(Kiosk 4) Polyneuropathy Associated with Lyme Disease: A Case Report

Case Diagnosis: Lyme Disease

Case Description or Program Description: 63-year-old male with history of type 2 diabetes and hypertension who presented with progressive weakness, gait instability, falls, weight loss, dysphagia and voice changes ongoing for several months. Early symptoms included back pain, radicular and systemic symptoms that had resolved. Exam was notable for tongue, bilateral calf and forearm fasciculation, moderate weakness with atrophy on upper extremities more than lower extremities, truncal instability, hyporeflexia with absent ankle jerk reflex and no sensory symptoms. Thoracic MRI showed facet arthropathy at T10-T11 while his cervical MRI showed multilevel foraminal narrowing. EMG showed mild scattered ongoing and chronic denervation in the bilateral upper and lower extremities suggestive for motor neuron disease. Further lab workup was obtained to identify a treatable diagnosis. Patient was started on Riluzole empirically.

Setting: Outpatient Clinic

Assessment/Results: Positive IgM and IgG Lyme antibody titer in serum. Lumbar puncture for CSF analysis showed elevated protein: 245, normal glucose: 70 and elevated white blood cells: 64 with differentials as followed: polymorphs 21, lymphocytes: 71, mononuclear: 7, eosinophils: 1. CSF was positive for Lyme IgG antibody confirming neuroborreliosis. Patient was admitted for suspected CNS Lyme disease. After completion of four weeks of IV ceftriaxone, physical and occupational therapy, he was living independently, and his neurologic symptoms had improved.

Discussion (relevance): Patient did not report typical symptoms of early localized Lyme disease and denied prior tick bite or known tick exposure. Early disseminated Lyme disease usually occurs weeks to months after initial infection and can be associated with neurologic findings including aseptic meningitis, cranial, motor or sensory neuropathy.

Conclusions: Some patients can present in a later stage of Lyme disease with dissemination in the absence of prior features of early infection or apparent tick exposure. It is important to consider neuroborreliosis in regions endemic for Lyme disease in patients with unexplained neuropathy or motor nerve disease.