A 4-year-old boy with ataxia and aphasia

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Figure 1:
Magnetization-prepared rapid gradient-echo (T₁-weighted; left view)and turbo spin-echo (T₂-weighted; right view) magnetic resonance images showing multifocal asymmetric edema of the cortical, deep grey matter and white matter tracts, with no cranial nerve involvement (black arrows).
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Figure 2:
Disseminated erythema migrans initially misdiagnosed as erythema multiforme. Published with permission of the patient’s parents.
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Figure 3:
Risk map for Lyme disease. Estimated risk areas in Ontario (2019) (www.publichealthontario.ca/-/media/documents/lyme-disease-risk-area-map-2019). Published with permission of the Government of Ontario (Public Health Ontario).

Table 1:

Causes of acute ataxia and aphasia in children

Condition	Ataxia	Aphasia
Acute cerebellitis	+
Acute cerebellar ataxia (postinfectious)	+
Bacterial meningitis	+	±
Mycoplasma pneumoniae pneumonia	+
Enterovirus encephalitis
HSV encephalitis	+
EBV encephalitis	+
Cerebellar tumour	+
Lyme disease (neuroborreliosis)	+	±

Table 2:

Results of cerebrospinal fluid investigations in a 4-year-old boy with aphasia and ataxia

Laboratory test	Result	Reference range
CSF glucose, mmol/L	2.9	3.3–4.4
CSF protein, g/L	0.55	0.15–0.45
CSF appearance	Clear/colourless	Clear/colourless
Red blood cells, × 10⁶ cells/L	<	1 0–5
White blood cells, × 10⁶ cells/L	39	0–7
CSF neutrophil differential	1%	NA
CSF lymphocyte differential	80%	NA
CSF mono/macro differential	19%	NA
Bacterial culture	Negative	Negative
PCR for HSV/VZV	Negative	Negative
PCR for enterovirus RNA	Negative	Negative
PCR for Borellia species	Negative	Negative

Note: CSF = cerebrospinal fluid, HSV = herpes simplex virus, NA = not applicable, PCR = polymerase chain reaction, VZV = varicella zoster virus.

Table 3:

Results of microbiologic investigations in a 4-year-old boy with aphasia and ataxia

Laboratory test	Result
EBV EA IgG	Nonreactive
EBV VCA IgG	Nonreactive
EBV EBNA IgG	Nonreactive
EBV VCA IgM	Reactive
Measles IgG	Reactive
Measles IgM	Nonreactive
Mumps IgG	Nonreactive
Mumps IgM	Nonreactive
Urine RNA for mumps	Negative
CMV IgG	Nonreactive
CMV IgM	Nonreactive
Bartonella IgG titre	1:256
Lymphocytic choriomeningitis IgG	Nonreactive
Lymphocytic choriomeningitis IgM	Nonreactive
Lyme IgG/IgM EIA	Reactive
Lyme IgM Western blot	Reactive
Lyme IgG Western blot	Reactive
Nasopharyngeal swab
Influenza A/B PCR	Negative
Viral culture	Negative
Stool culture
Bacterial culture	No growth
Norovirus PCR	Positive
Rotavirus ICT	Negative

Note: CMV = cytomegalovirus, EA = enzyme assay, EBNA = Epstein–Barr virus nuclear antigen, EBV = Epstein–Barr virus, EIA = enzyme immunoassay, ICT = indirect Coombs test, IgG = immunoglobulin G, IgM = immunoglobulin M, PCR = polymerase chain reaction, VCA = viral capsid antigen.