Clinical presentation of childhood neuroborreliosis; neurological examination may be normal.

OBJECTIVE: Neuroborreliosis has its highest incidence in children and the older people. Signs and symptoms are different between the different age groups. The aim of this study was to describe the clinical spectrum of neuroborreliosis in children. DESIGN: The Dutch Paediatric Surveillance system registered cases of childhood neuroborreliosis during 2 years. All Dutch paediatric hospitals took part in this surveillance. Criteria for reporting cases were strictly defined. RESULTS: 89 cases of neuroborreliosis were reported; in 66 cases diagnosis was confirmed. Facial weakness was one of the presenting symptoms in 47 cases (71%) and the only symptom in nine children (14%). The five complaints most frequently reported were: malaise, headache, fatigue, fever and neck pain. 52 children (79%) had one or more objective neurological signs at presentation, of which facial nerve palsy, other cranial nerve abnormalities and meningeal signs were most frequent. 14 patients (21%), however, had no neurological signs at physical examination. In these patients, the number of subjective complaints was higher, and the time interval to diagnosis was longer compared with those with objective neurological abnormalities. CONCLUSIONS: In this study, 79% of paediatric neuroborreliosis patients presented with neurological signs, most often facial nerve palsy. 21% presented in an atypical way without neurological signs. A thorough neurological examination is essential once neuroborreliosis is considered in children. Even in the absence of neurological signs, neuroborreliosis may be suspected in children with typical antecedents and multiple symptoms. Cerebrospinal fluid investigations are then required to confirm the diagnosis.

[Bruises in infants should always be accounted for]. / Een blauwe plek bij een zuigeling dient altijd verklaard te worden.

Haematomas were observed in three male infants under 1 year of age. In the first case, no suspicion regarding child abuse was raised, but, in retrospect, the appearance of haematomas coincided with the times he had been with a childminder. When he was admitted to hospital for a different reason, namely a serious airway infection, the causal relationship could no longer be established. In the second case, the grandparents told the general practitioner about their suspicion of maltreatment. CT revealed inflicted traumatic brain injury. In the third case, inflicted traumatic brain injury was also observed, in addition to a corner fracture of the tibia. Child abuse is a widespread problem that is not always recognized by physicians. Haematomas in infants should be evaluated carefully with thorough investigations for bleeding disorders on one hand and the possibility of child abuse on the other. A careful history concerning the circumstances of injury is essential, keeping in mind the age and development of the child. Localization and patterns of haematomas should also be evaluated. Haematomas in children who do not crawl or walk should lead to suspicion of child abuse. In the case of child abuse, direct action should be taken to ensure the safety of the child.