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American Academy of Pediatrics
Article

Validation of a Clinical Prediction Rule to Distinguish Lyme Meningitis From Aseptic Meningitis

Keri A. Cohn, Amy D. Thompson, Samir S. Shah, Elizabeth M. Hines, Todd W. Lyons, Elizabeth J. Welsh and Lise E. Nigrovic
Pediatrics January 2012, 129 (1) e46-e53; DOI: https://doi.org/10.1542/peds.2011-1215
Keri A. Cohn
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Amy D. Thompson
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Samir S. Shah
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Elizabeth M. Hines
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Todd W. Lyons
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Elizabeth J. Welsh
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Lise E. Nigrovic
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Abstract

Objectives: The “Rule of 7′s,” a Lyme meningitis clinical prediction rule, classifies children at low risk for Lyme meningitis when each of the following 3 criteria are met: <7 days of headache, <70% cerebrospinal fluid (CSF) mononuclear cells, and absence of seventh or other cranial nerve palsy. The goal of this study was to test the performance of the Rule of 7′s in a multicenter cohort of children with CSF pleocytosis.

Methods: We performed a retrospective cohort study of children evaluated at 1 of 3 emergency departments located in Lyme disease–endemic areas with CSF pleocytosis and Lyme serology obtained. Lyme meningitis was defined using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans [EM] rash). We calculated the performance of the Rule of 7′s in our overall study population and in children without physician-documented EM.

Results: We identified 423 children, of whom 117 (28% [95% confidence interval (CI): 24%–32%]) had Lyme meningitis, 306 (72% [95% CI: 68%–76%]) had aseptic meningitis, and 0 (95% CI: 0%–1%) had bacterial meningitis. Of the 130 classified as low risk, 5 had Lyme meningitis (sensitivity, 112 of 117 [96% (95% CI: 90%–99%)]; specificity, 125 of 302 [41% (95% CI: 36%–47%)]). In the 390 children without EM, 3 of the 127 low-risk patients had Lyme meningitis (2% [95% CI: 0%–7%]).

Conclusions: Patients classified as low risk by using the Rule of 7′s were unlikely to have Lyme meningitis and could be managed as outpatients while awaiting results of Lyme serology tests.

KEY WORDS
  • Lyme meningitis
  • aseptic meningitis
  • clinical prediction rule
  • validation
  • Abbreviations:
    CI —
    confidence interval
    CSF —
    cerebrospinal fluid
    ED —
    emergency department
    ELISA —
    enzyme-linked immunosorbent assay
    EM —
    erythema migrans
    HSV —
    herpes simplex virus
    Ig —
    immunoglobulin
    IQR —
    interquartile range
    LP —
    lumbar puncture
    PCR —
    polymerase chain reaction
    WBC —
    white blood cell count
    • Accepted September 9, 2011.
    • Copyright © 2012 by the American Academy of Pediatrics

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    Pediatrics
    Vol. 129, Issue 1
    1 Jan 2012
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    Validation of a Clinical Prediction Rule to Distinguish Lyme Meningitis From Aseptic Meningitis
    Keri A. Cohn, Amy D. Thompson, Samir S. Shah, Elizabeth M. Hines, Todd W. Lyons, Elizabeth J. Welsh, Lise E. Nigrovic
    Pediatrics Jan 2012, 129 (1) e46-e53; DOI: 10.1542/peds.2011-1215

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    Validation of a Clinical Prediction Rule to Distinguish Lyme Meningitis From Aseptic Meningitis
    Keri A. Cohn, Amy D. Thompson, Samir S. Shah, Elizabeth M. Hines, Todd W. Lyons, Elizabeth J. Welsh, Lise E. Nigrovic
    Pediatrics Jan 2012, 129 (1) e46-e53; DOI: 10.1542/peds.2011-1215
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