Lyme disease is one of the most common tick-borne illnesses in the United States. The classic presentation for Lyme disease includes erythema migrans, facial palsy, and heart block. Facial diplegia is rare and comprises about 2% of all facial palsies. The differential diagnosis for facial diplegia is broad and can be a diagnostic challenge.

Case Report: A 57-year-old man with past medical history of hypothyroidism presented multiple times with a three-week history of myalgias, arthralgias and abdominal pain to the emergency department in the month of July 2020. He was repeatedly tested negative for COVID-19 infection during the pandemic. A week later, he developed left peripheral facial weakness. He was diagnosed with Bell’s palsy and treated with steroids and antiviral medications. However, his symptoms continued to progress. Few days later, he presented to the hospital with facial diplegia. On neurological examination, he was unable to close both eyes and was unable to smile. Lyme antibody and Western blot were positive. Brain MRI revealed enhancement of bilateral internal auditory canals, labyrinthine segments, and geniculate ganglions. He was diagnosed with Lyme neuroborreliosis. His symptoms gradually improved after treatment with doxycycline.

In our case, there was a delay in the diagnosis and treatment of Lyme disease during the COVID-19 pandemic. Initial manifestation with nonspecific symptoms including myalgias, arthralgias and abdominal pain eventually progressed to complete peripheral facial weakness. Lyme neuroborreliosis was the culprit from the beginning. Unilateral facial palsy is often idiopathic. However, facial diplegia is typically associated with an underlying systemic illness. Prompt identification of the disease aids in early treatment and management.