Long COVID and Lyme Disease in a 26-Year-Old Medical Student

Long COVID and Lyme disease can produce overlapping symptoms
An isolated positive Lyme IgM test requires careful interpretation
This case illustrates the difficulty of identifying more than one possible contributor

Long COVID and Lyme disease are distinct conditions, but they can share symptoms such as fatigue, cognitive difficulties, dizziness, palpitations, pain and impaired daily functioning.

In a published case report, a previously healthy 26-year-old medical student developed persistent symptoms after COVID-19 and was subsequently treated for possible Lyme disease. Her complicated recovery illustrates how difficult it can be to determine whether symptoms arise from Long COVID, Lyme disease, autonomic dysfunction or several overlapping problems.

How Is Long COVID Defined?

The authors cited the World Health Organization’s clinical case definition of post-COVID-19 condition.

According to the WHO, post-COVID-19 condition usually begins within three months of a probable or confirmed SARS-CoV-2 infection. Symptoms generally last for at least two months, affect everyday functioning and cannot be explained by another diagnosis.

Common symptoms include fatigue, shortness of breath and cognitive dysfunction. Symptoms may persist after the initial infection, appear after an apparent recovery, or fluctuate and relapse over time.

Persistent symptoms following Lyme disease can have some similar characteristics, including fatigue, pain, cognitive difficulties and impaired daily functioning. However, Long COVID and prolonged symptoms following Lyme disease do not have identical definitions.

Post-Treatment Lyme Disease Syndrome (PTLDS) generally refers to persistent or recurrent symptoms that continue for at least six months after treatment for documented Lyme disease. The causes of these symptoms remain under investigation.

Symptoms Appear Four Months After COVID-19

A previously healthy 26-year-old medical student contracted COVID-19 in March 2020, near the beginning of the pandemic. Her acute symptoms resolved after approximately two weeks.

Four months later, she became ill again. Her symptoms included frontotemporal headaches, chest tightness, shortness of breath, palpitations, tachycardia, anxiety, dizziness, near-syncope when sitting or standing and blurred vision.

Her symptoms eventually expanded to include significant fatigue, mild cognitive impairment or “brain fog,” difficulty focusing, impaired memory recall, loss of appetite, diarrhea, heat intolerance and diffuse muscle pain.

Because she had a history of hypothyroidism, she was initially evaluated by an endocrinologist. However, testing indicated that she was euthyroid, meaning her thyroid function was within the expected range.

Lyme Testing Was Positive for IgM Antibodies

The patient’s Lyme Western blot reportedly showed two positive IgM bands, while her IgG Western blot was negative. The authors interpreted these results as consistent with early Lyme disease.

The patient had spent considerable time outdoors in a wooded area during pandemic social-distancing restrictions. Testing for other tick-borne infections was reportedly negative.

An isolated positive IgM result should be interpreted in the context of the timing of symptoms, possible tick exposure, clinical findings and the complete testing method. Standard testing guidance cautions against relying on an IgM immunoblot when symptoms have been present for more than 30 days because false-positive or prolonged IgM results can occur.

It was not clear from the case report whether the patient’s possible Lyme infection was acquired before, during or after her COVID-19 illness.

Her infectious disease specialist and primary care physician prescribed two weeks of doxycycline.

Her symptoms persisted and, in some respects, worsened following treatment.

She reported worsening blurred vision with bilateral floaters, increased palpitations and tachycardia, greater heat intolerance and more frequent near-syncopal episodes. These symptoms interfered with physical activity.

Her headaches remained nearly constant and began alternating between tension-like headaches and left-sided migraine-like episodes accompanied by nausea and scalp allodynia.

During the following weeks, she also developed insomnia and intermittent night terrors.

Did Her Symptoms Represent a Herxheimer Reaction?

The authors did not identify the worsening symptoms as a Jarisch–Herxheimer reaction.

A Jarisch–Herxheimer reaction is a temporary inflammatory response that can occur shortly after antibiotic treatment is started for a spirochetal infection such as Lyme disease. It usually begins relatively soon after treatment and is generally short-lived.

Because this patient’s symptoms persisted and continued to evolve, the case report does not establish that a Herxheimer reaction explained her worsening condition.

Changes in Smell After COVID-19

The patient experienced anosmia and ageusia for four or five days during her initial COVID-19 illness.

Anosmia refers to a partial or complete loss of smell. Ageusia refers to the loss of taste.

Following treatment for possible Lyme disease, she developed pronounced phantosmia, in which a person perceives smells that are not present or experiences distorted odors.

She described otherwise ordinary foods, perfumes and body odors as smelling like “burning rubber” or “rotting meat.”

She was referred for evaluation of her migraine-like headaches. Common abortive treatments, including triptans and calcitonin gene-related peptide antagonists, did not provide adequate relief.

Her clinicians subsequently considered the possibility of a post-COVID headache. She obtained some relief with medications used for headache and nausea.

Extensive Testing Did Not Identify One Explanation

The patient was later diagnosed with polycystic ovarian syndrome. Metformin improved the regularity of her menstrual periods but reportedly produced symptoms suggestive of hypoglycemia.

Her pulmonary evaluation was normal. Cardiac testing identified an incidental right bundle branch block that did not require an intervention.

Her collection of dizziness, tachycardia, heat intolerance, near-syncope and exercise intolerance was also consistent with autonomic dysfunction.

She participated in an individualized rehabilitation program directed at postural orthostatic tachycardia syndrome (POTS). Her program included carefully monitored physical activity and osteopathic manipulative treatment.

The authors also reported that she tried anxiety-reduction techniques and sleep-hygiene measures. These provided limited improvement in her fatigue and cognitive symptoms.

Exercise programs should be individualized, particularly for patients with Long COVID or post-exertional symptom worsening. This patient’s experience should not be interpreted as evidence that graded exercise is appropriate for every patient.

Symptoms Gradually Improved

By November 2020, the patient began to notice gradual reductions in palpitations, anxiety and cognitive fogginess. However, fatigue became more prominent, and she developed constipation and hair loss.

She subsequently contracted COVID-19 two more times. She received molnupiravir following one reinfection.

She also received two doses of the Moderna COVID-19 vaccine. According to the case report, she noticed moderate short-term improvement in fatigue and brain fog during the first 24 hours after her first dose.

Over the approximately three-year course described in the report, the patient gradually reached near-total remission. However, the case does not establish which treatment—or combination of treatments—was responsible for her improvement.

Could Lyme Disease Complicate Long COVID?

This case cannot determine whether Lyme disease caused, prolonged or intensified the patient’s Long COVID symptoms. It also cannot establish whether the isolated IgM findings represented a new Lyme infection, a false-positive result or another testing scenario.

Nevertheless, the case highlights the importance of considering alternative and concurrent diagnoses when symptoms persist after COVID-19.

The authors suggested that possible overlapping infections, including Lyme disease, and the reactivation of viruses such as Epstein-Barr virus deserve further study in the pathogenesis and management of Long COVID.

A patient may have Long COVID, Lyme disease, autonomic dysfunction or another medical condition at the same time. Identifying one diagnosis should not automatically end the evaluation for other plausible contributors.

Medical Dismissal Complicated Her Experience

The patient was medically knowledgeable and had access to healthcare, yet she reported that some clinicians ignored, misdiagnosed or attributed her physical symptoms to anxiety.

Anxiety can accompany a prolonged and uncertain illness, but it does not exclude infection, autonomic dysfunction, endocrine disease or another physical condition.

This case demonstrates the value of listening carefully, examining the complete timeline and periodically reconsidering the differential diagnosis when a patient’s symptoms remain unexplained.

Clinical Takeaway

Long COVID and Lyme disease can share fatigue, cognitive dysfunction, headaches, pain, palpitations, dizziness and exercise intolerance. Symptoms alone may not reliably distinguish between them.

This case involved possible Lyme disease diagnosed after COVID-19, but the Lyme test results and the source of the patient’s prolonged symptoms remained open to interpretation. Her gradual recovery followed multiple interventions and cannot be attributed to a single treatment.

A careful evaluation should consider the timing of infection, tick exposure, objective findings, the limitations of Lyme testing, autonomic dysfunction and other possible explanations for persistent symptoms.

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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