Demonstrating Lyme Neuroborreliosis(LNB) as one of the rare causes of bilateral multiple cranial nerve(CN) palsies 

Lyme disease is a multisystem infectious disease and one of the most common vector-borne diseases in the United States. Lyme Neuroborreliosis can present with an array of neurological disorders but can rarely cause multiple bilateral cranial nerve palsies. 

We present a 59 years-old male with a past medical history of hypertension, and hyperlipidemia who presented with diplopia. These symptoms preceded with a 12-centimeter rash in his right inguinal region 2 months prior to the onset of diplopia. He was initially treated for cellulitis with Keflex and then Bactrim with resolution of the rash. After the rash resolved, he started having retro-orbital headache, myalgia  and followed by diplopia with right gaze. Magnetic resonance imaging (MRI) with contrast was performed which showed enhancement of cisternal segments of bilateral CN III, V and VI with concerns for Lyme’s disease. Lyme antibodies were positive both in serum and CSF confirming the diagnosis. Patient was started on Ceftriaxone for two weeks per infectious diseases recommendations. Patient continued to have diplopia even at 3 month follow up clinic visit although his systemic symptoms have resolved.

Due to delayed diagnosis of the condition, patient progressed both clinically and had radiological evidence of LNB in the rare form of multiple CN involvement. Presentation of Lyme’s disease can be variable throughout its progression due to it’s multisystem involvement. LNB should be considered as one of the differential diagnosis, especially in an endemic region when patient presents with multiple cranial nerve palsies. Early clinical diagnosis needs to be established and treatment should be started to avoid progression and long term or permanent neurological deficits as in our patient.