Neuro-Psychiatric and Cognitive Impact of Tick-borne Disorders on Children and Adolescents

Transcription

1 Neuro-Psychiatric and Cognitive Impact of Tick-borne Disorders on Children and Adolescents Rosalie Greenberg, MD, FAPA, DFAACAP Child and Adolescent Psychiatrist Summit, New Jersey PA Lyme Medical Conference 2018 New Frontiers in Lyme and Related Tick-Borne Diseases April 6-7, 2018

2 PA Lyme Medical Conference 2018 New Frontiers in Lyme and Related Tick Borne Diseases The Hershey Lodge, Hershey, PA April 6 7, 2018 Disclosure Statement I do not have any financial arrangements or affiliations with any commercial entities whose products, research, or services may be discussed in these materials.

3 Outline General info re LD in youth Neurologic symptoms Cognitive issues Psychiatric symptoms Findings in 27 bipolar youngsters Co infections Caveats Conclusions

4 Lyme in Children According to the CDC: Most common among boys 5 19 years old Kids have 3x the rate of all other age groups 25% of Lyme cases are in children

5 Clinical Manifestations of BB Localized skin infection at bite site (erythema migrans or bullseye rash) Development of flu like symptoms: fever malaise arthralgias myalgias One third or more don t recall a rash and flu like symptoms could have been very mild

6 LD in Children Can be hard to recognize: Kids often get colds and fever Somatic complaints common in kids growing pains headaches problems with concentration Behavioral. emotional, and subtle cognitive changes may occur

7 LD onset in childhood Can interfere in multiple spheres: Physically (sports) Cognitive Development (Academic progression) Mentally/Emotionally Socially

8 Lyme Disease in the general population 15 40% develop neurologic problems Coyle PK: Neurologic lyme Disease. Semin Neurol 12: , 1992).

9 Lyme Children have CNS involvement more frequently than PNS involvement Peripheral neuropathy occur in 1% to 3% of kids Most common PNS manifestation is Bell s palsy with a sudden onset of facial palsy Bilateral facial palsy in 6% to 37% Kids are bitten by ticks more frequently around head and neck making them more vulnerable to CNS infections Neuropsychiatric symptoms are often misdiagnosed And perhaps underdiagnosed

10 Neurologic Manifestations in Children N=94 Headache 71% Facial Palsy 14% Sleep Disturbance 7% Papilledema 7% Diplopia 2% Paresthesia 2% Carpal tunnel syndrome 1% Guillain Barre like syndrome 1% Belman et al. Neurology 1993

11 Neurologic Lyme in Children (N=94) Onset of neuro problems 1.5 wks 51 months after initial systemic signs of LD Majority presented within 12 months of infection Belman et al. Neurology 1993

12 Lyme Disease and the Central Nervous System in Children The little literature available has focused more on cognitive effects

13 Cognitive effects of LD in Children N=41 children that were rx d with antibiotics vs. 14 controls with subacute rheumatological diseases vs. 23 healthy sibling controls Looked at predisease and post disease academic scores; performed of neuropsych testing and found no perceived long term deterioration in cognitive or personality areas as reported by parents But this may not represent all kids with LYD, as most had presented with rheumatologic sx and received early rx (i.e. didn t present with other LD and didn t receive early treatment) *Adams WV et al 1994

14 Chronic Lyme in Youth Case series 12/86 14% developed psychiatric and cognitive difficulties in the areas of attention and memory *Fallon et al. Neuropsychiatric Aspects of Lyme Disease in Children. Presented at the 12 th International Conference on Lyme Disease and other Spirochetal and Tick Borne Disorders, NY April 1999

15 Controlled Study of Cognitive Deficits in Children with Chronic Lyme Disease (Tager et al 2001) N=20 Deficits in visual and auditory attention Deficits in working memory and mental tracking

16 Cognitive Problems Associated with TBI Include difficulty with: 1. attention and concentration 2. speed and efficacy of processing info 3. learning and memory 4. auditory processing and language expression 5. planning and organization 6. multitasking 7. math and reading scores often significantly lower than their verbal and nonverbal intellectual abilities Shea, LJ, and Leventhal, JG The role of neurospsch testing in children with lyme disease (website). 2014

17 Neuropsychological Symptoms of TBD In Children Harder to recognize Tick bite may be unknown Regression in children harder to recognize Somatic complaints common in kids growing pains, headaches, problems with concentration The more common and yet more subtle manifestation may be in the emotional, cognitive and behavioral sphere

18 TBI related Neuropsychological Symptoms Index of suspicion crucial (Yogi Berra principle)

19 Lyme Encephalopathy It is one of the most common neurologic presentation of late LD Includes disturbances of: Memory (problems with short term memory, word finding) Attention (slowed processing speed) Sleep Mood (irritability, emotional lability) Marked fatigue Dyslexia Spatial discrimination Coyle PK. Neurologic Lyme disease. Semin Neurol Tager,F and Fallon BA. Psychiatric and cognitive features of Lyme disease. Psych Annals 2001

20 CDC study in New Jersey N=64 school children Medium duration of illness at time of interview=363 Medium # school days missed =103 (2 548) Median duration of home instruction days 78% had a fall in grade point average

21 Neuropsychiatric Symptoms of TBI Hypotheses Youth with neuropsych symptoms (especially non cognitive sx i.e. emotional and behavioral sx) of TBI are often misdiagnosed These neuropsych symptoms may be a presenting and much common manifestation of TBI in children

22 Mood Symptoms in a Controlled Study of Cognitive Deficits in Children with Chronic Lyme Disease N=20 Parent/child reported psychopathology. Regarding depression parents indicated: 41% (7/17)had suicidal thoughts and 11% (2/18) made a suicidal gesture. On child rating (CDI) 40% (8/20) had suicidal thoughts (Tager et al 2001)

23 Neurologic Lyme in Children (N=94) 36 kids or 38% had behavioral or mood changes Irritability Malaise Emotional lability Attentional issues Decreased interest in play (Belman et al. Neurology 1993)

24 TBI and Psychiatric Symptoms Children with Chronic LD have higher rates of Anxiety, Mood, and Behavioral Disorders than Children without LD (Fallon BA, Tager FA, Rykiel R: Neuropsychiatric aspects of Lyme disease in children. Abstract book, 12 th International Conference on Lyme Disease and other Spirochetal and Tick Borne Diseases, New York, NY April, pp30 31.)

25 Potential Psychiatric Symptoms of Lyme/TBI Psychosis Attention Deficit Hyperactivity Disorder Anxiety / Panic attacks Depression Bipolar disorder Autistic Spectrum Disorder Obsessive Compulsive Disorder Violent behavior / Irritability Suicidal thoughts Sleep disorders Cognitive Problems

26 Studies have shown that TBI has been associated with a myriad of Psychiatric Symptoms But What about the Converse?

27 Infections and Mental Illness Although many infections can precipitate psychiatric symptoms, the question is also how often are psychiatric symptoms or syndromes the result of infections?

28 TBI and PBD Sample Characteristics (N= 27) 22/27 (81%) boys 5/27 (19%) females Average age at BPD dx = 7.3 (5 12) 15 BPI * 12 BPII * * DSM IV TR criteria

29 Results of Testing R

30 Results of Serologic Testing Babesia (N=16) Mycoplasma Pneumoniae (N=11) Bartonella (N=8) Lyme (N=6) (if include Igenex IgG WB +: Lyme = 9) Anaplasma (N=1) Ehrlichia (N=1).

31 Results of Serologic Testing 89 % or 24/27 were positive on serologic testing 92% (22/24) with + serology complied with recommendation clinical assessment by a specialist in TBI Of these 92% or 20/22 were clinically diagnosed with 1 or > TBI Summary: 74% or 20/27 were diagnosed with a TBI 23.5% or 4/27 were positive for PANDAS

32 Review of 69 consecutive patients from a Private Pediatric Psychopharmacology Practice (2/1/15 2/1/18) 49/49 were positive when tested by specialized labs (Igenex, Galaxy etc.) 7 were negative when tested by either Quest Diagnostics (4) or Lab Corp (3) alone 6 had known TBI at the time of referral 7 did not get testing

33 The Problem of Multiplicity of TBI Still early in our understanding and without good studies separating out the individual infections Lyme if patient has it there is a good chance that co infections are also present e.g. Babesia Bartonella

34 Babesia Emotional lability Depression Clinical manifestations of Tick Borne Illness in Children Bryant KA, et Marshall, GS; 2000

35 Bartonella encephalopathy panic attacks confusion rage depression headaches cognitive dysfunction personality disorders bipolar disorder Dr. Jones Kids

36 Bartonella and Cognition Problems with working memory Slowed processing speed Small vessel disease Goes to collagen and RBC s Hypermobility syndrome

37 Bartonella Small Vessel Disease: CNS Features* 1. Mild cognitive impairment 2. White matter subcortical disconnection 3. Executive dysfunction impaired 4. NOT a dementia 5. Working memory impaired (RAM) 6. Processing speed delayed 7. Mood labile *BR Mozayeni MD

38 Caveats True prevalence of TBI in the general population in study area is unknown Each pathogen genus (e.g. Borrelia, Bartonella, Mycoplasma, etc.) consists of a wide variety of difference species only some of which affect human hosts. Cross reactivity of species may interfere with intra-genus testing results Testing for Mycoplasma pneumoniae is confusing Leading cause of respiratory infections, but can also cause gi, cv, musculoskeletal, renal, or neurologic problems (i.e. encephalitis) 1,2 1 Defilippi A, Silvestri M, Tacchella A, Giacchino R, Melioli G, Di Marco E, Cirillo C, Di Pietro P, Giovanni A. Rossi GA. Epidemiology and Clinical Features of Mycoplasma Pneumoniae Infection in Children. Respiratory Medicine. 2008; (102), Meyer PM, Sauteur JC, Streuli, 2 Goetschel, P. Mycoplasma Pneumoniae-Associated Encephalitis in Childhood Nervous System Disorder During or After a Respiratory Tract Infection Mycoplasma-Pneumoniae-Assoziierte Enzephalitis bei Kindern Neurologische Symptome im Rahmen eines Luftwegsinfektes. lin Padiatr. 2011; 223(4):

39 Caveats MP is also known to be carried by Ixodes ticks Co infection with PANDAS/PANS in addition to TBI high Could the latter indicate a heightened susceptibility or weakened immunity in these co infected individuals?

40 Issues to Consider Association does not mean causality What happens with treatment? More sensitive to psychiatric meds? When to stop-when does rx become more harmful than helpful?

41 Conclusions Initial presentation of TBI in youth may be symptoms of a variety of childhood mental disorders Although the temporal relationship between TBI and PBD cannot be determined, the high rate of TBI in the one case series presented is provocative Much more research is needed to clarify the interaction of TBI and psychiatric illness especially in children and adolescents