Lyme neuroborreliosis in HIV-1 positive men successfully treated with oral doxycycline: a case series and literature review

This 60-year-old Caucasian man had a medical history including intermittent alcohol problems and depression, for which he was treated with disulfiram and selective serotonin re-uptake inhibitors (SSRIs). He was diagnosed with HIV 23 years earlier but did not start antiretroviral therapy (ART) until 20 years after diagnosis (lamivudine, tenofovir and ritonavir-boosted atazanavir). Two years after commencing ART, he noticed a tick bite but no erythema migrans. One year later, he was admitted to hospital with confusion, psychomotor agitation and hyponatremia (serum sodium 116 mmol/L). He had completely stopped taking his HIV medication one month earlier, after a period of deteriorating compliance. The hyponatremia was thought to have been caused by a combination of water intoxication, syndrome of inappropriate antidiuretic hormone secretion and SSRI medication. It was corrected slowly and the patient improved with regard to confusion and agitation, but he showed remaining cognitive impairment. It was also noted that he had trouble walking and suffered from radicular pain in both legs. A computed tomography (CT) scan of his brain was normal. A cerebrospinal fluid (CSF) sample four weeks after admission showed markedly elevated levels of albumin and mononuclear cells (Table 1). High CSF and serum Borrelia antibody titers were present and the Borrelia antibody index was positive, indicating intrathecal antibody production. Treatment was given with 200 mg of oral doxycycline twice daily for 10 days. At the same time, ART was re-started. Three weeks later, his pain and motor symptoms had improved. The number of CSF mononuclear cells had decreased markedly (Figure 1). At follow-up six months later, this patient's symptoms had continued to improve and the level of mononuclear cells in his CSF was down to normal (data not shown).

This 39-year-old Caucasian man had primary HIV infection six years earlier. Two years after that, he fell ill with Guillain-Barré syndrome, which was treated with intravenous gammaglobulin, and ART was started with stavudine, lamivudine, saquinavir and nelfinavir given for eight months. The Guillain-Barré symptoms resolved [7]. He was admitted with slowly increasing headaches, weakness in both legs and right hand tremor. On admission, he was still without ART and had a CD4 cell count of 390 cells/μL. Two days before admission, this patient had experienced a sudden onset of vertigo and hearing loss in his right ear. A magnetic resonance imaging scan showed a pontine infarction. Levels of albumin and mononuclear cells in his CSF were markedly elevated (Table 1). Borrelia-antibody titers were high in both his serum and CSF, and the Borrelia antibody index was positive. Treatment was given with 200 mg of oral doxycycline twice daily for 19 days. His symptoms of headaches, weakness, tremor and vertigo started improving within three days of starting treatment, but the hearing loss remained. Repeated lumbar punctures showed declining levels of CSF albumin (data not shown) and mononuclear cells (Figure 1). At follow-up after six months, he was still experiencing a complete hearing loss in his right ear, but the other symptoms had subsided. He still had no ART.

This 62-year-old Caucasian man was diagnosed with a primary HIV infection seven years earlier. Viral load was high and the CD4 cells were low at 180 cells/μL. ART was started with lamivudine, zidovudine and ritonavir-boosted lopinavir for one year and was re-started after four years with efavirenz, abacavir and lamivudine. One year later, the patient noted a change in the taste of coffee but no other foodstuff. In the following months, he experienced gradually increasing problems with vertigo and unsteadiness. A few months later, he also noted symptoms of tremor, urge incontinence and intermittent headaches. A CT scan revealed normal-pressure hydrocephalus. Six months later, CSF sampling showed increased levels of protein and mononuclear cells (Table 1). Culture and polymerase chain reaction tests for opportunistic infections were negative, but a cytological examination pointed to a neurotrophic infection. Four months after the first CSF analysis, a new analysis of CSF and serum revealed high titers of CSF and serum Borrelia antibodies and a positive antibody index, consistent with LNB. Treatment was given with 200 mg of oral doxycycline twice daily for 10 days. All the symptoms (including the change of taste of coffee) started improving within five days of treatment initiation. At follow-up two months later, the symptoms had almost completely disappeared and CSF levels of mononuclear cells and albumin had normalized (Figure 1).

This 50-year-old Caucasian man had been diagnosed with HIV five years previously. The date of infection was not known. He had been treated with ART for four years, initially lamivudine, zidovudine and ritonavir-boosted lopinavir, which were subsequently changed to efavirenz, emtricitabine and tenofovir. After treatment, his CD4 cell count had risen from 180 to 450 cells/μL. He fell ill with fever and headaches, plus a rash, which was later diagnosed as erythema migrans. Some days later he noted a right-sided facial palsy. His CSF levels of albumin and mononuclear cells were elevated (Table 1). Titers of Borrelia immunoglobulin M (IgM) antibodies in his serum and CSF were elevated, but IgG antibodies were not. Treatment was given with 100 mg of oral doxycycline twice daily for 21 days. The symptoms improved within a few days after treatment initiation. At follow-up two months later, the patient was still experiencing a slight sensibility disturbance from the right side of his face, but all the other symptoms had subsided and CSF pleocytosis and albumin concentration had normalized (Figure 1). Borrelia IgG antibodies in his serum and CSF were now positive.