Case Report

A Case of Early Disseminated Neurological Lyme Disease Followed by Atypical Cutaneous Manifestations

Table 1

Some of the atypical presentations of Lyme disease reported in the literature.

AgeSexClinical presentationDiagnosticsTreatmentAuthor

69F4-Day history of right eye pain, fever, fatigue, unequal pupils, and ptosis; diagnosed to be having Horner syndrome after a positive cocaine stimulation test. Skin exam showed an atypical vesicopustular variant of erythema migrans. After treatment, Horner syndrome resolved.Initially Lyme antibody was negative; 4 weeks later, it turned positive. CSF culture positive for Borrelia burgdorferiIntravenous (IV) ceftriaxone for 4 weeksMorrison et al. [11]

25F1-Month history of sudden onset hearing loss along with fever, vertigo, nausea, and vomiting. 2 months prior to presentation, she had unsteady gait and several episodes of fever. 4 months later, she developed left sided facial palsy. 5 years ago, the patient recalled having a circular rash. After treatment, facial palsy improved with resolution of fevers and vertigo.MRI of brain was negative. Serology for syphilis and HIV was negative, and Western blot for IgM/IgG was positive for LymeCeftriaxone IV for 4 weeksPeeters et al. [16]

30MPresented with headache, neck pain, dizziness, tenderness behind the ears, weight loss, and unsteady gait. After treatment, there was complete clinical resolution.CT of head and MRI of head and neck were negative. IgG against VlsE C6 peptide of B. burgdorferi was positiveCeftriaxone IV for 2 weeksWinter et al. [17]

17MDeveloped fever, sore throat, cough, fever, myalgia, diarrhea, and lightheadedness. Serology for Lyme disease and anaplasmosis was negative. Chest X-ray showed cardiomegaly. EKG with prolonged PR interval. He was tachycardic and febrile. On arrival to tertiary care facility, he developed ventricular fibrillation leading to death. Autopsy revealed diffuse lymphocytic pancarditis.Lumbar puncture (LP) revealed lymphocytic pleocytosis. ELISA and IgM Western blot were positive. Immunohistochemistry and real-time PCR were positive in myocardium, lung, and brain tissueYoon et al. [10]

46MPresented with fatigue, presyncope, and palpitations found to be bradycardic in 3rd-degree atrioventricular (AV) block. Transvenous pacemaker was placed. Later developed unilateral Bell’s palsy. With treatment, his 3rd-degree AV block converted to normal sinus rhythm 3 days later.EKG
Serology was positive for Lyme
Echocardiogram showed no abnormality, with ejection fraction of 65%
Ceftriaxone IVLee and Singla [18]

49MPresented with fevers, chills, fatigue, and unilateral lower extremity swelling. He had dark colored urine. Was found to be hypotensive and was given vancomycin and ampicillin-sulbactam. Lactic acid, aminotransferase, and alanine transaminase were elevated. Blood work further showed anemia, leukopenia, and thrombocytopenia, increased lactate dehydrogenase, and decreased haptoglobin.Positive ELISA and IgM Western blot for Lyme. Negative serology for Ehrlichiosis, Anaplasmosis, and HIV. Positive for parvovirus B19 IgGDoxycycline 100 mgMehrzad and Bravoco [14]

8FPresented with acute onset of headache and diplopia. She was found to be having left 6th cranial nerve palsy and bilateral papilledema. CT and MRI of head were normal. She was found to be having pseudotumor cerebri secondary to acute neuroborreliosis. After treatment, she had resolution of symptoms except for mild residual left 6th cranial nerve palsy without papilledema.LP revealed elevated pressure with lymphocytic pleocytosis. Lyme ELISA positive, IgM 23, 37, 39, 41 positive, IgG 39, 41, 45, 58Ceftriaxone IV for 4 weeks and acetazolamideKan et al. [15]