Could Lyme Disease Be Causing Neuropathy or Small Fiber Neuropathy?

Many patients with Lyme disease describe symptoms that sound neurological long before a diagnosis is considered. They may report burning sensations in their feet, tingling in their hands, shooting pains, numbness, temperature sensitivity, or unexplained weakness.

These symptoms are often grouped under the term neuropathy, meaning damage or dysfunction of the peripheral nerves. In recent years, growing attention has focused on small fiber neuropathy (SFN), a form of neuropathy that may explain many of the sensory and autonomic symptoms reported by Lyme disease patients.

Can Lyme Disease Cause Neuropathy?

Yes. Lyme disease has long been associated with neurologic complications, including peripheral neuropathy.

Peripheral nerves carry signals between the brain, spinal cord, and the rest of the body. When these nerves are affected, patients may experience:

Numbness
Tingling
Burning sensations
Electric shock-like pains
Hypersensitivity to touch
Muscle weakness
Balance difficulties

Some patients develop symptoms during acute Lyme disease, while others describe neuropathic symptoms that persist long after the initial infection.

What Is Small Fiber Neuropathy?

Small fiber neuropathy affects the smallest sensory and autonomic nerve fibers in the body. These fibers help regulate pain perception, temperature sensation, sweating, heart rate, blood pressure, digestion, and other automatic functions.

Small fiber neuropathy has emerged as one of the most important neurologic explanations for persistent burning pain, tingling, sensory disturbances, and autonomic symptoms in Lyme disease patients.

Unlike large-fiber neuropathy, small fiber neuropathy often cannot be detected with routine nerve conduction studies or EMG testing.

Patients may experience:

Burning feet or burning hands
Pins-and-needles sensations
Temperature sensitivity
Pain from light touch
Autonomic dysfunction
Dizziness when standing
Palpitations
Abnormal sweating
Gastrointestinal symptoms

Burning Feet and Lyme Disease

Many patients with Lyme disease describe burning feet, particularly at night. The sensation may feel like heat, stinging, walking on hot pavement, or electric discomfort despite normal skin appearance.

Burning feet can occur with peripheral neuropathy, small fiber neuropathy, or autonomic dysfunction. When accompanied by tingling, numbness, or temperature sensitivity, clinicians may consider evaluation for small fiber nerve involvement.

Some patients report that the burning worsens during symptom flares, periods of increased inflammation, or following physical exertion.

Small Fiber Neuropathy and Autonomic Dysfunction

One reason small fiber neuropathy has received increased attention is its connection to autonomic dysfunction.

The same small nerve fibers responsible for pain and temperature sensation also help regulate automatic body functions. When these fibers become impaired, patients may develop symptoms involving multiple organ systems.

Common autonomic symptoms include:

Lightheadedness
Dizziness upon standing
Rapid heart rate
Exercise intolerance
Temperature dysregulation
Digestive disturbances
Abnormal sweating
Fatigue

Some Lyme disease patients with autonomic symptoms are eventually diagnosed with conditions such as POTS (Postural Orthostatic Tachycardia Syndrome), which may overlap with small fiber neuropathy.

How Is Small Fiber Neuropathy Diagnosed?

Diagnosing small fiber neuropathy can be challenging because routine neurologic testing may appear normal.

Skin biopsy remains one of the most commonly used tests for diagnosing small fiber neuropathy. The procedure measures intraepidermal nerve fiber density and may identify abnormalities even when EMG and nerve conduction studies are normal.

Additional testing may include:

Autonomic function testing
Tilt-table testing
Quantitative sensory testing
Neurologic examination

A normal EMG does not exclude small fiber neuropathy.

Can Nerve Damage From Lyme Disease Be Reversed?

This is one of the most common questions patients ask.

The answer depends on several factors, including the duration of symptoms, the severity of nerve injury, coexisting conditions, and response to treatment.

Some patients experience significant improvement over time. Others continue to have persistent symptoms despite treatment. Recovery may occur gradually and often requires addressing both the underlying infection and associated neurologic or autonomic dysfunction.

Clinical Perspective

When patients describe burning feet, tingling, numbness, temperature sensitivity, dizziness, palpitations, or unexplained pain, I consider the possibility of neuropathy and small fiber neuropathy.

These symptoms can significantly affect quality of life and may be overlooked when routine neurologic testing is normal.

Recognizing small fiber neuropathy may help explain why some Lyme disease patients experience both sensory symptoms and autonomic dysfunction.

Frequently Asked Questions

Can Lyme disease cause neuropathy?

Yes. Lyme disease can affect peripheral nerves and may lead to numbness, tingling, burning pain, weakness, or other neurologic symptoms.

Can Lyme disease cause small fiber neuropathy?

Research and clinical experience suggest that some Lyme disease patients develop symptoms consistent with small fiber neuropathy, including burning pain, sensory disturbances, and autonomic dysfunction.

What does Lyme neuropathy feel like?

Patients commonly describe burning sensations, pins and needles, numbness, electric shock-like pains, temperature sensitivity, and abnormal sensations affecting the hands, feet, face, or other areas.

Can nerve damage from Lyme disease be reversed?

Some patients improve substantially with treatment and time, while others experience persistent symptoms. Recovery depends on multiple factors, including the severity and duration of nerve involvement.

Clinical Takeaway

Lyme disease can affect the nervous system in ways that extend beyond traditional neurologic symptoms. Small fiber neuropathy may help explain burning pain, tingling, sensory disturbances, and autonomic dysfunction experienced by some patients.

If neuropathic symptoms persist despite normal routine testing, small fiber neuropathy may deserve consideration.

References

Novak P, Felsenstein D, Mao C, Octavien NR, Zubcevik N. Association of small fiber neuropathy and post-treatment Lyme disease syndrome. Brain Communications. 2022.
Oaklander AL, Nolano M. Scientific Advances in and Clinical Approaches to Small-Fiber Polyneuropathy: A Review. JAMA Neurology. 2019;76(10):1240-1251.
John J. Halperin. Neurologic manifestations of Lyme disease. Continuum (Minneap Minn). 2020;26(5):1194–1222.
Bransfield RC. Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist’s Clinical Practice. Healthcare (Basel). 2018;6(3):104.

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

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Could Lyme disease be causing neuropathy?