Case Report: Bilateral diaphragmatic dysfunction due to Borrelia Burgdorferi

[Sproetje]

Case Report: Bilateral diaphragmatic dysfunction due to Borrelia Burgdorferi
[version 1; referees: 2 approved]
(Volledige tekst)

diafragma is het middenrif.

https://f1000research.com/articles/3-235/v1

Suhail Basunaid1, Chris van der Grinten1, Nicole Cobben1,2, Astrid Otte2, Roy Sprooten2, Rohde Gernot1

Abstract


Summary:
In this case report we describe a rare case of bilateral diaphragmatic dysfunction due to Lyme disease.
Case report:
A 62-years-old male presented to the hospital because of flu-like symptoms. During initial evaluation a bilateral diaphragmatic weakness with orthopnea and nocturnal hypoventilation was observed, without a known aetiology. Bilateral diaphragmatic paralysis was confirmed by fluoroscopy with a positive sniff test. The patient was referred to our centre for chronic non-invasive nocturnal ventilation (cNPPV). Subsequent investigations revealed evidence of anti-Borrelia seroactivity in EIA-IgG and IgG-blot, suggesting a recent infection with Lyme disease, and resulted in a 4-week treatment with oral doxycycline. The symptoms of nocturnal hypoventilation were successfully improved with cNPPV. However, our patient still shows impaired diaphragmatic function but he is no longer fully dependent on nocturnal ventilatory support.
Conclusion:
Lyme disease should be considered in the differential diagnosis of diaphragmatic dysfunction. It is a tick-borne illness caused by one of the three pathogenic species of the spirochete Borrelia burgdorferi, present in Europe. A delay in recognizing the symptoms can negatively affect the success of treatment. Non-invasive mechanical ventilation (NIV) is considered a treatment option for patients with diaphragmatic paralysis.

Introduction

Patients with bilateral diaphragmatic paralysis may initially present with dyspnea, orthopnea, and as the disease progresses respiratory failure. Bilateral diaphragmatic paralysis is a severe generalized muscle weakness, however in few cases it has been observed that the diaphragm can be the only involved organ. The most common causes of bilateral diaphragmatic paralysis are damage to the phrenic nerves and generalized muscle diseases. Nocturnal ventilatory assistance may have a significant beneficial effect6. These patients show reduced ventilatory muscle strength, as measured by maximal inspiratory and trans-diaphragmatic pressures. These symptoms could improve in association with an improved functional score and decreased dyspnea under ventilatory assistance. Non-invasive positive pressure ventilation (NPPV) is the therapeutic tool of choice for symptomatic patients with bilateral diaphragmatic paralysis.

This case report describes the development of diaphragmatic paralysis in a patient with Lyme disease with the need for ventilatory support3,4.
................

First published: 06 okt 2014, 3:235 (doi: 10.12688/f1000research.5375.1)

Competing interests: The abstract describing this work has been presented at the European Respiratory Society Annual Congress 2013.

[Sproetje]

Central European Journal of Medicine

Borreliosis presenting as autonomic nervous dysfunction, phrenic nerve palsy with respiratory failure and myocardial dysfunction – a case report

Door: Andreja Möller Petrun, Andreja Sinkovič
Department of Medical Intensive Care, University medical centre Maribor, Ljubljanska 5, SI-2000 Maribor, Slovenia
Received 28 December 2012; Accepted 1 March 2013

https://www.degruyter.com/view/j/med.20 ... 0172-7.pdf

Abstract:

Unrecognized and untreated Borrelia infection can progress from localized inflammation (erythema migrans) to early or late generalized stage within weeks to months. Meningoradiculitis, arthritis, multiple erythemas, myositis, and myocarditis of the early generalized stage have a good prognosis after antibiotic treatment, but late manifestations can progress to chronic disease. Phrenic nerve palsy, autonomic nervous system dysfunction and carditis with acute heartfailure are among rare manifestations as well as late generalised stage with myelitis. We present a case of a patient with meningoradiculitis, autonomic nervous dysfunction, respiratory failure due to phrenic nerve palsy and acute heartfailure with systolic myocardial dysfunction. The diagnosis of Borrelia infection was confirmed by positive serological testing, appropriate response to antibiotic therapy and exclusion of other diseases. Our case suggests that in unexplained respiratory failure and acute systolic myocardial dysfunction, particularly associated with signs of meningoradiculitis, Borrelia infection should be included in the differential diagnosis.

phrenic zenuw:
https://nl.wikipedia.org/wiki/Nervus_phrenicus

[Sproetje]

Diaphragmatic paralysis and respiratory failure as a complication of Lyme disease


R A Abbott, S Hammans, M Margarson, B M Aji
Uit: BMJ Journals
Published in
Journal of Neurology, Neurosurgery & Psychiatry, September 2005

http://jnnp.bmj.com/content/76/9/1306

There have been five recorded cases of diaphragmatic paralysis as a complication of neuroborreliosis.1–5 Here we report another case of Lyme meningoradiculitis, caused by an identified tick, leading to bilateral diaphragmatic paralysis with an abbreviated course on treatment.

Discussion
The first case of diaphragmatic paralysis as a complication of Lyme disease was reported in 1986: a 73 year old male, treated with ampicillin and netilmicin, who required ventilation for 3 months and then died after receiving treatment for a pulmonary embolism.1 Another four cases have been reported in patients between the ages of 39 and 68, all of whom were treated with either doxycycline or ceftriaxone and two of whom required ventilation due to respiratory failure.1–5 All patients were well at follow up, although one patient had persistent phrenic paralysis 6 months after treatment.5

In all previous cases of diaphragmatic palsy as a complication of Lyme disease, either the patient reported dyspnoea or hypoxia was noted on ABG. The diagnosis of phrenic nerve palsy was made by the following methods: hemidiaphragm elevation, fluoroscopic screening of diaphragmatic movements, or electrical stimulation of phrenic nerves.1–5 Our patient had a lymphocytic meningitis with sensory and motor neuropathies including bilateral phrenic nerve palsies. Diaphragmatic paralysis due to Lyme disease was diagnosed on the basis of clinical features, chest ultrasonography, the presence of the tick head, and serology indicating a recent infection with B burgdorferi as well as a rapid response to antibiotic therapy.

The clinical diagnosis of Lyme disease may be supported by serologic testing. B burgdorferi antibody tests may be negative in early infection, but patients are usually seropositive at or shortly after presenting with neurological symptoms. In some patients, antibodies against B burgdorferi may be detectable in CSF slightly earlier than serum. Culture and B burgdorferi deoxyribonucleic acid detection using polymerase chain reaction may also be used but were not in our case.

The three patients reported in the literature with respiratory failure caused by neuroborreliosis were ventilated for 3 months, 1 month, and 13 months, respectively, whilst our patient required ventilation for only 22 days.1,2,4 We speculate that early recognition of the possibility of Lyme disease and appropriate treatment shortened our patient’s acute illness.
In conclusion, it is important to consider Lyme disease in the differential diagnosis of acute respiratory failure – with or without erythema migrans.

[VerlorengezondheidM]

Diaphragmatic paralysis due to Lyme disease.

Faul JL, et al. Eur Respir J. 1999.

Abstract
Lyme disease is a tick-borne spirochaete infection which, in a proportion of patients, can lead to neuropathy. This article describes a case of diaphragmatic paralysis due to Lyme disease. A 39-yr-old male presented to the hospital because of an acute left facial palsy. Six weeks prior to admission he had developed a circular rash on his left flank during a camping holiday. He also complained of shortness of breath and arthralgia for 1 week. His chest radiograph demonstrated a raised right hemi-diaphragm. Diaphragmatic paralysis was confirmed by fluoroscopy (a positive sniff test). Serology revealed evidence of recent infection by Borrelia burgdorferi. On the basis of the patient's clinical presentation, a recent history of erythema migrans, and positive Lyme serology, a diagnosis of neuroborreliosis was made. He received oral doxycycline therapy (200 mg x day(-1)) for three weeks. Facial and diaphragmatic palsies resolved within eight weeks. On the basis of this case, a diagnosis of Lyme disease should be considered in patients from endemic regions with otherwise unexplained phrenic nerve palsy.

Bron: https://www.ncbi.nlm.nih.gov/m/pubmed/10232450/