Chapter 68: Lyme disease initially diagnosed as juvenile rheumatoid arthritis
Lyme disease was first identified in 1975 in a group of children and adolescents living in Lyme, Connecticut who suffered from recurrent attacks of asymmetric swelling and pain in the knee. The patients were initially diagnosed with juvenile rheumatoid arthritis.
"The typical patient has had three recurrences, but 16 patients have had none," noted lead investigator Steere, then a postdoctoral fellow in rheumatology at Yale University.1 "During remission, some patients remembered short periods of joint pain, sometimes lasting only hours, without swelling (and therefore, not included as attacks)."
Pain also occurred in the ankle, wrist, temporomandibular joint, shoulder, hip, and elbow. Other symptoms included malaise, fatigue, headaches, myalgia, periorbital edema, and swelling of the hands or feet. Of the 12 subjects, seven suffered from "profound fatigue and hyperesthesia, sometimes persisting for months after the arthritis had gone," say Steere and colleagues. 1
A team of researchers including Steere would, 14 years later, report in the New England Journal of Medicine that chronic neurologic Lyme disease was one of the complications of Lyme disease. 2
Chapter 125: In need of a better understanding of Lyme disease in children
Steere and colleagues describe an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. "Attacks were usually short (median 1 week) with much longer intervening periods of complete remission (median 2.5 months), but some attacks lasted for months. To date, the typical patient has had three recurrences, but 16 [of 51] patients had none," say the authors, adding, "Over half had concomitant fever (100° – 103°F), malaise and fatigue, headache, and myalgia." 1
Only a handful of studies on children and adolescents with tick-borne diseases have been done, despite the prevalence of the diseases in this age group and the potential for long-term health consequences.
Bloom and colleagues from Tufts University School of Medicine in 1998 describe the complications of Lyme disease in children. "Five children [of 86] developed behavioral changes, forgetfulness, declining school performance, headache or fatigue and, in two cases, a partial complex seizure disorder."3
Vázquez and colleagues from the Department of Pediatrics and the Yale Children's Clinical Research Center report children ages 2 to 18 with prior cranial nerve palsy have significantly more behavioral changes (16 percent vs. 2 percent), arthralgias and myalgias (21 percent vs. 5 percent), and memory problems (8 percent vs. 1 percent) an average of four years after treatment for Lyme disease.4
Chapter 127: Case study: 16-year-old with Lyme disease presenting as depression
In a second case reported in 1998 by Fallon and colleagues, a 16-year-old boy, named David, was initially presumed to suffer from long-standing depression. He presented with anger, frustration, insomnia, poor appetite, mild weight loss, and passive suicidal ideation. His longstanding depression was "exacerbated recently when he stopped dating a girl after only two weeks because he felt too tired and not smart enough," according to the researchers. 5 "He reported feeling spaced out all the time, as if in a fog." David also lived in a Lyme endemic area.
David’s steep decline in cognitive behavior and IQ were initially presumed to be caused by "either laziness or mild depression."
He quit sports.
His grades declined from A and A- in seventh grade to nearly failing by tenth grade.
He appeared lazy because he found it hard to get out of bed in the morning.
He often forgot to hand in assignments that he had in fact completed.
He reported trouble staying awake in class and trouble concentrating.
His symptoms were extensive:
facial fasciculations (muscle twitches), myalgias
hyperacusis (sensitivity to sounds)
episodic paresthesias (burning or prickling sensation) of his face and hands
word-finding problems such that it was hard to finish sentences
short-term memory problems such that he could not recall conversations
While the young man had "had embedded tick bites," wrote the researchers, "he could not recall ever having had an erythema migrans rash."
David’s "Lyme ELISA was negative twice in the prior 3 months, his IgG Western blot revealed 4 of the 5 requisite CDC specific bands." The neuropsychologic evaluation, said the researchers, showed "significant deficits in processing speed and visual spatial memory." Researchers added, testing by a brain SPECT "revealed moderate to severe diffusely and heterogeneously decreased perfusion in the cortex and the central white matter, consistent with encephalitis, vasculitis, and Lyme disease."
David was diagnosed and treated with excellent results for probable Lyme encephalopathy with 12 weeks of intravenous ceftriaxone. He improved on sleep, appetite, headaches, joint pains, numbness, distractibility, short-term memory, and emotional behavior. His depression cleared without the need for antidepressant medications. His IQ improved by 22 points, and his school performance markedly improved.
Like the case of 7-year-old Susan, David’s case also illustrates the need for careful diagnosis and treatment of tick-borne infections in young people. So often these infections look like the common problems see in school-aged children: depression, ADHD, joint pains from growth spurts. These cases show the need to not only look at symptoms, but to be mindful of where students live and play.
Text from Dr. Daniel Cameron's Book: Lyme Disease takes on Medicine.
Steere AC, Malawista SE, Snydman DR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three connecticut communities. Arthritis Rheum. 1977;20(1):7-17.
Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990;323(21):1438-1444.
Bloom BJ, Wyckoff PM, Meissner HC, Steere AC. Neurocognitive abnormalities in children after classic manifestations of Lyme disease. Pediatr Infect Dis J. 1998;17(3):189-196.
Vazquez M, Sparrow SS, Shapiro ED. Long-term neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease. Pediatrics. 2003;112(2):e93-97.
Fallon BA, Kochevar JM, Gaito A, Nields JA. The underdiagnosis of neuropsychiatric Lyme disease in children and adults. Psychiatr Clin North Am. 1998;21(3):693-703, viii.