Panic Attack Without Anxiety: When the Body Reacts First

A woman with post-treatment Lyme disease syndrome (PTLDS) underwent routine dental extraction of four molars. Despite an uneventful surgery and aggressive multimodal pain management, the procedure triggered severe, widespread full-body pain that required ICU admission.

Lim from the University of California in San Francisco documented this case, which illustrates the extraordinary pain vulnerability that PTLDS patients can experience—and how poorly understood it remains—making it an important consideration for Lyme disease symptoms.

Five Years Bedbound Before Surgery

Before the dental procedure, this patient’s functionality was already severely affected. She had been bedbound for approximately five years and required a wheelchair.

Her medical history included fibromyalgia, hypothyroidism, anxiety, depression, and insomnia.

Her skin, spine, bone, and joint pain was severe and difficult to treat. She had frequent emergency department visits with notably poor response to opioids—but pain that responded to ketamine, a pattern consistent with central sensitization rather than peripheral nerve damage.

What Happened During Surgery

Prior to the extraction, she was able to taper off methadone. During surgery, physicians used an aggressive multimodal regimen including fentanyl, ketamine, acetaminophen, and ketorolac intravenously, followed by local anesthetic in all four quadrants.

Despite this, the woman developed severe, widespread pain after surgery. Her oral pain from the extraction itself was minor.

The main issue was total body pain—a flare of her underlying PTLDS symptoms triggered by the physiologic stress of the procedure.

Pain That Could Not Be Controlled

In the recovery room, additional fentanyl, hydromorphone, lorazepam, gabapentin, and oral ketamine failed to control her pain. A ketamine infusion was started. When pain remained severe, she was transferred to the ICU.

For two days, she received around-the-clock multimodal treatment including ketamine infusion, IV acetaminophen, ketorolac, sublingual buprenorphine, oxycodone, and hydromorphone.

She was discharged on day three with an extensive tapering regimen.

This level of pain from a routine dental extraction—requiring ICU-level intervention—underscores the degree of nervous system sensitization present in severe PTLDS.

Why Surgery Triggers Pain Flares in PTLDS

The mechanism behind this response is central sensitization—a state in which the brain and spinal cord become hyper-responsive to pain signals.

In patients with PTLDS, the nervous system is already operating at an elevated baseline. Any additional physiologic stress—surgery, infection, sleep deprivation, emotional distress—can push it past a threshold that produces widespread pain far exceeding what the triggering event would normally cause.

This is the same mechanism that drives allodynia, where even light touch becomes painful. In this patient, surgical stress amplified a sensitized nervous system that was already struggling to regulate pain signaling.

Lim notes that the persistent symptoms may be due to central sensitization, also known as central sensitivity syndrome. However, whether this sensitization reflects a truly post-infectious state or ongoing infection remains an open question.

Is PTLDS Post-Infectious — Or Persistent Infection?

This patient met the IDSA’s 2006 criteria for PTLDS: a documented episode of Lyme disease with post-treatment resolution, subsequent onset of fatigue and widespread musculoskeletal pain, symptoms lasting at least six months, and functional impairment severe enough to reduce daily ability.

Some clinicians attribute chronic PTLDS pain to inflammatory, musculoskeletal, neuropathic, or mixed mechanisms that persist after the infection has cleared. Others are concerned that ongoing symptoms may reflect a persistent infection that was never fully eradicated.

There are no tests to confirm that “post-treatment” means the infection has resolved. Trials suggesting that antibiotics are not effective in treating persistent infection have significant limitations.

And there is growing concern that Lyme disease and other tick-borne illnesses are more complex than originally thought.

It would be reasonable to revisit this patient’s clinical history to determine whether she was adequately treated for her infection. Some patients are diagnosed with PTLDS after receiving only three weeks of doxycycline.

Clinical Takeaway

Patients with PTLDS face extraordinary vulnerability to pain flares from procedures that would be routine for others—dental surgery triggered severe widespread pain requiring ICU admission despite aggressive multimodal pain management including fentanyl, ketamine, and local anesthetics. Central sensitization causes the brain and spinal cord to become hyper-responsive to pain signals, and in PTLDS patients the nervous system operates at an elevated baseline where additional physiologic stress can trigger widespread pain far exceeding what the procedure would normally produce. Pre-procedural planning should account for central sensitization, autonomic dysfunction, and the possibility that standard pain protocols will be insufficient.

Frequently Asked Questions

Can dental surgery trigger a Lyme disease pain flare?
Yes. In patients with PTLDS and central sensitization, the physiologic stress of surgery—even routine dental extraction—can trigger severe, widespread pain far beyond what the procedure would normally produce.

Why didn’t opioids control her pain?
Central sensitization involves amplified pain processing in the brain and spinal cord rather than peripheral tissue damage. Opioids primarily target peripheral pain pathways, which is why they were ineffective while ketamine—which acts on central NMDA receptors—provided more relief.

What is central sensitization?
Central sensitization is a state in which the nervous system becomes hyper-responsive to pain signals. It is believed to play a key role in the chronic pain of PTLDS, fibromyalgia, and other post-infectious conditions.

References

Lim S, Kinjo S. Exacerbation of chronic pain after dental extractions in a patient with post-treatment Lyme disease syndrome. Saudi J Anaesth. 2018;12(1):112–114.
Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther. 2014;12(9):1103–1135.

Social Converations with Dr. Daniel Cameron

Lyme Disease Pain After Dental Surgery: A PTLDS Case