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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 64-68

A case of neuroborreliosis: A challenge to physiatrist


1 Department of Physical Medicine and Rehabilitation, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Anaesthesiology and Critical Care, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission27-Apr-2020
Date of Acceptance11-Apr-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Vinay Kanaujia
Department of Physical Medicine and Rehabilitation, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_29_20

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  Abstract 


Lyme disease is a multisystem complex illness. Neuroborreliosis is a neurological manifestation of Lyme disease. Neuroborreliosis is not very common in India. Neuroborreliosis disease sequelae sometime resolves completely but in some cases it became chronic which ultimately impairs the quality of life. Early diagnosis, medical management, and proper rehabilitation protocol improve the outcome of the disease. This case report demonstrates medical and rehabilitation management of neuroborreliosis in a middle-aged female, a native of Garhwal, Uttarakhand, with some atypical presentation.

Keywords: Atypical presentation, Lyme disease, neuroborreliosis, rehabilitation


How to cite this article:
Kanaujia V, Verma S, Yadav RK, Patra B. A case of neuroborreliosis: A challenge to physiatrist. J Orthop Traumatol Rehabil 2021;13:64-8

How to cite this URL:
Kanaujia V, Verma S, Yadav RK, Patra B. A case of neuroborreliosis: A challenge to physiatrist. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 9];13:64-8. Available from: https://www.jotr.in/text.asp?2021/13/1/64/318406




  Introduction Top


Lyme disease is a vector-borne infectious disease commonly found in the United States and the European region. It is a multisystem disease, and its presentation may vary depending upon the system involved. Patients with Lyme disease may present with early disease that is characterized by a “bull's eye rash,” fever, and myalgias, or with an early disseminated disease that can manifest with arthralgias, cardiac conduction abnormalities, or neurologic symptoms. Neuroborreliosis is a neurological manifestation of Lyme disease. It is caused by spirochetes of the genus Borrelia burgdorferi and transmitted to humans through the bite of infected black-legged ticks.[1] (Incubation period varies from 3 to 32 days). Deer are the reservoir of the organism.[2] The classical clinical triad of acute neuroborreliosis includes lymphocytic meningitis, cranial neuropathy, and painful radiculopathy. Neuroborreliosis is less common in the Indian scenario; however, due to more migration of peoples, the cases are increasing. A few cases have been reported previously mainly from India.[3] This case report demonstrates the medical and rehabilitation management of neuroborreliosis in a middle-aged female, a native of Garhwal, Uttarakhand.


  Case Report Top


A 46-year-old woman resident of the hilly-forested area admitted in the intensive care unit (ICU) for sudden severe respiratory distress, who required mechanical ventilation. After 2 days of ICU, the course patient was successfully extubated and shifted to the neurology department. After medical stabilization, the patient was handed over to the department of physical medicine and rehabilitation for further management and rehabilitation. In history, the patient was having an intermittent low-grade fever for 10 days followed by abnormal sensations in the lower limb and then in the upper limb. Three days later, she was complaining of gradually progressive weakness of both lower limbs followed by upper limbs. She was also having hypophonia, difficulty in respiratory, deglutination, and tingling and burning sensation in the upper and lower limb. There was a history of working in the forest area before symptoms appear. There was also a history of a diffuse red rash over the right forearm. [Figure 1]. There was no history of seizures, bladder, and bowel involvement.
Figure 1: Lesion at forearm

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Physical examination showed largely symmetrical sensorimotor dysfunction, with greater motor involvement causing an areflexic flaccid quadriparesis with 5th, 7th, 9th, and 10th cranial nerve involvement.

The differential diagnosis of this picture is potentially broad encompassing myelopathies, polyneuropathies, and neuromuscular junction (NMJ) disorders. Acute myelopathies were ruled out by clinical examination as a predominant feature were of lower motor neuron type (weakness, hypotonia and decreased/absent reflexes) and the magnetic resonance imaging (MRI) of spine was normal. NMJ disorders also present with acute flaccid paralysis, but the presence of sensory symptoms and nerve conduction study (NCS) in our patient ruled out these diagnoses. Initially, acute polyneuropathy (Guillain–Barré) was taken into consideration which was favored by cerebrospinal fluid finding and NCS, but it was mild responsive of intravenous immunoglobulin (Ig) for 5 days. Laboratory investigations and imaging studies are summarized in [Table 1] and [Table 2], respectively. The patient was diagnosed as neuroborreliosis given highly positive serology (Borrelia IgG and IgM). In the 2nd week of admission, she was started on tablet doxycycline 100 mg twice a day (BD), tablet amoxicillin 500 mg orally three times a day (TDS) per orally (PO), and injection ceftriaxone 1 g intravenous BD for 14 days. Neuropathic pain was managed with tablet gabapentin 600 mg and tablet amitriptyline 10 mg along with other symptomatic management. We have received the patient in the 3rd week of admission, with a nasogastric (NG) tube given having a weak gag reflex and indwelling urinary catheter in situ. The weakness was more pronounced on the right side (Medical Research Council [MRC] grade 2/5) than on the left side (MRC grade 3/5) in the upper limb. There was distal (MRC grade 1/5) more than proximal weakness (MRC grade 2/5) in her lower limbs. Initially, regular chest physiotherapy and passive/active-assisted mobilization of the upper and lower limbs were started. Breathing exercise, swallowing exercises, oromotor stimulation, and facial muscle stretching exercises were started. Tilt table training was done to adapt postural hypotension. At the end of the 3rd week of admission, the NG tube was removed as bedside swallowing tests were found normal. Oral feeding started with semisolid and then shifted to solid food items. When the patient became asymptomatic in tilt table at the angle of 90 degree for 30 minutes. After that MAT exercises were started to train the patient for strength and stability.[4] Along with the these exercises, transfer training [wheel chair (wc) to mat, wc to commode, wc to bed, mat to wc, commode to wc and bed to wc ] was done by occupational therapist. The strengthening exercise protocol was started [Table 3]. Serial examination showed recovery in the upper and lower limbs [Table 4]. On the 6th week of admission, standing training was done within the parallel bar with bilateral ankle–foot arthrosis followed by robotic gait training on LOKOMAT. On the 7th week of admission, she was able to walk within the parallel bar with support. After achieving a Hassle-free walking, the patient was taken out parallel bar and started walking on the ground with a walker. At the time of discharge, she has improved significantly in muscle power in the upper limb (MRC grade 4/5 bilaterally) and in the lower limb (MRC grade 3/5 proximally and MRC grade 2/5 distally). Her functional independence score was 82 at the time of discharge and 48 at transfer. Home-based exercise program with some home modification was explained and advised to review after 1 month.
Table 1: Investigation 1

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Table 2: Investigation 2

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Table 3: Therapeutic exercises protocol

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Table 4: Comparison of muscle strength at initial evaluation, reassessment, and discharge

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  Discussion Top


Neurological manifestations, termed Lyme neuroborreliosis, occur in about 10% of patients with Lyme disease.[5] Lyme disease has three stages: early infection, disseminated infection, and late-stage infection. Early infection is characterized by a local erythematous skin lesion called erythema migrans at the site of bite of tick followed by flu-like features, such as fever, cough, running nose, and muscle aches.[6] A tick bite can be unrecognized in most cases because of the small size of tick and regular working in the forest area as found in our case, the patient had not given the history of the tick bite, but the rash was present in the right lower back region. The second stage of the disease shows neurological involvement. Neurologic symptoms of neuroborreliosis include meningoradiculitis (which is more common in European patients), cranial nerve abnormalities, and altered mental status. The most commonly affected cranial nerve is the facial nerve.[7] Other cranial nerves may also be involved very rarely. There are few reports on cases of Lyme disease with more than one cranial neuropathy.[8] In this case on clinical examination, we have found the involvement of multiple cranial nerves (fifth, seventh, ninth and tenth cranial nerve). Neuropathic pain may be as severe to affect daily life due to radiculitis. In our case, the patient was having severe neuropathic pain. Late-stage Lymes can present with Lyme arthritis. 10%–20% of people with untreated Lyme disease will develop chronic arthritis. Lyme arthritis primarily affects only a few joints (knee is the most common) but can shift from one joint to another, primarily large joints such as elbow, shoulder, and hip. People treated with appropriate antibiotics in the early stages of Lyme disease usually recover rapidly and completely. Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil. People with a certain neurological or cardiac form of illness may require intravenous treatment with antibiotics such as ceftriaxone or penicillin [Table 5].[9]
Table 5: Evidence-based treatment protocol of Lyme disease

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  Conclusion Top


Neuroborreliosis may present with both acute and persistent manifestations. Persistent manifestations may produce profound impairment in the quality of life of the patient. Proper medical and rehabilitation management may limit the disease course and reduce morbidity. These types of clinical manifestations of burgdorferi infection have not been reported before, to our knowledge, and they demonstrate that the whole spectrum of burgdorferi infection is still unknown.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rupprecht TA, Koedel U, Fingerle V, Pfister HW. The pathogenesis of Lyme neuroborreliosis: From infection to inflammation. Mol Med 2008;14:205-12.  Back to cited text no. 1
    
2.
Grubhoffer L, Golovchenko M, Vancovÿ M, Zacharovovÿ-Slavíckovÿ K, Rudenko N, Oliver JH Jr. Lyme borreliosis: Insights into tick-/host-Borrelia relations. Folia Parasitol (Praha) 2005;52:279-94.  Back to cited text no. 2
    
3.
Vasudevan B, Chatterjee M. Lyme borreliosis and skin. Indian J Dermatol 2013;58:167-74.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Buck M. Mat activities. In: Adler S, editor. PNF in Practice. 4th ed. Berlin, Heidelberg: Springer; 2014. p. 193-236.  Back to cited text no. 4
    
5.
Pachner AR, Steiner I. Lyme neuroborreliosis: Infection, immunity, and inflammation. Lancet Neurol 2007;6:544-52.  Back to cited text no. 5
    
6.
Hengge UR, Tannapfel A, Tyring SK, Erbel R, Arendt G, Ruzicka T. Lyme borreliosis. Lancet Infect Dis 2003;3:489-500.  Back to cited text no. 6
    
7.
Halperin JJ. Nervous system Lyme disease. Infect Dis Clin Nort Am 2008;22:261-74.  Back to cited text no. 7
    
8.
Halperin JJ, Logigian EL, Finkel MF, Pearl RA. Practice parameters for the diagnosis of patients with nervous system Lyme borreliosis (Lyme disease). Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1996;46:619-27.  Back to cited text no. 8
    
9.
Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: A review. JAMA 2016;315:1767-77.  Back to cited text no. 9
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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