In the recent issue of the Journal of the Pediatric Infectious Diseases Society, Paydar-Darian et al examine the role of lumbar puncture (LP) on management of children with facial palsy in a Lyme endemic area (1). The authors performed a retrospective cross sectional study of 620 children with peripheral facial palsy who presented to a single emergency department in a Lyme disease endemic area. Case of Lyme associated facial palsy was defined as the presence of clinically diagnosed erythema migrans or positive 2 tier serology test. The primary outcome was whether an LP was performed. Of 620 unique patients, 211 had facial palsy due to Lyme disease. Other causes of facial palsy included mastoiditis, otitis media, trauma and presumptive herpes simplex infection. Clinicians were more likely to perform LP on patients presenting with headache, meningitis and during summer months. The median cerebrospinal fluid (CSF) count was higher among patients with Lyme disease compared to other patients, 61 cells/mm3 (IQR 18-155) vs 2 cells/mm3 (IQR 1-3 cells/mm3). Majority, 70 (86%) of patients with Lyme disease had CSF pleocytosis. Children who underwent LP were more likely to have received parenteral antibiotics 71/149 (63%) LP performed vs 6/80 (2%) no LP performed and were more likely to be hospitalized 87/140 ( 62%) LP performed vs 29/480 (6%) LP not performed. The authors conclude that LP maybe useful in patients with unknown cause of meningitis but question its utility for patients with confirmed Lyme infection (1).

This study addresses an important clinical dilemma regarding a need for LP in patients with facial palsy due to suspected Lyme disease. LP is recommended for patients with facial palsy and symptoms consistent meningitis. For patients with CSF pleocytosis, the AAP Committee on Infectious Diseases Red Book committee recommends ceftriaxone or cefotaxime. Oral doxycycline is recommended for patients with severe allergy to cephalosporins as an alternative to cephalosporin desensitization (2). Multiple European studies showed that oral doxycyline is an acceptable alternative to parenteral antibiotics for treatment of neuroboreliosis. Oral doxycycline is inexpensive, rapidly absorbed and its bioavailability (when taken on empty stomach) is excellent (>90%), (3). CNS penetration exceeds the estimated MIC for B burgdorferi (4). Given the morbidity associated with the use of peripherally inserted central catheters (5) and unclear benefit of parenteral antibiotics over oral doxycycline, their use is increasingly questioned (1, 6). Oral doxycycline has been shown to be effective in treating facial palsy and meningitis due to Lyme disease in European pediatric and adult populations but data from the US are lacking. Lyme neuroboreliosis in Europe is primarily caused by B garinii and or B afzelii. It is not clear whether this experience can be extrapolated to the US population where neuroboreliosis is caused by B burgdorferii sensu stricto. The clinical efficacy of oral doxycycline in US Lyme neuroborreliosis should be further examined.

So which patients need LP?  Patients who present with meningitis and facial palsy due to unknown cause or who are ill appearing should undergo a diagnostic LP in order to determine etiology and best treatment. Advent of CSF multiplex PCR panels aid in rapid diagnosis of common causes of meningitis and further increase the utility of LP. Patients with facial palsy without meningitis can be safely treated with oral antibiotics. Because patients with Lyme facial palsy often have CSF pleocytosis even in the absence of symptoms of meningitis, and can be safely treated with oral doxycycline, it is unclear what if any benefit LP adds to management of patients with known Lyme neuroborreliosis. Prospective comparative studies conducted in the US focusing on neuroborreliosis in older pediatric patients with CSF pleocytosis would assist clinicians in evidence based decisions regarding the safety and efficacy of oral doxycycline and the need for LP.

Written by: Jana Shaw, MD, MPH, SUNY Upstate Medical University

References

  1. Paydar-Darian N, Kimia AA, Lantos PM et al. Diagnostic Lumbar Puncture Among Children With Facial Palsy in a Lyme Disease Endemic Area. J Pediatric Infect Dis Soc. 2017; 6: 205-208.
  2. Lyme disease. In: Kimberlin DW, Jackson MA, Long SS, ed. Red Book: 2015 Report of the Committee on Infectious Diseases. 30 ed. Elk Grove Village, IL. American Academy of Pediatrics 2015:516-523.
  3. Saivin SHouin G. Clinical pharmacokinetics of doxycycline and minocycline. Clin Pharmacokinet. 1988 Dec;15(6):355-66.
  4. Dotevall L, Hagberg L. Successful oral doxycycline treatment of Lyme disease-associated facial palsy and meningitis. Clin Infect Dis 1999; 28: 569–74.
  5. Thompson ADCohn KAShah SS et al. Treatment complications in children with Lyme meningitis. Pediatr Infect Dis J. 2012; 31:1032-5.
  6. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089–134.
  7. Dotevall L, Hargberg L. Penetration of Doxycycline into Cerebrospinal Fluid in Patients Treated for Suspected Lyme Neuroborreliosis . Antimicrob Agents Chemoth.1989; 33: 1078-1080