Infectious causes of stroke - The Lancet Infectious Diseases

Here's a good one! 

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)00020-1/fulltext?elsca1=etoc&elsca2=email&elsca3=1473-3099_201506_15_6_&elsca4=Public%20Health%7CInfectious%20Diseases%7CInternal%2FFamily%20Medicine%7CNeuropsychiatry%7CNeurology%7CLancet

Infectious causes of stroke

Adam Garkowskiemail, Joanna Zajkowska, Anna Moniuszko, Piotr Czupryna, Sławomir Pancewicz

DOI: http://dx.doi.org/10.1016/S1473-3099(15)00020-1

    Summary
   
We read with great interest the excellent Review by Jennifer Fugate and colleagues1 about the infectious causes of stroke. Their Review is useful for daily practice, since physicians often focus excessively on autoimmune causes of central nervous system vasculitis causing stroke, while forgetting about infectious causes. However, we think that apart from neurosyphilis, which is mentioned in great detail, an additional comment on stroke caused by another spirochetal disease, Lyme neuroborreliosis, is needed. This rare form of Lyme neuroborreliosis is seldom mentioned in the medical literature.

About 60 cases of vasculitis and subsequent stroke due to Lyme neuroborreliosis have been described. Additionally, we have seen this form of Lyme neuroborreliosis in four patients in our department over the past 7 years. In a study of patients from eastern Saxony (Germany) done by Back and colleagues,2 the same form was seen in 11 patients between 1997 and 2011, with the estimated proportion of cerebral vasculitis in patients with Lyme borreliosis being 0·3%. Almost all cases reported in the literature have been described by European authors, which relates to the higher prevalence of Borrelia garinii in Europe, the most neurotropic genospecies of Borrelia.

The most common clinical manifestation of vasculitis due to Lyme neuroborreliosis is ischaemic stroke with pathological changes resembling those occurring in vasculitis induced by infection with Treponema pallidum.2, 3 Most patients are relatively young.2 The vasculitis caused by Lyme neuroborreliosis is usually associated with a prodromal clinical course suggesting Lyme neuroborreliosis with symptoms of meningitis, cranial neuritis, or radiculoneuritis weeks to months before the onset of symptoms of stroke.

Medical history might also reveal a past history of tick bites or erythema migrans. MRI usually shows multiple and bilateral ischaemic lesions, and sometimes meningeal enhancement.2, 4 In this case, cerebral angiography and transcranial Doppler often detect different degrees and location of segmental stenosis suggestive of vasculitis.2, 4 Patients with Lyme neuroborreliosis associated vasculitis need immediate diagnosis and antibiotic treatment because the condition is potentially life-threatening.2, 5 A high index of suspicion is needed in patients who live in or have come from areas with high prevalence of tick-borne diseases, and in those without cardiovascular risk factors, but with stroke-like symptoms of unknown cause.

We declare no competing interests.

References

    Fugate, JE, Lyons, JL, Thakur, KT, Smith, BR, Hedley-Whyte, ET, and Mateen, FJ. Infectious causes of stroke. Lancet Infect Dis. 2014; 14: 869–880
        View in Article | Summary | Full Text | Full Text PDF | PubMed | Scopus (2)
    Back, T, Grünig, S, Winter, Y et al. Neuroborreliosis-associated cerebral vasculitis: long-term outcome and health-related quality of life. J Neurol. 2013; 260: 1569–1575
        View in Article | CrossRef | PubMed | Scopus (6)
    Miklossy, J, Kuntzer, T, Bogousslavsky, J et al. Meningovascular form of neuroborreliosis: similarities between neuropathological findings in a case of Lyme disease and those occurring in tertiary neurosyphilis. Acta Neuropathol. 1990; 80: 568–572
        View in Article | CrossRef | PubMed | Scopus (27)
    Topakian, R, Stieglbauer, K, Nussbaumer, K et al. Cerebral vasculitis and stroke in Lyme neuroborreliosis. Two case reports and review of current knowledge. Cerebrovasc Dis. 2008; 26: 455–461
        View in Article | CrossRef | PubMed | Scopus (38)
    Buchwald, F, Abul-Kasim, K, Tham, J et al. Fatal course of cerebral vasculitis induced by neuroborreliosis. Neurol India. 2010; 5: 139–141
        View in Article | CrossRef | Scopus (1)