Altoid tin games

Altoids Tin Travel Games - Pocket Size Fun - More DIY How To Projects

I am in love with these mini travel game sets!
I want to see how many games I can come up with that will fit in a travel size tin!

Amy Tan on Lyme Disease

I have late-stage neuroborreliosis. I have had this disease since 1999.

My case is in many ways typical. Like many, I had little awareness of Lyme disease, for I did not live in what was considered the tick-infested hotbeds on the East Coast. I am a Californian -that’s where I file my taxes- and I live among the hills of San Francisco with its tick-free, concrete sidewalks. For a good long while it did not seem significant that I also have a home in New York, that I weekend in the country, and my main form of exercise is hiking. In addition to trekking in the woodlands of Mendocino, Sonoma, and Santa Cruz counties in California, I have also sojourned to leafy spots in Connecticut and upstate New York. I once loved to sit in the tall grass next to the river, and lean my back against a shady oak tree.

I passed off my early symptoms -a stiff neck, insomnia, a constant headache, and a bad back followed by a frozen shoulder- as the unpleasant aftermath of too much airplane travel.

Click Here to read the rest of her story

With This Burger, I Thee Wed - NYTimes.com

Down-Home Celebrations - With This Burger, I Thee Wed - NYTimes.com

Birthing a baby Giraffe

nature never ceases to amaze me...

How to Create Embroidery from Pictures

Crafter Dolin O'Shea of Lulu Bliss shows us how to create an embroidery pattern from a photo, in this case a photo of her cute dog Mikey. Dolin's 101 on Embroidery article is in the current issue of CRAFT:06.

Dolin and I have been friends for over 10 years now and she's one of the craftiest people I know personally. Over the years she's taught me so much about embroidery and also introduced me to the Sublime Stitching patterns by Jenny Hart back in 2000.

To get some carbon transfer paper when working with dark fabric as mentioned in the video, visit the Sublime Stitching store.

From the pages of CRAFT: 06:

CRAFT: 06 - "101: Embroidery, Learn to paint pictures with floss and fabric", pgs 132-137. You can preview the article in our Digital Edition.

Subscribe to CRAFT Magazine and get 4 quarterly issues delivered to your door for only $34.95 (US).

Posted by Natalie Zee Drieu | Mar 21, 2008 01:30 PM on Craft

Love

How to Sew Your Own Produce Bags - CraftStylish

How to Upcycle a T-Shirt into a Cardigan - CraftStylish

Dress Up Your Bike with a Crocheted Seat Cover - CraftStylish

Crafty Inspiration: Plastic Bottle Purse - CraftStylish


Check Out This Butterfly! - CraftStylish

Learn how to make Wall-e out of recycled materials on Filth Wizardry's Blog! It is so 100% awesome!



Orange-Coconut Macaroons



Orange-Coconut Macaroons and more delicious recipes, smart cooking tips, and video demonstrations on marthastewart.com

These delectable one-bowl wonders mix up in a matter of minutes.

3 days until execution date

Please Cross Post!!!
Contact Arnold Schwarzenegger
(916)-445-2841

pal_95945@yahoo.com wrote:

Please call Gov Schwarzenegger at (916) 445-2841 and politely tell him you oppose cutting funds for animal shelters. He plans to limit the time animals are kept in California shelters from 6 days to 3 days. This is devastating news. Please call today. That's all you have to say when the person picks up the phone. It's easy and will help a lot!

If you prefer to send an email, go to www.gov.ca.gov

, then click on the "Interact" tab and send a message that way.

If you want to add anything to your message, you could suggest that he look at the breeders. Currently they pay no taxes, have to get no permits and pay no fines because they have no oversight. There would be millions of dollars in revenue right there.

Thank you and please forward to everyone you know in California.

Lyme misdiagnosed as psychiatric illness

For those of you trying to document your diagnosis, or trying to prove disability, the article below may be helpful to you. It is from a 2002 Psychiatry textbook, written by Dr. Brian Fallon of Columbia University Medical Center. It also highlights other infectious diseases that may cause psychiatric symptoms, often misdiagnosed as a psychiatric disorder rather than the function of a disease process.

Shadock's 2002 Comprehensive Textbook of Psychiatry

CHAPTER 2. NEUROPSYCHIATRY AND BEHAVIORAL NEUROLOGY 2.9 NEUROPSYCHIATRIC ASPECTS OF OTHER INFECTIOUS DISEASES

BRIAN ANTHONY FALLON, M.D., M.P.H. http://www.columbia-lyme.org

Spirochetal Diseases

Non-HIV Viral Infections of the Central Nervous System

Subacute Spongiform Encephalopathies

Other Infectious Causes of Neuropsychiatric Disorders

Emerging Areas of Investigation

Suggested Cross-References

Ever since the link between severe neuropsychiatric disorders and infectious disease was established in the early 1900s by the identification of the cause of syphilis, questions have been asked about the role of other infectious organisms in the etiology of neuropsychiatric disorders. At times the link between an infectious agent and a neuropsychiatric disorder is obvious, as in the case of neurosyphilis, the viral influenza outbreak of the 1920s, and the current human immunodeficiency virus (HIV) and Lyme disease epidemics. At other times the link is less clear but strongly suspected, as has been true for chronic fatigue syndrome or in the search for bacterial or viral etiologies of obsessive-compulsive and psychotic disorders. Psychopathology may emerge as a result of direct invasion of the central nervous system (CNS) by neurotropic agents or by an indirect host-determined cellular, humoral, or cytokine immune response to infectious organisms that inadvertently damages host tissue. In its effort to protect, the immune response may thereby provoke neuropsychiatric disorders.

This section focuses on selected infectious diseases other than HIV disease that invade the CNS and that have been directly associated with neuropsychiatric syndromes. Particular attention will be paid to the neuropsychiatric aspects of Lyme disease because it has spread rapidly since the 1970s in various parts of the world and has been associated with a plethora of neuropsychological and neurobehavioral problems in both children and adults. In addition, the concluding portion of this section will briefly address a few areas of recent investigation on the overlap of infectious disease and neuropsychiatry.

SPIROCHETAL DISEASES

Under the umbrella of the order of spirochetes are three agents that are known to invade the CNS. These include borrelia, treponema, and leptospira. Borrelia, which require an arthropod vector and a mammalian or bird reservoir, are commonly known to cause relapsing fever and Lyme disease. Treponema, which are spread person to person and do not use an arthropod vector, are the spirochetes responsible for syphilis. Leptospira, which are spread by contaminated water, are the agents of Weil's disease, which can have CNS manifestations.

Lyme Disease Lyme disease (Lyme borreliosis), transmitted by the bite of an infected Ixodes tick, can cause a vast array of neuropsychiatric disorders, ranging from mild mood changes to psychosis and severe memory loss. Lyme disease has been reported throughout the United States and in many countries throughout the world. The causative agent of Lyme disease, Borrelia burgdorferi, is initially inoculated into the skin by an infected tick, typically inducing a local rash, known as erythema migrans, which is reported by approximately two thirds of infected patients. Rapidly disseminated by the bloodstream through the body, B. burgdorferi has been found in the CNS as soon as 3 weeks after initial skin infection. Known to be neurotropic, B. burgdorferi may reside in the cerebrospinal fluid (CSF) or adhere to glial cells or other brain tissue. Like its spirochetal counterpart, Treponema pallidum, B. burgdorferi may remain latent, causing illness months to years later. Partly because of this latency in disease expression, patients may be unable to recall the initial tick bite or rash. Antigenic variability, which refers to the ability to express different surface antigens and to thus evade the immune response, is a feature of borrelial organisms that B. burgdorferi shares.

Diagnosis The epidemiological surveillance criteria for the diagnosis of Lyme disease in the United States require a history of exposure to an area endemic for Lyme disease and either a physician-diagnosed erythema migrans rash or serological evidence of exposure to B. burgdorferi and at least one of the following three clinical features: (1) arthritis; (2) neurologic symptoms (cranial or peripheral neuropathy, meningitis, encephalomyelitis, or encephalitis with evidence of intrathecal antibody production); or (3) cardiac conduction defects. Although useful for epidemiological monitoring, these criteria are unduly restrictive and should not be used for clinical purposes, because these criteria exclude patients who might have Lyme disease, such as seropositive patients who have diffuse arthralgias but not frank arthritis or patients who have encephalopathy without objective CSF abnormalities. Further complicating the diagnosis is the unreliability of the serologic tests. False-positive results might result because of cross-reactivity with other spirochetal organisms.

False-negative results may occur because the patient is tested too soon after infection and before an appropriate antibody response is mounted or because the patient's immune response has been abrogated as can occur when a patient is given antibiotic shortly after initial infection. It is not uncommon for a patient with Lyme disease to have negative or equivocal test results in one laboratory, but positive ones in another or for a patient to have negative test results initially but positive ones several months later after antibiotic treatment has been initiated. For these reasons a rational approach to the diagnosis of Lyme disease must be based upon the primary clinical presentation, followed by the supportive evidence of laboratory test results. Laboratory tests that can be helpful include indirect tests such as the enzyme-linked immunosorbent assay (ELISA) and Western blot analysis and direct tests such as the polymerase chain reaction (PCR) assay for borrelial deoxyribonucleic acid (DNA) or antigen detection assay. When Lyme disease is suspected, the clinician should order both an ELISA and a Western blot, as some patients may have a negative ELISA result but a positive Western blot result.

Bands of particular significance on the Western blot include the ones identified by the Centers for Disease Control as being most frequent and specific, as well as the 31kD (OspA) and 34 kD (OspB) bands. Although highly specific for B. burgdorferi DNA, the PCR assay has low sensitivity. Although laboratory testing is a valuable component of the diagnostic assessment, negative test results cannot be used to exclude Lyme disease in a patient with typical clinical features and a history of exposure to a Lyme disease endemic area.

Clinical Features The erythema migrans rash is the hallmark feature of early Lyme disease; antibiotic treatment at this stage often results in cure. Although typically the rash has a bull's eye, rounded appearance, it may also have a triangular, elongated, or other shape. Because patients may not recall seeing the rash, the flu-like symptoms that often occur shortly after the rash may be ignored, only to be followed several months to years later by the emergence of a multisystem disease affecting the joints, the heart, the eyes, and the peripheral or central nervous system; 15 to 40 percent of patients may have neurologic signs as their presenting feature. Headaches may be followed by meningitis, cranial neuritis, motor or sensory radiculitis, or an encephalitis characterized by mood lability and disturbances of memory or sleep. Although suggestive of Lyme disease, Bell's palsy may occur in only 5 to 10 percent of a sample of patients with neurologic Lyme disease. Symptoms of radiculoneuropathy or peripheral nerve involvement include sharp stabbing or deep boring pains that may radiate from the spine into an extremity of the trunk; areas of numbness, burning, or tingling; weakness; and fasciculations. In later stages of Lyme disease a minority of patients may develop a chronic meningoencephalomyelitis characterized by somnolence, confusion, poor concentration, impaired memory, myoclonus, apraxia, ataxia, paraparesis, dysarthria, dysphasia, seizures, or bladder abnormalities. Some of these patients may be misdiagnosed as having multiple sclerosis because of a relapsing and remitting course and the concurrence of spinal motor signs, ataxia, bladder dysfunction, and, less often, optic neuritis.

The profile of neuropsychiatric Lyme disease typically includes disturbances of cognition and mood. On formal neuropsychological testing, more than 50 percent of patients with chronic neurologic Lyme disease will show impairment in short-term memory, processing speed, or attention. This cognitive impairment, although worsened by marked pain or mood disorders, exists independently of the physical symptoms or the severity of concurrent depression. Typical cognitive symptoms include word-finding problems, word-substitutions, new-onset dyslexia, transient episodes of geographic disorientation, marked inattention and distractibility, difficulty with organization, and the sensation that one's brain is in a fog. Less commonly, the severity of the cognitive disturbance causes a global impairment, suggestive of a new-onset dementia.

Although the full spectrum of psychiatric disorders has been associated with B. burgdorferi infection, by far the most frequent are disturbances of mood, characterized by irritability, mood swings, and sleep loss. The majority of controlled studies in which patients with Lyme disease are compared to healthy controls or to patients with other illnesses reveal that depression occurs more frequently in the group with Lyme disease. Children with neurological Lyme disease typically present with complaints of headaches as the most common symptom, followed by behavioral, cognitive, or mood disturbance as the next most prevalent symptom. Behavioral problems include falling asleep in class, agitation, and poor school performance; common cognitive problems include attentional and short-term memory and visospatial deficits; common mood problems include irritability and new-onset anxiety. Other less common neuropsychiatric aspects associated with Lyme disease in adults and children include panic attacks, transient paranoia, illusions or hallucinations (visual, olfactory, auditory), anorexia, depersonalization, violent outbursts, obsessive-compulsive disorder, agitated mania, hyperacute sensitivity to light or sound, and what appears to be personality change. Because of the multisystem involvement in Lyme disease and the frequent concurrence of anxiety and depression, patients may be mistakenly diagnosed as having a primary psychiatric or a somatoform disorder before Lyme disease is even considered. If Lyme disease is considered but serological tests are equivocal despite the presence of a clinical profile typical of Lyme disease, the somatoform label may once again be mistakenly applied.

A 22-year-old previously healthy college graduate in his first few months of law school developed joint and muscle pains. A medical workup was negative, but the symptoms persisted and worsened, accompanied by fatigue so severe that he was unable to go to class or to study. Referral to a psychiatrist resulted in treatment with a selective serotonin reuptake inhibitor (SSRI) for possible depression without much benefit. Further medical workup revealed a positive result for Lyme disease ELISA with an equivocal Western blot analysis result. The diagnosis of probable Lyme disease was made and the patient was given a 6-week course of oral antibiotics, with a marked improvement in symptoms. Over the following 4 months his prior symptoms returned accompanied by headaches, word-finding problems, paresthesias, shooting and stabbing pains, and hypersensitivity to light and sound. Several consulting doctors gave conflicting opinions, with some firmly stating that this could not be persistent Lyme disease as it had been adequately treated and others stating that persistent infection was indeed possible and that additional treatment with antibiotics was warranted. The Lyme tests remained equivocal and a brain magnetic resonance imaging (MRI) revealed no abnormalities. Three additional months of oral antibiotics resulted in some improvement of arthritic symptoms, but the fatigue and cognitive problems remained. Several months later, the patient developed paranoid delusions followed by a manic episode for which he was hospitalized. Without further testing such as a spinal tap or electroencephalogram (EEG), his doctors dismissed Lyme disease as a possible cause for his new-onset mania. The patient was discharged on antipsychotic agents and lithium, with only a partial improvement in his mood lability. An outpatient internist then checked the patient's spinal fluid, which showed white blood count of 7 × 109 per liter 7 (white blood count [WBC]) and evidence of B. burgdorferi antibodies in both his serum and cerebral spinal fluid (CSF). The diagnosis of neuroborreliosis was made and the patient was placed on a 3-month course of intravenous antibiotics. Although the mood lability, mania, and cognitive problems dramatically resolved with long-term antibiotic treatment, 3 years later the patient had not yet returned to school because of problems with persistent fatigue. At that point, because a PCR assay of his plasma was positive for Lyme disease and a brain single photon emission computed tomography (SPECT) scan revealed global heterogeneous hypoperfusion, the patient was once again treated with antibiotics.

This case highlights the diagnostic difficulties of Lyme disease: the confusion triggered by equivocal results on serological tests, the need to consider B. burgdorferi as the cause for new-onset mania, the inadequate response to standard psychiatric medications, the initially robust but subsequently partial response to antibiotic regimens, and the persistence of the DNA of the organism despite aggressive antibiotic therapy.

Tests for CNS Lyme Disease Examination of the CSF is crucial to rule out other possible causes of CNS disease and to identify the presence of Lyme meningitis or encephalitis. In early neurologic Lyme disease, a spinal tap may reveal lymphocytic pleocytosis, mildly increased protein, and, in some cases, an elevated immunoglobulin G (IgG) index or the presence of oligoclonal bands. In later-stage neurological Lyme disease, however, the CSF may appear normal. MRI studies may reveal punctate white matter lesions on T2-weighted images, suggestive of a demyelinating disorder such as multiple sclerosis. EEG studies are generally normal, although diffuse slowing or epileptiform discharges may be seen. SPECT and positron emission tomography (PET) studies may be particularly helpful in late-stage Lyme disease. Recent reports indicate that many patients with Lyme encephalopathy have a pattern of either global or heterogeneous hypoperfusion, which in some cases improves after antibiotic treatment (Fig. 2.9-1). Given the difficulties facing the clinician attempting to determine whether the fatigue, mood lability, and cognitive tracking problems are caused by primary depression or by an underlying systemic disease, functional imaging studies are a valuable tool to assist in the differential diagnosis.

FIGURE 2.9-1 Transverse views obtained with Technetium-99m HMPAO SPECT. The two views on the left are of the brain of an adolescent with Lyme encephalopathy and demonstrate moderate heterogeneous hypoperfusion. The views on the right are of the brain of an adolescent without encephalopathy and demonstrate a normally perfused scan. The color spectrum scale, from purple to white, represents low to normal perfusion. (See color Plate 2.)

Differential Diagnosis In considering the diagnosis of Lyme disease, it is important to ask the patient about exposure to a Lyme disease-endemic area, history of a tick bite or unusual rash, and the presence of multisystemic involvement. Called the "new great imitator" (after the original great imitator, syphilis), the broad spectrum of atypical neurological manifestations of Lyme disease include strokes, Guillain-Barré syndrome, cerebellar syndromes, seizures, pseudotumor-like syndrome in children, spastic paraparesis, multiple–sclerosis–like illnesses, and progressive dementias. Similarly, other diseases that may look like neuropsychiatric Lyme disease need to be excluded, such as major depression with somatic preoccupation, panic disorder, systemic lupus erythematosus or other connective tissue diseases, chronic fatigue syndrome, endocrinological disorders, vitamin deficiencies, other infectious illnesses, vascular dementias, and other neurodegenerative disorders.

Treatment For early Lyme disease without CNS involvement, 3 to 4 weeks of oral doxycycline (Vibramycin) (100 mg twice a day), amoxicillin (Amoxil) (500 mg three times a day), or cefuroxime (Ceftin) (500 mg twice a day) is recommended. For Lyme disease with CNS involvement, an initial course of 4 to 6 weeks of intravenous ceftriaxone (Rocephin) (2 grams/day) or cefotaxime (Claforan) (2 grams/8 hours) is recommended. Symptoms may worsen during the first week of antibiotic treatment, much like the Jarisch-Herxheimer reaction during the treatment of syphilis. For patients who relapse, longer and repeated courses of antibiotics are often helpful. Failure to treat Lyme disease early in its course or for a sufficiently long duration may lead to a chronic illness characterized by persistent waxing and waning neuropsychiatric disturbances, arthralgias, myalgias, sensory-hyperacuities, and severe fatigue. In some patients these symptoms reflect the effects of persistent infection while in others the symptoms may reflect a residual postinfectious syndrome. Because the laboratory tests for chronic Lyme disease are not sufficiently reliable to document the presence or absence of persistent infection, decisions regarding treatment should be based primarily upon the physician's clinical judgment. Given the emerging literature that indicates that B. burgdorferi is capable of remarkable persistence in the human host despite standard courses of antibiotic treatment and clinical reports documenting improvement in chronic Lyme disease among some patients treated with long courses of antibiotics, many community physicians are now willing to treat such patients more aggressively. Other physicians, wary of the risks associated with long-term antibiotic treatment, choose not to treat these patients. Until well-controlled studies are conducted of patients with chronic symptoms, the debate on the proper antibiotic treatment for chronic Lyme disease will continue. A vaccine for Lyme disease was introduced in 1999; however, it is only effective in about 50 to 75 percent of cases.

Neurosyphilis The cause of syphilis, Treponema pallidum, was identified in 1905. Because of the cognitive loss and neuropsychiatric disturbances associated with tertiary neurosyphilis, these patients accounted for 5 to 15 percent of psychiatric hospital admissions and were diagnosed as having general paresis, general paralysis of the insane, or dementia paralytica. With penicillin treatment of primary and secondary syphilis, neurosyphilis is now an uncommon cause of hospital admissions.

Primary syphilis is manifest by a syphilitic ulcer, the chancre, at the site of inoculation. Secondary syphilis, a result of hematogenous dissemination of the spirochete, is characterized by flu-like symptoms followed by a skin rash, generalized lymphadenopathy, and mucosal lesions. Left untreated, both primary and secondary syphilis resolve on their own, after which the patient enters a latent period during which infection is present but clinical symptoms are not manifest. After months to years, about one third of patients with untreated latent syphilis develop tertiary syphilis that affects the brain or heart.

As in neuroborreliosis, invasion of the CNS by Treponema pallidum occurs early in the disease and may be asymptomatic for months to years prior to clinical expression.

Clinical neurosyphilis can be divided into four types: syphilitic meningitis, meningovascular syphilis, parenchymatous neurosyphilis, and gummatous neurosyphilis. Syphilitic meningitis, the result of direct meningeal inflammation, rarely has focal findings. Meningovascular syphilis results from the ischemic changes caused by proliferative endarteritis, resulting in permanent CNS damage. In parenchymatous neurosyphilis (general paresis or tabes dorsalis), which generally starts 10 to 20 years after infection, there is direct neural destruction resulting in diminished neuron concentration, demyelination, and gliosis (Fig. 2.9-2). In gummatous neurosyphilis, the mass effect causes neurological symptoms.

FIGURE 2.9-2 Tabes dorsalis. Degeneration of the posterior column in the sacral and thoracic cord (myelin sheath stain). Reprinted with permission from Merritt HH, Adams RD, Solomon

HC: Neurosyphilis. Oxford University Press, New York, 1946.)

General paresis often starts with subtle cognitive and emotional changes, such as problems with concentration and irritability; if untreated, it can lead to memory loss, confabulation, anomia, apraxia, or pseudobulbar palsy. The disease may mimic any other psychiatric disorders as well. Half of the patients with neurosyphilis will manifest dementia of whom one quarter will have prominent psychiatric manifestations such as depression, paranoia, psychosis, or mania. A worsening of symptoms during the first 24 hours after the initiation of antibiotic treatment has been termed the Jarisch-Herxheimer reaction; in rare cases, psychosis may emerge shortly after antibiotics are started. With disease progression there is loss of muscle tone and fine motor control and seizures, spasticity, and eventually paralysis and death occur. Focal neurological findings are rare, consistent with the generalized pathophysiology. Tabes dorsalis on the other hand develops somewhat later than general paresis, 15 to 20 years after infection, and causes a more characteristic clinical picture of lancinating pains, attacks of abdominal pain, and paresthesias. Because of progressive loss of proprioception and sensation, patients compensate by walking with a broad-based, shuffling gait. Unlike patients with general paresis, not all patients with tabes will have CSF abnormalities.

Tests T. pallidum is difficult to demonstrate in the CSF and difficult to culture. Although PCR techniques are being developed to detect the genetic material of the spirochete, this method is currently only available in research laboratories. Clinicians must rely upon serological tests in the context of a careful history and physical examination. Serological tests for syphilis include the nontreponemal Veneral Disease Research Laboratory (VDRI) and rapid plasma reagin (RPR) tests and, for confirmatory purposes, the fluorescent treponemal antibody-absorption (FTA-ABS) test. CSF studies are useful to confirm the diagnosis of neurosyphilis if clinical findings are suggestive, to diagnose asymptomatic involvement so that treatment can be started, and to follow treatment efficacy. These CSF studies are limited by the low specificity of the typical abnormalities of elevated protein, g-globulin, and leukocyte count and the low sensitivity (but high specificity) of the VDRL test. The CSF FTA-ABS test on the other hand is thought to have excellent sensitivity but less specificity than the CSF VDRL test.

Neuroradiological studies of neurosyphilis report the presence of cortical atrophy, most commonly affecting the frontal and temporal lobes.

Treatment The goal in clinical neurosyphilis is to reverse the manifestations or arrest the disease progression, although in some patients antibiotic therapy may not be able to achieve these goals. Standard courses consist of intravenous aqueous penicillin G, 12 to 24 million units daily in divided doses at 4-hour intervals for 2 weeks, or intramuscular weekly injections of 2.4 to 4.8 million units of penicillin G benzathine for 3 weeks or intramuscular injections of 2.4 million units of penicillin G procaine four times daily for 2 weeks. The likelihood of marked improvement for patients with general paresis is less than that for patients with syphilitic meningitis or meningovascular syphilis, reflecting the pathological process, which in the former is irreversible neuron damage and in the latter is CNS inflammation. During the first year after treatment, the serum and CSF should be regularly monitored for the reemergence of reactivity so that treatment can be reinitiated if necessary. Certain conditions, such as comorbid HIV infection, may place patients at greater risk for persistence of treponemal infection after antibiotic treatment. However, most neurosyphilis patients, when treated, will show improvement in the cognitive, psychiatric, and functional domains.

NON-HIV VIRAL INFECTIONS OF THE CENTRAL NERVOUS SYSTEM

Numerous viruses are invasive and neurotropic, with the extent of consequent neuronal dysfunction varying widely depending upon the virulence of the virus and the immunological response of the host. This section will focus upon agents known to cause striking neuropsychiatric diseases: herpes simplex, rabies, measles, and subacute sclerosing panencephalitis; Table 2.9-1 presents other infectious causes of neuropsychiatric disorders.

Table 2.9-1 Selected Infectious Causes of Neuropsychiatric Disorders

Herpes Viruses Included under the spectrum of herpesviruses are human herpesvirus 1 (HHV-1), that is, herpes simplex virus 1; HHV-2, that is, herpes simplex virus 2, varicella-zoster virus, Epstein-Barr virus (EBV), cytomegalovirus (CMV), HHV-6, HHV-7, and Kaposi's sarcoma herpesvirus.

Herpes Simplex Herpes simplex encephalitis is a dramatic disorder, characterized by the abrupt onset of fever, personality change, and headaches, followed by cognitive changes and focal neurological signs, such as aphasia, visual field deficits, hemiparesis, or partial seizures. Although focality is an important feature of herpes simplex encephalitis, other viruses, such as the LaCrosse virus or the nonpolio enteroviruses, may also cause focal signs. Neurobehavioral aspects of herpes simplex encephalitis such as hallucinations, memory loss, or behavioral disturbances may be the primary clinical feature, a consequence of the predilection of the virus for the temporal lobes. Although the course of illness is typically rapidly progressive, resulting in refractory seizures, coma, and death within 2 weeks, occasionally the progression may be slower with varied neuropsychiatric features.

HSV-1 is usually transmitted orally entering the CNS through sensory nerves, particularly the trigeminal ganglia. HSV-2 is transmitted genitally and may seed the sacral ganglia or disseminate hematogenously. Herpes simplex viruses typically produce a lytic infection with neuronal necrosis and tissue destruction, and intranuclear inclusion bodies in the neurons and glia. Patients who survive herpes simplex encephalitis may exhibit postencephalitic symptoms, such as amnesia, aphasia, and less commonly, the Klüver-Bucy syndrome or dementia.

Routine serological studies are of little value in suspected herpes simplex encephalitis. The CSF usually demonstrates leukocytosis (approximately 100 cells/mm3), a moderate protein elevation, and a normal or depressed glucose content. PCR analysis of the CSF to detect HSV DNA is at present the diagnostic procedure of choice because the PCR assay has high sensitivity and specificity. Recent studies indicate that approximately 80 percent of patients with biopsy-proven herpes simplex encephalitis will have focal EEG abnormalities consisting of slowing or repetitive epileptiform discharges in the frontotemporal area. MRI studies in early stages of herpes simplex encephalitis may reveal T2 prolongation in the insular cortex and cingulate gyrus. SPECT or PET imaging may show reduced blood flow in the orbitofrontal and temporal regions. Brain biopsy can be helpful in cases that are difficult to diagnose, although the complication rate is approximately 3 percent.

If untreated, 40 to 70 percent of patients with herpes simplex encephalitis will die. Antiviral therapies include acyclovir (zovirax) and vidarbine (Vira-A); however, even with acyclovir treatment fewer than 40 percent of patients survive with minimal or no sequelae (Fig. 2.9-3).

FIGURE 2.9-3 Herpes encephalitis. A, Contrast-enhanced axial CT scan shows diffuse

decreased density of the left temporal lobe with minimal hypodensity of the medial right

temporal lobe. An abnormal CT scan is usually not seen until day 6 to 7 after the onset of

manifestations. Eventually, a majority of scans show gyral enhancement in the sylvian fissure area.

These findings should raise the suspicion of an underlying infectious lesion such as herpes, early

infarction from emboli or vasculitis, or metastatic tumors. B, T2-weighted axial MRI scan shows diffuse

increased signal intensity along the left temporal lobe cortex as well as the posteromedial left temporal

lobe. Both medial frontal lobes are involved as well. An abnormal MRI scan is usually seen by day 1 or 2

after the onset of manifestations. The patient was treated for herpes encephalitis and responded to

acyclovir therapy. (Reprinted with permission from Jubelt B, Miller JR: Viral infections. In Meritt's

Textbook of Neurology, ed 9, LP Rowland, editor. Williams & Wilkins, Baltimore, 1995.)

Epstein-Barr Virus Most adults have evidence of past exposure to EBV, with approximately 50 percent

seropositivity among children over age 5. Infection in childhood is generally mild, whereas in

adolescence and young adulthood it may result in infectious mononucleosis or, rarely, a fulminant

life-threatening disease. EBV enters the body by infecting oral mucosal epithelial cells. The clinical

symptoms of infectious mononucleosis of sore throat, headache, malaise, and fatigue are largely a

result of the vigorous cellular immune response to EBV infection rather than direct cytotoxic effects.

Significant neurological complications of EBV infection are rare, occurring in less than 0.5 percent of

cases of infectious mononucleosis.

EBV encephalitis occurs usually within 1 to 3 weeks after the onset of clinical infectious

mononucleosis. Patients with EBV encephalitis may present with cerebellar ataxia, personality

changes, psychosis, transient global amnesia, perceptual distortions of size and space, focal

neurological findings, seizures, or coma. EEG usually reveals generalized slowing with occasional

sharp-wave activity. The diagnosis of an EBV neuropsychiatric syndrome requires an appropriate clinical

history in the setting of serological evidence of acute or, rarely, chronic active infection. In cases of EBV

encephalitis commonly there is a lymphocytic pleocytosis (atypical lymphocytes are particularly

suggestive) with elevated protein. In most cases EBV encephalitis is self-limited, with recovery occurring

within weeks to months; rarely, acute EBV infection may result in a relapsing or chronic encephalitis.

Treatment is generally supportive.

Other Herpes Viruses With herpes zoster, neuropsychiatric complications occur most frequently in immunocompromised patients, resulting in encephalitis, myelitis, or leukoencephalitis. With CMV infection, encephalitis may also occur because CMV is tropic for the CNS; however, only in rare exceptions has CMV encephalitis occurred in non–HIV-infected immunocompromised individuals.

Rabies Although most cases of human rabies occur after animal bites, other sources of rabies infection include aerosols (risk for spelunkers) and person-to-person transmission following corneal transplants. The virus replicates locally at the site of inoculation and subsequently spreads to the CNS by retrograde axonal transport, infecting the lower areas of the brain most prominently, particularly the limbic system, hippocampus, brainstem, and cerebellum. Limbic system involvement may result in aberrant sexual behavior and behavioral dyscontrol, whereas brainstem involvement typically results in alterations of body temperature and respiratory control. The site and amount of inoculation is associated with morbidity. For example, multiple dog bites to the face may result in a 60 percent mortality rate without prophylactic intervention whereas multiple bites to the hand are associated with lower mortality rates of about 15 percent. The incubation period prior to symptomatic expression ranges from a few days to several years. Once symptoms emerge, the course is rapidly fatal. Most patients get the furious form characterized by agitation, hallucinations, odd behaviors, extreme excitability, and in some cases, hydrophobia. Diagnosis is based on the history of an animal bite in a patient with unexplained encephalitis that has been confirmed by the demonstration of rabies antigen on a skin biopsy of the patient or from a putatively infected animal. There is no treatment for rabies virus infection. Disease prevention is critical, aided by preexposure vaccination in high-risk individuals and postexposure prophylaxis with rabies immunoglobulin and rabies vaccine (Fig. 2.9-4).

FIGURE 2.9-4 Rabies. Inclusion bodies (Negri bodies) in cytoplasm of ganglion cell of cerebral cortex. (Reprinted with permission from Jubelt B, Miller JR: Viral infections. In Merritt's Textbook of Neurology, ed 9, LP Rowland, editor. Williams & Wilkins, Baltimore, 1995.)

Subacute Sclerosing Panencephalitis Subacute sclerosing panencephalitis is a very rare slow infection with measles virus that causes progressive inflammation and sclerosis of the brain. Primarily affecting children and young adults, the rate of subacute sclerosing panencephalitis decreased markedly after 1960 as a result of widespread measles vaccination, with a current rate in the United States of only 1 per 100 million people per year. The onset generally occurs 7 to 12 years after measles and is subtle, characterized by gradual changes in behavior and school performance. Neuropsychological testing may demonstrate reduced overall intelligence and problems with reading, writing, and visuospatial processing. Neuropsychiatric symptoms may include hallucinations, apraxia, agnosia, and Balint's syndrome (optic ataxia, simultanagnosia, and sticky fixation). Repetitive myoclonic jerks are common, at times accompanied by movement disorders and cerebellar ataxia. In advanced stages, dementia, mutism, cortical blindness, optic atrophy, stupor, coma, and death occur.

The usual course of the illness is 1 to 3 years, with rare patients surviving up to 10 years.

Serological testing may reveal unusually high titers of antibodies to measles virus. CSF studies typically show high measles antibody titers and a greatly elevated gamma globulin fraction with oligoclonal bands in a CSF with slightly elevated protein concentrations. EEG studies are essential, particularly in the myoclonic stage, when they reveal high-amplitude bilateral and stereotyped complexes that repeat every 3 to 5 seconds. MRI studies may reveal enlarged ventricles and diffuse brain atrophy, with multifocal low-density white matter lesions and lucent areas in the basal ganglia. PET and SPECT studies may reveal early subcortical hypermetabolism followed by global cortical and subcortical hypometabolism.

No treatments are known to reverse the disease, although slightly prolonged survival has been reported with isoprinosine (Inosiplex) and with intraventricular or intrathecal injections of interferon-a.

Progressive Multifocal Leukoencephalopathy This disease affects immunocompromised subjects and is a progressive infection of oligodendroglial cells with the JC papovavirus. Typically the onset is abrupt with focal neurological or neuropsychological signs and the course is almost invariably fatal within 2 to 4 months. Definitive diagnosis requires a brain biopsy. Neuroimaging studies reveal multifocal areas of high signal intensity in the white matter. Functional imaging with PET or SPECT may reveal a heterogeneous pattern of reduced metabolic activity and perfusion.

SUBACUTE SPONGIFORM ENCEPHALOPATHIES

Included in this group are Creutzfeldt-Jakob disease; kuru, a dementing disease of three New Guinea tribes that is most likely spread by ritual cannibalism; Gerstmann-Straüssler syndrome, a familial disorder characterized by dementia and ataxia; and fatal familial insomnia, a disorder causing disturbances of sleep and of motor, autonomic, and endocrine function. These disorders are all slow infections caused by a transmissible agent not yet clearly described that may be a prion, a virino or an atypical virus. Prions are proteinaceous agents devoid of nucleic acid that are crucial in the pathogenesis of the spongiform encephalopathies. A virino is a small molecule (probably a nucleic acid) associated with a host protein. Characteristic of the neuropathology of these disorders is the neuronal vacuolation that leads to spongy degeneration of the cerebral cortical gray matter.

Creutzfeldt-Jakob Disease Invariably fatal, this transmissible, rapidly progressive disorder occurs mainly in middle age or older and is manifest early on by fatigue, flu-like symptoms, and mild cognitive impairment or focal findings such as aphasia or apraxia. Subsequent psychiatric manifestations include mood lability, anxiety, euphoria, depression, delusions, hallucinations, or marked personality changes. Progression of disease occurs over months leading to dementia, akinetic mutism, coma, and death. Other common neurological findings are generalized startle myoclonus, cortical blindness, and extrapyramidal and cerebellar signs.

The rates of Creutzfeldt-Jakob disease range from 0.25 to 2 cases per million persons a year worldwide. The infectious agent self-replicates and can be transmitted to humans by inoculation with infected tissues and sometimes by ingestion in food. Iatrogenic transmission has been reported via transplantation of contaminated cornea or to children via contaminated supplies of human growth hormone. Household contacts are not at greater risk than the general population, unless there is direct inoculation. Because of an epidemic of a newly recognized prion disease, bovine spongiform encephalopathy (mad cow disease), among cattle in the United Kingdom and because of the unexpected recent emergence of cases of an atypical form of Creutzfeldt-Jakob disease among teenagers in the United Kingdom, fears exist that transmission to humans may have occurred as a result of eating infected meat (Fig. 2.9-5).

FIGURE 2.9-5 Creutzfeldt-Jakob disease. Section from cortex showing status spongiosis of the neuropil, loss of neurons, and prominent astrocytosis. (PTAH stain × 120). (Reprinted with permission from Jubelt B, Miller JR: Viral infections. In Merritt's Textbook of Neurology, ed 9, LP Rowland, editor. Williams & Wilkins, Baltimore, 1995.)

Diagnosis requires pathological examination of the cortex, which reveals the classic triad of spongiform vacuolation, loss of neurons, and glial cell proliferation. Genetic susceptibility is a factor in disease risk, indicated by a common polymorphism of the human prion protein. An immunoassay for Creutzfeldt-Jakob disease in the CSF is currently under development, showing promise in supporting the diagnosis of Creutzfeldt-Jakob disease in patients with dementia. EEG abnormalities, although not specific for Creutzfeldt-Jakob disease, are present in nearly all patients: a slow and irregular background rhythm with periodic complex discharges. Computed tomography (CT) and MRI studies may reveal cortical atrophy later in the course of disease; SPECT and PET reveal heterogeneously decreased uptake throughout the cortex. There is no known treatment for Creutzfeldt-Jakob disease.

OTHER INFECTIOUS CAUSES OF NEUROPSYCHIATRIC DISORDERS

A variety of bacterial, mycoplasmal, fungal, and parasitic infections can cause neuropsychiatric disturbances as a result of a chronic meningitis or sequelae from an acute infection (Table 2.9-1).

EMERGING AREAS OF INVESTIGATION

Chronic Fatigue Syndrome Chronic fatigue syndrome, more commonly referred to as myalgic encephalomyelitis in the United Kingdom and Canada, is a multisystem syndrome characterized by 6 months or more of severe, debilitating fatigue, often accompanied by myalgia, headaches, pharyngitis, low-grade fever, cognitive complaints, gastrointestinal symptoms, and tender lymph nodes. The search for an infectious cause of chronic fatigue syndrome has been active because of the high percentage of patients who report abrupt onset after a severe flu-like illness. In the mid-1980s chronic fatigue syndrome was linked to infection with Epstein-Barr virus. After EBV was shown in controlled studies to have no specific role in the etiology of chronic fatigue syndrome, reports have linked chronic fatigue syndrome to a variety of other agents, including enteroviruses, retroviruses, and new lymphotropic herpesviruses but these reports have not been consistently replicated in well-designed studies. Certain organisms, however, such as B. burgdorferi (which causes Lyme disease), can result in a chronic fatigue syndrome-like picture; however, most cases of CFS are not linked to Lyme disease. Evidence of immune dysregulation has been frequently reported among patients with chronic fatigue syndrome, but the data are not consistent across studies nor are they reflective of illness severity. Various studies have found high rates (15 to 54 percent) of depressive disorders among patients with chronic fatigue syndrome. In addition, recent research has shown that patients who are most likely to be plagued by persistent fatigue after an acute viral illness are patients with preexisting or comorbid psychiatric problems. However, other research has shown that the cognitive impairment in chronic fatigue syndrome exists even in the absence of preexisting or comorbid psychiatric disorders, thus leading to the conclusion that psychiatric disorders alone cannot account for chronic fatigue syndrome. At present, chronic fatigue syndrome is best conceptualized as a heterogeneous syndrome of uncertain etiology, most likely involving an interplay of psychiatric, infectious, neuroendocrine, and immunological factors.

Group A b-Hemolytic Streptococci Poststreptococcal autoimmunity has been postulated to be a cause of certain types of childhood-onset obsessive-compulsive disorders and Tourette's disorder based on the observation that children who develop Sydenham's chorea are often observed to have tics or obsessive-compulsive symptoms prior to the onset of the chorea. These pediatric autoimmune neuropsychiatric disorders are characterized by abrupt and dramatic symptom exacerbations that are temporally related to group A b-hemolytic streptococcal infections. Recent research has identified a genetic marker in pediatric autoimmune neuropsychiatric disorders that has previously been shown to be both highly specific and sensitive in identifying individuals with rheumatic fever. In one study 85 percent of children who developed streptococcal-related obsessive-compulsive disorder or tics and 89 percent of children with Sydenham's chorea carried the D8/17 monoclonal antibody marker on DR+ cells in the peripheral circulation, whereas only 17 percent of healthy controls carried this marker. Investigations are currently underway to determine whether treatments that modulate the immune response (e.g., intravenous g-globulin or plasmapheresis) are effective in eliminating obsessive-compulsive disorder and tic disorders among children with pediatric autoimmune neuropsychiatric disorders.

Borna Disease Virus Borna disease virus (BDV) is a small neurotropic ribonucleic acid (RNA) virus that infects various domestic animal species, causing disturbances in behavior and cognition and, rarely, death. Researchers have found that BDV targets cells of the limbic system in animals and compromises their neuronal function without causing direct damage. BDV has recently been linked to a wide array of neuropsychiatric disorders in humans. Evidence suggestive of BDV infection in humans has been accumulating from several research centers. One research group recently identified serum antibodies to BDV in 9.6 percent of 416 people with schizophrenia, major depressive disorders, bipolar I disorder, and other neuropsychiatric disease whereas these serum antibodies were found in only 1.5 percent of 203 healthy controls. Reverse transcriptase-PCR identified BDV RNA sequences in 13 of a subset of 26 psychiatric patients but in none of 23 healthy controls. Other reports have identified BDV antibodies in 6.8 percent of patients with psychiatric illnesses versus 3 percent of surgical controls. These studies represent provocative preliminary findings that suggest a possible role for BDV in a subset of human neuropsychiatric diseases; well-controlled microbiological and epidemiological studies are needed to determine the significance of these reports.

SUGGESTED CROSS-REFERENCES

Acquired immune deficiency syndrome is discussed in Section 2.8; interactions of the immune system and the CNS are discussed in Section 1.12; neuropsychological testing is discussed in Section 7.4; and neuroimaging is discussed in Section 2.13. Obsessive-compulsive disorder and schizophrenia are discussed in Chapter 15 and Chapter 12, respectively.

SECTION REFERENCES

Ackerman R, Rehse-Kupper B, Gollmer E, Schmidt R: Chronic neurologic manifestations of erythema migrans borreliosis. Ann NY Acad Sci 64:506, 1988.

Ancar B, Yalaz K, Oktem F, Köse G: Long-term follow-up of patients with subacute sclerosing panencephalitis treated with intraventricular alpha-interferon. Neurology 48:526, 1997.

Bates DW, Buchwald D, Lee J, Kith P, Doolittle T, Rutherford C, Churchill H, Schur P, Wener M, Wybenga D, Winkelman J, Komaroff AL: Clinical laboratory test findings in patients with chronic fatigue syndrome. Arch Intern Med 155:97, 1995.

Bode L, Zimmermann W, Ferszt R, Steinbach F, Ludwig H: Borna disease virus genome transcribed and expressed in psychiatric patients. Nat Med 1:232, 1995.

Bloom BJ, Wyckoff PM, Meissner HC, Steere AC. Neurocognitive abnormalities in children after classic manifestations of Lyme disease. Pediatr Infect Dis J 17:189, 1998.

Brown P, Cathala F, Castaigne P, Gajdusek DC: Creutzfeldt-Jakob disease: Clinical analysis of a consecutive series of 230 neuropathologically verified cases. Ann Neurol 20:597, 1986.

*Burrascano JJ: Lyme disease. In Conn's Current Therapy, Rakel RE, editor. Saunders, Philadelphia, 1997.

Collinge J: New diagnostic tests for prion diseases. N Engl J Med 335:963, 1996.

Coyle PK: Neurologic Lyme disease. Semin Neurol 12:200, 1992.

Coyle PK, Schutzer SE, Deng Z, Krupp LB, Belman AL, Benach JL, Luft BJ: Detection of Borrelia burgdorferi-specific antigen in antibody-negative cerebrospinal fluid in neurologic Lyme disease. Neurology 45:2010, 1995.

DeLuca J, Johnson SK, Ellis SP, Natelson BH: Cognitive functioning is impaired in patients with chronic fatigue syndrome devoid of psychiatric disease. J Neurol Neurosurg Psychiatry 62:151, 1997.

*Demitrack MA, Abbey SE, editors: Chronic Fatigue Syndrome. Guilford Publications, New York, 1996.

Fallon BA, Nields JA, Burrascano JJ, Liegner K, DelBene D, Liebowitz MR: The neuropsychiatric manifestions of Lyme borreliosis. Psychiatric Q 63:95, 1992.

*Fallon BA, Nields JA: Lyme disease: A neuropsychiatric illness. Am J Psychiatry 151:1571, 1994.

Fallon BA, Das S, Plutchok JJ, Tager F, Liegner K, Van Heertum R: Functional brain imaging and neuropsychological testing in Lyme disease. Clin Infect Dis 24(Suppl): S57-63, 1997.

Haywood AM: Transmissible spongiform encephalopathies. N Engl J Med 337:1821, 1997.

Heegaard ED, Hornsleth A: Parvovirus: The expanding spectrum of disease. Acta Paediatr 84:109, 1995.

Hendler N, Leahy W: Psychiatric and neurologic sequelae of infectious mononucleosis. Am J Psychiatry 135:842, 1978.

Hooshmand H, Escobar MR, Kopf SW: Neurosyphilis: A study of 241 patients. JAMA 219:726, 1972.

*Huang C, Chatterjee NK, Grady LJ: Diagnosis of viral infections of the central nervous system. N Engl Med 340:483, 1999.

*Huisman TA, Wohlab G, Nadal D, Boltshauser E, Martin E: Unusual presentations of neuroborreliosis (Lyme disease) in childhood. J Comput Assist Tomogr 23:39, 1999.

Krupp LB, Masur D, Schwartz J, Coyle PK, Langenbach LJ, Fernouist SK, Jandorf L, Halperin JJ: Cognitive functioning in late Lyme borreliosis. Arch Neurol 48:1125, 1991.

Lawrence C, Lipton RB, Lowy FD, Coyle PK: Seronegative chronic relapsing neuroborreliosis. Eur Neurol 35:113, 1995.

Lecour H, Miranda M, Magro C, Rocha A, Goncalves V: Human leptospirosis—a review of 50 cases. Infection 17:10, 1989.

Logigian EL, Kaplan R, Steere AC: Chronic neurologic manifestations of Lyme disease. N Engl J Med 323:1438, 1990.

Jones KJ, Garada BM, Holman BL, Steere AC: Reversible cerebral hypoperfusion in Lyme encephalopathy. Neurology 1997; 49:1661, 1997.

Oksi J, Kalimo H, Marttila RJ, Marjamaki M, Sonninen P, Nikoskelainen J, Viljanen MK: Inflammatory brain changes in Lyme borreliosis. Brain 119:2143, 1996.

Pachner AR: Borrelia burgdorferi in the nervous system: The new "Great Imitator." In Lyme Disease and Related Disorders. Ann N Y Acad Sci 539:56, 1988.

Sauder C, Muller A, Cubitt B, Mayer J, Steinmetz J, Trabert W, Ziegler, Wanke K, Mueller-Lantzsch N, de la Torre JC, Grasser FA: Detection of borna disease virus (BDV) antibodies and BDV RNA in psychiatric patients: Evidence for high sequence conservation of human blood-derived BDV RNA. J Virol 70:7713, 1996.

*Scheld WM, Whitley RJ, Durack DT, editors: Infections of the Central Nervous System. Lippincott-Raven, New York, 1997.

Swedo SE, Leonard HL, Mittleman BB, Allen AJ, Rapoport JL, Dow SP, Kanter ME, Chapman F, Zabriskie J: Identification of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections by a marker associated with rheumatic fever. Am J Psychiatry 154:110, 1997.

Swedo SE: Sydenham's chorea: A model for childhood autoimmune neuropsychiatric disorders. JAMA 272:1788, 1994.

Thomas EW: Syphilis: Its course and management. MacMillan, New York, 1949.

Waltrip RW, Buchanan RW, Summerflet A, Breier A, Carpenter WT, Bryant NL, Rubin SA, Carbone KM: Borna disease virus and schizophrenia. Psychiatry Res 56:33, 1995.

Wessely S, Chalder T, Hirsch S, Pawlikowska T, Wallace P, Wright DJM: Postinfectious fatigue: Prospective cohort study in primary care. Lancet 345:1333, 1995.

*Yolken RH, Torrey EF: Viruses, schizophrenia, and bipolar disorder. Clin Microbiol Rev 8:131, 1995.

Books@Ovid

Copyright © 2000 Lippincott Williams & Wilkins

Harold I. Kaplan, M.D, Benjamin J. Sadock, M.D and Virginia A. Sadock, M.D.

Kaplan & Sadock's Comprehensive Textbook of Psychiatry

Free Pintable and Lyme experience

Ice Cream Fill In Words Game. Using this picture on the game to figure out the six words that fill in the boxes of the game. All six words are related to ice cream and available on page two of the game which is the answer key. Great for summer kids activity or children’s birthday party.

>>> Ice Cream Fill In Words Game. pdf

TOUCHED BY LYME: Is having Lyme-induced MCS a criminal offense?

Some people with Lyme disease develop a host of related problems, like extreme sensitivity to light, sound, and various chemicals in the environment. (This last condition is called multiple chemical sensitivity, or MCS. For people who have it, being around gasoline fumes, cologne, and even clothes washed in certain detergents, can literally be life-threatening.)

Eighteen-year-old Makayla Berndt has all of the above-mentioned health issues and more. She’s also the founder of a Yahoo group for teens and young adults with Lyme disease, a published writer, and a frequent contributor to many Lyme-related internet discussion groups.

Her health problems recently led to a harrowing encounter with the police in Williams, a small town near Interstate 5 in northern California.

She gave me permission to excerpt one of her recent yahoo postings:

So last night around 9:15 p.m. my mom and I were coming back from a doctor’s appointment trip, and the car needed gas. With my MCS, I can't be in the car when my mom is fueling up without getting a huge reaction which affects my airways. So my mom dropped me off at a park, which was down the street from the gas station....you can see the gas station and park from each other. She wanted me to take our pepper spray with me, for protection. I had my sunglasses, earplugs and mask on.

So I am waiting for my mom, and a police car drives up. Two policemen come out of the car, and ask me what I am doing. I told them that my mom was down the street getting gas and that I have MCS... I can't handle the fumes from the gas. One of the policemen says "Right" with the tone of "Yeah, Right"—didn't believe me. Then they pointed their flashlight at me and I flinched...light sensitivity. And then of course they have fragrance on them, so I was reacting and my lungs were burning and I was having a hard time breathing.

So I told them that I was about to step back, because I was reacting to their laundry soap. And the police man says again "Right" in the same tone as before...so I stepped back, and they stepped forward. Then I showed them the pepper spray that I had in my hand, like you can see it if you want. And he asked why I had it, I told him 1) that my over-protective mom told me to carry it and 2) because I am sick, I have Lyme and I needed to protect myself if something happened. He then says “Right" again. Then he asked if I was from around the area, and I said, "No, I am traveling home from a doctor’s appointment, and my mom and I are on our way home." So then one of the men asked if I had ID, and I don't drive so I don't have one. So he asked me for all my information, and I gave it to him.

At this point, Makayla’s mom returned, saw her daughter being questioned by the police, and came barreling out of the car yelling, “If you have cologne on, you are causing her damage!” After she verified what Makayla had already told the police, they finally let them go. Legs still trembling from her scary encounter, Makayla turned on her oxygen to help her breathe better, and “took all the detox agents that I had.”

In our phone conversation, Makayla said she doesn’t necessarily blame the police for stopping to talk to her. (Yes, she must have looked a bit odd with her sunglasses, carbon filter face mask, and earplugs, standing at the edge of the park at nine o’clock at night.)

But, she says, the cops obviously didn’t believe what she was saying, and when she tried to step back to protect herself from their harmful fragrance, they kept coming closer. She said her body was already reacting to just being around them in the open air. If they had put her in the enclosed environment of the police car, she fears she might have passed out or stopped breathing.

At this point, Makayla recommends that people in her situation carry a note from their doctor in their wallet or purse, explaining why they need to wear protective gear. Or perhaps a Medic-Alert bracelet.

Here’s my two cents worth: This is one more example of why we need increased public awareness of Lyme disease and related ills. Police officers are trained to respond to any number of unusual circumstances. The idea of encountering someone with MCS shouldn’t be a foreign concept to them. MCS is, after all, a protected condition under the Americans with Disabilities Act. This protection should include not having your life unwittingly imperiled by policemen who happen along while your mom is filling up the gas tank.

Please Rescue me

Please save this girl and let her know there are kind people in the world who will not starve her! I want to pull her out; this is just so sad. Can someone foster her! PLEASE. We will pay for vet bills and food? She will need TLC. I will start looking for a home for her. Am Staff mix female. VERY emaciated, a seizure from owner now released for rescue. A very nice girl who did not deserve to be treated like this. She was out in the play yard with several small dogs and paid no attention to them.

Please cross post!!!! Her time is up! If you unable to help, please Kindly consider donation, so she can be kenned. Our rescue just received over 10K vet bills for 2 dogs.

You can make donation via website:http://www.scooterspals.org/

Or sending check:Scooter's Pals -228 Commercial Street, Nevada City, CA 95959 Let me know ASAP; the transport is coming this Monday and I want her out of the shelter. Thank you! Marianna 916-508-9418

Merced shelter!

Holistic Pregnancy and Crafty Crochet

Cristen Andrews of shares with us her plastic bag crafts and shows us how to get started with crocheting plastic bags.

Breastfeeding Benefits to Mother and Child

Unsung Benefits of Breastfeeding
by: Philip J. Goscienski, M.D.

From the Stone Age until just a few generations ago, human infants’ only sustenance was mother’s milk, but modern infant formula seems to be an adequate substitute. After all, infant mortality in Western societies is at historic lows and growth patterns are normal. But is that all there is to it? Could there be other advantages to breastfeeding, both to the mother and to the infant?

Post-delivery stress discomfort.
All those hours of labor may be natural, but they are exhausting and stressful for mom. It’s not so easy on baby, either! First, that cushion of fluid suddenly vanishes in a big gush as labor begins. Then comes the big squeeze as the infant is mashed against the opening of the uterus, and through a birth canal that is so narrow that the baby’s skull elongates just to fit through. It takes a day or so before a newborn’s head gets its normal rounded shape back.

Read the story »

These thin chocolate cookies with ganache icing dipped into grated coconut make the perfect nests for two or three miniature chocolate eggs.
Bird's Nest Cookies and more delicious recipes, smart cooking tips, and video demonstrations on marthastewart.com

Free Fathers Day Printables

Free printable Fathers Day Cookout coloring sheet is free to printout as many copies as you would like. Fun kids activity for a father’s day cookout so each kid can color the picture for their dad.

Print Daddy's Little Monkey Card from Mom's Break

Kids Activity Fathers Day Card Making - Cut out the bear card on dotted line then have child write their own message in the white belly box to make a Father's Day card. This is a great card making craft for kids to do for Father's Day.- From Mom's Break

Orange Bear. jpg
Yellow Bear. jpg
Pink Bear. jpg
Blue Bear. jpg
Red Bear. jpg
Purple Bear. jpg
Brown Bear. jpg
Green Bear. jpg
White Bear for coloring. jpg

The “# 1 DAD” design prints at approximately height of six and half inches and width of five and half inches (printer may vary) so it will fit on most shirts. Below is an example image of what a shirt would look like after the shirt is made into a Fathers Day gift. Colors may vary by the color of shirts and iron-on transfer paper you use. This is not reverses (mirror) so if your iron on transfer paper instructions you to reverse (mirror) the image before printing then you will need to pick that setting on your printer options however most new types of iron on transfer paper do not require mirroring.
*** Important - Follow the directions of the iron on transfer paper you choose to make the “#1 DAD” Father's Day gift.

>>> Number One Dad Iron-on Transfer or Craft .pdf

To Donate To Mom's Break Please Click Here

LymeLife and lyme in Canada

Disarray And Disenchantment, Amid The Deer Ticks

Enlarge

Amid a Lyme disease outbreak, Scott's mother (Jill Hennessy) worries about his safety — even on the front porch. Screen Media Films

Lymelife

• Director: Derick Martini
• Genre: Family comedy-drama
• Running time: 94 minutes

Rated R: profanity, sexual situations, fist fights, gun threats

Enlarge

Scott's developer father (Alec Baldwin) shows his dubious family a dream house. Screen Media Films

NPR.org, April 9, 2009 · Midway though Lymelife, an unhappily drunk suburban mom drops the family's Monopoly set, and little green plastic houses scatter.

And because the movie has already offered vignettes of tract homes, not to mention close-ups of miniature abodes in a real estate office, there's just one conclusion to be drawn: Cookie-cutter houses are the problem.

Longtime couples drifting apart? Sexual awakening a drag? Teenagers growing to hate their parents? Blame it on the mini-mansions.

Director Derick Martini does present some other suburban afflictions, notably the one mentioned in the film's title: Lyme disease threatens late-'70s Long Island, where Brenda (Jill Hennessy) tapes shut the cuffs of 15-year-old son Scott (Rory Culkin), and where their neighbor Charlie (Timothy Hutton) suffers long-term consequences after a tick bite.

Charlie is also enduring unemployment and depression, and perhaps hallucinations. (Is he the only one who sees that ominous deer prowling the neighborhood, possibly carrying Lyme-diseased ticks?)

Plus, Charlie knows that his wife, Melissa (Cynthia Nixon), is having an affair with her boss, the ambitious residential-property developer named Mickey (Alec Baldwin) who is Brenda's husband. Mickey tells his sons that Long Island real estate will soon make him a millionaire; Brenda can't stop recalling how much happier they were back in Queens.

Martini scripted this proficient but mostly unsurprising movie with his brother Steven, and the two have acknowledged that it's autobiographical. So naturally the story turns on the younger generation — especially on Scott.

Regularly bullied at school, Scott takes lessons in macho from his obnoxious father and his older brother Jim (Kieran Culkin), who is home for a visit before beginning a stint in the military. But Scott is tormented less by other guys than by his seemingly hopeless love for longtime friend Adrianna (Emma Roberts), who lives next door. She is, of course, the daughter of Melissa and Charlie.

Sly Adrianna looks out for bland Scott, but she tells him she prefers to date older boys. Still, the two have a crucial bond: the emotional wreckage strewn by their parents' entanglements.

While the movie focuses on Scott and his idealized crush, Hutton and Baldwin give the most colorful performances. Charlie and Mickey's near-confrontation in a bar shows how much more compelling Lymelife could have been if the Martinis had downplayed the coming-of-age-kids stuff.

Conventionally, the director sets the period with TV reports (the seizure of the U.S. Embassy in Tehran) and pop-culture fandom (Scott wants to be Han Solo). The music, which ranges from Boston and Bad Company to Frank Sinatra, is less chronologically specific, and sometimes kind of confusing.

The movie concludes with tracking shots of homes, and a foreboding reflection in a new house's glass exterior. Yet for all its emphasis on suburbia and its discontents, Lymelife never quite convinces that its story's environs are essential — or even all that interesting.

The emergence of Lyme disease in Canada
Nicholas H. Ogden, DPhil, L. Robbin Lindsay, PhD, Muhammad Morshed, PhD,
Paul N. Sockett, PhD and Harvey Artsob, PhD

Canadian Medical Association Journal, 2009 Jun 9;180(12):1221-4.
Free, full text here:
http://www.cmaj.ca/cgi/content/full/180/12/1221

http://dx.doi.org/10.1503/cmaj.080148

Review

Lyme disease, caused by the bacterium Borrelia burgdorferi and
transmitted by tick vectors, is the most commonly reported vector-borne
disease in the temperate zone. More than 20 000 cases are recorded
annually in the United States. In about 80% of cases, early Lyme disease
is characterized by a skin lesion, erythema migrans, which expands to a
diameter of more than 5 cm from the site of the tick bite. If left
untreated, the disease can progress to early disseminated Lyme disease
with neurologic (facial palsy, meningitis and meningoradiculoneuritis,
also known as Bannwarth syndrome) and cardiac (usually atrioventricular
block, sometimes with myopericarditis) involvement, and then to late
disseminated Lyme disease with neurologic manifestations (peripheral
neuropathy or encephalomyelitis) and Lyme arthritis.

B. burgdorferi is transmitted by ticks, which feed on wildlife reservoir
hosts of the pathogen, particularly rodents and birds. Ixodes
scapularis, the blacklegged tick (Figure 1), is the main vector in
eastern and central North America. Ixodes pacificus, the western
blacklegged tick, is the main vector west of the Rocky Mountains. Both
tick species are indiscriminate in their choice of host and will feed on
humans; as such, they can transmit pathogens from wildlife to humans.

Recent studies have suggested that the risk of exposure to Lyme disease
is emerging in Canada because the range of I. scapularis is expanding, a
process that is predicted to accelerate with climate change. Here we
review the available and emerging surveillance information and discuss
its relevance to the early diagnosis and prevention of Lyme disease. We
based this review on a search of the MEDLINE database using the key
words "Lyme," "Ixodes " and "Canada."