Lyme disease: Clinical manifestations in children
- Eugene D Shapiro, MD, FAAP
Eugene D Shapiro, MD, FAAP
- Professor of Pediatrics, Epidemiology, and Public Health and Investigative Medicine
- Yale University School of Medicine
Lyme disease is a tick-borne illness primarily caused by a number of pathogenic genomospecies of the spirochete Borrelia burgdorferi sensu lato . B. burgdorferi sensu stricto is the sole cause of the disease in the United States. B. burgdorferi sensu stricto, B. afzelii, and B. garinii and a number of other genomospecies may cause disease in Europe and B. afzelii, and B. garinii have been identified in Asia. Lyme disease has a broad spectrum of clinical manifestations. The clinical manifestations vary, in part, due to differences in the infecting genomospecies.
The clinical manifestations of Lyme disease in children will be reviewed here. The clinical manifestations of Lyme disease in adults and the microbiology, epidemiology, treatment, and prevention of Lyme disease are discussed separately. (See "Epidemiology of Lyme disease" and "Clinical manifestations of Lyme disease in adults" and "Diagnosis of Lyme disease" and "Treatment of Lyme disease" and "Prevention of Lyme disease".)
The clinical manifestations of Lyme disease depend on the stage of the illness [2-4]:
●Early localized disease
●Early disseminated disease
- Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet 2012; 379:461.
- Steere AC. Lyme disease. N Engl J Med 1989; 321:586.
- Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis 2000; 31:533.
- Nadelman RB, Wormser GP. Lyme borreliosis. Lancet 1998; 352:557.
- Gerber MA, Shapiro ED, Burke GS, et al. Lyme disease in children in southeastern Connecticut. Pediatric Lyme Disease Study Group. N Engl J Med 1996; 335:1270.
- 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.
- Tugwell P, Dennis DT, Weinstein A, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med 1997; 127:1109.
- Aguero-Rosenfeld ME, Wang G, Schwartz I, Wormser GP. Diagnosis of lyme borreliosis. Clin Microbiol Rev 2005; 18:484.
- Nowakowski J, Schwartz I, Liveris D, et al. Laboratory diagnostic techniques for patients with early Lyme disease associated with erythema migrans: a comparison of different techniques. Clin Infect Dis 2001; 33:2023.
- Feder HM Jr. Lyme disease in children. Infect Dis Clin North Am 2008; 22:315.
- Smith RP, Schoen RT, Rahn DW, et al. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med 2002; 136:421.
- Nadelman RB, Nowakowski J, Forseter G, et al. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med 1996; 100:502.
- Goldberg NS, Forseter G, Nadelman RB, et al. Vesicular erythema migrans. Arch Dermatol 1992; 128:1495.
- Cutaneous tumors and tumor syndromes. In: Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence, 3rd ed, Paller AS, Mancini AJ (Eds), WB Saunders, Philadelphia 2006. p.205.
- Wormser GP, Brisson D, Liveris D, et al. Borrelia burgdorferi genotype predicts the capacity for hematogenous dissemination during early Lyme disease. J Infect Dis 2008; 198:1358.
- Belman AL, Iyer M, Coyle PK, Dattwyler R. Neurologic manifestations in children with North American Lyme disease. Neurology 1993; 43:2609.
- Wormser GP, McKenna D, Carlin J, et al. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med 2005; 142:751.
- Christen HJ, Hanefeld F, Eiffert H, Thomssen R. Epidemiology and clinical manifestations of Lyme borreliosis in childhood. A prospective multicentre study with special regard to neuroborreliosis. Acta Paediatr Suppl 1993; 386:1.
- Christen HJ, Bartlau N, Hanefeld F, et al. Peripheral facial palsy in childhood--Lyme borreliosis to be suspected unless proven otherwise. Acta Paediatr Scand 1990; 79:1219.
- Nigrovic LE, Thompson AD, Fine AM, Kimia A. Clinical predictors of Lyme disease among children with a peripheral facial palsy at an emergency department in a Lyme disease-endemic area. Pediatrics 2008; 122:e1080.
- Clark JR, Carlson RD, Sasaki CT, et al. Facial paralysis in Lyme disease. Laryngoscope 1985; 95:1341.
- Rahn DW, Malawista SE. Lyme disease: recommendations for diagnosis and treatment. Ann Intern Med 1991; 114:472.
- Shapiro ED, Gerber MA. Lyme disease and facial nerve palsy. Arch Pediatr Adolesc Med 1997; 151:1183.
- Halperin JJ, Shapiro ED, Logigian E, 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.
- Belman AL, Reynolds L, Preston T, et al. Cerebrospinal fluid findings in children with Lyme disease-associated facial nerve palsy. Arch Pediatr Adolesc Med 1997; 151:1224.
- Kuiper H, de Jongh BM, van Dam AP, et al. Evaluation of central nervous system involvement in Lyme borreliosis patients with a solitary erythema migrans lesion. Eur J Clin Microbiol Infect Dis 1994; 13:379.
- Skogman BH, Croner S, Nordwall M, et al. Lyme neuroborreliosis in children: a prospective study of clinical features, prognosis, and outcome. Pediatr Infect Dis J 2008; 27:1089.
- 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.
- Vázquez M, Sparrow SS, Shapiro ED. Long-term neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease. Pediatrics 2003; 112:e93.
- Adams WV, Rose CD, Eppes SC, Klein JD. Cognitive effects of Lyme disease in children. Pediatrics 1994; 94:185.
- Bingham PM, Galetta SL, Athreya B, Sladky J. Neurologic manifestations in children with Lyme disease. Pediatrics 1995; 96:1053.
- Krbkova L, Stanek G. Therapy of Lyme borreliosis in children. Infection 1996; 24:170.
- Thorstrand C, Belfrage E, Bennet R, et al. Successful treatment of neuroborreliosis with ten day regimens. Pediatr Infect Dis J 2002; 21:1142.
- Skogman BH, Glimåker K, Nordwall M, et al. Long-term clinical outcome after Lyme neuroborreliosis in childhood. Pediatrics 2012; 130:262.
- Ljøstad U, Skogvoll E, Eikeland R, et al. Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial. Lancet Neurol 2008; 7:690.
- Treatment of Lyme disease. Med Lett Drugs Ther 1997; 39:47.
- Avery RA, Frank G, Glutting JJ, Eppes SC. Prediction of Lyme meningitis in children from a Lyme disease-endemic region: a logistic-regression model using history, physical, and laboratory findings. Pediatrics 2006; 117:e1.
- Shah SS, Zaoutis TE, Turnquist J, et al. Early differentiation of Lyme from enteroviral meningitis. Pediatr Infect Dis J 2005; 24:542.
- Eppes SC, Nelson DK, Lewis LL, Klein JD. Characterization of Lyme meningitis and comparison with viral meningitis in children. Pediatrics 1999; 103:957.
- Tuerlinckx D, Bodart E, Jamart J, Glupczynski Y. Prediction of Lyme meningitis based on a logistic regression model using clinical and cerebrospinal fluid analysis: a European study. Pediatr Infect Dis J 2009; 28:394.
- Tveitnes D, Natås OB, Skadberg Ø, Øymar K. Lyme meningitis, the major cause of childhood meningitis in an endemic area: a population based study. Arch Dis Child 2012; 97:215.
- Rothermel H, Hedges TR 3rd, Steere AC. Optic neuropathy in children with Lyme disease. Pediatrics 2001; 108:477.
- Nord JA, Karter D. Lyme disease complicated with pseudotumor cerebri. Clin Infect Dis 2003; 37:e25.
- Feder HM Jr, Gerber MA, Krause PJ, et al. Early Lyme disease: a flu-like illness without erythema migrans. Pediatrics 1993; 91:456.
- Steere AC, Sikand VK, Schoen RT, Nowakowski J. Asymptomatic infection with Borrelia burgdorferi. Clin Infect Dis 2003; 37:528.
- Seltzer EG, Shapiro ED. Misdiagnosis of Lyme disease: when not to order serologic tests. Pediatr Infect Dis J 1996; 15:762.
- Bachman DT, Srivastava G. Emergency department presentations of Lyme disease in children. Pediatr Emerg Care 1998; 14:356.
- Gerber MA, Zemel LS, Shapiro ED. Lyme arthritis in children: clinical epidemiology and long-term outcomes. Pediatrics 1998; 102:905.
- Culp RW, Eichenfield AH, Davidson RS, et al. Lyme arthritis in children. An orthopaedic perspective. J Bone Joint Surg Am 1987; 69:96.
- Steere AC, Malawista SE, Snydman DR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three connecticut communities. Arthritis Rheum 1977; 20:7.
- Thompson A, Mannix R, Bachur R. Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics 2009; 123:959.
- Steere AC, Schoen RT, Taylor E. The clinical evolution of Lyme arthritis. Ann Intern Med 1987; 107:725.
- Szer IS, Taylor E, Steere AC. The long-term course of Lyme arthritis in children. N Engl J Med 1991; 325:159.
- Shapiro ED. Long-term outcomes of persons with Lyme disease. Vector Borne Zoonotic Dis 2002; 2:279.
- Feder HM Jr, Johnson BJ, O'Connell S, et al. A critical appraisal of "chronic Lyme disease". N Engl J Med 2007; 357:1422.
- Baker PJ. Chronic Lyme disease: in defense of the scientific enterprise. FASEB J 2010; 24:4175.
- Marzec NS, Nelson C, Waldron PR, et al. Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease - United States. MMWR Morb Mortal Wkly Rep 2017; 66:607.
- Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008; 336:1124.
- EARLY LOCALIZED DISEASE
- Erythema migrans
- - Clinical features
- - Associated findings
- - History of tick bite
- - Differential diagnosis
- EARLY DISSEMINATED DISEASE
- Multiple erythema migrans
- Neurologic manifestations
- - Cranial nerve palsy
- - Meningitis
- Nonspecific symptoms
- Other manifestations
- LATE DISEASE
- CONGENITAL LYME DISEASE
- "CHRONIC LYME DISEASE" IN CHILDREN
- BORRELIA MIYAMOTOI INFECTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS