis: a potentially preventable cause of stroke. Lyme disease Lyme disease caused by the bacteria Borrelia burgdorferiand is transmitted by the bite of the ticks Ixodes scapularisand Ixodes pacificus. In very few case reports was the positron emission tomography (PET) used. Unfortunately, most CT and MRI findings of the brain and spine in patients with Lyme disease are often within normal limits, even among patients with known neurological manifestations, writes Alves Simo. Although imaging features of LNB are nonspecific, cranial nerve or leptomeningeal enhancement can help in differentiation from multiple sclerosis. Garkowski A, ebkowska U, Kubas B et al. The .gov means its official. Lyme serology was positive in both blood and CSF, and intrathecal Borrelia burgdorferi antibody production was confirmed. Open Forum Infectious Diseases. Lyme View Bruno Di Muzio's current disclosures, see full revision history and disclosures, herpes simplex virus 1 (HSV-1) encephalitis, herpes simplex virus 2 (HSV-2) encephalitis, varicella zoster virus (VZV) encephalitis, HIV-associated neurocognitive disorders (HANDs), progressive multifocal leukoencephalopathy, Brownell-Oppenheimer variant of sporadic Creutzfeldt-Jakob disease, Heidenhain variant of sporadic Creutzfeldt-Jakob disease, acute necrotizing encephalopathy of childhood, Central nervous system infectious diseases, e.g. Lyme neuroborreliosis is a common feature of B burgdorferi infection (as a neurological manifestation occurring in 10%15% of all Lyme disease cases [35]) and may involve any part of the nervous system and its coverings, but it usually manifests as separate or simultaneous lymphocytic meningitis, radiculoneuritis, and/or cranial neuritis [1, 6]. Remarkably, this patient responded dramatically to a 3-week-long administration of ceftriaxone [26]. Lyme neuroborreliosis may affect any part of the nervous system, including its meninges. 1). Both MRA and CTA do not offer adequate sensitivity; thus, a normal angiogram does not exclude the diagnosis of vasculitis [21]. There are some terms that help differentiate these patients with non-specific symptoms of fatigue, myalgia, and arthralgia,from those with acute infection 3: Lyme disease is endemic in some areas of North America and Europe. Magnetic resonance imaging (A and B) and proton magnetic resonance spectroscopy (1H-MRS) (C and D) of a 32-year-old man with right facial nerve palsy and meningitis in the course of Lyme neuroborreliosis. Axial magnetic resonance imaging (MRI) of a 19-year-old man with a right-sided facial nerve palsy and confirmed diagnosis of early Lyme neuroborreliosis (LNB). Reference article, Radiopaedia.org (Accessed on 27 Jun 2023) https://doi.org/10.53347/rID-35564, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":35564,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/cns-infectious-diseases/questions/880?lang=us"}. In a study by Murray et al [16], 1 case of intracranial mass lesion was described. No Lip and Lac peak was also observed in patients with LNB in this study. Neuroradiology. Plotkin M, Hautzel H, Krause BJ, et al. and transmitted securely. 2011;11 (9): . In a study (Schwenkenbecher et al [7]) of patients from Germany, myelitis was seen in approximately 7% of patients with LNB, and diagnoses offered on the basis of MRI spine imaging confirmed its occurrence in all of these patients (Figure 8). After the 21-day-long treatment with ceftriaxone, the patient was discharged with considerable neurological improvement. Bonduelle T, Tang HM, Marchal C, Thomas B. Control at month 3 (df) and 12 (gi) revealed a subtotal resorption of edema (d and g) and hemorrhages (f and i) with subtle persistent gadolinium enhancement (h). Magnetic resonance imaging (MRI) of the head of 55-year-old patient who was admitted for an acute confusional state with anterograde memory loss and falls. A. G., U. ., and B. K. conceived the concept and structure of the review; A. G., Ew. In a study by Agarwal and Sze [13], the authors compared MRI findings of 66 patients suffering from LNB with 50 healthy control subjects. 2018;9(5):833-844. doi: 10.1007/s13244-018-0646-x. In contrast to the previous 1H-MRS study, the long TE (TE=135 ms) was selected to evaluate the changes in the NAA/Cr ratio more precisely. How is it Adam Garkowski and others, Imaging of Lyme Neuroborreliosis: A Pictorial Review, Open Forum Infectious Diseases, Volume 7, Issue 10, October 2020, ofaa370, https://doi.org/10.1093/ofid/ofaa370. G., El. bacteremia as a result of distant infection. All authors: No reported conflicts of interest. The https:// ensures that you are connecting to the The patient reported a several-week history of muscle weakness in the both limbs, and bilateral Babinskis sign was also present. Clinical symptoms of cranial neuritis usually corresponds with contrast enhancement of the affected nerve [13]. Single voxel 1H-MRS spectrum of the normal-appearing medulla oblongata of the 2 persons (A and B). G., K. R., and J. It is a form of myelopathy. Follow-up MRI 11 months after treatment showed visible reduction of the lesion (G and H). 2009;253(1):167-73. doi: 10.1148/radiol.2531081103. Symptoms include 6,9: psychomotor delay/regression superimposed signs of basal ganglia and brainstem dysfunction ataxia ophthalmoplegia dystonia All authors: No reported conflicts of interest. MBA DMYMD, Zimmerman RD, Grossman RI. An official website of the United States government. (PMID: 28109263), [6] Imaging Findings. In addition, there was also an abnormally high signal intensity in FLAIR surrounding the cerebral aqueduct of Sylvius (Fig. Alba MA, Espgol-Frigol G, Prieto-Gonzlez S, et al. Keywords: Lyme neuroborreliosis, MRI, Neuritis, Myelitis, Encephalitis Go to: Introduction Severe Lyme neuroborreliosis with bilateral hemorrhagic temporal encephalitis. Search for other works by this author on: Independent Department, Laboratory of Molecular Imaging, Medical University of Biaystok, Department of Infectious Diseases and Neuroinfections, Medical University of Biaystok, Lyme neuroborreliosis: clinical outcomes, controversy, pathogenesis, and polymicrobial infections, Diagnosis and management of Lyme neuroborreliosis, The pathogenesis of lyme neuroborreliosis: from infection to inflammation, Lyme neuroborreliosis-epidemiology, diagnosis and management, Common and uncommon neurological manifestations of neuroborreliosis leading to hospitalization, European Federation of Neurological Societies, EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis, The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America, Quality Standards Subcommittee of the American Academy of Neurology, Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology, Clinical usefulness of intrathecal antibody testing in acute Lyme neuroborreliosis, Relevance of the antibody index to diagnose Lyme neuroborreliosis among seropositive patients, MR imaging assessment of brain and cervical cord damage in patients with neuroborreliosis, Brain magnetic resonance imaging does not contribute to the diagnosis of chronic neuroborreliosis, Lyme neuroborreliosis manifesting as an intracranial mass lesion, Severe Lyme neuroborreliosis with bilateral hemorrhagic temporal encephalitis, Neuroborreliosis-associated cerebral vasculitis: long-term outcome and health-related quality of life, Vasculitis and stroke due to Lyme neuroborreliosis - a review, Cerebrovascular manifestations of Lyme neuroborreliosis-a systematic review of published cases, Central nervous system vasculitis: still more questions than answers, Proton MR spectroscopy in neuroborreliosis: a preliminary study, Neuronal loss or dysfunction in patients with early Lyme neuroborreliosis: a proton magnetic resonance spectroscopy study of the brain, Fluorine-18-labeled fluorodeoxyglucose-positron emission tomography studies of acute brainstem Lyme neuroborreliosis [corrected] Case report, Lyme neuroborreliosis: a potentially preventable cause of stroke, Dramatic response to a 3-week course of ceftriaxone in late neuroborreliosis mimicking atypical dementia and normal pressure hydrocephalus. Disseminated disease associated with neurologic, cardiac, chronic skin, or articular involvement begins later (within a few months to years after disease onset). (A) Sagittal T2-weighted turbo inversion recovery magnitude (TIRM) sequence, (B) axial T2-weighted image, (C) sagittal postcontrast T1-weighted image, and (D) axial postcontrast T1-weighted image revealed hyperintense, homogeneously enhancing lesion in the cervical spinal cord (arrows). Wormser GP, Dattwyler RJ, Shapiro ED et-al. Dramatic response to a 3-week course of ceftriaxone in late neuroborreliosis mimicking atypical dementia and normal pressure hydrocephalus, http://creativecommons.org/licenses/by-nc-nd/4.0/, http://wwwold.pzh.gov.pl/oldpage/epimeld/2016/index_mp.html. Mygland A, Ljstad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I; European Federation of Neurological Societies. (A) Fluid-attenuated inversion recovery (FLAIR) image shows focal hyperintense lesion in the white matter of the left frontal lobe. Lyme disease is a bacterial infection transmitted to humans through tick bites. (A) Sagittal, and (B) axial postcontrast T1-weighted images demonstrated thin short-segment leptomeningeal enhancement of spinal cord (arrows). Angiography may show different degrees and location of multifocal narrowing and poststenotic dilatation of the medium- and large-caliber cerebral vessels. (B) Corresponding restricted diffusion. However, the therapy was discontinued because it was poorly tolerated by the patient. Lyme disease Magnetic resonance imaging of a 19-year-old woman with meningitis and right peripheral facial nerve palsy. However, this is based on anecdotal observations and not supported by systematic studies. 3. Plotkin et al [24] reported a case of a 58-year-old woman who experienced progressive dysesthesia, abasia, and ataxia together with nausea and vomiting. Materials and Methods Institutional review board approval was obtained and HIPAA compliance was followed. The second FDG-PET examination ordered after antimicrobial therapy demonstrated no abnormality in this area, reflecting clinical remission [24]. The physical examination was normal; there were no detectable symptoms of cranial nerves palsy. White matter lesions are not a prominent feature of LNB. Then, the patient was treated with ceftriaxone for 21 days and showed gradual symptomatic improvement, which further confirmed the diagnosis of LNB, and finally the patient was discharged with substantial neurological improvement. She was admitted to the Department of Infectious Diseases and Neuroinfection of the Medical University of Biaystok, presenting with a sudden onset of severe headache and vomiting. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America, Halperin JJ, Shapiro ED, Logigian E, et al. (B) Follow-up MRI 12 months after treatment showed only a slight reduction in the size of the lesion. They found that white matter hyperintensities in patients with LNB are comparatively unusual. The results support the utility of SPECT scans of the brain in the diagnosis and management of patients with the chronic form of the disease. Infect. Agarwal R, Sze G. Neuro-lyme disease: MR imaging findings. The pathogenesis of lyme neuroborreliosis: from infection to inflammation, Lyme neuroborreliosis-epidemiology, diagnosis and management. In Europe, approximately 65 500 patients are affected by this disease annually [1]. See related articles below for a list of regions of the CNS which may become infected. 4. Methods: The authors analyzed the distribution of cerebral lesions in a cohort of 27 patients with PTLDS. Guillain 2020;267:852854. Myelitis is a collective term simply referring to any inflammation of the spinal cord. Involvement of other cranial nerves rarely occurs. 2011;11 (9): . Auwaerter P, Bakken J, Dattwyler R et-al. No abnormalities were revealed on the CT of the brain. Disease manifestations can be multisystem and nonspecific includes 1,2,4,5: cutaneous: erythema migrans. 2006;43 (9): 1089-134. In our recent study, published in 2019, we performed 1H-MRS examinations on 26 patients diagnosed with early LNB and 26 controls (healthy volunteers). In Europe, approximately 65 500 patients are affected by this disease annually [1]. Department of Radiology, Medical University of Biaystok, Correspondence: Adam Garkowski, MD, Department of Radiology, Medical University of Biaystok, Poland, M. Skodowskiej-Curie 24A, 15-276 Biaystok (. Lyme