Clinical, diagnostic and immunological characteristics of patients with possible neuroborreliosis without intrathecal Ig-synthesis against Borrelia antigen in the cerebrospinal fluid.

Magnus Vrethem,Jan Ernerudh,Pia Forsberg,Ulf Garpmo,Mona Widhe

doi:10.4081/ni.2011.e2

Abstract

The diagnosis of neuroborreliosis is not always straightforward. Intrathecal immunoglobulin (Ig) synthesis against Borrelia antigen may not be detected, at least early in the disease course. Also other neurological and infectious diagnoses have to be considered. We have studied patients with clinical possible neuroborreliosis without intrathecal Ig synthesis against Borrelia antigen in the cerebrospinal fluid (CSF) (n=17). Diagnosis was based on typical clinical history and at least one of the following findings; mononuclear leucocytosis in the CSF (n=4); typical erythema migrans >5 cm in diameter in relation to debut of symptoms (n=8); prompt clinical response to antibiotic teratment (n=14). Also other possible diagnoses had to be excluded. Seventeen patients first investigated because of suspected neuroborreliosis but later confirmed with other diagnoses were used as controls. All patients had a lumbar puncture. Borrelia specific IFN-γ and IL-4 secretion was investigated in peripheral blood (PBL) and CSF with an ELISPOT assay. Polymerase chain reaction (PCR) was used to reveal any Borrelia antigen in the CSF. Six of 17 patients with possible neuroborreliosis showed high IFN-γ secretion in peripheral blood, otherwise we found no statistically significant differences between the groups. PCR did not reveal any Borrelia antigen in CSF. The diagnosis and treatment of possible but not confirmed neuroborreliosis is a clinical challenge. The clinical response to treatment may be the best option in these cases.

Highlights

We have studied patients with - clinical possible neuroborreliosis without n intrathecal Ig synthesis against Borrelia antio gen in the cerebrospinal fluid (CSF) (n=17)
We identified a subgroup of patients with typical neurological symptoms without intrathecal synthesis of Borrelia specific antibodies (n=17, 9 women and 8 men, mean age 50.5 years) but with intrathecal leucocytosis (n=4), erythema migrans in relation to symptoms (n=8) and/or response to antibiotic treatment (n=14), referred to as possible neuroborreliosis
The mean of triplicates or duplicates was used in the analysis of cytokine results

Summary

Introduction

We have studied patients with - clinical possible neuroborreliosis without n intrathecal Ig synthesis against Borrelia antio gen in the cerebrospinal fluid (CSF) (n=17). Intrathecal synthesis of Borrelia antibodies is of diagnostic importance[4] and so is mononuclear leucocytosis in the cerebrospinal fluid (CSF) and signs of blood-brain barrier damage.[5] Polymerase chain reaction (PCR) has been utilised in several studies but is not routinely recommended due to the limited clinical sensitivity of this method.[6,7] When the diagnosis of neuroborreliosis is confirmed or highly likely treatment with antibiotics is initiated. The purpose of our study was to investigate diagnoses were used as controls (8 women and typical erythema migrans >5 cm in diameter in patients with clinical possible neuroborreliosis 9 men, mean age 44.5 years).

Materials and Methods

26 Headache F 56

Discussion