Lyme disease is a tick-borne multisystemic disease with multiple clinical presentations including rheumatological conditions. We present a 12 year old girl complaining of fever, arthralgia and redness in her eyes which was found to be the result of panuveitis. Borrelia antibodies were positive and she received 21-day treatment regimen with Ceftriaxon with resolution of all complaints at the end of treatment. Lyme disease classically occurs in three stages starting with erythema migrans, however atypical presentations skipping this stage and presenting with opthalmologic involvement in form of uveitis can be seen.
Lyme disease is one of the most common tick-borne infectious diseases [
A 12-year-old girl patient admitted to our clinic with a history of eighteen days of fever and arthralgia of ankles. She did not have any rash accompanying fever but had redness in her eyes, mild myalgia, nausea and vomitting . She did not have similar symptoms before she had been followed for ten days at another center, complete blood cell count and biochemical markers were within normal limits but sedimentation rate and C-Reactive Protein (CRP) were elevated. (sedimentation: 69 mm/h, CRP: 170.6 mg/L). Viral markers were negative, Brucella agglutination was negative, Anti nuclear antibodies (AN-A), c-ANCA, p-ANCA were negative, anti dsDNA titer were within normal limits. Eye examination showed severe panuveitis and papillitis (Figures 1(a) and 1(b)).
Cranial tomography was normal. Echocardiography showed no pericardial or pleural effusions. Ceftriaxon therapy was started for the treatment of an infection of unknown origin and steroid eye drops for uveitis. After ten days of ceftriaxon treatment the patient admitted to our clinic with complaints of fatigue, myalgia and still elevated acute phase reactans.
On physical examination, she did not have any kind of rash and there was no sign of arthritis. Blood pressure was within normal limits. Opthalmologic examination revealed continuous but milder papilitis and panuveitis compared to previous examination. Sedimentation rate was still high (67 mm/h), ANA was 1/80 stained in nucleolar pattern and anti ds DNA was elevated (194 IU/ mL). C3 and C4 levels were normal. Anticardiolipin and anti phospholipid antibodies were negative. Urinanalysis showed no proteiuria. Because of continous papillitis, panuveitis and history of fever, arthralgia, myalgia, the tests for infectious etiology were extended.
Borrelia antibodies were studied by enzyme linked immunoassay (ELISA) test and IgM was found to be > 200 IU and IgG was negative. Result of the test was confirmed with western blot analysis. She was diagnosed as Lyme Borreliosis with panuveitis and papillitis and
ceftriaxon therapy was started again and continued until twenty day treatment regimen was completed.
She was afebrile at the end of treatment, arthralgia and myalgia were resolved. Acute phase reactants were within normal limits (ESR 12 mm/hr and CRP < 0.5) ANA and anti ds DNA were negative. In opthalmologic examination, there was no sign of uveitis and papillitis (
Our patient was in the risk group of borreliosis as most cases of borreliosis are seen in people aged 5 - 14 years and 50 - 59 years [
After Ixodes tick bite,following localized skin rash, within days to weeks spirochetes disseminate resulting in the presence of B.burgdoferi in blood, cerebrospinal fluid, heart, retina, brain, muscle, bone, spleen, liver and meninges of patients leading to a variety of symptoms [4,6]. Stage 1 of disease occurs from days to weeks after tick bite and characterized by typical rash of Erythema migrans[
months and characterized by encephalitis, encephalomyelitis, serebral arteritis, polyneuropathy, mono or oligoarthritis and acrodermatitis chronica [
About 30% - 70% patients have constitutional complaints including malaise and fatigue, headache, short lasting migratory arthralgias and myalgias, low grade fever and lymphadenopathy [1-4]. Rheumatological manifestations include musculoskeletal pain and short attacks of frank arthritis [
Acute neuroborreliosis is diagnosed only in 10% - 15% of patients, it develops after weeks to months [2,4,5]. Early invasion into central nervous system can occur within 2 weeks however only half of these patients have CNS symptoms during this period [
Ocular neuroborreliosis can be seen in every stage but most frequently in second and third stages [5,7,9]. Various ocular symptoms including pain, visual impairment, photophobia, diplopia and lack of accomadation may be seen [
Ocular inflammation occuring in an endemic zone, report of contact with a tick, previous history of erythema migrans, positive serology with presence of IgM in early stage or IgG in late stage raise the suspicion of Lyme disease [
Antibiotic treatment not only shortens duration of illness but also prevents complications and chronic infections [
Course of disease may skip any individual stage for example a patient with neuroborreliosis does not need to have erythema migrans in past [
Our patient had atypical signs and symptoms of borreliosis that diagnosed with opthalmologic problems. Therefore, it should be kept in mind that lyme borreliosis may have many different presentations and it should be considered in differential diagnosis of unexplained clinical pictures.