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Chapter 6: TBE in children

only a few months of age. 12–15 The idea that However, both in retrospective data from a
5
pediatric TBE could be underdiagnosed is fairly large cohort and prospective data from
further substantiated by a high incidence, the a study with broad inclusion criteria, it was
highest in years, in a prospective study of noted that fever >38.5° C (101.3° F) was not
6
neurologic complaints at the pediatric emer- always observed in pediatric TBE. Next to
6
gency ward, demonstrating the adage, “he fever, headache and vomiting have been
who seeks will find.” reported as central features of childhood TBE
at rates of approximately 90–100% and 50–
To summarize, children evidently get tick bites 90%, respectively. Self-reported fatigue/
and they do contract TBE. The disease itself, malaise, behavioral changes, photophobia,
the child’s attributes (e.g., age, physical muscle pain, etc. are commonly reported, but
activity level, etc.) and parental as well as have occurred at varying frequencies. 1–
medical community awareness may influence 3,5,6,16,17,19 Meningeal signs have been observed
the number of children who are diagnosed. as a prevalent finding, noted in >80% of
infected children, 1,3,16,17 but here as well,

young children have less pronounced clinical
5
Children’s clinical course of TBE presentation. When classifying the clinical
appearance of pediatric TBE, meningitis has
Acute phase or nonspecific phase been noted in 63–79% of cases,
meningoencephalitis in 21–38%, and meningo-
The onset and acute phases of TBE in children encephalomyelitis in 0–4%. 1,16,19 Other
have been found similar in part to the clinical findings in childhood TBE have been tremor,
picture seen in adulthood, but there are also impaired general appearance, somnolence,
differences reported. Tick-bites have been lymphadenopathy, apathia, hyperesthesia,
recalled in 50–75% of childhood TBE hyperesthesia, and confusion/cognitive
1,3,5,6,16,17,19,20
cases. 3,5,16,17 Approximately 70% (or even dysfunction. Though unusual,
more) children had a biphasic clinical course, some children have presented with seizure
1,5,17
i.e., a flu-like prodrome followed by a short and hemiparesis.
asymptomatic period and thereafter a varying
degree of meningitis to meningoencephalo- Detection of anti-TBE virus (TBEV) antibodies,
myelitis, as reported in retrospective as described in other chapters, is required to
studies. 1,3,16,17 However, others have reported establish a diagnosis in childhood TBE.
much fewer biphasic courses, certainly among However, some children have needed testing
preschool-age children. 5,6 That younger of both acute and convalescent sera, as
individuals may have a vague/nonspecific antibodies may be absent in the initial
5,6
phase. Although serologies are reported as
clinical presentation and a generally milder
clinical course is well established, 2,3,5,18 but this diagnostic, they are of little help at the first
clinical assessment in the acute phase.
may also denote that childhood TBE manifests
differently in children versus adults and that Instead, the clinical presentation corroborated
5,6
the condition may be underdiagnosed. This with routine laboratory evaluation has been
needed to guide the clinician. Nonspecific
notion is further emphasized by Meyer et al,
who reported a case series of TBE appearing inflammatory signs, i.e., leukocytosis, elevated
11 C-reactive protein (CRP), and elevated
as fever without localized symptoms.
erythrocyte sedimentation rate (ESR) have
In the majority of reports on pediatric TBE, been reported in many children with TBE. 1–
3,5,16,17
fever has been present in virtually all cases at
diagnosis. 1,3,16,17

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