Lyme Disease Hemifacial Spasm: When Facial Twitching Has an Infectious Cause
Facial twitching may not be benign
Testing can be negative early
Symptoms may persist for years
Infection may be the missing cause
Lyme disease hemifacial spasm is a rare but important neurologic presentation. A case report illustrates how unexplained facial twitching may be linked to infection—even after years of symptoms and negative testing.
In the article, “Hemifacial spasm from Lyme disease: Antibiotic treatment points to cause”, LeWitt and colleagues describe a 44-year-old woman whose diagnosis became clear only after an unexpected response to antibiotics.
Initial Diagnosis: Hemifacial Spasm
The patient, with no prior neurologic history, developed progressive facial twitching.
Her symptoms included:
- Involuntary facial spasms
- Difficulty speaking and eating
- Inability to keep her left eye open
An ELISA test for Lyme disease was negative, and she was diagnosed with hemifacial spasm (HFS).
HFS is typically attributed to irritation of the seventh cranial nerve.
Five Years Without an Answer
The patient remained symptomatic for five years.
Surgical exploration was performed but revealed:
- No vascular compression
- No structural abnormality
The cause of her symptoms remained unexplained.
The Unexpected Clue
Following surgery, the patient was treated with an oral cephalosporin for a wound infection.
During this treatment:
- Her hemifacial spasm completely resolved
- This was the first resolution since symptom onset
The rapid improvement raised suspicion of an underlying infection.
The resolution of HFS within 10 days of antibiotic therapy led clinicians to reconsider the diagnosis.
Revisiting the History
Further evaluation revealed:
- A tick bite five years earlier
- A rash surrounding the bite
- A low-grade fever lasting one week
The tick exposure preceded the onset of facial spasms by approximately six months.
Confirming Lyme Disease
A lumbar puncture and cerebrospinal fluid PCR testing confirmed infection with Borrelia burgdorferi.
The patient was treated with:
- Intravenous ceftriaxone (2 g/day for 56 days)
Following treatment:
- The severity of facial spasms markedly decreased
- Chronic fatigue symptoms improved
Residual symptoms were later managed with botulinum toxin.
Why This Case Matters
This case highlights several important clinical lessons:
- Lyme disease may present with isolated neurologic symptoms
- Standard testing may initially be negative
- Symptoms can persist for years before diagnosis
- Response to antibiotics may reveal an underlying cause
Unexplained neurologic symptoms should prompt reconsideration of Lyme disease.
For related patterns, see neurologic Lyme disease.
Clinical Perspective
This case reflects the importance of careful clinical reasoning.
As emphasized by Sir William Osler:
“A physician must obtain a history, elicit pertinent findings, and interpret them within the broader context of medical knowledge.”
When symptoms do not fit expected patterns, clinicians must be willing to reconsider the diagnosis.
Clinical Takeaway
Lyme disease hemifacial spasm is an uncommon but meaningful presentation of neurologic Lyme disease.
Persistent facial twitching may reflect underlying infection—even when early tests are negative.
Recognizing this possibility can lead to appropriate treatment and improved outcomes.
Related Reading
References
- LeWitt TM. Clin Neuropharmacol. 2016.
- Stone MJ. Am J Cardiol. 1995;75(4):269-276.
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.