Lyme Disease vs Bell’s Palsy: When Facial Paralysis Is Misdiagnosed
Facial paralysis may be an early sign of Lyme disease
Lyme neuroborreliosis can be mistaken for Bell’s palsy
Delayed recognition may postpone neurologic treatment
Bell’s palsy is often considered an isolated facial nerve disorder. But in some patients, facial paralysis may actually be an early neurologic manifestation of Lyme disease.
When Lyme disease is not initially considered, diagnosis and treatment may be delayed — especially in patients without a known tick bite or classic bull’s-eye rash.
Facial paralysis initially diagnosed as Bell’s palsy
According to a published case report, a young woman developed facial weakness during the final months of pregnancy with deviation of the mouth, impaired taste sensation, and difficulty closing her eyes.
She was diagnosed with right-sided Bell’s palsy and treated with methylcobalamin and prednisolone. However, her symptoms did not improve.
Two months later, she developed rapidly progressive weakness involving all four limbs along with severe radiating neck and back pain that left her bedridden.
Further testing eventually revealed Lyme disease confirmed by ELISA and PCR testing.
Learn more about neurologic Lyme disease and delayed Lyme disease diagnosis.
Lyme neuroborreliosis may mimic Bell’s palsy
Facial nerve palsy is one of the best recognized neurologic manifestations of Lyme disease.
Some patients develop isolated facial paralysis, while others experience additional neurologic symptoms including:
- neck pain
- headache
- radicular pain
- limb weakness
- numbness or tingling
- difficulty walking
In this case, the patient ultimately developed asymmetric bilateral facial weakness and progressive neurologic impairment consistent with Lyme neuroborreliosis.
The authors noted that none of the reported patients exhibited an erythema migrans rash, reinforcing that Lyme disease may still occur without classic skin findings.
Why Lyme disease may be missed
Bell’s palsy is frequently labeled idiopathic, meaning no clear cause is identified.
But Lyme disease should remain part of the differential diagnosis, particularly in patients with:
- outdoor or tick exposure
- facial palsy with systemic symptoms
- neck pain or radicular symptoms
- bilateral facial weakness
- persistent neurologic symptoms
- poor response to steroids alone
Recovery after Lyme disease treatment
The patient was treated with intravenous ceftriaxone and oral azithromycin for 14 days.
Three months after discharge, she was able to walk independently. At 6-month follow-up, she reportedly had no demonstrable neurologic deficit.
Early recognition and treatment of Lyme neuroborreliosis may improve recovery and reduce the risk of prolonged neurologic complications.
Learn more about persistent Lyme disease and post-treatment Lyme disease syndrome.
Frequently Asked Questions
Can Lyme disease cause Bell’s palsy?
Yes. Lyme disease is a recognized cause of facial nerve palsy and may present as unilateral or bilateral facial weakness.
What is Lyme neuroborreliosis?
Lyme neuroborreliosis refers to neurologic involvement from Lyme disease and may affect the brain, cranial nerves, spinal cord, or peripheral nerves.
Can Bell’s palsy be misdiagnosed?
Yes. Some patients diagnosed with Bell’s palsy may actually have Lyme disease or another underlying neurologic condition.
Does Lyme facial palsy always occur with a rash?
No. Some patients with Lyme-associated facial paralysis do not recall a tick bite or develop a classic erythema migrans rash.
Can patients recover from neurologic Lyme disease?
Many patients improve with appropriate treatment, although recovery time and long-term outcomes vary depending on severity and treatment timing.
Clinical Takeaway
Lyme disease may present with facial paralysis that initially resembles Bell’s palsy, particularly when classic Lyme features are absent.
Considering Lyme disease in patients with facial weakness and neurologic symptoms may help reduce delayed diagnosis and improve recovery outcomes.
Related Articles
These related articles explore Lyme-associated facial palsy, neurologic Lyme disease, diagnostic delays, and treatment outcomes.
Treatment Varies for Bell’s Palsy in Children With Lyme Disease
Patient With Facial Palsy From Lyme Disease Fails Treatment
Can Bell’s Palsy Lead to Nonflaccid Facial Palsy in Lyme Disease?
Lyme Disease Misdiagnosis
Lyme Disease Symptoms Guide
References
- Kayal N, Ghosh R, Mazumdar PS, et al. Bilateral facial nerve palsy in a young woman from West Bengal: Do not forget Lyme neuroborreliosis. Neurol India. 2021;69(4):997-1001.
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
