Dados do Trabalho

Título

Neuroborreliosis, mantaining a high suspition: Case report

RESUMO

A previously healthy 38-year-old woman presented to an emergency care in São Paulo -Brazil due to severe holocranial headache, nausea and vomiting for the last 7 days. During initial evaluation, she was agitated and disoriented in time and space, but had otherwise normal physical and neurological exams. She denied fever and skin rash and had no signs of meningeal irritation. As for epidemiologic history, she lived in Geneva and was recently vacationing in the USA (Kansas and Washington) before coming to Brazil.
Initial tests showed mild neutrophilic leukocytosis and a positive -hCG test. Inflammatory and rheumatologic tests were normal and there were no organ disfunctions. Brain MRI showed only non-specific FLAIR hyperintensity in some cortical sulci. CSF analysis showed a slightly elevated opening pressure 21cmH2O, 38 cells with lymphocitic predominance, 65mg/dL protein, normal glucose and somewhat elevated ADA 4,8mg/dL and lactate 22mg/dL. Serologies for toxoplasma, syphilis, herpes family and bacteriological, micobacteriological and fungal test were negative. Nevertheless, due to clinical suspicious of encephalitis, IV acyclovir and ampicillin were introduced empirically.
After 5 days, due to symptomatic maintenance, further analysis of the CSF was conducted with a negative herpes-family PCR and a positive ELISA IgM for Borreliosis. Ampicillin and acyclovir were discontinued and intravenous ceftriaxone was introduced and maintained for 28 days with progressive symptomatic improvement.
Discussion: Lyme disease is a tick-borne illness, endemic in the USA and some parts of Europe. It usually starts within a month of the tick bite by presenting with characteristic skin rash and constitutional symptoms. After a few months, neurologic findings may follow, being the most commom presentations cranial nerve palsies, radiculopathy, lymphocytic meningitis and, rarely, encephalomyelitis. For the diagnosis, ELISA and Westernblotting essays for B. burgdoferi s.s. antigens are used.
As for the treatment, being the patient pregnant, she was unable to receive oral doxycycline. In these cases possible options are IV cefotaxime, G penicillin or ceftriaxone, which was the therapy of choice in this case.
Final Comments: In this study we present an unusual case in our country, with non-specific symptoms. Serologic testing combined to an epidemiologic exposure were key for the diagnosis, reinforcing the importance of extensive questioning of travel history during anamnesis.

Palavras Chave

Neuroborreliose, Lyme, borreliosis, meningitis