Can Lyme Disease Affect the Brain? Neurologic Symptoms Explained
Lyme disease can affect the brain and nervous system.
Neurologic symptoms may occur before arthritis develops.
Early recognition and treatment may improve outcomes.
Can Lyme disease affect the brain? Yes. Lyme disease can involve the central and peripheral nervous systems, leading to neurologic symptoms such as facial nerve palsy, meningitis, painful nerve inflammation, cognitive symptoms, headaches, and balance problems. Rarely, Lyme neuroborreliosis can also cause inflammation involving brain tissue.
Neurologic Lyme disease can be difficult to recognize because symptoms vary considerably from one patient to another. Some patients develop obvious neurologic findings such as facial weakness or meningitis, while others report memory problems, difficulty concentrating, headaches, dizziness, nerve pain, or imbalance.
A review by Govil and colleagues highlights the neurologic features of Lyme disease that clinicians—including rheumatologists—should recognize.1
In their article entitled Common Neurologic Features of Lyme Disease That May Present to a Rheumatologist, Govil and colleagues describe the various ways Lyme disease can affect the brain and nervous system.1
The authors emphasize that rheumatologists should recognize neurologic presentations because patients may initially seek care for joint pain rather than classic early Lyme disease findings.
It is particularly important for clinicians to take a thorough history and not rely on the presence of an erythema migrans (EM) rash. By the time later joint or neurologic symptoms develop, an earlier rash may no longer be present or may never have been recognized.
Can Lyme Disease Affect the Brain?
Neurologic Lyme disease may involve the brain, meninges, cranial nerves, spinal nerve roots, or peripheral nerves. Symptoms vary depending on the structures involved and the stage of infection.
Some patients develop obvious neurologic deficits such as facial weakness, while others experience more subtle problems including cognitive slowing, memory complaints, headaches, dizziness, or imbalance.
The most common neurologic features of early disseminated Lyme disease include:
- Cranial nerve VII palsy, or facial weakness
- Aseptic meningitis syndrome
- Acute painful radiculoneuritis
Less common neurologic manifestations include:
- Cerebrovascular complications, including vasculitis
- Encephalomyelitis
- Encephalitis
- Intracranial hypertension syndromes, particularly in adolescents
Early disseminated Lyme disease may also present with lymphocytic meningitis that can resemble viral meningitis.
How Common Are Neurologic Symptoms in Lyme Disease?
Johnson and colleagues examined 1,230 reported Lyme disease cases in Ontario, Canada, from 2005 through 2014.2
Neurologic manifestations were reported in 41% of the overall surveillance cohort, although the frequency varied considerably by stage of disease.2
These findings reinforce an important clinical point: Lyme disease should not be viewed exclusively as a rash-and-arthritis illness. Nervous system involvement is an important part of the clinical spectrum.
Can Lyme Disease Cause Brain Lesions?
Some patients with Lyme neuroborreliosis have abnormalities on brain MRI, including white matter lesions. However, these findings are not specific for Lyme disease and may resemble those seen with multiple sclerosis, small vessel disease, migraine, aging, or other neurologic conditions.
Many patients with neurologic Lyme disease have a normal brain MRI. Imaging findings therefore need to be interpreted together with the patient’s history, neurologic examination, laboratory testing, spinal fluid findings when appropriate, and overall clinical picture.
For additional clinical examples, see How Does Lyme Disease Affect the Brain? 6 Cases.
Rarely, Lyme Neuroborreliosis Can Cause Encephalitis
Lyme neuroborreliosis can rarely involve the brain tissue itself. Rosendahl and colleagues described a 74-year-old immunosuppressed woman who developed confusion, paranoid delusions, dysphasia, tremor, myoclonus, and other neurologic abnormalities.3
She did not recall a tick bite or erythema migrans rash and did not have the classic painful meningoradiculitis often associated with European Lyme neuroborreliosis. Brain MRI showed substantial abnormalities involving the basal ganglia, thalami, medial temporal lobes, and mesencephalon. Spinal fluid findings and intrathecal Borrelia burgdorferi antibodies supported the diagnosis of Lyme neuroborreliosis with encephalitis.3
After 14 days of antibiotic treatment—seven days of intravenous ceftriaxone followed by seven days of oral doxycycline—the patient’s clinical condition improved and the MRI abnormalities completely resolved. However, she continued to report some memory difficulties at six months.3
The case was unusual, and the authors noted that immunosuppression may have contributed to the atypical presentation and extensive MRI abnormalities. A larger Scandinavian study estimated that encephalitis occurred in approximately 3.3% of patients with Lyme neuroborreliosis in the cohorts examined, emphasizing that encephalitis is a rare manifestation rather than a typical presentation.4
Can Lyme Disease Cause Memory and Cognitive Problems?
Cognitive complaints are reported by some patients with Lyme disease. Symptoms may include:
- Memory problems
- Difficulty concentrating
- Slowed thinking
- Word-finding difficulties
- Mental fatigue
- Sleep disturbance
- Brain fog
These symptoms are not specific to Lyme disease and can occur with many neurologic, medical, psychiatric, sleep-related, metabolic, and medication-related conditions.
The mechanisms responsible for persistent cognitive symptoms following Lyme disease remain under investigation. Infection-related effects, inflammation, immune mechanisms, autonomic dysfunction, sleep disruption, and other factors may overlap in individual patients.
Importantly, cognitive symptoms do not require visible abnormalities on a routine brain MRI. The dramatic MRI findings reported in rare cases of Lyme encephalitis should not be considered typical of patients who report brain fog, memory problems, or difficulty concentrating.
For a more detailed discussion, see Neuroinflammation in Lyme Disease and Brain Fog.
Why Neurologic Lyme Disease Can Be Difficult to Diagnose
Neurologic Lyme disease does not always present in a textbook fashion.
A patient may not remember a tick bite. An erythema migrans rash may never have been noticed. Symptoms may appear after the initial exposure, and the neurologic presentation can overlap with many other conditions.
The Rosendahl case illustrates this problem particularly well. The patient had no recalled tick bite or recognized erythema migrans rash and presented with confusion and other atypical neurologic symptoms rather than classic painful meningoradiculitis.3
This does not mean that unexplained cognitive or neurologic symptoms should automatically be attributed to Lyme disease. Other neurologic, infectious, metabolic, medication-related, and systemic causes may need to be considered. Rather, Lyme disease remains one diagnostic consideration when the clinical presentation and exposure history are compatible.
What Should Clinicians Keep in Mind?
- A recalled tick bite is not required.
- An erythema migrans rash may not have been recognized.
- Neurologic involvement may occur during disseminated Lyme disease.
- Facial palsy, meningitis, and radiculoneuritis are more typical than encephalitis.
- Brain MRI may be normal or abnormal depending on the neurologic manifestation.
- MRI abnormalities are not specific for Lyme disease.
- Other neurologic and infectious diagnoses must also be considered.
Careful history-taking remains particularly important when symptoms do not fit neatly into a single diagnosis.
Frequently Asked Questions
Can Lyme disease affect the brain?
Yes. Lyme disease can affect the central and peripheral nervous systems. Neurologic Lyme disease may present with facial nerve palsy, meningitis, painful radiculoneuritis, cognitive symptoms, headaches, balance problems, and peripheral neuropathy.
What are the neurological symptoms of Lyme disease?
Neurologic symptoms may include facial weakness, severe headaches, neck stiffness, nerve pain, numbness or tingling, memory problems, difficulty concentrating, slowed thinking, sleep disturbances, fatigue, and balance problems. Less common complications include encephalomyelitis, cerebrovascular involvement, intracranial hypertension, and encephalitis.
Can Lyme disease cause brain lesions?
Brain MRI abnormalities have been reported in some patients with Lyme neuroborreliosis, but they are not specific to Lyme disease. Many patients with neurologic Lyme disease have a normal brain MRI. Rare cases of Lyme encephalitis have produced more substantial inflammatory MRI abnormalities.
Can Lyme disease cause encephalitis?
Yes, but encephalitis appears to be a rare manifestation of Lyme neuroborreliosis. Published cases have documented confusion, cognitive changes, neurologic abnormalities, and inflammatory changes on brain MRI.
Can Lyme disease affect the brain without a known tick bite?
Yes. Patients do not always remember a tick bite, and an erythema migrans rash may not have been recognized. The absence of a recalled tick bite or rash does not by itself exclude Lyme disease.
Can neurologic Lyme disease be treated?
Many patients improve with appropriate antibiotic therapy, particularly when Lyme disease is recognized and treated promptly. Recovery varies according to the neurologic manifestation, severity of illness, duration of symptoms before treatment, and individual patient factors. Some patients may continue to experience symptoms after objective findings have improved.
Clinical Takeaway
Lyme disease can affect multiple parts of the nervous system, including the meninges, cranial nerves, nerve roots, peripheral nerves, and, rarely, brain tissue itself.
Facial nerve palsy, meningitis, and painful radiculoneuritis are more typical neurologic manifestations than encephalitis. Patients may also report cognitive symptoms, headaches, nerve pain, dizziness, or balance problems, and routine brain MRI may be normal.
Neurologic Lyme disease can present in different ways. A careful history, recognition of neurologic symptoms, appropriate testing, and consideration of alternative diagnoses remain important when evaluating patients with otherwise unexplained neurologic illness.
Related Articles
Neuroinflammation in Lyme Disease and Brain Fog
Why Early Lyme Disease Tests Can Be Negative
References:
- Govil S, Capitle E, Lacqua A, Khianey R, Coyle PK, Schutzer SE. Common Neurologic Features of Lyme Disease That May Present to a Rheumatologist. Pathogens. 2023;12(4):576. doi:10.3390/pathogens12040576.
- Johnson KO, Nelder MP, Russell C, et al. Clinical manifestations of reported Lyme disease cases in Ontario, Canada: 2005–2014. PLoS One. 2018;13(6):e0198509. doi:10.1371/journal.pone.0198509.
- Rosendahl SB, Ravn P, Lebech AM, Stenør CPM. Lyme neuroborreliosis with encephalitis: A rare case. IDCases. 2023;31:e01704. doi:10.1016/j.idcr.2023.e01704.
- Knudtzen FC, Eikeland R, Bremell D, et al. Lyme neuroborreliosis with encephalitis; a systematic literature review and a Scandinavian cohort study. Clin Microbiol Infect. 2022;28(5):649–656. doi:10.1016/j.cmi.2021.11.001.
This article is for educational purposes and is not intended as medical advice. Patients with new, severe, or progressive neurologic symptoms should seek appropriate medical evaluation.
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
So informative, but where do I find someont that can treat me? I have been 2+ years on abx on and off, tests only show babesia WA1.
My facial nerves are somewhat effected, weaker left side of mouth, but not enough for a doctor to say cranial nerve involvment, neck pain & head pain, and wide spread nerve pain also, but nothing showing on NCS or EMG.
Is there a simple approach or is it years of trial and error?
I advise my patients to continue followup with other specialists for other potential conditions. I also have patients who have to change doctors to get a fresh perspective.
I wish you would elaborate.
My granddaughter was diagnosed with Cat Scratch Fever – Bartonella henselae. She has the stretch mark looking legions on her skin. She is also suffering with sleep issues, anxiety, social anxiety, OCD, etc. She has been out of school for a year. She has been on Clarithromycin and Rafampin for 3 months with 1 month still to go. She is seeing a cognitive behavioral therapist once a week. She just got blood work done and it was positive for B duncani. They have put her on Minocycline in addition to the other two. They are recommending IVIG in one month if things don’t improve. The therapist is recommending neurobiofeedback. Are we doing the right thing? If she does the IVIG will all of her neurologic symptoms magically go away? I sure would appreciate any help and advice you have.
I advise my patients to look beyond Bartonella if they suspect a tick-borne infection. For example, I would have considered Babesia. I don’t see any mention of treatment for Babesia. I would typically advised treatment for Babesia before beginning IVIG.