Page 117 - Human Lyme Neuroborreliosis

Treatment 101

doxycycline, differences between U.S. and European B. burgdorferi strains
and species and their initial clinical presentation might not make the data fully
applicable to U.S. cases [2]. Treatment responses might be expected to be
comparable in U.S. and European cases, but this too had not yet been
confirmed [2].

Recommendations

At the nexus of the yet resolved debate is still the appropriate drug, dose,
route, and duration of initial antimicrobial therapy for LNB which varies even
among contemporary experts. The 1996 Summary Statement of the Quality
Standards Subcommittee of the AAN and the related Practice Parameter [2]
asserted that causally-related neurologic disease which included lymphocytic
meningitis and encephalomyelitis, and encephalopathy associated with
memory or cognitive dysfunction and abnormal neurologic examination, MRI
or CSF abnormalities, warranted treatment with 2 to 4 weeks of parenteral
beta-lactam antimicrobial therapy. A caveat was that limited European data
suggested oral regimens might be effective in acute meningitis [6]. Steere and
colleagues [17] called for early treatment of EM, flu-like symptoms and co-
infections with oral therapy beginning with doxycycline for 10 to 20 days
noting the limited utility of serological testing in the first 2 weeks of infection.
However cardiac and nervous system organ dissemination and clinical
involvement warranted parenteral therapy with ceftriaxone as first choice
therapy. Acute facial cranial neuritis was treatable with oral therapy similar to
early infection. The latest Practice Parameter [7] called for initial treatment of
Lyme meningitis, any neurological syndrome with CSF pleocytosis, peripheral
radiculopathy, diffuse neuropathy, MNM and cranial neuropathy with oral
doxycycline for 10 to 28 days allowing further treatment with parenteral
therapy in relatively severe cases, as well as those unresponsive to an initial
course of oral doxycycline, and others with CNS parenchymal involvement or
encephalopathy. Treatment regimens for childhood and adult LNB, which can
be found in standard textbooks of neurology [18-19], are shown in Tables 1
and 2.

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