Facial paralysis due to Lyme disease initially attributed to a virus

In their article “Bilateral facial paralysis: an atypical presentation of Lyme disease,” Collignon and colleagues describe the case of a 35-year-old man who was admitted to the hospital complaining of disabling back pain, which was preceded by facial paralysis.¹

The patient was admitted to the emergency department for acute back pain that had been progressively worsening over an 8-week period. The pain began 5 weeks after a minor surfing accident. Repeated X-rays and additional tests were normal.

“The intensity of the pain is greater at night and the patient sleeps little. These pains are described as intense burns.”

At his consultation, the facial paralysis was unilateral but within 48 hours, it had progressed to bilateral. His primary care physician attributed the Bell’s palsy to a virus.

“The patient had not been overly concerned because the attending physician had reassured the patient that the condition was trivial,” the authors state.

Three months earlier the patient had been bitten by mosquitoes and possibly a tick.

He also had an erythema migrans rash in his armpit 4 weeks before the onset of his symptoms. However, clinicians attributed the rash to “sweat-related rubbing.”

Subsequent testing for Lyme disease was positive and the man was treated successfully with 14 days of IV Ceftriaxone.

“After a few days, there is an improvement in symptoms both in terms of paralysis and pain,” the authors state. “After four weeks, the neurological examination normalized with full recovery from diplegia.”

The authors point out, “The general practitioner who examined our patient at the beginning with unilateral facial paralysis had wrongly concluded that he had a cold paralysis without any other assessment.”

Furthermore, they suggest, Lyme disease can be difficult to diagnose with varied presentations. “Only a thorough history and a detailed clinical examination could limit diagnostic error, particularly in the neurological damage of this disease.”