Unmasking Neuroborreliosis: Intractable Headache and Facial Nerve Palsy as Initial Rare Manifestations of Lyme Meningitis
Niranjana Kesavamoorthy1, Nicholas Briski1, Maarib Hassan1, Dipakkumar Pandya1
1JFK University Medical Center
Objective:
To emphasize the rare central nervous system manifestation of neuroborreliosis to ensure timely diagnosis and
management.
Background:
Patients with neuroborreliosis may experience peripheral and central nervous system involvement, primarily manifesting as meningoencephalitis, cranial neuropathies, and polyradiculopathies. Neurological presentations typically occur earlier during the infection, with facial nerve palsy being the most common manifestation, which can be unilateral or bilateral. We report a rare clinical manifestation of intractable headaches and facial nerve palsy as an initial CNS manifestation of Lyme meningitis.
Results:
A 22-year-old male presented with intractable left-sided headaches. One month earlier, after camping, he developed an enlarging rash followed by headache and fever, which briefly improved with levofloxacin. Days later, he developed a severe throbbing headache (10/10) and left facial weakness. At an outside emergency room, he was diagnosed with Bell’s palsy and treated with prednisone and valacyclovir. On presentation, he was afebrile with left lower motor neuron facial palsy, photophobia, and neck pain. A macular, oval, pink rash with central clearing was present on his lower back. There was an absence of leukocytosis. Serum Lyme Western blot was positive for immunoglobulin M (IgM) and immunoglobulin G (IgG). He was started on intravenous doxycycline, methylprednisolone, and valacyclovir. Cerebrospinal fluid showed pleocytosis, elevated protein, and positive Lyme IgM, confirming Lyme meningitis. He was continued on doxycycline 100 mg twice daily for 4 weeks. He had a complete recovery.
Conclusions:
Untreated Lyme disease may progress to neurological involvement. Meningitis without other clinical manifestations is uncommon in central nervous system Lyme disease. Isolated cranial nerve palsy accompanied by severe headaches can represent an initial clinical presentation of Lyme meningitis. Early recognition and management of neuroborreliosis can lead to excellent recovery.
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