MENINGITIS AFTER ACUTE BORRELIA-BURGDORFERI INFECTION IN AN HIV-POSITIVE PATIENT

History and clinical findings: A 39-year-old HIV positive patient deve loped myalgia, headache and cough 4 weeks after a tick bite. His tempe rature was 37.4 degrees C and a circular pale erythema was noted over the left lower leg. Investigations: C-reactive protein was raised to 1 20 mg/l, white blood cell count was 5860/mu l, CD4-lymphocyte count 25 0/mu l. The chest radiogram showed pneumonitic infiltration in the lef t lower lobe. There were IgM antibodies against Borrelia burgdorferi. Treatment and course: Left lower lobe pneumonia and chronic erythema m igrans were diagnosed and he was given oral azithromycin (500 mg on th e first day and 250 mg for 4 days). The pneumonia cleared up, but 2 we eks later he developed symptoms of meningitis (496 cells per mu l, 87% lymphocytes, positive Borrelia burgdorferi antibody titer), which qui ckly and lastingly responded to ceftriaxon (2 g daily by brief infusio n for 14 days). Conclusion: This immune-compromised HIV-infected patie nt developed disseminated borreliosis with CNS involvement 2 weeks aft er the occurrence of chronic erythema migrans. The initial treatment o f the latter with azithromycin was unable to prevent the meningitis. I t is unlikely that there was a causal connection between the borrelios is and the pneumonia.