Lyme Disease in a “Non-Endemic” Region

Until recently, India has been considered a non-endemic region for Lyme disease, the authors point out. And, “Although it had been considered extremely rare in India, a recent study conducted in Nagarahole and Bandipur in South India surprisingly revealed a high seroprevalence (19.9%) of Borrelia burgdorferi infection in a population at risk (forest workers and staff).”

This finding challenges geographic assumptions about where Lyme disease occurs—assumptions that directly contributed to this patient’s misdiagnosis and months of disability.

Initial Presentation: Facial Palsy Misdiagnosed

According to the case report, a young woman was admitted to the hospital with “rapidly evolving progressive weakness of all four limbs, and lancinating pain over the back of the neck and lower back, radiating to upper and lower limbs.”

Her symptoms had developed over a 1-week period and left the patient bedridden. Ten days prior, she had developed a fever, which resolved within 2 days.

Two months before the onset of symptoms—during the last months of her pregnancy—she developed a “slight deviation of her angle of the mouth toward the left side, along with grossly decreased taste sensation and difficulties in closing eyes, blowing, and whistling.” This lasted for one month.

She was diagnosed with right-sided Bell’s palsy but Lyme disease was not considered, initially.

Failed Treatment and Progressive Deterioration

The woman was treated with methylcobalamin and prednisolone. However, her symptoms did not improve.

This lack of response should have prompted reconsideration of the diagnosis. Bell’s palsy typically improves with corticosteroid treatment. When it doesn’t, alternative diagnoses—including infectious etiologies like Lyme disease—should be pursued.

Instead, the patient continued to deteriorate. Her initial facial palsy progressed to severe quadriparesis with lancinating pain, leaving her bedridden.

Diagnostic Testing Reveals Lyme Disease

Further testing revealed the patient was positive for Lyme disease by ELISA and PCR.

She was treated with intravenous ceftriaxone (2 g/day) and oral azithromycin (500 mg/day) for 14 days.

Three months after her discharge from the hospital, the woman was able to walk without assistance. And, at the 6-month follow-up visit, she had “no demonstrable neurological deficit.”

The dramatic improvement with antibiotic therapy confirms what the diagnostic tests suggested: this was Lyme neuroborreliosis all along, not idiopathic Bell’s palsy.

Why Geographic Bias Delayed Diagnosis

Currently, only 10 cases of Lyme disease have been reported in India. Four of these cases involved lower motor neuron–type facial paresis.

In this case, the patient “also had an asymmetric lower motor neuron–type bilateral facial paresis, which was misdiagnosed by her treating physicians as right-sided Bell’s palsy leading to a delay in diagnosis.”

Interestingly, the authors point out, none of these patients exhibited an erythema migrans (bull’s-eye) rash.

The assumption that Lyme disease doesn’t occur in India—despite emerging seroprevalence data showing 19.9% infection rates in at-risk populations—directly contributed to the misdiagnosis. When clinicians believe Lyme disease is “extremely rare,” they don’t test for it even when clinical presentation suggests it.

Emerging Recognition in Non-Endemic Zones

The authors suggest: “The possibility of Lyme neuroborreliosis should be considered more often from now on because in the last year four cases with the kindred clinical syndrome have been described from a so-called ‘non-endemic zone.'”

This recommendation challenges the binary thinking about endemic versus non-endemic regions. As this case demonstrates, Lyme disease occurs in areas traditionally considered non-endemic—and geographic assumptions lead to missed diagnoses.

The recent seroprevalence data showing nearly 20% infection rates among forest workers suggests that Lyme disease may be far more common in India than previously recognized. It’s not that Lyme disease is newly arriving in India—it’s that clinicians are now beginning to look for it.

Clinical Implications for Facial Palsy Evaluation

Bell’s palsy is often considered a diagnosis of exclusion—idiopathic facial nerve paralysis without identified cause. However, when facial palsy occurs in the setting of other neurologic symptoms, systemic illness, or failure to respond to standard treatment, infectious etiologies must be considered.

This patient had several red flags that should have prompted earlier Lyme testing: facial palsy during pregnancy (when immune changes can affect disease presentation), progression to bilateral involvement, systemic symptoms including fever, development of limb weakness and radicular pain, and failure to improve with corticosteroid therapy.

Any one of these findings should prompt reconsideration of the Bell’s palsy diagnosis. Together, they strongly suggest an infectious or inflammatory etiology requiring different treatment.

Frequently Asked Questions

Can Lyme disease cause Bell’s palsy?
Yes. Lyme disease is a well-recognized cause of facial nerve palsy. In endemic areas, Lyme disease should be tested in all cases of facial palsy, particularly bilateral cases or those occurring with systemic symptoms.

Why was Lyme disease not considered initially?
The patient lived in India, considered a non-endemic region. Geographic assumptions prevented clinicians from testing for Lyme disease despite clinical presentation consistent with neuroborreliosis.

Should Bell’s palsy be treated differently if Lyme is suspected?
Yes. Idiopathic Bell’s palsy is treated with corticosteroids. Lyme-related facial palsy requires antibiotic therapy. Failure to respond to steroids should prompt Lyme testing.

How common is Lyme disease in India?
Previously considered extremely rare, recent data shows 19.9% seroprevalence among forest workers in South India. Only 10 cases have been formally reported, suggesting significant underdiagnosis.

Can facial palsy from Lyme disease progress to paralysis?
Yes. This patient progressed from facial palsy to quadriparesis (weakness of all four limbs) when Lyme neuroborreliosis went untreated. Early recognition and treatment prevent progression.

Clinical Takeaway

Bell’s palsy misdiagnosed as idiopathic led to months of progressive disability and left this patient bedridden. The case illustrates how geographic assumptions about endemic boundaries prevent appropriate diagnostic testing. A young woman in India developed facial palsy during late pregnancy. Clinicians diagnosed Bell’s palsy and treated with methylcobalamin and prednisolone. When symptoms didn’t improve—and instead progressed to bilateral facial involvement, severe limb weakness, radicular pain, and inability to walk—the Bell’s palsy diagnosis should have been reconsidered immediately. Instead, it took months before Lyme testing was performed. ELISA and PCR confirmed Borrelia burgdorferi infection. Treatment with intravenous ceftriaxone and azithromycin produced dramatic improvement. Within three months she could walk unassisted. At six months she had no neurologic deficits. The authors’ conclusion deserves emphasis: Lyme neuroborreliosis should be considered in patients presenting with facial palsy and neurologic symptoms even in “non-endemic zones.” Recent seroprevalence data showing 19.9% infection rates among forest workers in South India suggests Lyme disease is not rare in India—it’s underdiagnosed. Geographic bias prevented appropriate testing despite clinical presentation screaming for it: bilateral facial palsy, systemic symptoms, progressive neurologic deterioration, failure to respond to standard treatment. The lesson extends beyond India. Clinicians worldwide dismiss tick-borne illness based on geographic assumptions rather than clinical evidence. This patient became bedridden because of those assumptions. How many others remain undiagnosed for the same reason?