Neuroborreliosis as a chameleon – mimicking tuberculous meningitis

Aims: Differential diagnosis of a neuroborreliosis

Methods: The case of a 16 year old boy with a severe manifestation of a neuroborreliosis is presented. In the initial exploration he appeared with for five weeks increasing spastic-atactic gait abnormality, disturbance of micturition, back pain, hyperactive reflexes with broadened reflex areas, especially regarding the lower limb, with positive Babinski signs and finally inexhaustible cloni.

Results: The performed MRI showed leptomeningeal enhancement along the whole spinal cord, transverse myelitis on the level of T 6–8 and polyradiculopathy. In the lumbar punction the cell count was 348/µl with 294 lymphocytes, protein 8.4g/l, glucose 21mg/dl, lactate 5 mM with a massive barrier disturbance. With suspicion of a spinal tuberculosis a tuberculostatic combination therapy according to the appropriate guidelines was initiated and augmented by ceftriaxone to cover a potential neuroborreliosis. The initial serology of the cerebrospinal fluid showed marginal elevated IgM- with distinctly raised IgG-titre. However, due to the massive barrier disturbance an autochthonal antibody production could not be verified. Tbc PCR, direct preparations, skin tests and quantiferon-assay remained negative. With reconstitution of the blood-brain barrier a CSF/serum index appeared for B. burgdorferi-IgM of 9 and for B. b.-IgG of 10. Thereupon, neuroborreliosis phase II/III could be diagnosed. During the three-week intravenous antibiotic therapy the liquor status improved and a nearly complete resolution of the spinal and radicular contrast medium enhancement appeared. Clinically, the gait abnormality improved only to a very small extent, whereas the disturbance of micturition disappeared subjectively.

Conclusion: In the presented case of neuroborreliosis an autochthonal borrelia antibody production could only be proved in the course of a normalisation of the blood-brain barrier and therefore resulted in the correct diagnosis finding. The time-consuming exclusion of a tuberculosis necessitated a therapy ex juvantibus.