Prediction of Lyme Meningitis in Children From a Lyme Disease–Endemic Region: A

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http://pediatrics.aappublications.org/cgi/content/abstract/117/1/e1

PEDIATRICS Vol. 117 No. 1 January 2006, pp. e1-e7

(doi:10.1542/peds.2005-0955)

PEDIATRICS Vol. 117 No. 1 January 2006, pp. e1-e7

ELECTRONIC ARTICLE

Prediction of Lyme Meningitis in Children From a Lyme Disease–Endemic Region:

A Logistic-Regression Model Using History, Physical, and Laboratory Findings

BACKGROUND. Differentiating Lyme meningitis (LM) from other forms of aseptic

meningitis (AM) in children is a common diagnostic dilemma in Lyme disease–

endemic regions. Prior studies have compared clinical characteristics of

patients

with LM versus patients with documented enteroviral infections. No large

studies have compared patients with LM to all patients presenting with AM and

attempted to define a clinical prediction model. OBJECTIVE. To create a

statistical model to predict LM versus AM in children based on history,

physical, and

laboratory findings during the initial presentation of meningitis.

METHODS. Children older than 2 years presenting to the Alfred I. duPont

Hospital for Children between October 1999 and September 2004 were identified if

both Lyme serology and cerebrospinal fluid (CSF) were collected during the same

hospital encounter. Patients were considered to have Lyme disease only if they

met Centers for Disease Control and Prevention criteria (documented erythema

migrans and/or positive Lyme serology). Patients were eligible for study

inclusion if they had documented meningitis (CSF white blood cell count: >8 per

mm3). Retrospective chart review abstracted duration of headache and cranial

neuritis (papilledema or cranial nerve palsy) on physical examination and

percent

CSF mononuclear cells. Using logistic-regression analysis, the type of

meningitis (LM versus AM) was simultaneously regressed on these 3 variables. The

Hosmer-Lemeshow test was performed and the area under the receiver operating

characteristic curve was calculated.

RESULTS. A total of 175 children with meningitis were included in the final

statistical model. Logistic-regression analysis included 27 patients with LM

and 148 patients classified as having AM. Duration of headache, cranial

neuritis, and percent CSF mononuclear cells independently predicted LM. The

Hosmer-Lemeshow test revealed a good fit for the model, and the Nagelkerke R2

effect

size demonstrated good predictive efficacy. Odds ratios based on the

logistic-regression results were calculated for these variables. The final model

was

transformed into a clinical prediction model that allows practitioners to

calculate

the probability of a child having LM.

CONCLUSIONS. Longer duration of headache, presence of cranial neuritis, and

predominance of CSF mononuclear cells are predictive of LM in children

presenting with meningitis in a Lyme disease–endemic region. The clinical

prediction

model can help guide the clinician about the need for parenteral antibiotics

while awaiting serology results.

A. Avery, DO, MAa,b, , MD, MSa,c, ph J. Glutting, PhDd

and C. Eppes, MDb,e

a Department of Pediatrics

c Clinical Informatics

e Division of Infectious Diseases, Alfred I. duPont Hospital for Children,

Wilmington, Delaware

d School of Education, University of Delaware, Newark, Delaware

b Department of Pediatrics, Jefferson University, Philadelphia,

Pennsylvania

Key Words: Lyme disease • meningitis • regression analysis

Abbreviations: CDC—Centers for Disease Control and Prevention • LM—Lyme

meningitis • AM—aseptic meningitis • CSF—cerebrospinal fluid •

PCR—polymerase

chain reaction • WBC—white blood cell • ROC—receiver operator

characteristic •

Ig—immunoglobulin • AUC—area under the curve • OR—odds ratio

Accepted Jul 21, 2005.