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The prevalence of Lyme disease and associated coinfections in people with persistent post concussive syndrome

Sergio Azzolino1, 2* and Frederick R. Carrick1, 3, 4
  • 1 Carrick Institute, Neurology, United States
  • 2 Harvard Medical School, GCSRT, United States
  • 3 Bedfordshire Centre for Mental Health Research in association with the University of Cambridge (BCMHR-CU), Neurology, United Kingdom
  • 4 Harvard Macy Institute, United States

Introduction: Traumatic brain injuries and Lyme disease compromise the health and activities of millions of patients per year. The chronic symptoms and disability of traumatic brain injuries (TBI) and Lyme disease share a similar clinical presentation. Despite many concussions healing relatively quickly, a number of these patients are refractory to healing and have persistent disabling symptoms called post-concussion syndrome (PCS). Furthermore, according to the Centers for Disease Control and Prevention (CDC), Lyme disease is the most commonly reported vector-borne illness and the fifth most common disease in the National Notifiable Diseases Surveillance System, making it an important public health concern. Neurological manifestations of Lyme disease, called Neuroborreliosis, are reported in up to 15% of patients with Lyme disease. We have identified an alarming number of individuals suffering from PCS that are refractory to care and that have serologically tested positive for Lyme disease. As a consequence we started to routinely test PCS patients for Lyme disease that had no history of or testing for Lyme disease. Methods: We desired to investigate the prevalence of Lyme disease and co-infections in our post concussive patients that remained symptomatic over one year after a TBI. We searched a variety of databases for randomized controlled trials of mTBI and Lyme Disease up until January, 2018 without success. Our search included Cochrane Injuries Group's specialized register, Cochrane Depression, Anxiety and Neurosis Group's specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, ERIC, and PsycBITE. Because of the lack of research in this area we decided to perform a retrospective chart review of our patients that were symptomatic a minimum of one year after a TBI that we also had tested for Lyme disease to ascertain if there was a relationship. Hypothesis: Based on our experience and clinical observations, we hypothesized that a significant percentage of PCS patients that are symptomatic after one year from the date of injury may continue to be symptomatic due to ongoing undiagnosed and untreated Lyme disease or associated co-infection. Materials and Methods: The study was a single-center retrospective review of patient charts performed at our clinical facility in San Francisco, California. All charts were anonymized ensuring patient confidentiality appropriate to the Declaration of Helsinki. Each record that was accepted in our review met the study criteria for inclusion and were not disqualified by any of the exclusionary criteria. Statistical Analysis The statistical analysis was performed using STATA 14 (College Station, Texas). Linear regression models and correlations were fitted to identify any laboratory predictors of TBI and effect sizea were identified by Eta Squared calculations. Results Our review identified 217 PCS patient records that met our criterion (93 females with a mean age of 34 years, 120 males with a mean age of 40 years and 4 individuals with unidentified gender). The normality of the distributions of data was verified using Kolmogorov-Smirnov with Lilliefors Significance Correction and Sharpiro-Wilk tests of normality. Chi2 and logistic regression models including all laboratory tests and including males and females revealed several highly statistically significant predictors of TBI if the patient had a positive Western Blot Igenex IgM or IgG test (P = 0.000), or B. Burgdorferi IgM or IgG (P = 0.008). All other laboratory testing was not significantly associated with predicting a PCS. The effect sizes were moderately large for Western Blot IgM and IgG and small-medium for B. Burgdorferi IgM and IgG. The laboratory tests were more significant as predictors for females compared to males, although statistically significant for both. Conclusions: Traumatic brain injuries are a major cause of death and disability among people of all ages affecting approximately 10 million people worldwide. Most patients with mild traumatic brain injury (mTBI) recover rather quickly, but other report PCS, the underlying pathophysiology of which is largely unknown. PCS, is a complex disorder characterized by multiple pathophysiological processes or “polypathology” whose main features are white matter degradation, neuronal loss, protein misfolding, and persistent neuroinflammation. Alterations in the neurotransmitter and neuroendocrine systems are also very common. Despite emerging new understandings of the pathophysiology of these injuries, there is relatively little sound epidemiological data to accurately predict risk factors for post-concussive syndrome. Numerous studies have documented risk factors such as age (children and elderly being more susceptible then adults), female sex, injury-related litigation, pre-existing stress, premorbid psychiatric or cognitive conditions (such as learning disabilities). Additionally, several genetic polymorphisms involving brain-derived neurotrophic factor (BDNF) and the interleukins (IL) have been shown to have a potential effect on the severity of axonal injury, inflammation, blood-brain barrier disruption, neuronal survival, regeneration and plasticity. It has long been known that production of cytokines is increased in the brain following contusions, with expression of IL-6, IL-1b, and TNF-a by mononuclear cells and IL-1b by astrocytes. However, there has been little reported on the role of systemic infections such as Lyme disease that present with a similar profile of symptoms. A relatively inexpensive and widely used blood test to assess the prevalence of Lyme disease in PCS would dictate the need for appropriate antimicrobial treatment to cure the infection. It is likely that this intervention, might also alleviate symptoms such as cognitive disturbances, dizziness, and fatigue. Given the cost of interventions for PCS, the diagnosis and treatment of co-morbid infections could prove to have a significant impact on the standard of care of PCS. We have identified that specific Lyme blood markers are statistically significant predictors of PCS in our patient population. We do not know if this correlation is specific to our clinical population of PCS patients or if there is a general or global association.

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Keywords: Post concussion syndrome, Lyme Disease, Neuroinfectious diseases, TBI, Rehabilitation

Conference: International Symposium on Clinical Neuroscience 2018, Orlando, Florida, United States, 24 May - 26 May, 2018.

Presentation Type: Poster

Topic: Clinical Applications in health, disease, and injury to the nervous system

Citation: Azzolino S and Carrick FR (2018). The prevalence of Lyme disease and associated coinfections in people with persistent post concussive syndrome. Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience 2018. doi: 10.3389/conf.fneur.2018.60.00047

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Received: 29 Mar 2018; Published Online: 14 Dec 2018.

* Correspondence: Dr. Sergio Azzolino, Carrick Institute, Neurology, Cape Canaveral, United States, sergioazzolino@gmail.com