Vision loss in teenager due to Lyme disease

In their article, “Neuroborreliosis with intracranial hypertension and visual loss in a pediatric patient: illustrative case,” Ku and colleagues present a unique case involving a teenage boy who developed progressive vision loss due to Lyme disease. [1]

“We present a rare case of intracranial hypertension due to [Lyme disease] in a pediatric patient treated with EVD placement for CSF diversion and intravenous ceftriaxone, resulting in a significant improvement in symptoms,” including vision loss, the authors state.

A 13-year-old boy was admitted to the emergency department complaining of a headache (which had been ongoing for 4 weeks), neck stiffness, nausea, vomiting, and abdominal pain, along with progressive vision loss over a 1-week period.

“This case highlights a rare but significant complication of neuroborreliosis. Intracranial hypertension with resulting neurological deterioration, while uncommon, can occur in patients with Lyme disease.”

Two weeks earlier he tested positive for Lyme disease and began treatment with doxycycline. The following week, test results were positive, as well, for Babesia and clinicians prescribed atovaquone and azithromycin.

However, his symptoms did not improve and an MRI was performed, which indicated “bilateral posterior scleral flattening, prominent optic apillae at the site of optic nerve insertion, tortuosity of the intraorbital optic nerves, and prominence of the optic nerve sheath complex.” The findings were suggestive of papilledema and increased intracranial pressure.

Although follow-up testing for Lyme disease remained positive, “a peripheral smear to identify Babesia species was negative on two separate studies,” the authors state. Therefore, the patient was switched to IV ceftriaxone.

“Given concern for idiopathic intracranial hypertension (IIH), he was also started on acetazolamide,” the authors state. And, because his visual symptoms, including vision loss, were getting progressively worse, an external ventricular drain (EVD) was placed for CSF diversion. This remained in place for 12 days for CSF drainage.

After a 3-week course of IV ceftriaxone, the patient had a complete resolution of symptoms including his vision loss, headaches, neck stiffness, nausea and vomiting.

Authors Conclude:

• “Intracranial hypertension with resulting neurological deterioration, while uncommon, can occur in patients with Lyme disease.”
• “While neurosurgical intervention in cases of Lyme disease is uncommon, it is important for neurosurgeons to be aware of disease complications that may require neurosurgical expertise.”