Oculomotor nerve paralysis and bilateral facial nerve paralysis as presenting signs of Lyme disease

Abstract

Lyme disease is a tick-borne illness caused by the spirochete Borrelia burgdorferi . On occasions, patients with Lyme disease present with isolated cranial nerve palsies; multiple palsies have rarely been reported in the literature.We discuss the case of a patient, who presented with a third nerve palsy and bilateral seventh nerve palsies and was subsequently diagnosed as suffering from Lyme disease.To our knowledge, this is the first reported case of Lyme disease presenting with this combination of neurological signs. A 53-year-old male from the Scottish Western Isles presented with a two-day history of double vision. On examination, he was found to have a left third cranial nerve palsy and a left seventh cranial nerve palsy. Five days later, the patient developed a right seventh cranial nerve palsy. Serum and CSF enzymelinked immunosorbent assay (ELISA) and Western blot analysis were both positive for Lyme disease as was CSF polymerase chain reaction (PCR) analysis. Subsequently, the patient gave a history of multiple tick bites over the previous few years. He was commenced on appropriate antibiotic therapy and oral prednisolone. A rapid improvement in his condition was noted. This case demonstrates the importance of considering the diagnosis of Lyme disease in patients with multiple cranial neuropathies, especially those residing in, or with a history of travel to, endemic areas. In addition, it illustrates how early diagnosis, with the institution of appropriate therapy, leads to a prompt improvement in neurological symptoms and signs.