Brainstem encephalitis in neuroborreliosis: typical clinical course and distinct MRI findings
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ORIGINAL COMMUNICATION
Brainstem encephalitis in neuroborreliosis: typical clinical course and distinct MRI findings Thomas Pfefferkorn1 · Joachim Röther2 · Bernd Eckert3 · Hendrik Janssen4 Received: 10 August 2020 / Revised: 20 August 2020 / Accepted: 24 August 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Objective In this retrospective observational study and referring to a historical case presented in 2009, we searched for typical clinical and imaging features of brainstem encephalitis in neuroborreliosis. Methods In addition to the historical case we describe five affected patients. Results All patients had a very similar prolonged clinical course with unspecific symptoms such as wasting, fatigue and headache. Brainstem signs were irregularly observed. MRI showed symmetrical brainstem alterations in all patients. In coronary FLAIR imaging these changes formed a figure resembling a Philippine tarsier. Conclusions A subset of patients with neuroborreliosis develops a brainstem encephalitis with a typical clinical course and distinct MRI findings. Keywords Borreliosis · Encephalitis · MRI
Introduction
Methods
Neuroborreliosis is a common neuroinfectious disease in the northern hemisphere with meningoradiculitis, cranial neuritis and lymphocytic meningitis as typical manifestations [1]. Encephalitis is a rare manifestation with MRI findings that are considered unspecific [2]. An interesting case by Haene and Tröger published in 2009 described profound symmetrical MRI lesions in the mesencephalon and diencephalon in a patient with brainstem encephalitis in neuroborreliosis [3].
In this retrospective observational study we present a series of five additional patients with brainstem encephalitis in neuroborreliosis. All patients were treated between 2014 and 2018 in two German hospitals. Special focus was put on clinical presentation and MRI findings.
Results Medical history and clinical findings
* Thomas Pfefferkorn thomas.pfefferkorn@klinikum‑ingolstadt.de 1
Department of Neurology, Klinikum Ingolstadt, Krumenauerstrasse 25, 85049 Ingolstadt, Germany
2
Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
3
Institute of Radiology and Neuroradiology, Asklepios Klinik Altona, Hamburg, Germany
4
Institute of Radiology and Neuroradiology, Klinikum Ingolstadt, Ingolstadt, Germany
All patients presented with a prolonged clinical course of two to six months and unspecific symptoms such as wasting (5/5) fatigue (4/5) and headache (4/5). A single tick-bite or a local skin redness (erythema migrans) prior to symptom onset was not remembered by any of the patients. On clinical examination, none of the patients showed signs of meningoradiculitis. Brain stem signs were present irregularly and included dysarthria, dysmetria, hoarseness, gait disturbances and double vision. Case 2 was complicated by a small right frontal ischemic stroke causing a mild left-sided hemiparesis. Borreliosis associated vasculitis was considered the probable etiology.
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