Atypical case: Bannwarth syndrome and weight loss

Bannwarth syndrome is a neurological disease caused by an infection with Borrelia burgdorferi, the bacterial agent of Lyme disease. The disease causes intense nerve pain and is characterized by “painful radiculopathy, neuropathy, varying degrees of motor weakness, lower motor neuron (LMN) facial nerve palsy and cerebrospinal fluid (CSF) lymphocytic pleocytosis,” writes Diaz et al. in the journal Clinical Neurology and Neurosurgery.


Bannwarth syndrome is typically seen in Europe. However, in 2017 doctors from Mayo Clinic described 5 patients with the disease living in Minnesota and Wisconsin. All of the patients presented with peripheral neuropathy.

Now, a 2019 case report by Diaz ¹  describes a 60-year-old man from the United States with a variant Bannwarth syndrome. The man initially presented with high liver function tests and weight loss of approximately 25 lbs.

For 3 weeks he experienced progressive back pain, along with peripheral neuropathy, which included arm and leg weakness, numbness in his hands and a right facial droop. Shortly after he was admitted to the hospital, the man developed a complete facial palsy.

“Throughout this time, severe central back pain persisted requiring neuropathic pain agents and opiates for adequate pain-control,” writes Diaz.

An EMG and nerve conduction study of his upper and lower body demonstrated prolonged distal latencies and slowed conduction velocity seen in polyradiculopathy.

The spinal tap revealed a lymphocytic pleocytosis (96%) and elevated protein (156) consistent with lymphocytic pleocytosis.

A patient with Bannwarth syndrome due to Lyme disease presents with liver dysfunction and weight loss. Click To Tweet

His serologic and spinal fluid was positive for Lyme by Western blot IgG. The serologic test revealed only one IgM band. A CSF:serum antibody index assay was not performed.

Anaplasmosis was considered as the cause of transaminitis (high liver function) but the tests were negative. Serologic tests were positive for Babesia but there was no evidence of parasites in his blood.

The man’s evaluation led to a diagnosis of a variant Bannwarth syndrome. And he was treated successfully with 4 weeks of intravenous ceftriaxone.

“On follow-up at 2 months, facial paralysis, pain, motor, and sensory deficits had resolved with return to baseline weight and liver function tests,” the authors write.

“Our case demonstrates the importance of consideration of Bannwarth syndrome in the differential of meningoradiculitis, even in the setting of atypical features such as liver dysfunction and weight loss,” writes Diaz.

Editor’s note: This case suggests the need to look for Bannwarth syndrome in patients living in the U.S. It also highlights the importance of considering this condition in patients who present with painful radiculopathy, neuropathy, varying degrees of motor weakness, and lower motor neuron (LMN) facial nerve palsy, even with a normal spinal tap.

  1. Diaz MM, Wesley SF. Meningoradiculitis and transaminitis from neuroborreliosis: A case of variant Bannwarth syndrome. Clin Neurol Neurosurg. 2019 Sep 23;186:105532.
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