Bannwarth Syndrome Lyme Disease: Symptoms, Diagnosis, and Case Example

Can Lyme disease cause severe nerve pain, weakness, and even urinary problems? Bannwarth syndrome is a neurologic form of Lyme disease that can present with intense radicular pain and unusual neurologic symptoms — including autonomic dysfunction affecting the bladder.

This case highlights how early Lyme neuroborreliosis can be missed — and why recognizing neurologic patterns matters for timely diagnosis and treatment.

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Case: Severe Pain, Weakness, and Urinary Retention

A 66-year-old man presented to the emergency department with generalized muscle pain, fatigue, and severe neck pain that had been occurring for two weeks — beginning shortly after he was bitten by two ticks while performing yard work.

His physician initially suspected pneumonia and prescribed antibiotics. His symptoms did not improve — they worsened. Pain radiated down his entire spine into his upper and lower extremities, leading to right arm weakness and new onset urinary retention.

Examination revealed paraspinal tenderness and diminished deep tendon reflexes bilaterally. His pain score was 8 out of 10. Laboratory findings included an elevated ESR of 100 mm/h, C-reactive protein of 8.8 mg/L, white blood cell count of 12 k/uL, and creatinine kinase of 27 units/L.

This pattern is consistent with neurologic Lyme disease, where infection affects the nerves and spinal roots in ways that can closely resemble other conditions.

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Diagnosis: Bannwarth Syndrome

Western blot and ELISA testing were positive, confirming early disseminated Lyme disease with Borrelia burgdorferi. A spinal tap showed lymphocytic pleocytosis and a positive Lyme disease titer.

The diagnosis of Bannwarth syndrome was based on the combination of severe radiculopathy, upper extremity weakness, and urinary dysfunction — findings the authors describe as pathognomonic for this condition.

The urinary retention in this case reflected Lyme-induced sacral radiculitis affecting the nerves controlling bladder function. The authors suggested that direct invasion of spirochetes into the bladder wall may also have played a role — though the exact mechanism remained uncertain.

This condition is often missed early and contributes to Lyme disease misdiagnosis, especially when symptoms do not follow classic patterns.

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Treatment and Outcome

The patient was treated with a 21-day course of intravenous ceftriaxone. His symptoms improved significantly, with complete resolution of urinary retention.

This case demonstrates that even severe neurologic Lyme disease — including unusual autonomic symptoms — can improve substantially with appropriate antibiotic treatment when the diagnosis is recognized promptly.

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What Is Bannwarth Syndrome?

Bannwarth syndrome is a neurologic manifestation of Lyme disease, most commonly reported in Europe but also present in the United States — where it is often misdiagnosed due to limited clinical awareness.

It is characterized by radicular pain in virtually all cases, along with sleep disturbance in approximately 75%, headache in 47%, fatigue and malaise, paresthesia, peripheral nerve palsy, meningeal signs, and weakness.

The pain is often severe, burning, or stabbing in character and is typically worse at night. It may respond poorly to standard pain medications, making the diagnosis more challenging when the underlying infection is not considered.

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Why Bannwarth Syndrome Is Often Missed

Bannwarth syndrome is underrecognized in the United States for several reasons. Symptoms mimic other neurologic or musculoskeletal conditions. Pain may be mistaken for disc disease or spine pathology. Urinary symptoms may be attributed to unrelated causes. And clinical awareness of this presentation remains limited outside of specialists familiar with Lyme neuroborreliosis.

The authors note that neurologic symptoms — particularly when associated with a recent or suspected tick bite in an endemic region — should prompt thorough evaluation for Lyme neuroborreliosis and assessment for Bannwarth syndrome. Prompt diagnosis and treatment with antibiotics can reduce unnecessary imaging, patient anxiety, and most importantly, prevent debilitating complications.

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Frequently Asked Questions

What is Bannwarth syndrome?

Bannwarth syndrome is a neurologic manifestation of Lyme disease involving nerve root inflammation, severe radicular pain, and neurologic symptoms. It is caused by Borrelia burgdorferi infection affecting the peripheral and central nervous system.

Can Lyme disease cause urinary retention?

Yes. In this case, Lyme-induced sacral radiculitis affected the nerves controlling bladder function, leading to urinary retention. Possible direct invasion of spirochetes into the bladder wall may also have contributed.

Is Bannwarth syndrome common in the United States?

It is less commonly recognized in the US than in Europe but does occur and may be significantly underdiagnosed. Lack of clinical awareness is a primary reason cases are missed.

Can Bannwarth syndrome be treated successfully?

Yes. Antibiotic treatment — typically intravenous ceftriaxone — can lead to significant improvement and recovery. In this case, complete resolution of urinary retention followed a 21-day course of treatment.

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Clinical Takeaway

Bannwarth syndrome demonstrates how Lyme neuroborreliosis can present in ways that fall well outside the classic rash-and-joint-pain picture. Severe radicular pain, progressive weakness, and autonomic dysfunction such as urinary retention may reflect Lyme disease when they occur after tick exposure in an endemic area — even when other features of Lyme disease are absent.

Physicians need to be aware of the rare neurologic manifestations of Lyme neuroborreliosis. Early recognition and treatment can prevent disease progression and long-term neurologic complications.

When neurologic symptoms are severe, unusual, or fail to respond to standard treatment — particularly after possible tick exposure — Bannwarth syndrome and Lyme neuroborreliosis should be in the differential diagnosis.

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Related Articles

• Neurologic Lyme Disease
• Lyme Disease Misdiagnosis
• Burning Pain With Normal EMG
• Allodynia and Lyme Disease

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References

1. Omotosho YB, Sherchan R, Ying GW, Shayuk M. A unique case of Bannwarth syndrome in early disseminated Lyme disease. Cureus. 2021;13(4):e14680. doi:10.7759/cureus.14680.

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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