ABSTRACT & COMMENTARY
Oral Antibiotics for CNS Lyme Disease
By Joseph E. Safdieh, MD
Assistant Professor of Neurology, Weill Cornell Medical College
Dr. Safdieh reports no financial relationships relevant to this field of study.
SYNOPSIS: Lyme disease with CNS involvement may respond well to oral doxycycline therapy and intravenous antibiotics may not be necessary.
SOURCE: Bremell D, Dotevall L. Oral doxycycline for Lyme neuroborreliosis with symptoms of encephalitis, myelitis, vasculitis or intracranial hypertension. Eur J Neurol 2014;21:1162-1167.
Lyme disease is a common spirochetal infection in the United States and Europe. It is caused by Borrelia burgdorferi, which is acquired via a tick bite. Typical manifestations include a local "bullseye" rash (erythema migrans) followed by systemic dissemination to the joints, heart, and nervous system. Neurologic symptoms are usually caused by meningeal involvement and involve the peripheral nervous system (PNS). These symptoms include facial palsy, headache, and painful radiculitis. European and American guidelines recommend that Lyme disease with PNS involvement can be successfully treated with oral doxycycline or intravenous ceftriaxone, but state that for cases of Lyme disease with central nervous system involvement, intravenous ceftriaxone should be used.1 CNS involvement includes encephalitis, myelitis, vasculitis, or intracranial hypertension. There have been no controlled trials of specific therapies for Lyme disease with CNS involvement. In this study, the authors present outcomes data in a retrospective cohort of patients with neurologic Lyme disease (CNS and/or PNS) who were treated only with oral doxycycline.
The study was conducted at a hospital in Sweden over a 22-year period from 1990-2012. Patients were diagnosed with Lyme neuroborreliosis if they had symptoms consistent with CNS or PNS involvement and CSF mononuclear pleocytosis with either preceding erythema migrans or positive CSF Lyme antibodies. All patients were treated with oral doxycycline and underwent repeat CSF analysis 4-8 weeks after treatment and a follow-up visit at 6 months. During the study period, a total of 366 patients were diagnosed with Lyme neuroborreliosis, of which 31 had CNS involvement. The majority of CNS presentations were of the encephalitis type. The most common symptoms were cognitive impairment, confusion, and ataxia. Most patients were treated for 10 days, and some for 21 days. Pre-treatment CSF mononuclear cell count was 213 cells/uL before treatment in patients with CNS involvement. Post-treatment, the CSF cell count improved significantly with a mean of 22 mononuclear cells/uL. CSF protein also decreased significantly after treatment. Of note, most patients improved clinically. Ten became normal, 12 had mild residual deficits, and four had major residual deficits. The authors conclude that oral doxycycline is a reasonable, effective, and appropriate treatment for CNS Lyme disease.
COMMENTARY
This is an important study which does suggest that Lyme disease, whether with CNS or PNS involvement, may respond well to oral doxycycline. The fact that all patients had a significant improvement in their follow-up CSF cell count and protein provides objective evidence that the oral antibiotic was effective in treating the Lyme infection. This study confirms that CNS involvement in Lyme disease is relatively rare (31 patients out of 366 with neurologic Lyme disease) and when it does occur is a serious illness. The fact that only four patients from the cohort were left with major residual deficits does suggest that CNS Lyme patients may indeed do well with doxycycline. This study is not the final word on the subject. Its retrospective design and lack of a comparison group to intravenous ceftriaxone weakens the authors’ conclusion. That said, there are no randomized studies of intravenous vs oral antibiotics in CNS Lyme disease, nor are there any rigorous controlled studies in acute CNS Lyme disease treatment, so this study does add some value to the literature. Currently, the major American guidelines still recommend intravenous ceftriaxone for neurologic Lyme disease with CNS involvement based on the available evidence and expert consensus. Clearly, more studies are needed to definitely answer this question.
REFERENCE
- Halperin JJ, 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. Neurology 2007;69:91-102.
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