606 - An Unusual Case of Acute Transverse Myelitis in an 8-Year-Old with Lyme Disease: A Rare Neurological Twist

Publication Number: 606.3934

Safiuddin Hasan Mohammed, Kapi'olani Medical Center for Women and Children, Honolulu, HI, United States; Natascha Ching, University of Hawaii, John A. Burns School of Medicine, Kapiolani Medical Center for Women & Children, Honolulu, HI, United States

Background: Lyme disease (LD), a tick-borne infection caused by Borrelia burgdorferi, often begins with erythema migrans. If untreated, severe complications such as carditis, arthritis, meningitis and acute transverse myelitis (ATM) can occur.

Objective: We report a case of an 8 year old boy who was diagnosed with lyme neuroborreliosis with ATM.

Design/Methods: Case review

Results: A 8 year old male from Illinois presented with fever, headache, neck pain, and vomiting for 6 days. One month before admission, he had a neck rash from a bug bite, treated with 10 days of cephalexin for cellulitis. Parents denied a tick then or at regular tick checks. The rash resolved and he returned to baseline before traveling to Hawaii. This patient was always outdoors in an area with a high population of deer. While on vacation, he developed a fever, frontal headache, neck pain and vomiting and went to an emergency department (ED) where SARS-CoV2 and influenza tests were negative and he was discharged. Due to worsening symptoms, he was brought to Kapiolani Medical Center for Women & Children (KMCWC) ED the next day, where baseline labs, spine radiograph and neck computed tomography (CT) scan were normal. His symptoms persisted, prompting another ED visit 2 days later where he had limited neck flexion and 3+ patellar reflexes bilaterally. A lumbar puncture was performed showing cerebrospinal fluid (CSF) WBC 184, RBC 4, 82% lymphocytes, 2% neutrophils and 16% macrophages, protein 79 mg/dl and glucose 36 mg/dl. A multiplex polymerase chain reaction (PCR) CSF meningitis and encephalitis panel was negative. Magnetic resonance imaging (MRI) of the brain and spine revealed ATM at C2-C3 & T1-T4. The patient was admitted for ceftriaxone and vancomycin until the CSF culture was negative. Due to ATM, he received steroids for 5 days. LD was diagnosed by B. burgdoferi ELISA total 4.68, IgM 3.72, IgG 1.48, and B. burgdorferi IgM immunoblot bands 23,39,41 and IgG negative and Borrelia species DNA +PCR CSF. Ophthalmologic evaluation was normal with no signs of ocular LD. Ceftriaxone was restarted and he was discharged to complete a total of 28 days of ceftriaxone. At the end of treatment, he had resolution of symptoms and a normal neurological examination.

Conclusion(s): This case underscores the importance of considering lyme neuroborreliosis in pediatric patients presenting with neck pain, headache, and vomiting, even with mild neurological signs if coming from LD endemic area. MRI of the brain and spine can aid in diagnosing transverse myelitis supporting a Lyme disease diagnosis.