Lyme Meningitis in Children with Aseptic Meningitis

By Hal B. Jenson, MD, FAAP

Dean, Western Michigan University School of Medicine, Kalamazoo, MI

Dr. Jenson reports no financial relationship to this field of study. This article originally appeared in the December 2011 issue of Infectious Disease Alert. At that time it was peer reviewed by Timothy Jenkins, MD, Assistant Professor of Medicine, University of Colorado, Denver Health Medical Center. Dr. Jenkins reports no financial relationship to this field of study.

Synopsis: The prevalence of Lyme meningitis among children with nonspecific aseptic meningitis occurring from April through December in the years 2006 through 2009 in an endemic area for Lyme disease was 13.3% (95% confidence interval [CI], 6.3%-25.1%).

Source: Garro AC, et al. Prevalence of Lyme meningitis in children with aseptic meningitis in a Lyme disease-endemic region. Pediatr Infect Dis J 2011;30:990-991.

A descriptive study enrolled children 2-18 years of age presenting to a pediatric emergency department in Rhode Island during the months of April through December of 2006-2009. Children were enrolled who had pleocytosis, defined as white blood cell count of > 8/mm3 in the cerebrospinal fluid (CSF), in the absence erythema migrans rash, cranial neuropathy, papilledema, a positive Gram stain, antibiotic use within 2 weeks, chronic neurologic disease, or an indwelling ventricular shunt. Serum Borrellia burgdorferi studies were recorded if ordered by the referring physician, though this testing is not standard of care and was not required for study participation. CSF B. burgdorferi ELISA studies were performed if there was sufficient CSF.

Confirmed Lyme meningitis was defined by positive 2-tier B. burgdorferi serologic studies using the Centers for Disease Control and Prevention (CDC) criteria (ELISA followed by Western blot of positive or equivocal samples, with Western blot IgM positive for at least 2 of 3 proteins at 23, 39, and 41 kD; and IgG positive for at least 5 of 10 proteins at 23, 28, 30, 39, 41, 45, 58, 66, and 93 kD). Probable Lyme meningitis was defined by positive CSF B. burgdorferi ELISA, which is not diagnostic for Lyme meningitis but suggestive in the presence of pleocytosis.

Of the 104 children who were screened, a total of 60 children were enrolled. Among the excluded cases were 10 children with erythema migrans, which is diagnostic of Lyme disease, and 9 children with cranial neuropathy without erythema migrans, which in the presence of pleocytosis indicates a high probability of Lyme meningitis. The median age was 10 years (range, 2.8-18.0 years), 57% were male, 56% were non-Latino white, 26% were Latino, 10% were black, and 8% were other ethnicity.

Among the 60 children there were 30 children with tier-2 B. burgdorferi serologies available, which showed 8 confirmed cases (8/60) for a minimum prevalence of Lyme meningitis of 13.3% (95% CI, 6.3%-25.1%). Of these 8 cases, 7 had sufficient CSF for ELISA and 6 were positive. CSF ELISA of the remaining 30 children identified 1 case of probable Lyme meningitis. The minimum prevalence of confirmed or probable cases (9/60) was 15.0% (95% CI, 7.5%-27.1%). None of the 9 children had a history of Lyme disease.

Commentary

This interesting report probably underestimates the prevalence of Lyme meningitis in children because serum B. burgdorferi studies are not standard of care and in this study were obtained in only half of the cases. CSF B. burgdorferi ELISA may be performed but may be negative, as occurred in 1 case in this series, because the intrathecal antibody response is usually detectable after at least 2 weeks of neurologic symptoms.

The results indicate that clinicians should perform serum B. burgdorferi studies for children presenting with undifferentiated aseptic meningitis in Lyme disease-endemic regions during appropriate seasons. Lyme meningitis is very amenable to treatment and failure to diagnose may permit progression and delay resolution of symptoms.