Spirochetal infections have a broad spectrum of clinical manifestations and severity, with 10-15% of those infected with Lyme disease having CNS involvement. This is due to meningeal seeding of the spirochetes in early disseminated Lyme disease. Due to variability in presentation, diagnosis is often difficult to make.  

A 50-year-old previously healthy man presented to our hospital with acute onset total right sided facial tingling and weakness. Prior to hospitalization, patient had presented to his primary doctor three weeks prior for painful paresthesias of his low back, right hip, right buttocks, and left thigh. His primary doctor ordered a hip XR, which was negative, and prescribed Flexeril. Due to persistent pain and paresthesias, patient was then started on prednisone, and he then developed a right facial droop, pressure-like headache, and double vision leading to his presentation to the hospital. At our initial assessment, patient had a right 7^th nerve palsy with House-Brackmann grade of IV, right 5^th nerve palsy, and right 6^th nerve palsy. Motor and sensory testing elsewhere were normal, although patient had non-specific complaints of shoulder and hip girdle pain with paresthesias into his extremities. Lumbar puncture was performed, which was significant for CSF pleocytosis and eventually CNS Lyme returned as positive. Patient empirically started on IV Ceftriaxone after lumbar puncture and had eventual clinical improvement.

This case illustrates the prolonged time to diagnosis, and possible worsening with steroidal treatment, in a patient with CNS Lyme disease. While our patient’s initial presenting symptoms appear non-specific, the initial complaint concerning for mechanical radiculopathy without apparent mechanical precipitant could suggest the possibility of a radiculoneuritis. The constellation of radiculoneuritis, multiple cranial neuropathies, and CSF pleocytosis helped us to make the diagnosis of CNS Lyme.