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10/3/2004
Pediatric Lyme Disease
Dr. Ann F Corson
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Risk Factors Risk Factors
• Having pets that come in and out, dogs or
• Age 10-19
cats
• Rural (suburban) vs. urban, 3x risk
• Single family homes • Outdoor activities:
• Horseback riding
• Homes with yards +/- woods or attached land
• Hunting, fishing
• Homes within 100 feet of woodland
• Any activity in the woods or open land or abutting
• Tick hosts being seen on land: deer, mice high grasses including field sports, golf
Public Health Reports 2001, Volume 116, 146-156. Risk Factors for Lyme Disease in
Chester Country, Pennsylvania
• Activities in any outdoor area frequented by deer
• CDC: Any child under 9 yrs at risk with many
new cases LD in children under 14 yrs Anyone can be infected on any
MMWR 1991. 42; 557-558
warm day of any month of the year!
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Signs and Symptoms Signs and Symptoms
• Lyme disease is truly is the “great imitator” of our • All children
time just as syphilis was for prior generations – Tick bite – less than 50% remember a bite,
• All organ systems of the body can be affected even less remember an EM rash
• Onset of illness may be abrupt or indolent – Flu-like illness at any time of year in 80%
• Symptoms are often vague and shift from day to (parents often claim the child was never
day therefore many children are thought be well again)
maligning
– Fatigue, often unrelieved by rest, in 100%
• Children often don’t understand what is wrong
with their bodies – Unexplained cyclical fevers
– Headaches occur in 90% to 100%
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Signs and Symptoms Signs and Symptoms
• All children, cont.
• All children, cont.
– Abdominal pain in about 50%, can mimic
– Dizziness
acute appendicitis, mesenteric adenitis,
– Neck pain and stiffness in almost 90%
Crohn’s disease, colitis, irritable bowel
– Sore throats
syndrome, sometimes vomiting, heartburn
– Swollen lymph nodes
– Excessive thirst – Urinary urgency and frequency, sudden lack
– Chest pains in at least 70%, some have palpitations
of control in toilet trained child, return to or
– Sense of air hunger or shortness of breath, dry cough
new onset enuresis.
– Rashes that come and go, malar rashes, new
psoriasis
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Signs and Symptoms Signs and Symptoms
• All children, cont.
• All children, cont.
– Migratory arthralgias, joint pains in 50% to
100% (arthritis in only 40%), myalgias in over – Neurological symptoms are protean and can
80%, back ache, morning stiffness, pain at appear at any time during the course of
rest, muscle weakness infection (few weeks to over a year or more)
• Hypersensitivity of skin, scalp and hair
– Frequent illnesses, dark circles under their • Hypersensitivity to noise, light, smell
eyes, intermittent red, hot pinnae of ears • Alterations of taste
– Sleep disturbance in over 80% • Poor balance and coordination
• Trouble falling asleep • Uncharacteristic behavior outbursts, mood disturbances,
• Frequent awakenings depression in over 90% with suicidal thoughts in over 40%
• Excessive sleep • Social withdrawal, decreased participation
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Signs and Symptoms Signs and Symptoms
• All children, cont. • All children, cont.
– Neurological symptoms, cont. – Neurological symptoms, cont.
• New onset phobias, anxiety disorders • When measured with formal neuropsychiatric testing,
• Oppositional behaviors children demonstrate defects in auditory and visual
• Obsessive compulsive disorders sequential processing
• Deterioration in school performance in over 90% less commonly:
• Difficulty with concentration and attention in school with • Movement disorders – spasticity, ataxia, motor or vocal
easy distractibility as well as “brain fog” in over 80% tics
• Word finding problems in over 80% • Cranial neuropathies, e.g. Bell’s Palsy or optic nerve
neuritis (can result in visual loss)
• Short term memory difficulties in over 90%
• Peripheral neuropathies – numbness and tingling, distal
• New onset ADD
parasthesias, subtle weakness
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Signs and Symptoms Signs and Symptoms
• Adolescents
• All children, cont.
– Parents and teachers may think any unusual
– Neurological symptoms, cont. behaviors are just “normal” adolescence or
• Peripheral motor weakness
problems such as illicit drug use or new onset
• Partial complex seizures
psychiatric disorder
• Apparent demyelinating disease (multiple sclerosis)
• Spinal cord involvement – Mood swings, oppositional behaviors, anxiety,
• Pseudo tumor cerebri or increased intracranial pressure, depression
papilledema
– Self mutilating behaviors
– Teenagers often do not report to or show
parents problems with their bodies
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Signs and Symptoms Signs and Symptoms
• Adolescents, cont. • Pre-schoolers and toddlers
– Teens can also turn to alcohol and illicit drugs – Mood swings, sudden emotional outbursts
as self medication – Irritability
– Teenage girls may have pelvic pain or – Personality changes
menstrual problems, ovarian cysts, boys may – Regression of motor and social skills
have testicular pain (developmental milestones)
– Teens need to be aware that Borrelia may be – Changes in play behavior, tire easily, less
sexually transmitted and that a fetus can active
acquire the infection from the mother during
pregnancy
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Signs and Symptoms Congenital Lyme disease
• Pre-schoolers and toddlers, cont. • Infants can be infected with Borrelia
– Trouble falling asleep, frequent awakenings transplacentally in any stage of pregnancy
– Nightmares, new phobias, recurrence of and/or via mother’s breast milk.
separation anxiety • The co-infections: Babesia, Bartonella,
– Diaper rash unresponsive to normal treatment Mycoplasma and perhaps even the
– Frequent URIs, ear and throat infections, Ehrlichias can be transmitted
bronchitis, pneumonia transplacentally to the developing fetus.
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Congenital Lyme disease Congenital Lyme disease
• Gestational Borreliosis can be associated • Borrelia spirochetes have been found at autopsy
with repeated miscarriages, fetal death in in fetal brain, liver, adrenal glands, spleen, bone
utero, fetal death at term (stillbirths), marrow, heart and placenta
– None of the infected tissues showed any sign of
hydrocephalus, cardiovascular anomalies, inflammation
intrauterine growth retardation, neonatal • Maternal antibiotic treatment during pregnancy
respiratory distress, “sepsis” and death, does not guarantee that the fetus will be free of
neonatal hyperbilirubinemia, cortical infection
blindness, sudden infant death syndrome • Mothers with Lyme disease should be treated
and maternal toxemia of pregnancy. throughout pregnancy
Sunday, October 03, 2004 Pediatric Lyme Disease 19 Sunday, October 03, 2004 Pediatric Lyme Disease 20
Congenital Lyme disease Congenital Lyme disease
• Infants either infected congenitally or from • Infants infected congenitally can have
breast milk can have
– Small windpipes (tracheomalacia)
– Floppiness with poor muscle tone
– Irritability – Eye problems (cataracts)
– Frequent fevers and illness early in life – Heart defects
– Joint sensitivities and body pain • Infants bitten very early in life will have
– Skin sensitivity many of the same symptoms
– Gastro esophageal reflux – loss and decline in developmental milestones
– Developmental delays
– Learning disabilities and psychiatric problems
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Co-Infections Co-Infections
• Bartonella henselae: abdominal pain, • Ehrlichiosis: high fevers, headaches,
headache, visual problems, significant lymph muscle pains, flu-like symptoms. Labs
node enlargement (e.g. mesenteric adenitis), can show low WBC, platelets and
rashes, unusual “stretch marks”, resistant
neurological deficits, new onset seizure disorder,
increased liver enzymes
acute encephalitis • Mycoplasma sp.: fatigue, abdominal pain
• Babesia microti (and other species): malarial • Viruses: abdominal pain, mouth sores
like illness inside red blood cells with intermittent
fevers, chills, day and night sweats, abdominal
pain, profound fatigue
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Co-Infections Evaluation
Co-Infections are the rule, not the exception • Tick borne disease is a clinical diagnosis
• Co-Infections are often best diagnosed clinically • Laboratory testing can be very difficult as many
patients are serologically negative for antibodies
• Co-Infected patients are:
to Borrelia despite active infection
– sicker
• Routine labs are usually unremarkable
– more likely to have failed prior treatment
• Even the majority of spinal taps reveal normal
– require longer treatment with multiple agents
spinal fluid
• Co-Infections must be eradicated or Borrelia • Full evaluation at labs that specialize in TBD can
infection will persist be very helpful although negative results do not
mean absence of disease
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Treatment School issues
• Treatment lasts as long as is necessary • Teachers, school administrators, school
– Until children are completely symptom free for 2 to 3
months
health professionals, pediatricians, family
– No more cyclical Herxheimer reactions practitioners and parents all need to be
– No recurrence of Lyme symptoms with concomitant aware of the protean manifestations of
infections, illnesses or stresses, e.g. surgery, trauma,
psychological stresses
TBD
• Sickest children often need many months of • Mental health professionals and educators
intravenous antibiotic therapy in Lyme endemic areas need to recognize
• Children whose diagnosis and treatment are the possible infectious etiology of
delayed may suffer considerable impairment
neuropsychiatric disease in children.
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School issues Social impact
• It is imperative to identify children with persistent • Isolation
neuroborreliosis so they can receive appropriate
medical, psychological and educational • Loss of peers and normal socialization
assistance. • Loss of self-esteem
• Two Federal laws exists that protect students
with Lyme disease and supercede state codes • Inability to participate in sports or
and regulations: extracurricular activities
– IDEA: Individuals with Disabilities Education Act • Loss of academic work
www.ideapractices.org
– Section 504 of the 1973 Rehabilitation Act • Interruption of normal family life
www.504idea.org
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Social impact Prevention
• Quote from Pat Smith, President of the Lyme • Avoid exposure to ticks
Disease Association, from her address to • Get the deer out of your yard and spray yard
Congress: with permethrin
“The emotional damage these children suffer is • Clear away underbrush and cut back shrubbery
tremendous and it follows them though out the most
• Wear protective clothing and use appropriate
impressionable stages of their lives. To get out of
bed is an accomplishment, to shower is a miracle.
insecticides while outdoors
They have few or no friends, no regular school • Put out Damminix® for mice to use in nests
attendance, no sports or activities, and no self- • Contact your local government regarding tick
esteem. Some contemplate suicide, unfortunately, and deer control and elimination
some are successful.”
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Caveats Caveats
• Any child who becomes ill after a tick bite • Neurological signs and symptoms are often the
most common indication of persistent infection
needs a full evaluation for the presence of after inadequate treatment
co-infections • In 1989, Dr. Pachner predicted that “If, as it now
• Any child who becomes ill after a tick bite seems, the Lyme spirochete is indeed highly
who was treated with 3 to 4 weeks of oral neurotrophic and able to remain dormant in the
CNS for long periods, we may well see a sizable
antibiotics has most likely been number of individuals who currently have latent
inadequately treated. neuroborreliosis presenting in the future with
• Initial inadequate treatment makes future symptomatic infection.”
treatment more difficult
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Selected references Selected references
Andrew Pachner. Neurological Manifestations of Lyme Desease, the
New “Great Imitator”, Reviews of Infectious Deseases. Vol II, MacDonald, MD. Gestational Lyme Borreliosis Implications for the
Supplement 6. September-October 1989. Fetus, Rheumatic Disease Clinics of North America, Volume 15,
Number 4. November 1989.
Pietrucha, MD. Neurological Manisfestations of Lyme Disease in
Children Lyme Disease and other Tick-Borne Diseases: A Two Day Discussion
A review of over 300 children with LD. 1991 of the Most Recent Developments in Research and Clinical
Management, November 13-14,1999.
Bloom et al. Neurocognitive abnormalities in children after classic
manifestations of Lyme disease, Pediatric Infectious Disease
Journal 1998;17:189-96. Lyme & Other Tick-Borne Diseases: Focus on Children & Adolescents,
A National Conference for Physicians & Allied Health Professionals,
November 4, 2000.
Fallon et al. The Underdiagnosis of Neuropsychiatric Lyme Disease in
Children and Adults, The Psychiatric Clinics of North America.
Volume 21 Number 3 September 1998. The Lyme Times: issues July-October 1999, Winter 2001/Spring 2002,
Fall/Winter 2002/3.
Tager et al. A Controlled Study of Cognitive Deficits in Children With
Chronic Lyme Disease, The Journal of Neuropsychiatry and Clinical Personal communication, Dr. Charles Ray Jones 2003-2004.
Neurosciences 2001: 13:500-507.
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Selected references
• Web sites:
– www.ilads.org
– www.lymepa.org
– www.lymediseaseassociation.org
Sunday, October 03, 2004 Pediatric Lyme Disease 37
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