Lyme disease should be suspected in any patient with chronic lymphocytic meningitis or mild meningoencephalitis with associated cranial neuritis or radiculitis. Lab tests include serologic assays like immunofluorescent assay and enzyme-linked immunoassay tests for anti–B. burgdorferi antibodies. Specific anti–B. burgdorferi antibody also appears in CSF, where it can be detected even when serum antibody tests are negative. (To establish whether these antibodies are synthesized intrathecally, serum and CSF antibody levels should be measured simultaneously.28)

The CSF profile in Lyme disease encephalomeningitis includes these findings:

• Opening pressure: normal
• White blood cell count >100 (>90% lymphocytes)
• Glucose: normal
• Protein: mild to moderate increase
• Oligoclonal bands: present
• B. burgdorferi antibody: positive

Following are diagnostic criteria for Lyme neuroborreliosis:

Possible neuroborreliosis	Compatible neurologic abnormality and history of tick bite or travel or residence in endemic area
Probable neuroborreliosis	Compatible neurologic abnormality and serum immunoreactivity to B. burgdorferi
Definite neuroborreliosis	Compatible neurologic abnormality plus one of the following: Acrodermatitis chronica atrophicans or lymphocytoma Serum and CSF immunoreactivity or CSF reactivity alone against B. burgdorferi by enzyme-linked immunoassay or Western blot Serum immunoreactivity to B. burgdorferi and non-neurologic organ system Lyme involvement Seroconversion or fourfold rise in antibody titer between acute and convalescent sera

In most patients with late Lyme disease (especially those with cortical dysfunction, but also many without), the EEG demonstrates nonspecific generalized slowing, focal slowing, increases in sharp wave activity, or a combination of these.13

MRI may show multifocal white-matter abnormalities, infarct patterns, periventricular and subinsular encephalomalacia, and pontine and medullary atrophy.25,27

Lyme Neuroborreliosis Table adapted from L Reik. Lyme Disease. In WM Scheld, RJ Whitley, DT Durack (eds), Infections of the Central Nervous System. Philadelphia: Lippincott–Raven, 1997;685–718.
Adapted from: Goldstein MA and Harden CL. Infectious states. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;83-133.
With permission from Elsevier (www.elsevier.com).
Reviewed and revised March 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.