Objective:

To highlight the diagnostic challenges in a patient initially presenting with nonspecific symptoms and later developing severe neurological decline, leading to a diagnosis of Lyme meningoencephalitis. 

Background:

A 29-year-old female presented with a 2-week history of GI symptoms, body aches, fatigue, and dizziness. She was evaluated in the emergency department with normal labs and vitals, no travel history, animal exposures, sick contacts, or known mosquito/tick bites. After discharge with supportive care for a presumed viral infection, she returned days later with persistent headaches, vomiting, lethargy, nuchal rigidity, and confusion.

Design/Methods:

The patient was started on ceftriaxone, vancomycin, and acyclovir due to concern for meningoencephalitis. She required sedation for a CT head. Lumbar puncture was performed, with CSF tests sent for VDRL, cryptococcal antigen, West Nile virus, autoimmune panels, and basic labs. Lyme Disease serology, West Nile virus serology, Syphilis RPR, and cryptococcal antigen serology were also ordered. COVID-19 tests were conducted, and an MRI brain was performed. 

Results:

CT head without contrast revealed no pathology. LP showed lymphocytic pleocytosis (96), elevated protein (126.5), and low glucose levels (33). MRI was unremarkable. Biofire testing and blood cultures were negative. Antibiotics and antivirals were discontinued as the patient began returning to baseline. The initial COVID-19 test was negative, but the repeat was positive, leading to a five-day course of Paxlovid. New-onset bradycardia prompted a cardiology consult, which raised concerns for Lyme carditis. Lyme Western Blot returned positive (IgM and IgG), initiating doxycycline. Remarkably, the patient fully recovered within three days of hospitalization. 

Conclusions:

This case underscores the importance of maintaining a high index of suspicion for Lyme meningoencephalitis in patients with atypical symptoms, particularly in endemic areas. The clinical decline and diagnosis highlight the need for thorough follow-up and reassessment in patients with evolving neurological signs, as early recognition and intervention are crucial for improving outcomes.