To highlight the importance of recognizing the early stages of Lyme disease with neurologic symptoms (neuroborreliosis), specifically when approaching a bilateral cranial neuropathy, as well as the response to treatment.

An elderly patient presented to our neurology clinic for evaluation of bilateral facial pain. Symptoms started earlier in the summer after she fell while gardening, and shortly afterwards noticed a rash over her left clavicle. She was told it was shingles. Days later she developed hemifacial pain which eventually became bilateral. She was diagnosed with bilateral trigeminal neuralgia in our clinic and an MRI of the brain was ordered to rule out anatomic or traumatic cause.

The patient eventually went to the ER before the MRI because of the pain. After more history was taken in the ER the neurology resident ordered serum Lyme titers as well as attempting a lumbar puncture for CSF analysis. Although the lumbar puncture was unsuccessful, the serum IgG and IgM for Lyme disease were positive, indicating an active infection. The patient was discharged home on the appropriate antibiotic treatment and when seen in 4 weeks in the neurology clinic she was almost symptom free.

Although bilateral cranial nerve VII palsies are most commonly reported, this case report highlights the importance of recognizing it as a cause for likely any bilateral cranial neuropathy. Lyme Disease should be high on the differential in any patient with a bilateral cranial neuropathy/neuritis, in the setting of the appropriate season and if they are living in an area considered endemic for Lyme Disease.

Early recognition and antibiotic treatment of the neurologic symptoms of Lyme Disease can have a significant and early improvement in a patient’s quality of life, as well as reducing health care costs associated with the expense of neuroimaging and anticonvulsant treatment of the pain.