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ARTICLES: Aris C. Garro, Maia Rutman, Kari Simonsen, Jenifer L. Jaeger, Kimberle Chapin, and Gregory Lockhart Prospective Validation of a Clinical Prediction Model for Lyme Meningitis in Children Pediatrics 2009; 123: e829-e834 [Abstract] [Full text] [PDF]

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Validation of Lyme Prediction Model

Robert A. Avery, Stephen C. Eppes, and Samir S. Shah   (15 May 2009)

Validation of Lyme Prediction Model 15 May 2009
Robert A. Avery, Division of Neurology Children's Hospital of Philadelphia, Stephen C. Eppes, and Samir S. Shah Send letter to journal: Re: Validation of Lyme Prediction Model averyr{at}email.chop.edu Robert A. Avery, et al.	We appreciate the work by Garro et al (1) prospectively validating the clinical prediction model for Lyme meningitis we developed from a retrospective cohort (2). In fact, our model was also recently validated in a retrospective cohort of children from Belgium (3). Garro and colleagues (1) should be commended for their work as prediction models are rarely validated. Despite the relatively small number of enrolled subjects, this prospective validation provides further support for performing a multicenter study to determine whether a prediction model can address two key issues in caring for pediatric patients presenting with aseptic meningitis. Firstly, can the model decrease antibiotic use in children who are at “low risk” for Lyme meningitis? Secondly, for those children at “high risk” for LM, can early treatment with parental antibiotics while awaiting confirmatory serology testing reduce the number of days an indwelling catheter is needed, thus reducing the risk of a catheter-related complications? While the “Rule of 7’s” suggested by Garro et al (1) is an easy concept to remember, it should noted that facial nerve palsy is not the only cranial neuropathy seen in Lyme meningitis (4). It is unclear whether Garro et al (1) or Tuerlinckx et al (3) considered the presence of papilledema, as we did in our model, to be classified as cranial neuritis. In our own clinical experience, abducens nerve palsy and papilledema are excellent clues, in the correct context, to raise your suspicion for Lyme meningitis versus aseptic meningitis. Papilledema has been reported to be the only neurologic finding in patients with Lyme meningitis prior to their progression to meningitis (5). As papilledema caused by Lyme meningitis can lead to vision loss (6), a fundus examination and measurement of cerebrospinal fluid opening pressure in all children with suspected meningitis are important elements in the evaluation of children with Lyme meningitis. Robert A. Avery, D.O. Children’s Hospital of Philadelphia Philadelphia, PA Stephen C. Eppes, M.D. A.I. duPont Hospital for Children Wilmington, DE Samir S. Shah, M.D., M.S.C.E. Children’s Hospital of Philadelphia Philadelphia, PA References 1. Garro AC, Rutman M, Simonsen K, Jaeger KL, Chapin K, Lockhart G. Prospective validation of a clinical prediction model for Lyme meningitis in children. Pediatrics. 2009; 123:e829-834. 2. Avery RA, Frank G, Glutting JJ, Eppes SC. Prediction of Lyme meningitis in children from a Lyme disease-endemic region: A logistic- regression model using history, physical, and laboratory findings. Pediatrics. 2006; 117:e1-7 3. Tuerlinckx D, Bodart E, Jamart J, Glupczynski Y. Prediction of Lyme meningitis based on a logistic regression model using clinical and cerebrospinal fluid analysis: A European model. Pediatr Infect Dis J. 2009; 28:394-397. 4. Shah SS, Zaoutis TE, Turnquist J, Hodinka RL, Coffin SE. Early differentiation of Lyme from Enteroviral meningitis. Pediatr Infect Dis J. 2005;24:542-545. 5. Steenhoff AP, Smith MJ, Shah SS, Coffin SE. Neuroborreliosis with progression from pseudotumor cerebri to aseptic meningitis. Pediatr Infect Dis J. 2006; 25:91-92. 6. Raucher HS, Kaufman DM, Goldfarb J, Jacobson RI, Roseman B. Wolff RR. Pseudotumor cerebri and Lyme disease: a new association. J Pediatr. 1985; 107:931-933. Conflict of Interest: None declared