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The Lancet Vol. 351-February 7, 1998
title: Lyme disease presenting as Tourette's syndrome
authors: Michael Riedel, Andreas Straube, Markus J Schwartz, Betina Wilske,
Norbert Muller
Lyme borreliosis is often misdiagnosed , both in adults and children. (1)
Central Nervous system manifestations of Lyme disease include neurological
and
psychiatric symptoms. (2) Although abnormal movements have been observed in
Lyme disease, (3) a Tourette's syndrome has not been reported.
A boy at the age of 4 years developed a simple motor tic (blinking) that
resoved within a year without treatment. At the age of 9 years, he developed
multiple orafacial tics including shaking of the head, and several weeks
later
a vocal tic occurred. The tics became exacerbated under stress, as typically
seen in Tourette's syndrome. Social disabilities such as loss of impulse
control, social withdrawl, worsened performance at school followed. He came
to
hospital at 11 months after onset of symptoms.
Serum IgM antibody titres against Borrelia burgdorferi measured by ELISA
were not increased; although IgG antibody titres (ELISA) were increased at
58
U/mL (normal \< U/ml) and 100 U/mL at another examination 2 weeks later.
Immunoflourescence absorption test (IFT) was also increased (1:28 [normal
\<1:16]). IgG immunoblot (4) was positive. All results indicated an
infection
with B burgdorferi. Examination of cerebral fluid showed a slight
lymphocytic
pleocytosis (16 cells per uL) (5) which suggested an inflammatory reaction.
The CSF: serum IgG ratio for IgG antibodies was 2.0, indicating intraethecal
production of B. burgdorferi specific IgG antibodies, as occurs in
neuroborreliosis. (4)
The boy was treated with intravenous ceftriaxone 2 g daily for 14 days.
The tics improved after the sixth dose, and after the tenth dose the tics
resolved completely. His social skills returned to normal. Follow-up
examinations showed no reccurence of tics or other neurological or
psychiatric
disorder. Serum IgG antibody titre tests and IFT tests against B burgdorferi
were 11 U/mlL and 1:32 after 1 year.
Rapid efficacy of antibiotic treatment followed by a decrease in
Borrelia-specific antibody titres suggests that the multiple motor and vocal
tics were at least partially caused by the tertiary stage of borreliosis.
(5)
Persistence of the tics and increasing severity of the social disabilities
over
several months suggest that the first signs of a Tourette-like syndrome 11
months previously were an expression of an early Lyme infection. Infection
with B burgdorferi should be considered in cases of Tourette's syndrome in
endemic areas.
1. Shapiro ED, Selzter EG, Lyme disease in children. Semin Neurol
1997;17:39-44.
2. Kaplan RF, Jones-Woodward L,. Lyme encephalopathy; a
neuropsychological
perspective. Semin Neurol 1997;17:31-37
3. Fallon BA, Nields JA, Parsons B, Liebowitz MR, Klein DF, Psychiatric
manifestations of Lyme Borreliosis. J Clin Psychiatry 1997;54:263-68
4. Wilske B, Fingerle V, Herzer P, et al. Recombinant immunoblot in the
serodiagnosis of Lyme borreliosis. Med Mikrobiol Immunol 1993; 182:255-70.
5. Pfister HW, Wilske B, Weber K., Lyme borreliosis: basic science and
clinical aspects. Lancet 1994; 363:1031-16
--
"Never doubt that a small group of thoughtful, committed citizens can change
the world. Indeed, it's the only thing that ever has."
- Margaret Mead
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