Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published November 7, 2018


Are CSF tests necessary to establish a diagnosis of Lyme disease with central nervous system involvement? 

It is not uncommon during the summer and fall months in New England to make a diagnosis of Lyme polyradiculitis or meningoradiculitis in a patient who presents with a syndrome of subacute, multifocal, painful radiculitis. The syndrome typically affects the arms and legs in an asymmetric fashion and is often associated with cranial nerve palsies. Read the latest Case Records of the Massachusetts General Hospital here.

Clinical Pearls

Q: How long after initial infection do patients with Lyme meningoradiculitis typically present?

A: Patients who have Lyme meningoradiculitis typically present 2 to 18 weeks after infection, during the early disseminated phase, with pain, sensory loss, and areflexic weakness.

Q: What cranial nerve palsy is most commonly seen in patients with Lyme meninogoradiculitis?

A: Over half of patients with Lyme meningoradiculitis present with seventh cranial nerve palsy — a manifestation of Lyme disease that many recognize — but any cranial or spinal nerve root may be involved.

Morning Report Questions

Q: Are cerebrospinal fluid (CSF) polymerase-chain-reaction (PCR) assays recommended in cases of suspected Lyme neuroborreliosis?

A: Direct detection of the infectious agent with CSF PCR assays is usually not possible. CSF PCR assays for Lyme-related borrelia are not recommended, and a negative assay does not influence diagnostic considerations, because sensitivity of the assay is poor.

Q: Are CSF tests necessary to establish a diagnosis of Lyme disease with central nervous system involvement?

A: When a patient is seropositive and has a characteristic clinical syndrome for Lyme neuroborreliosis, CSF tests for Lyme disease are unnecessary to establish a diagnosis. When Lyme neuroborreliosis with central nervous system involvement is suspected, detection of intrathecal Borrelia burgdorferi antibody production can support the diagnosis, but its absence does not rule out the diagnosis. The best method for the detection of intrathecal B. burgdorferi antibody production is determination of the CSF–serum antibody index with quantitative enzyme-linked immunosorbent assays (ELISAs) or similar assays, rather than immunoblot assays.

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