engleski

Chronic Lyme neuroborreliosis mimicking tuberculous meningitis

INTRODUCTION: Chronic Lyme neuroborreliosis can present atypical CSF findings making it diagnostically challenging since it mimics other infective and non-infective neurological diseases. Case report: A 60-year-old man was admitted to the hospital because of intermittent numbness and tingling sensation in his right foot, gait instability and double vision for the past three months. During the last 9 months he also noticed a low-grade fever and significant weight loss. His family history was positive for pulmonary tuberculosis. Exam revealed wide-based unsteady gait and ysdiadochokinesia. His brain MRI showed hyperintense lesions in thalamus, internal capsule, basal ganglia and tegmentum of mesencephalon and pons in FLAIR sequence and discrete imbibition of leptomeninges in the postcontrast T1-weighted image. MRI of the cervicothoracic spine showed imbibition of leptomeninges at the C2-Th1 level in postcontrast T1WI and intramedullary hyperintense lesion in T2WI at the C3-C6 level. Cerebrospinal fluid revealed mononuclear (98%) pleocytosis (170x106/L), protein content of 12.47 g/L and glucose level of 0.7 mmol/L. Gram, India ink and acid-fast stains were negative. CSF bacterial and fungal cultures, Cryptococcus antigen latex agglutination and Xpert®MTB/RIF (PCR) assay were negative. Adenosine deaminase in the CSF was 68.9U/L and the interferon-gamma release assay was positive. Blood-brain barrier dysfunction with intrathecal synthesis of IgG was found. Serum and CSF Borrelia burgdorferi IgG antibodies were positive (609IU/L and 2400IU/L, respectively). The calculated CSF IgG-antibody index was 3.6 indicating intrathecal synthesis of B.burgdorferi IgG. The treatment consisted of isoniazid, rifampin, ethambutol and pyrazinamide with high- dose dexamethasone (32mg per day) in addition to intravenous ceftriaxone (2g per day). Antituberculous treatment was terminated only when consecutive CSF cultures of M.tuberculosis were reported negative. The patient recovered fully and the control MRI was completely normal. CONCLUSION: We conclude that in all patients with brainstem encephalitis or acute transverse myelitis, neuroborreliosis should always be considered regardless of unusual CSF findings.

Chronic Lyme neuroborreliosis, mimicking, tuberculosis, meningitis

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