Clinical case report.

A 33-year-old male who recently emigrated from Georgia, where he worked in a chicken slaughterhouse, presented to our hospital with four weeks of progressive ascending sensory changes with associated bowel and bladder incontinence. Two months prior, he developed a round, erythematous rash with central clearing and tested positive for Borrelia burgdorferi serum antibodies, treated with oral doxycycline. His rash abated but he developed neurological symptoms as above.

Neurological examination was notable for 4/5 strength in bilateral lower extremities with associated hyperreflexia, including sustained clonus, and extensor plantar responses. Sensory exam showed decreased vibration and proprioception in bilateral lower extremities with a suspended sensory level between T5-T11. MRI demonstrated T2 flair sequence with multiple scattered hyperintense lesions throughout cervical and thoracic spinal cord with areas of T1 post-contrast enhancement. Cerebrospinal fluid (CSF) studies were positive for Borrelia burgdorferi IgM, IgG and type 2 pattern oligoclonal bands, with confirmatory positive ELISA blood panel. Remaining infectious and inflammatory studies, including CSF and serum myelin oligodendrocyte glycoprotein and aquaporin-4 antibodies were negative.

Due to high suspicion for myelopathy due to neuroborreliosis, IV methylprednisolone and IV ceftriaxone were initiated. Within days of initiating treatment, motor strength, hyperreflexia, sensory changes, and gait were markedly improved.

Our case report shows a case of ATM due to neuroborreliosis, an uncommon etiology, highlighting the importance of a broad infectious differential to identify treatable causes of ATM.