Involvement of the Central and Peripheral Nervous System
As more becomes known about the possible long-term effects of neurological Lyme disease, also known as Lyme borreliosis, it becomes imperative that both the general public and medical professionals are made more aware of this disease.
The organisms that cause Lyme disease in Europe include at least three species within the bacterial genus Borrelia. These are Borrelia burgdorferi sensu stricto, Borrelia garinii and Borrelia afzelii.
The clinical features may vary according to genospecies: B. garinii tends to cause a classic picture of neuroborreliosis as described below whereas B. afzelii tends to cause skin lesions and less specific neurological symptoms which may be more difficult to diagnose [1].
People with this disease may develop an extensive range of symptoms that affect both the body and mind. In many cases these symptoms are similar to those that may develop in the disease syphilis (although transmission is different) because these bacterial (spirochaetal) diseases are closely related.
What is the Role of the Doctor?
Because of the diverse clinical features of Lyme neuroborreliosis, doctors from many disciplines need to be aware of and consider this infection in their differential diagnosis. Otherwise, the crucial diagnosis of Lyme disease may be missed. The symptoms that develop may mimic other disorders. They can occur in any person at any age, including children.
If left untreated, there is a high risk that the patient will start suffering a great range of bodily and mental symptoms. The sooner the infection is treated, the better the chances of a full recovery. Therefore it is essential that doctors diagnose their patients correctly and offer the right treatments as soon as possible.
Symptoms that affect the Nervous system
Neuro-psychiatric symptoms tend to develop after early signs and symptoms of the infection have occurred, although they may be the earliest and/or only signs, possibly occuring as early as one week after infection. Whilst this stage, termed early Lyme neuroborreliosis (< 6 months) can be painful and debilitating, it may not progress to late Lyme neuroborreliosis if properly treated.
After what is often a flu-like start to the infection, patients may develop arthritic, cardiac or early neurological problems. Neurological problems may include:
- Meningitis – inflammation of the brain’s enveloping membrane.
- Painful radiculitis – inflammation of the nerve roots, known as Bannwarth’s syndrome.
- Cranial neuritis – inflammation of the cranial nerves.
- Encephalopathy – cognitive inefficiency.
- Encephalomyelitis – inflammation of the brain and spinal cord.
- Encephalitis – inflammation within the brain.
- Peripheral neuropathy – particularly small fibre damage.
Lyme associated neurological symptoms may include:
- Facial palsy/weakness (Bell’s palsy = VII cranial nerve palsy).
- Headache/neckache.
- Double vision (VI cranial nerve palsy and III cranial nerve palsy).
- Sensory disturbances – eg parasthesia, rseulting in tingling, numbness and pain, often in a dermatomal distribution.
- Dizziness, tinnitus and vertigo.
- Excessive sensitivity to noise or light.
- Shoulder droop
- Debilitating fatigue.
- Suspected gastrointestinal motility disturbances
- At any time after infection, symptoms affecting a person’s thinking, memory and ability to process information may appear. These symptoms, known as cognitive symptoms are listed in detail below.
Disorders of the nervous system are a common feature of late-stage Lyme disease.
As noted, neuro-psychiatric symptoms that mimic other neurological and psychiatric disorders may develop at any stage of untreated or undertreated disease.
Main symptoms indicating nervous system involvement
Symptoms of cognitive loss such as:
- Memory impairment or loss (‘brain fog’).
- Slowed processing of information.
- Word-finding problems with reduced verbal fluency.
- Dyslexia and problems dealing with numbers.
- Visual/spatial processing impairment (losing things, getting lost, disorganisation)
- Poor abstract reasoning
- Losses in fields of attention/executive functions such as inability to maintain divided or sustained attention
- Poor auditory and mental tracking and scanning (loss in ability to follow daily affairs, which is complicated by persistent distractibility)
Neurological symptoms and signs including:
- Headaches.
- Neuralgia/neuropathic pain, ie pain which may have a pricking/stinging quality, with excessive sensitivity to light touch or pressure.
- Facial palsy, numbness and tingling, especially of the face.
- Seizures.
- Autonomic dysfunction – problems in regulation of pulse and blood pressure eg POTS (postural orthostatic tachycardia syndrome).
- Cranial nerve disturbances such as – Optic neuritis, difficulty swallowing, distortions of taste and smell, visual disturbance, vertigo, dizziness and tinnitus.
- States that mimic other defined neurological disorders such as Parkinson’s disease, MS, Bell’s palsy, stroke, ALS, Motor Neurone Disease.
- In children, indications of neurological involvement include behaviour changes, learning disabilities, school phobia, hypersensitivities of the skin and headaches.
Some patients have developed Lyme-related psychiatric symptoms:
- Psychoses including hallucinations and delusions.
- Emotional lability: rapid mood swings, episodes of rage, crying, reduced impulse control.
- Depression.
- Suicidal thoughts and behaviour.
- Anxiety/Panic attacks.
- Mood swings that may mimic bipolar disorder (manic-depression).
- Obsessive-compulsive disorder (OCD).
- Sleep Disorders.
- An Attention deficit/hyperactivity disorder (ADD/ADHD)-like syndrome.
- Autism-like syndrome.
- Delirium.
- A progressive dementia.
Patients may also be wrongly diagnosed with hypochondrial and somatoform disorders as well as ME (Myalgic Encephalitis) and CFS (Chronic Fatigue Syndrome), if they are perceived as having edically unexplained symptoms.
References:
1) Strle, F et al. 2006. “Comparison of findings for patients with Borrelia garinii and Borrelia afzelii isolated from cerebrospinal fluid.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 43 (6) (September): 704-10. http://www.ncbi.nlm.nih.gov/pubmed/16912943
2) Fallon, Brian a, Elizabeth S Levin, Pernilla J Schweitzer, and David Hardesty. 2010. “Inflammation and central nervous system Lyme disease.” Neurobiology of disease 37 (3) (March): 534-41.
Further Sources of Information
Why psychologists need to know about Lyme
*The Lyme Disease Research Program at Columbia University, New York has further professional information upon the role of neurology and psychiatry. Available here
*Dr. Robert Bransfield, a psychiatrist who specialises in infectious causes of neuropsychiatric illness, has developed a structured clinical interview to assess Lyme seronegative patients. Available here