Hemifacial Spasm and Lyme Disease: When Treatment Response Raises Suspicion
Clinical response to treatment can sometimes provide clues to an underlying diagnosis. A reported case of hemifacial spasm (HFS) highlights how improvement following antibiotic therapy prompted further evaluation for Lyme disease. :contentReference[oaicite:0]{index=0}
Initial Presentation
A 44-year-old woman with no prior neurologic history developed persistent facial twitching. The spasms interfered with speech, eating, and her ability to keep her left eye open.
Initial evaluation included Lyme disease testing, which was negative by ELISA. She was diagnosed with hemifacial spasm, a neuromuscular disorder involving involuntary contractions of muscles innervated by the facial nerve.
A Prolonged Course
Her symptoms persisted for five years despite evaluation and management.
She eventually underwent surgical exploration, which did not reveal vascular compression or other structural causes typically associated with HFS.
Unexpected Improvement with Antibiotics
Following surgery, she was prescribed a 10-day course of an oral cephalosporin for a wound infection.
During this treatment, her hemifacial spasms resolved completely for the first time since onset. The improvement lasted several days after the antibiotic course ended.
This unexpected response raised the possibility of an underlying infectious process.
Revisiting the History
Further history revealed that five years earlier, she had sustained a tick bite associated with a rash and low-grade fever.
The tick exposure preceded the onset of her neurologic symptoms by approximately six months.
Diagnostic Reevaluation
Additional testing, including cerebrospinal fluid analysis and PCR testing, supported a diagnosis of Lyme disease.
The patient was treated with intravenous ceftriaxone (2 g daily for 56 days).
Response to Treatment
Following treatment, the severity of her hemifacial spasm decreased significantly. Her fatigue also improved.
Several years later, she continued to have mild residual symptoms requiring intermittent botulinum toxin injections.
Clinical Perspective
This case illustrates how treatment response may occasionally prompt reconsideration of an underlying diagnosis.
While antibiotic response alone is not diagnostic, it may serve as a clinical clue—particularly when combined with exposure history and supportive testing.
Accurate diagnosis often depends on integrating history, examination findings, and evolving clinical information over time.
Patients may benefit from understanding neurologic Lyme disease, reviewing testing limitations, and considering coinfections when symptoms are unexplained or persistent.
References
- LeWitt TM. Hemifacial Spasm From Lyme Disease: Antibiotic Treatment Points to the Cause. Clin Neuropharmacol. 2016.
- Stone MJ. The wisdom of Sir William Osler. Am J Cardiol. 1995.
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
Thank you Dr. LeWitt. It was Accurate Inductive Reasoning that helped to diagnose my Lyme. My relapses of Lyme usually start with facial twitching and then go away with antibiotics. Dr.LeWitt is also right on the money with the 2 months of I.V. Ceftriaxone. This was working great for me as well, until Health Ontario pulled the plug on it and told my Dr. she’d lose her license if she treated another Lyme Patient. More cutting edge research like this will will eventually lift the “ban” on Lyme. Thank you.
I have mild to severe atypical hemifacial spasms that come and go and started about a year ago or so. I’ve scored a 129 on the MSIDS questionnaire by Dr. Horowitz online and very high on another online chronic lyme symptom tests. I was finally tested through regular insurance for Lyme last week (as the insurance route is all I can afford ) I remember several tick bites as I loved hiking in the woods most of my life in the Northeastern US and elsewhere, but I don’t remember a rash ever. The test came back with only the IgM 23 band positive and so not a diagnosis for Lyme according to the CDC. I just want to mention the spasms so someone can be aware if there IS a connection and that I have SO many symptoms on those lists and have already had MRI of brain , MRI of heart, ultrasound on thyroid and blood work on thyroid, etc etc etc like all the chronic illness patients I hear of. Perhaps this information of the atypical hemifacial spasms with “no known cause” with be of interest to you as your article was to me in the quest to find the answer to my “mysterious list of symptoms” . Thanks ! Mary
A previous blog at reported differing hemifacial presentations in Lyme disease. You will likely need to include several specialists beyond the a tick borne evaluation until you get an answer.