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Prospective validation of a clinical prediction model for Lyme meningitis in children.

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Abstract

OBJECTIVE:

Lyme meningitis is difficult to differentiate from other causes of aseptic meningitis in
Lyme disease-endemic regions. Parenteral antibiotics are indicated for
Lyme meningitis but not viral causes of aseptic meningitis. A clinical prediction model was developed to distinguish
Lyme meningitis from other causes of aseptic meningitis. Our objective was to prospectively validate this model.

METHODS:

Children between 2 and 18 years of age presenting to Hasbro Children’s Hospital from April through October of 2006 and 2007 were enrolled if a lumbar puncture for meningitis showed a cerebrospinal fluid white blood cell count of >8 cells per microL. Cerebrospinal fluid was sent for
Lyme antibody testing. The probability of
Lyme meningitis was calculated by using the percentage of cerebrospinal fluid mononuclear cells, duration of headache, and presence of cranial neuropathy by using the prediction model. Definite
Lyme meningitis cases were defined as cerebrospinal fluid pleocytosis with (1) positive
Lyme serology confirmed by immunoblot or (2) erythema migrans rash. Possible
Lyme meningitis cases were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid
Lyme antibody. Sensitivity, specificity, and likelihood ratios for definite and possible
Lyme meningitis were determined by using 10% increments of calculated probability of
Lyme meningitis.

RESULTS:

Fifty children were enrolled, including 14 children with definite
Lyme meningitis, 6 with possible
Lyme meningitis, and 30 with aseptic meningitis. A calculated probability of <10% for
Lyme meningitis had a negative likelihood ratio of 0.006 for definite and possible
Lyme meningitis cases. A calculated probability of >50% for
Lyme meningitis had a positive likelihood ratio of 100 using these definitions.

CONCLUSIONS:

A clinical prediction model using the percentage of cerebrospinal fluid mononuclear cells, headache duration, and presence of cranial neuropathy can differentiate children with
Lyme meningitis from children with aseptic meningitis. Our findings suggest categories of low (<10%), indeterminate (10%-50%), and high (>50%) probability of
Lyme meningitis.

Pediatrics. 2009 May;123(5):e829-34. doi: 10.1542/peds.2008-2048. Research Support, Non-U.S. Gov’t; Validation Studies

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