Case report: Lyme disease causes inflammation of the spinal cord

There have only been 8 documented pediatric cases of Lyme disease causing transverse myelitis. In this report, the authors describe the ninth case involving a 10-year-old boy.

In their article “Case report: Subacute transverse myelitis with gait preservation secondary to Lyme disease and a review of the literature,” Colot and colleagues describe a 10-year-old boy who suffered from neck pain with irradiation in the upper limbs for 13 days.

Transverse myelitis (TM) is an inflammation of both sides of one section of the spinal cord. Diagnosis requires clinical symptoms and evidence of inflammation within the spinal cord via cerebrospinal fluid analysis and/or magnetic resonance imaging.

Treatment of transverse myelitis typically includes oral steroids, intravenous immunoglobulins, plasma exchange, and immunomodulatory therapies.

“Clinical features consist of sensory disturbances in most patients, followed by weakness and sphincter dysfunction. Children suffer from more severe clinical impairment than adults,” the authors wrote.

In fact, one study found 89% of the pediatric patients were bed- or wheelchair-bound or required assisted ventilation.

In this case report, Colot et al. provides evidence that the clinical presentation of neuroborrelial transverse myelitis differs from classical TM.

“TM secondary to Lyme disease is more often subacute with gait preservation and is limited to the cervical spine,” the authors wrote.

Lyme disease triggers inflammation in spinal cord

A 10-year-old boy presented to his pediatrician with “persistent nocturnal and rotational neck pain with irradiation in the upper limbs for 13 days with a feeling of heaviness and paresthesia in the fingers.”

The boy also had a fever for 11 days, along with fatigue and headaches.

MRI findings of the spine suggested longitudinal extensive transverse myelitis (LETM).

“A spinal MRI showed an extensive T2 hypersignal between C1 and C7, with a normal T1 signal confirming the diagnosis of LETM.”

An extensive workup was performed using blood serologies and autoimmune factors. A CSF analysis found an increased white blood cell count in cerebrospinal fluid.

“The patient was treated with high-dose methylprednisolone IV for 5 days and Ceftriaxone IV,” the authors wrote. After 48 hours, the boy’s symptoms decreased, his CSF bacterial culture was negative and Ceftriaxone was stopped.

He remained on steroids but 2 days later, his neck pain and laterocollis (head tilted to one side) reappeared.

“Our case illustrates that neuroborrelial TM should be treated with long-term [antibiotic] therapy and that steroids do not seem to improve the prognosis.”

Since the patient lived in a tick-endemic area, he was tested for Lyme disease.

“The test results of Borrelia IgG in the blood and intrathecal IgG synthesis were positive, confirming the diagnosis of TM secondary to Lyme disease,” the authors explained.

“The patient reported that he had an erythematous spot in the neck a few months back, which was suggestive of an erythema migrans, but he did not remember that he had suffered from a tick bite,” the authors explained.

After 23 days of treatment with Ceftriaxone and Doxycycline, the patient made a complete recovery.

Authors Conclude:

“After an extensive review of the pediatric literature, we wish to emphasize five aspects of TM secondary to Lyme disease:”

1. presentation is more often subacute
2. lesions are mainly located in the cervical spine
3. gait is usually preserved
4. sphincter dysfunction is unusual
5. recovery is usually complete after prolonged antibiotic therapy

The authors suggest: “[Transverse myelitis] in a subacute presentation, gait preservation, a discrepancy between the severe mainly cervical imaging manifestations and the minimal clinical signs and symptoms, and the absence of sphincter dysfunction should raise suspicion of TM secondary to Lyme disease.”