Acute Hemiparesis Revealing Neuroborreliosis in a 3-Year-Old Boy

Case Study: We report a previously healthy 3-year-old boy who presented with acute left hemiparesis without signs of ongoing infection. MRI lacked signs of vascular abnormalities but instead demonstrated a restriction in the diffusion-weighted imaging of the right lobulus paracentralis with a corresponding leptomeningeal contrast enhancement. Suspecting a case of focal meningoencephalitis empirical antibiotic and antiviral treatment was initiated, however, lumbar puncture revealed sterile cerebrospinal fluid (CSF) without abnormalities in cell count, glucose, or total protein content. A tick bite was reported 1 month before presentation without any local erythematous skin lesion. Accordingly, laboratory results showed intrathecal production of quantitative (IgM/IgG pos) as well as qualitative Borrelia burgdorferi-specific antibodies in liquor and serum (IgM > 86 U/mL, IgG 39 U/mL) indicating that a CNS infection with Borrelia burgdorferi was imminent. Thus, antiviral therapy was stopped and ceftriaxone treatment was continued for 14 days. The hemiparesis disappeared within a few hours and the boy recovered without any neurologic sequelae. MRI findings were negative for either a preceding epileptic seizure or a migraine attack and EEG was normal, so Todd paresis is unlikely. In conclusion, our findings indicate that our patient suffered from a Borrelia-associated meningoencephalitis which presented itself with an acute unilateral paresis, which regressed within hours. We conclude that neuroborreliosis should be considered as a differential diagnosis in children with stroke-like episode, even without elevated cell count or total protein in CSF.

Keywords: neuroborreliosis, hemiparesis.