We present a case of Lyme neuroborreliosis that presented with three months of constipation and abdominal pain. The patient had truncal weakness but no other neurological findings. CSF studies showed a lymphocytic pleocytosis, positive Lyme IgG, and confirmation of infection with C6 antibody presence.

The central nervous system is the third most prevalent system to be involved with Lyme disease, occurring in 10-15% of cases. It is difficult to diagnose, as many patients have nonspecific symptoms. The classic triad includes lymphocytic meningitis, cranial neuropathy, and radiculoneuritis. Radiculoneuritis is diagnosed much less commonly than meningitis or cranial neuropathies. Gastrointestinal Lyme disease is well-described in pediatric patients, though rare in adults.

Case Report.

A 49-year-old male presented with three months of abdominal pain radiating to his back, and significant constipation requiring multiple enemas. He denied weakness or urinary issues. CT abdomen showed colonic ileus, EGD showed gastropathy, and colonoscopy was unremarkable.

His neurologic exam was intact, though he displayed truncal weakness and asymmetric abdominal distension. MRI of the spine was obtained which showed abnormal enhancement of the lower cervicothoracic and cauda equina nerve roots. MRI brain showed right oculomotor and bilateral trigeminal nerve enhancement. EMG showed active denervation of thoracic paraspinal muscles. CSF analysis showed elevated protein and lymphocytic pleocytosis. Lyme ELISA and Lyme IgM were positive, with negative IgG on three samples. He denied recent tick exposure, but endorsed this three months before symptom onset. A confirmatory C6 antibody test ultimately returned positive. His symptoms eventually improved with IV ceftriaxone.

Radiculoneuritis may present in unique ways, and we should keep a broad differential in mind. This case demonstrates the rare occurrence of Lyme neuroborreliosis masquerading as abdominal pain and colonic ileus, and demonstrates the importance of recognizing isolated radiculoneuritis as a manifestation of Lyme neuroborreliosis.