Objective:

To highlight that Lyme neuroborreliosis, though rare, can present with longitudinally extensive transverse myelitis (LETM). We also want to emphasize the importance of excluding other autoimmune, metabolic and paraneoplastic causes in the diagnostic evaluation.

Background:

A 63-year-old Midwestern woman with history of hypertension and alcohol-related hyponatremia presented with 5–6 weeks of progressive fatigue and gait impairment. She was previously able to walk 3–4 miles a day but now had difficulty ambulating to the bathroom. She denied fever, rash, or recent tick bite and reported decreased alcohol intake since symptom onset. MRI brain revealed hyperintense lesions in the medulla, pons, and left cerebral peduncle, while cervical MRI showed a posterior C2–C6 lesion with leptomeningeal enhancement. Examination revealed brisk reflexes and distal loss of vibration sensation bilaterally without weakness. CSF demonstrated lymphocytic pleocytosis (179 cells), elevated protein (256 mg/dL), and positive oligoclonal bands. Serum Lyme IgM and IgG and CSF Lyme IgG were positive, and other autoimmune, metabolic, and paraneoplastic causes were ruled out. Although no history of tick bite or other stigmata of Lyme, she was treated with intravenous ceftriaxone followed by doxycycline for 28 days. She had clinical improvement in ambulation. Six-month follow-up imaging showed resolution of brainstem and cervical cord lesions, further confirming Lyme neuroborreliosis presenting as longitudinally extensive transverse myelitis.

Design/Methods:

NA

Results:

NA

Conclusions:

This case highlights an atypical presentation of neuroborreliosis with brainstem and cervical cord lesions. Attention to atypical imaging findings such as leptomeningeal enhancement can aid in when to expand your differential diagnosis. Recognition of rare CNS manifestations of Lyme disease is critical, particularly in endemic regions, to guide appropriate testing and treatment.