Article Text

  1. S. Sattar1,
  2. L. Shah1
  1. 1Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, NV.


Introduction Lyme disease is the most common vector-borne disease in the United States. We report a confirmed case of early Lyme disease presenting with meningitis and encephalopathic changes, an uncommon finding.

Case Report This 16-year-old Puerto Rican male from New Jersey was on summer vacation visiting the Grand Canyon when he developed a 2-week history of intermittent headaches, nausea, bilateral facial weakness, and facial paresthesias for 6 days. He denied diplopia, hearing deficits, ataxia, rash, fever, vomiting, diarrhea, or illicit drug use. Physical examination revealed that he was afebrile, with neurologic findings of bilateral facial weakness and upward gaze nystagmus. His CBC was normal, but his ESR was 77 mm/hr and his CRP was 35 mg/dL. CSF results were WBC 125/mm3 with 95% mononuclear cells, RBC 90/mm3, protein 63 mg/dL, and glucose 51 mg/dL CT scan and MRI with and without contrast of the brain were normal. IV acyclovir and ceftriaxone were given. After 2 days a maculopapular rash over lower extremities developed. CSF Lyme IgM and IgG titers confirmed the diagnosis. The facial paralysis partially resolved after 6 days, and his panencephalitis panel was negative for other etiologies. He was discharged home to complete 4 weeks of IV ceftriaxone.

Discussion Lyme disease is caused by the transmission of Borrelia burgdorferi, a spirochete, through the bite of the Ixodes tick. Even though the majority of cases reported in the United States occur in the Atlantic and Pacific Coast states, Lyme disease has been reported in 49 of the 50 states. Neurologic presentations include headache, aseptic meningitis, papilloedema (25-30%) and facial nerve paralysis.

Conclusion This patient presented with disseminated Lyme disease with meningoencephalitis and facial nerve paralysis as the presenting features prior to the appearance of cutaneous manifestations. The diagnosis of Lyme disease should be considered in patients who present with a combination of meningoencephalitis and facial nerve paralysis.

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