Neurologic Lyme Disease in Children
Lyme disease can affect the nervous system in both adults and children. When the infection involves the nervous system, it is often referred to as Lyme neuroborreliosis. Although neurologic Lyme disease has been widely studied in adults, pediatric cases may present differently and can sometimes be overlooked.
Children with neurologic Lyme disease may develop facial nerve palsy, meningitis, headaches, or other neurologic symptoms. However, some children present with more subtle or diffuse symptoms such as fatigue, irritability, mood changes, or loss of appetite. Because these symptoms may appear gradually and are not always specific, the diagnosis can sometimes be delayed.
A review of the pediatric literature emphasizes the importance of recognizing the wide range of neurologic manifestations in children with Lyme disease.1 Awareness of these patterns can help clinicians identify cases that might otherwise be missed.
How Neurologic Lyme Disease Develops
Lyme disease is caused by infection with bacteria belonging to the Borrelia burgdorferi complex, transmitted through the bite of infected ticks. After entering the body, the bacteria can spread through the bloodstream and affect multiple tissues, including the nervous system.
When the infection reaches the nervous system, it can lead to inflammation involving the brain, meninges, cranial nerves, or peripheral nerves. This condition is known as Lyme neuroborreliosis.
Although neurologic Lyme disease occurs in both adults and children, studies suggest that the clinical presentation in children may differ in several important ways.1
Common Neurologic Symptoms in Children
Children with Lyme neuroborreliosis most often present with cranial nerve involvement or meningitis. Among the pediatric population, facial nerve palsy and lymphocytic meningitis are frequently reported manifestations.1
Facial nerve palsy may appear suddenly and is often the symptom that leads families to seek medical attention. In some studies conducted in endemic regions, facial nerve palsy was observed in the majority of children diagnosed with neuroborreliosis.
However, neurologic Lyme disease can also produce a broader range of symptoms. These may include:
- persistent headaches
- neck stiffness
- fatigue
- loss of appetite
- mood changes or irritability
- dizziness
- difficulty concentrating
Some children also experience diffuse neurologic symptoms that are less specific. Because these symptoms may overlap with other common childhood conditions, the diagnosis may not be immediately apparent.
Behavioral, Neuropsychiatric, and Autonomic Symptoms
In some children, Lyme disease affecting the nervous system may present with behavioral, neuropsychiatric, or autonomic symptoms rather than obvious focal neurologic findings. These manifestations may not always be recognized as neurologic in origin.
Some children develop sudden changes in behavior, mood, or cognition during the course of their illness. These symptoms may resemble pediatric acute-onset neuropsychiatric syndrome (PANS) or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). In such cases, children may experience abrupt onset of anxiety, obsessive behaviors, emotional lability, or other behavioral changes.
Autonomic nervous system dysfunction may also occur in some children with Lyme disease. The autonomic nervous system regulates functions such as heart rate, blood pressure, and digestion. When this system is affected, children may develop symptoms such as:
- dizziness or lightheadedness
- rapid heart rate
- fatigue with standing
- exercise intolerance
- temperature regulation problems
- gastrointestinal symptoms
These symptoms are sometimes associated with conditions such as postural orthostatic tachycardia syndrome (POTS), which has been reported in some patients with Lyme disease and other infections affecting the autonomic nervous system.
In clinical practice, some children with persistent neurologic symptoms may also show features consistent with small fiber neuropathy. This condition involves injury to small sensory and autonomic nerve fibers and can cause burning pain, tingling, altered temperature sensation, and autonomic instability. Small fiber neuropathy has been described in association with infections and inflammatory conditions affecting the nervous system and may contribute to persistent neurologic or autonomic symptoms in some patients.
Cranial Nerve Involvement
Facial nerve palsy is the most widely recognized neurologic sign of Lyme disease in children. The paralysis is typically unilateral but can occasionally affect both sides of the face.
Other cranial nerves may also be involved. Less commonly reported findings include:
- abducens nerve involvement
- trigeminal nerve symptoms
- trochlear nerve abnormalities
Rare neurologic manifestations described in the pediatric literature include transient weakness on one side of the body or seizures associated with inflammation of the central nervous system.1
Lyme Meningitis in Children
Lyme meningitis can occur when the infection involves the membranes surrounding the brain and spinal cord. In children, the symptoms may be milder than those seen in other forms of meningitis.
Some children experience headaches, neck stiffness, or fatigue without the dramatic symptoms typically associated with bacterial meningitis. Because of this more subtle presentation, Lyme meningitis may initially be mistaken for viral illness or other neurologic conditions.
In endemic areas, Lyme disease has been identified as one of the more common causes of meningitis in children between the ages of five and nine.1
Seizures and Other Rare Neurologic Manifestations
Seizures are uncommon but have been reported in children with neurologic Lyme disease. In most cases, seizures occur in the setting of central nervous system involvement such as meningoencephalitis or inflammatory brain lesions.
Published reports describe generalized tonic–clonic seizures and other seizure-like episodes in some children with Lyme neuroborreliosis. These manifestations are considered rare and typically occur alongside other neurologic findings.
Because seizures have many possible causes in childhood, careful evaluation is required to determine whether Lyme disease or another neurologic condition is responsible.
Why Neurologic Lyme Disease in Children Can Be Missed
Several factors may contribute to delays in diagnosing neurologic Lyme disease in children.
First, children may have difficulty describing their symptoms clearly. Complaints such as fatigue, headache, or changes in mood may appear nonspecific and may not immediately suggest a neurologic illness.
Second, the neurologic examination may sometimes appear normal early in the course of the disease. Studies have noted that some children with Lyme neuroborreliosis initially show no clear abnormalities on neurologic examination, which can contribute to delayed recognition.1
Third, neurologic Lyme disease may resemble other conditions. Children may initially receive diagnoses such as migraine, viral meningitis, Bell’s palsy, anxiety, or functional disorders before Lyme disease is considered.
Limitations of Diagnostic Testing
The evaluation of suspected neurologic Lyme disease may include blood tests and, in some cases, examination of the cerebrospinal fluid obtained through lumbar puncture.
In published guidelines, lumbar puncture is often discussed as part of the diagnostic process. Cerebrospinal fluid abnormalities such as pleocytosis or intrathecal antibody production may support the diagnosis when present.1
However, spinal fluid findings are not always definitive. In clinical practice, spinal tap results may be negative or nonspecific even when neurologic Lyme disease is suspected. A negative spinal fluid test therefore does not necessarily rule out the condition, and the clinical picture remains an important part of the evaluation.
European Research and the Need for U.S. Studies
Much of the detailed research on Lyme neuroborreliosis in children comes from European studies. These investigations have provided important insights into the neurologic manifestations of Lyme disease in pediatric populations.
However, the species of Borrelia bacteria circulating in Europe differ from those most commonly found in the United States. Additional pediatric research conducted in North America would help clarify whether the clinical patterns observed in European studies apply equally to children in the United States.
Clinical Course and Recovery
Many children diagnosed with Lyme neuroborreliosis improve with appropriate treatment. Studies suggest that the overall prognosis in children may be favorable compared with adults.
Nevertheless, recovery is not always immediate. Some children may experience persistent symptoms for weeks or months after the initial illness. In certain cases, neurologic or functional symptoms may continue for longer periods.
In clinical practice, some children remain ill despite repeated evaluations, and families may struggle to find clear explanations for persistent symptoms. These experiences highlight the importance of continued research and careful clinical follow-up.
Final Thoughts
Neurologic Lyme disease in children can present with a range of symptoms, from facial nerve palsy and meningitis to headaches, fatigue, mood changes, behavioral symptoms, and autonomic dysfunction.
Because early symptoms may be subtle and diagnostic tests have limitations, the condition can sometimes be overlooked. Recognizing the diverse neurologic presentations of Lyme disease in children may help clinicians identify cases earlier and guide appropriate evaluation and care.
Reference
1. Kozak S, Kaminiów K, Kozak K, Paprocka J. Lyme Neuroborreliosis in Children. Brain Sciences. 2021;11(6):758. doi:10.3390/brainsci11060758.
