As a practicing pediatrician in East Hampton, NY, where Lyme disease is endemic, I read with interest the recently published case by Riva Kamat, MD, involving a girl with Lyme meningitis who underwent a lumbar puncture.1
As a practicing pediatrician in East Hampton, NY, where Lyme disease is endemic, I read with interest the recently published case by Riva Kamat, MD, involving a girl with Lyme meningitis who underwent a lumbar puncture.1 I have seen several cases of Lyme meningitis as well as Bell palsy from Lyme disease. Bell palsy from Lyme disease is a peripheral neuropathy, not a symptom of meningitis--as was described in Dr Kamat's case. In and of itself, Bell palsy does not constitute an indication for treatment of CNS disease. Animal studies have shown that many monkeys with early-stage infection with Borrelia burgdorferi have a moderate amount of leukocytosis in the cerebrospinal fluid (CSF). The more specific test for CNS disease is elevated CSF antibody production compared with paired serum.
Most physicians in this area of New York do not do spinal taps on patients with headaches and an erythema chronicum migrans rash unless they have meningismus. Seventh cranial nerve palsy alone is not an indication for a spinal tap.
----Gail Schonfeld, MD
East Hampton, NY
I thank Dr Schonfeld for her comments. In northeastern Virginia, where I work, the incidence of Lyme disease is lower than in New York State. Still, we see a fair number of patients with this infection at our hospital. When I saw the patient in our case study in the pediatric emergency department, she had had severe headaches for over a week and left-sided facial paresis. Our pediatric infectious disease specialist and pediatric neurologist both advised the lumbar puncture.
While I appreciate that there are variations in every pediatrician's practice, I believe this patient clearly had Lyme meningitis. The reference cited supports this decision.1 Lyme disease-associated neurological complications can present with cranial neuropathies, headaches, seizures, etc. This child did not have meningismus; however, the diagnosis of meningitis was supported by her clinical symptoms and by the pleocytosis and CSF findings.
----Riva Kamat, MD
Inova Fairfax Hospital for Children
Falls Church, Va
Kamat R. Bell palsy from Lyme meningitis.
Consultant For Pediatricians.
Halperin JJ, Shapiro ED, Logigian E, et al. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.