A 46-year-old Canadian man developed Bell’s palsy after frequent summer hiking in tick-endemic regions of New England, Quebec, and Ontario. Emergency clinicians correctly diagnosed Lyme disease based on facial drooping, multiple erythema migrans rashes, and outdoor exposure history—prescribing antibiotics immediately rather than waiting for test results. Critically, they avoided corticosteroids, which recent research shows cause worse long-term outcomes in Lyme-related facial palsy. The case demonstrates why differentiating Lyme-associated Bell’s palsy from idiopathic (viral) Bell’s palsy matters: treatment with steroids for presumed viral causes can harm patients when the underlying cause is bacterial infection.
The Clinical Presentation
There are varying presentations of Lyme disease with the two most common symptoms including erythema migrans and arthritis, according to the authors of a case review published in the Canada Communicable Disease Report. [1] But they also point out that “Bell’s palsy is not rare — it has been found in 8.2% of reported cases in Canada.”
A healthy 46-year-old man was admitted to the emergency room with left facial drooping and an inability to completely close his left eyelid. There were “several red blotchy areas with dusky centres on his back approximately 2 cm in height and 3 to 5 cm in length,” the authors write. “The patient reported frequent hiking in New England, Quebec, and Ontario over the summer.”
Correct Diagnosis Prevented Steroid Harm
Emergency room clinicians correctly diagnosed the patient as having Lyme disease and prescribed a 10-day course of doxycycline immediately rather than waiting for test results. “His diagnosis was probable early disseminated Lyme disease presenting as Bell’s palsy with multiple erythema migrans lesions,” the authors state.
Differentiating Bell’s palsy due to Lyme disease is important, they point out, since “one could do harm by treating it as idiopathic Bell’s palsy” which often requires treatment with steroids. And a recent study [2] found “worse long-term outcomes associated with corticosteroid use in acute Lyme disease facial palsy.”
Treatment Recommendations
For this patient, the authors advised ordering a Western blot, extending treatment to 21 days, scheduling a follow-up visit to monitor and reassuring him that “most Lyme disease facial palsies resolve.”
At least one-third of patients with Lyme disease in the USA remain ill on long-term follow-up. [3-4] But the authors of this review did not address treatment if the 46-year-old man continued to be ill. They did, however, recommend that Lyme disease “should be considered in any patient with a new onset of Bell’s palsy.”
Clinical Perspective
This case illustrates excellent emergency medicine practice. The clinicians recognized the critical clue: multiple erythema migrans lesions combined with facial palsy in a patient with tick exposure. By treating empirically for Lyme disease rather than waiting for test results, they prevented both diagnostic delay and the harm caused by inappropriate steroid use. The decision to avoid corticosteroids was crucial—research shows steroids worsen long-term outcomes in Lyme-related facial palsy, likely by suppressing immune response to active infection. The extension from 10 to 21 days of antibiotics reflects emerging evidence that neurologic Lyme manifestations benefit from longer treatment courses.
Frequently Asked Questions
Can Lyme disease cause Bell’s palsy?
Yes. Bell’s palsy occurs in 8.2% of reported Lyme disease cases in Canada and is a common early neurologic manifestation when infection spreads beyond the initial tick bite site.
Why are steroids harmful in Lyme-related Bell’s palsy?
Steroids suppress immune response to active bacterial infection. Research shows corticosteroid use in Lyme disease facial palsy causes worse long-term outcomes, including persistent weakness and synkinesis (involuntary facial movements).
How do doctors differentiate Lyme Bell’s palsy from viral Bell’s palsy?
Key clues include tick exposure history, outdoor activities in endemic regions, presence of erythema migrans rash (especially multiple lesions), and timing during tick season. When Lyme is suspected, treat empirically rather than waiting for test results.
Do most patients with Lyme-related facial palsy recover?
Most recover with appropriate antibiotic treatment, but at least one-third of Lyme patients remain ill on long-term follow-up, emphasizing importance of adequate treatment duration and monitoring.
How long should Bell’s palsy from Lyme disease be treated?
Initial treatment often extends from 10 days to 21 days or longer when neurologic involvement is present. Treatment duration should be individualized based on response and symptom severity.
Related Reading:
Lyme Disease Misdiagnosis: Why It Happens & What to Know
Neurologic Lyme Disease: When Infection Affects the Brain
Steroids Harmful to Patients with Bell’s Palsy from Lyme
Treatment Varies for Bell’s Palsy in Children with Lyme
References:
- New-onset Bell’s palsy and Lyme disease. Can Fam Physician. 2017;63(12):941.
- Jowett N, Gaudin RA, Banks CA, Hadlock TA. Steroid use in Lyme disease-associated facial palsy is associated with worse long-term outcomes. Laryngoscope. 2016.
- Shadick NA, Phillips CB, Logigian EL, et al. The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Ann Intern Med. 1994;121(8):560-567.
- Asch ES, Bujak DI, Weiss M, Peterson MG, Weinstein A. Lyme disease: an infectious and postinfectious syndrome. J Rheumatol. 1994;21(3):454-461.
An incident of Bell’s palsy and slurred speech along with a visit to a Lyme literate doctor in the same week changed the course of my life and health. I didn’t choose the Lyme literate doctor but was the driver of a Lyme patient which gave me an “unofficial” visit with the doctor who found my illness that had little by little impacted my life for 13 plus years.