title: Lyme disease-related intracranial hypertension in children: clinical and imaging findings.
abstract: Lyme disease (LD) is a tick-borne infection that is endemic to multiple areas of the United States. Patients with LD may present with sign and symptoms of intracranial hypertension (IH). The objective of this study is to evaluate the history, clinical findings, CSF analysis, and brain imaging results in pediatric patients with increased intracranial pressure secondary to LD. A retrospective database search was performed using the International Classification of Diseases (ICD) 9/10 codes to identify patients diagnosed with LD and IH between 2004 and 2014 at a tertiary referral pediatric hospital. Clinical, laboratory and neuroimaging data for each patient were reviewed. Seven patients met inclusion criteria; mean age was 9.6 years (standard deviation 4.0 years); 4/7 patients were male. Average body mass index was 18.8 kg/m(2) (standard deviation 3.0 kg/m(2)). Fever was present in four patients. Four had a history of LD related erythema migrans. All had elevated CSF opening pressure with leukocytosis and lymphocytic predominance. MRI obtained in six patients showed contrast enhancement of various cranial nerves. Tentorial enhancement was noted in all patients. In addition, patients had widening of the optic nerve sheath (ONS), optic nerve protrusion, and flattening of the posterior globe consistent with increased intracranial pressure. All patients had resolution of their symptoms after initiation of antibiotic therapy. In endemic areas, LD should be included in the differential of IH. MRI can help distinguish IH due to LD from its idiopathic form due to the presence of tentorial and cranial nerve enhancement in the former in addition to abnormal CSF showing leukocytosis with lymphocyte predominance.
authors.affiliation: Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, AOB 5400, Pittsburgh, PA, 15224, USA. sriram.ramgopal2@upmc.edu.
authors.forename: Sriram
authors.initials: S
authors.lastname: Ramgopal
authors.affiliation: Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Rawad
authors.initials: R
authors.lastname: Obeid
authors.affiliation: Section of Neuroradiology, Department of Radiology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Giulio
authors.initials: G
authors.lastname: Zuccoli
authors.affiliation: Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Catalina
authors.initials: C
authors.lastname: Cleves-Bayon
authors.affiliation: Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Nowalk
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002443:Ceftriaxone / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004318:Doxycycline / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D019586:Intracranial Hypertension / Q000134:cerebrospinal fluid / Q000150:complications* / Q000000981:diagnostic imaging*; D008193:Lyme Disease / Q000134:cerebrospinal fluid / Q000150:complications* / Q000000981:diagnostic imaging*; D008279:Magnetic Resonance Imaging; D008297:Male; D009900:Optic Nerve / Q000000981:diagnostic imaging; D012720:Severity of Illness Index
chemical_list: D000900:Anti-Bacterial Agents; D002443:Ceftriaxone; D004318:Doxycycline
keywords: Borrelia burgdorferi; Intracranial hypertension; Lyme disease; Neuroborreliosis; Pseudotumor cerebri