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Neuroborreliosis: Pathogenesis, Symptoms, Diagnosis, and Treatment

  • Authors: Tobias A. Rupprecht, MD; Volker Fingerle, MD
  • CME Released: 3/7/2011
  • Valid for credit through: 3/7/2012, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, infectious disease physicians, neurologists, and other health professionals caring for patients with Lyme disease.

The goal of this activity is to describe the pathogenesis, symptoms, diagnosis, and management of neuroborreliosis, based on a review.

Upon completion of this activity, participants will be able to:

  1. Describe the epidemiology and pathogenesis of Lyme neuroborelliosis (LNB)
  2. Describe the characteristic symptoms and diagnosis of LNB
  3. Describe the treatment and management of LNB


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  • Tobias A. Rupprecht, MD

    Abteilung für Neurologie, AmperKliniken AG Dachau, Dachau, Germany


    Disclosure: Tobias A. Rupprecht, MD, disclosed the following relevant financial relationships:
    Served as a consultant for: Genzyme Corporation; Mikrogen; Virotech

  • Volker Fingerle, MD

    National Reference Centre for Borrelia, LGL Oberschleißheim, Germany


    Disclosure: Volker Fingerle, MD, has disclosed no relevant financial relationships.


  • Elisa Manzotti

    Editorial Director, Future Science Group, London, United Kingdom


    Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME Author(s)

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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    For Physicians

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    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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Neuroborreliosis: Pathogenesis, Symptoms, Diagnosis, and Treatment: Epidemiology



The incidence of Lyme borreliosis varies considerably from region to region (an overview is given by Hubalek[7]). In Germany, Lyme borreliosis must legally be notified to local health services in the six eastern states only. Between 2002 and 2009, the reported incidence in these six territories varied between 17.8 and 37.5 per 100,000 inhabitants.[8] In a prospective, population-based study covering the region of Würzburg, the incidence was 111/100,000 per year.[9] The individual probability of becoming infected with B. burgdorferi by a tick bite depends on several factors:

  • The proportion of infected ticks – a European meta-analysis found 18.6% of the adult and 10.1% of the nymphal ticks to be infected, but the rate varied, depending on the region and the tick stage, from 1.5 to 75%.[10] Of note, there was no differentiation between human-pathogenic and -nonpathogenic B. burgdorferi species.
  • The duration of the tick’s feeding – while the North American tick Ixodes scapularis needs at least 24–48 h of feeding until Borrelia are transmitted, experiments with gerbils and Ixodes ricinus (endemic to Europe) have shown that after only 16.7 h of feeding, 50% of the animals were infected with B. burgdorferi.[11–13] The reason for this discrepancy can be found at the location of B. burgdorferi inside of the ticks: while Ixodes scapularis harbors the bacteria only in the mid-gut (where they have to detach and migrate to the salivary gland before being injected into the host), a part of the Borrelia in I. ricinus can already be found directly in the salivary glands.[14]
  • The borrelial species – skin biopsies from patients with erythema migrans reveal mostly B. afzelii (in 70–90% of the cases) and significantly less B. garinii (10–20%), while both species can be equally found in the ticks.[3,7,10,15] This suggests that borrelial species vary in their infectivity.

Considering the necessary duration of feeding and the proportion of infected ticks, spirochetal inoculation after a tick bite is the exception and not the rule. A study from south-west Germany has shown that only approximately 2.6% of all tick bites lead to a clinically apparent infection.[16]

The most frequent manifestation of Lyme borreliosis – accounting for approximately 90% of cases – is erythema migrans, while the CNS is the most frequent destination of dissemination. According to population-based prospective studies performed both in Germany and Sweden, the incidence of Lyme neuroborreliosis (LNB) is approximately 3–11/100,000 per year.[9,17]