Background Although the incidence of Lyme disease is highest in children, there are few prospective data on the clinical manifestations and outcomes in children. Methods We conducted a prospective, longitudinal, community-based cohort study of children with newly diagnosed Lyme disease in an area of Connecticut in which the disease is highly endemic. We obtained clinical and demographic information and performed serial antibody tests and follow-up evaluations. Results Over a period of 20 months, 201 consecutive patients were enrolled; their median age was 7 years (range, 1 to 21). The initial clinical manifestations of Lyme disease were a single erythema migrans lesion in 66 percent, multiple erythema migrans lesions in 23 percent, arthritis in 6 percent, facial-nerve palsy in 3 percent, aseptic meningitis in 2 percent, and carditis in 0.5 percent. At presentation, 37 percent of the patients with a single erythema migrans lesion and 89 percent of those with multiple erythema migrans lesions had antibodies...

Lyme disease in children in southeastern Connecticut. Pediatric Lyme Disease Study Group.

https://www.amjmed.com/article/S0002-9343(95)99915-9/pdf

The clinical spectrum of early lyme borreliosis in patients with culture-confirmed erythema migrans

The incidence and the endemic range of Lyme disease in the United States have increased steadily since the disease was originally recognized in Lyme, Connecticut, in 1975. Because of the varied clinical manifestations of this illness and the use of unstandardized serologic testing methods, diagnosis is often uncertain and treatment outcomes are often difficult to evaluate. The antibiotic regimens that are commonly used in clinical practice have changed rapidly. They show much regional variation with little critical comparison of treatment results. The clinical diagnosis and the literature on the treatment of the various stages of Lyme disease are reviewed. The reported data are supplemented with recommendations based on 15 years of clinical experience with this illness.

Lyme Disease: Recommendations for Diagnosis and Treatment

. Lyme borreliosis is a tick-borne infection caused by the spirochete Borrelia burgdorferi, whose discovery in 1982 solved an aetiological mystery involving a variety of dcrmatological and neurological disorders and explained their association with Lyme disease. Lyme borreliosis occurs frequently and is readily treatable with antibiotics.



Along with its discovery, however, came the realization that it is difficult to diagnose accurately, especially antibody diagnosis. False-positive antibody results in particular led to gradual widening of the clinical spectrum, and differential diagnosis became increasingly difficult.



This prospective, multicentre study presents a systematic description of Lyme borreliosis in childhood, emphasizing epidemiological and clinical issues. Because, predominantly, inpatients were examined, Lyme neuroborreliosis was the focus of the study, with the chief concern being to minimize false-positive results. To this end, we chose to narrow the diagnostic criteria, using the presence of specific antibodies in the cerebrospinal fluid as the determining factor.



The epidemiological investigation was focused on the incidence of Lyme neuroborreliosis in childhood in southern Lower Saxony as well as on the prevalence of Lyme neuroborreliosis among acute-inflammatory neurological illnesses in children. The clinical part of the study aimed at establishing criteria for differential diagnosis in addition to the detection of specific antibodies. The detection of specific IgM antibodies using an IgM capture ELISA confirmed the presence of acute Lyme borreliosis.



The study examined 208 children with Lyme borreliosis, of whom 169 had Lyme neuroborreliosis, from mid-1986 until the end of 1989. The yearly incidence of Lyme neuroborreliosis in Lower Saxony was 5.8 cases/100,000 children aged 1 to 13. The manifestation index was 0.16, or one case of Lyme neuroborreliosis per 620 infected children, compared with the presence of specific antibodies against B. burgdorferi for children in the same age group and region. Both the seasonal distribution of Lyme borreliosis, which peaked in summer and autumn, as well as the information about when the tick bites took place point to an incubation period of a few weeks.



The most frequent manifestation of Lyme neuroborreliosis in childhood was acute peripheral facial palsy, found in 55% of all cases (n = 93). Lyme borreliosis proved to be the most frequently verifiable cause of acute peripheral facial palsy in children, causing every second case of this disorder in summer and autumn. Bilateral facial palsy was, without exception, found to be caused by Lyme borreliosis; thus it can be considered a specific neurological sign of this infection.



The second most common manifestation of Lyme neuroborreliosis in childhood was aseptic meningitis (27.2%, n = 46). Lyme borreliosis was the third most common cause of aseptic meningitis in childhood (11.8%).



Meningoradiculoneuritis with peripheral nerve involvement (Bannwarth syndrome) was diagnosed in only 3.6% of the children (n = 6), although this is the most common symptom of Lyme neuroborreliosis in adult patients.



The head and neck region proved to be the predominant site of tick bites in children; adults experience most bites on their extremities. The difference in the site of the infection, as well as the short duration of the illness in children and the early treatment, may partially explain the profound differences in the clinical spectrum of Lyme neuroborreliosis in children and adults.



Nearly all cases with a positive history of tick bite and/or erythema migrans in the head and neck region showed ipsilateral facial palsy suggesting a direct invasion via the affected nerve by B. burgdorferi.



Inflammatory changes in the cerebrospinal fluid along with the presence of specific antibodies are the conditio sine qua non for a diagnosis of Lyme neuroborreliosis. The presence of IgM antibodies in the cerebrospinal fluid has proved to be the most reliable diagnostic criterion, and is responsible for the early diagnosis of acute Lyme neuroborreliosis in children. The IgM capture ELISA facilitated the simple and reliable detection of intrathecal antibody synthesis which could be successfully demonstrated in three-quarters of the cases with Lyme neuroborreliosis. Specific IgG testing was negative in most cases because of the relatively short duration of the illness in children, and is therefore of less importance here than in the diagnosis of cases of Lyme neuroborreliosis in adults.



Acute Epstein-Barr and varicella-zoster viral infections both caused false-positive findings in the IgM capture ELISA.



High dose intravenous penicillin G proved to be highly effective in paediatric cases of Lyme neuroborreliosis. Although the rate of spontaneous remission may be very high, it is not possible to predict on a patient-by patient basis just when this will occur. Thus consistent antibiotic therapy is indicated.

Epidemiology and clinical manifestations of lyme borreliosis in childhood : a prospective multicentre study with special regard to neuroborreliosis

The risk of Lyme disease for humans in the eastern United States is dependent on the density of host-seeking Ixodes scapularis Say nymphal stage ticks infected with Borrelia burgdorferi. Although many local and regional studies have estimated Lyme disease risk using these parameters, this is the first large-scale study using a standardized methodology. Density of host-seeking I. scapularis nymphs was measured by drag sampling of closed canopy deciduous forest habitats in 95 locations spaced among 2° quadrants covering the entire United States east of the 100th meridian. Sampling was done in five standardized transects at each site and repeated three to six times during the summer of 2004. The total number of adults and nymphs of the seven tick species collected was 17,972, with 1,405 nymphal I. scapularis collected in 31 of the 95 sites. Peak global spatial autocorrelation values were found at the smallest lag distance (300 km) and decreased significantly after 1,000 km. Local autocorrelation statistics identified two significant high-density clusters around endemic areas in the northeast and upper Midwest and a low-density cluster in sites south of the 39th parallel, where only 21 nymphs were collected. Peak nymphal host-seeking density occurred earlier in the southern than in the most northern sites. Spatiotemporal density patterns will be combined with Borrelia prevalence data as part of a 4-yr survey to generate a nationwide spatial risk model for I. scapularis-borne Borrelia, which will improve targeting of disease prevention efforts.

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Spatiotemporal patterns of host-seeking Ixodes scapularis nymphs (Acari: Ixodidae) in the United States.

In 1982 and 1983 practicing pediatricians in a Lyme disease-endemic county, reported 90 cases of Lyme disease among children 19 years of age and younger (median age, 9 years). Three-fourths of the children had initial symptom onset in the summer months, with peak incidence in July. Infection occurred twice as often in boys than in girls, and tick bites were recalled by less than half (49%) of the children or parents. Erythema chronicum migrans was present in two-thirds (67%) of the cases with median onset 7 days after a definite tick bite. Arthritis or arthralgia occurred in 59% and neurologic symptoms, especially seventh nerve palsy, occurred in 14%. Asymmetric involvement of a few large joints, especially the knee, was most commonly reported for those with joint involvement. antibiotics were prescribed for 79% of the children, three-fourths of whom were treated with oral penicillin. Initial diagnosis of Lyme disease is usually made on clinical grounds alone because serologic tests are often negative. Serologic tests for antibody to Borrelia burgdorferi were more often positive in cases with neurological or joint involvement, in addition to erythema chronicums migrans (80%), than in cases presenting with erythema chronicums migrans only.

Lyme disease in childhood: clinical and epidemiologic features of ninety cases.

A 7-year-old male with associated anomalies of the limbs and urinary tract, very similar to three previously reported patients, is described. Acral malformations noted in the four patients have been oligodactyly, ectrodactyly, brachydactyly, and polydactyly in varying but characteristic combination. A pattern of distribution of the limb defects has been evident. The limb anomalies in the present case are a composite of those described in the previously reported patients. Urinary tract abnormalities include unilateral renal agenesis and duplication of the collecting system. Minor anomalies present in two or more patients were arched palate, sternal deformity, hypoplastic auricular helices, widely spaced teeth, coxa valga, cinodactyly of the fifth finger, hypospadias, cryptorchidism, antimongoloid slanting of palpebral fissures. Findings not previously reported were Brushfield9s spots, vertically grooved nasal tip, deficient pectoralis major muscle, hypoplastic twelfth ribs, spina bifida occulta of L5. All patients have been phenotypic males, with increased paternal reproductive age in three. The authors suggest that a new syndromic (acro-renal) relationship of unknown etiology has been established.

Associated acral and renal malformations: a new syndrome?

Epidemiological and clinical characteristics of 210 cases of Lyme disease in Westchester County, New York, reported during 1982 and 1983 are described. Most cases occurred during summer months in individuals under age 40 (male: female ratio 1:2 to 1). Symptoms included skin rash (75 per cent), joint pain or swelling (50 per cent), Bell's palsy (11 per cent), and aseptic meningitis (3 per cent). With greater public and medical awareness of this tick-borne disease, Lyme disease is being recognized with increasing frequency characteristic of an emerging epidemic in Westchester County.

Lyme disease: epidemiologic characteristics of an outbreak in Westchester County, NY.

Lyme Disease during Pregnancy A Cord Blood Serosurvey

Early definitions limited public health essentially to sanitary measures invoked against nuisances and health hazards with which the individual was powerless to cope, and which, when present in one individual could adversely affect others. Insanitation and later communicability were the criteria followed in deciding whether a problem fell within theconcern and jurisdiction of public health. With the great bacteriologic and immunologic discoveries of the late nineteenth and early twentieth centuries, and the subsequent development of techniques for their application, the concept of prevention of disease in the individual was added. Public health then came to be regarded as an integration of sanitary science and medical science.’

Anita S. Curran

Papers

Lyme disease in childhood: clinical and epidemiologic features of ninety cases.

Associated acral and renal malformations: a new syndrome?

Lyme disease: epidemiologic characteristics of an outbreak in Westchester County, NY.

Lyme Disease during Pregnancy A Cord Blood Serosurvey

Public health: priorities and policy setting in the real world.