We report on a patient who developed seronegative
Lyme neuroborreliosis complicating
chemotherapy for
chronic lymphatic leukemia. After the fifth cycle of
chemotherapy (FCR:
fludarabine,
cyclophosphamide,
rituximab and
prednisone) the 63-year-old patient developed night sweat,
arthralgia in elbows, wrists, proximal interphalangeal joints (PIPs) and strong
neuropathic pain in both legs, followed by
paresthesia and
hypesthesia in the feet, arms and face. Laboratory analysis revealed an elevated
C-reactive protein (CRP), a slight elevation of liver
enzymes and decreased
IgG levels. Cerebrospinal fluid (CSF) analysis showed a lymphomononuclear
pleocytosis and an elevation of
protein. A broad diagnostic work-up was negative including a negative Borrelia
IgG and
IgM ELISA. The patient did not remember recent
tick bites, but after specific questioning he recollected a transient
erythema on his leg developing just before the start of the last cycle of
chemotherapy. As the combination of
neuropathic pain and
arthralgia, the transient
erythema and the lymphomononuclear
pleocytosis raised the suspicion of
Lyme neuroborreliosis, the patient was treated for 3 weeks with
ceftriaxone. On
therapy all symptoms resolved and CRP normalized. Retrospective PCR analysis of a CSF sample confirmed the clinical diagnosis by detecting Borrelia garinii
DNA. This case demonstrates that in immunosuppressed patients borrelial serology may be negative and that additional diagnostic approaches (including tests for direct Borrelia detection) may be needed to demonstrate borrelial
infection.