Transverse Myelitis and Lyme Disease: A Rare Neurologic Case

Lyme disease can rarely affect the spinal cord.
A young man developed weakness, numbness, and urinary retention.
MRI findings were consistent with transverse myelitis.

I will be discussing a 25-year-old man with transverse myelitis and Lyme disease. “He showed gradual improvement in gait, motor and sensory functions of his lower extremities along with a resolution of neurogenic bowel,” wrote the authors. They added, “He continues to need intermittent self-catheterization for neurogenic bladder.” ¹

Dumic and colleagues first discussed this case in the journal IDCases in 2019. ¹

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Early Symptoms Before Diagnosis

A previously healthy 25-year-old man presented with inability to urinate and frequent falls associated with bilateral lower extremity weakness and numbness.

Two weeks earlier, he described a red circumferential rash approximately 10 cm in diameter.

The CDC only requires a 5 cm rash to meet erythema migrans criteria for Lyme disease.

He lived in Wisconsin and had extensive tick exposure. He lived next to wooded areas, hiked, camped, fished, and had two dogs.

He did not recall a tick bite.

He also developed:

• mild headache
• neck stiffness
• possible fever
• flu-like symptoms

Despite these findings, he was not treated for Lyme disease.

The rash disappeared within one week without treatment, which can occur with erythema migrans.

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Rapid Neurologic Decline

Five days before admission, his condition worsened significantly.

He developed:

• urinary retention
• progressive numbness
• bilateral leg weakness
• bowel dysfunction
• difficulty walking
• frequent falls

The sensory deficit progressed from his left foot upward into the thorax.

Physical examination revealed:

• weakness in both legs
• mild spasticity of the knees
• increased reflexes
• diminished sensation
• a positive Babinski sign

A positive Babinski sign may indicate injury involving the central nervous system.

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MRI Findings Suggestive of Myelitis

MRI imaging of the cervical and thoracic spine revealed T2 hyperintensity involving the spinal cord at multiple levels, findings suggestive of myelitis.

Myelitis refers to inflammation involving the spinal cord.

The patient’s spinal fluid demonstrated pleocytosis, meaning an increased white blood cell count suggestive of inflammation.

His Lyme antibody test was negative.

However, PCR testing for Lyme disease was positive and was confirmed through Mayo Medical Laboratories. ¹

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Transverse Myelitis and Autonomic Dysfunction

The patient’s neurologic findings were consistent with acute transverse myelitis.

He also developed autonomic dysfunction involving bowel and bladder control.

The autonomic nervous system regulates many involuntary body functions including:

• bladder function
• bowel function
• heart rate
• blood pressure
• intestinal activity

The patient ultimately required intermittent self-catheterization because of neurogenic bladder dysfunction.

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Treatment for Lyme Neuroborreliosis

The patient was treated with IV ceftriaxone for Lyme disease.

He also received:

• intravenous acyclovir for two days
• high-dose IV methylprednisolone for three days

According to the authors, he gradually improved in gait, sensory function, motor function, and bowel control.

However, persistent bladder dysfunction remained. ¹

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What This Case Teaches Us

The authors identified several important clinical lessons:

1. Acute transverse myelitis can occur in Lyme disease.
2. Spinal fluid may show significant inflammation despite negative Lyme antibody testing.
3. PCR testing helped confirm Lyme neuroborreliosis in this patient.
4. Neurologic Lyme disease may improve with antibiotic treatment, although residual symptoms can persist.

The authors also noted that several additional cases of Lyme-associated transverse myelitis have previously been reported. ¹

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Questions Raised by This Case

1. How frequently does transverse myelitis occur in Lyme disease?
2. Would Lyme disease have been diagnosed if PCR testing had been negative?
3. Could longer antibiotic treatment have improved persistent bladder dysfunction?
4. Were additional autonomic symptoms present but unrecognized?

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Clinical Perspective

Lyme neuroborreliosis can occasionally present with severe neurologic complications involving the spinal cord.

This case highlights the importance of considering tick-borne illness in patients presenting with acute transverse myelitis, autonomic dysfunction, weakness, numbness, and unexplained inflammatory spinal cord findings.

Negative antibody testing does not completely exclude neurologic Lyme disease, particularly early in illness.

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Inside Lyme Podcast Series

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention