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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
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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.

Accreditation Statements

    For Physicians

  • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Future Medicine Ltd. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.

    Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

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Neuroborreliosis: Pathogenesis, Symptoms, Diagnosis, and Treatment: Executive Summary


Executive Summary


  • The incidence of Lyme borreliosis varies between regions and was 111/100,000 per year in a population-based study from Germany.
  • The probability of infection after a tick bite depends mainly on the rate of infected ticks, the borrelial species and the duration of feeding.
  • The CNS is the most frequent destination of dissemination, but Lyme neuroborreliosis (LNB) accounts for only approximately 3–11% of Lyme borreliosis cases in Europe.


  • Borrelia burgdorferi possesses several mechanisms of immune evasion, especially antigenic variation, inactivation of the host immune system and hiding in protective niches of the host.
  • Invasion of the CNS appears to vary between the USA (mainly hematogenous spread) and Europe (along structures such as the peripheral nerves).
  • CXCL13 appears to play a key role in the B-cell-dominated immune response in the cerebrospinal fluid in LNB.
  • The neuronal dysfunction is either the result of a direct process (cytotoxicity of B. burgdorferi) or indirectly (e.g., through lipoproteins, inflammatory bystander reactions or autoimmune phenomena).


  • The clinical picture of acute LNB is well defined and encompasses meningoradiculitis, cranial neuritis, focal neurological deficits and/or meningitis in the majority of cases.
  • Chronic neuroborreliosis is a rare disease with both clinical and laboratory objective findings.
  • Post-Lyme disease is a poorly defined syndrome as yet, which applies to treated patients with persisting (mostly subjective) symptoms but without evidence of an ongoing infection.


  • According to the existing guidelines, a typical clinical picture in combination with inflammatory cerebrospinal fluid changes and an intrathecal production of B. burgdorferi-specific antibodies is required for a definite diagnosis of LNB.
  • CXCL13 appears to be a promising marker for the diagnosis of early cases with negative antibody index, for activity of disease and as a therapy marker.
  • Owing to the lack of adequate studies, the lymphocyte transformation test and CD57+ cell counts cannot be recommended for the diagnosis of acute or chronic LNB.


  • Oral doxycycline and intravenous β-lactam antibiotics appear to be equally effective.
  • There is no evidence that antibiotic treatment beyond 21–28 days is more effective, especially in the prevention of persisting symptoms.