Lyme Neuroborreliosis With an Unusual and Severe Presentation

Stroke-like symptoms and rapid decline
Blood tests were negative for Lyme disease
Diagnosis confirmed through spinal fluid analysis

Neuroborreliosis is a form of Lyme disease that affects the central nervous system. It often presents with headaches, meningitis-like symptoms, encephalopathy, or stroke-like features.

Diagnosis typically relies on clinical findings and cerebrospinal fluid (CSF) analysis rather than blood tests alone. :contentReference[oaicite:0]{index=0}

A Complex Clinical Presentation

In this case, a woman with multiple underlying conditions—including lupus, congenital hydrocephalus requiring a ventriculoperitoneal (VP) shunt, and migraines—presented with a rapidly worsening illness.

Initial testing revealed renal failure and complications related to over-shunting. On the second hospital day, she suffered cardiac arrest requiring resuscitation and vasopressor support.

Neurologic and Systemic Complications

MRI of the brain revealed an acute ischemic insult along with multiple abnormalities. Additional findings included:

• Bilateral pulmonary emboli
• Stress-induced cardiomyopathy
• Severe neurologic impairment requiring ventilation

These overlapping findings complicated the diagnostic process.

Diagnosis Confirmed by Spinal Tap

Despite negative blood testing for Lyme disease, cerebrospinal fluid analysis revealed clear evidence of infection:

• Pleocytosis (318 cells/dL)
• Elevated protein (1,208 mg/dL)
• Positive intrathecal antibodies to Borrelia burgdorferi

“Lumbar puncture results revealed elevated Borrelia antibodies in the CSF… while blood tests remained negative.”

This pattern highlights the importance of considering Lyme disease symptoms and pursuing further evaluation when initial testing is inconclusive.

Outcome

The patient was treated with intravenous ceftriaxone but showed minimal improvement.

After two weeks of hospitalization and ongoing critical illness, the family elected to withdraw care. The patient passed away shortly thereafter.

Why This Case Matters

This case illustrates how Lyme neuroborreliosis can present with atypical and severe features, including stroke-like symptoms and multisystem complications.

Diagnosis may be delayed when blood tests are negative—patterns commonly seen in delayed Lyme disease diagnosis.

Neurologic Lyme disease can be difficult to recognize, particularly when symptoms overlap with other conditions, as described in our neuropsychiatric Lyme disease guide.

When patients present with unexplained neurologic decline—especially with complex or overlapping conditions—Lyme disease should remain part of the differential diagnosis.

Clinical Perspective

This case underscores the challenges of diagnosing Lyme disease in medically complex patients.

Underlying conditions such as lupus and congenital neurologic abnormalities may obscure the clinical picture, delaying recognition of infection.

Severe outcomes are often multifactorial—but early recognition of Lyme neuroborreliosis remains critical.

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