Lyme Neuroborreliosis: Is a Lumbar Puncture Necessary?
Lyme neuroborreliosis lumbar puncture decisions can be challenging for clinicians. In this Inside Lyme Podcast, I discuss a case that highlights the diagnostic role of cerebrospinal fluid testing and whether a lumbar puncture is always necessary when neurologic Lyme disease is suspected.
The case was described by Portales-Castillo and colleagues in the journal Cureus in the article “To Lumbar Puncture or Not to Lumbar Puncture.” The authors reported a case of early disseminated Lyme neuroborreliosis presenting with facial palsy and painful radiculoneuritis.¹
Case Presentation
A 61-year-old woman was admitted to the hospital with an inability to close her left eye and abnormal facial sensations. She also had a raised circular rash and swelling at the base of the index finger on her right hand.
She initially believed the lesion was a spider bite and was treated with cephalexin for presumed cellulitis.
Three weeks later she developed posterior neck pain, bilateral arm pain, and progressive arm weakness. Her weakness progressed to the point that she could no longer comb her hair.
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The pain later became associated with progressive arm weakness over several weeks.
The patient subsequently developed Bell’s palsy. Lyme disease testing by IgM Western blot was positive, consistent with acute infection.
Clinical Diagnosis of Lyme Neuroborreliosis
The physicians considered a diagnosis of early disseminated Lyme neuroborreliosis.
“After discussion with neurology and infectious disease consultants, the diagnosis of early disseminated Lyme neuroborreliosis manifesting as painful radiculoneuritis, motor weakness, and facial nerve palsy (Bannwarth syndrome) was considered a strong possibility based on clinical presentation and serologic criteria,” the authors wrote.
The patient declined a lumbar puncture, questioning whether the results would change treatment decisions.
Instead, physicians treated her empirically for Lyme disease.
Response to Treatment
The patient received doxycycline for four weeks along with prednisone (60 mg for 5 days) and eye drops.
Her Bell’s palsy and pain resolved and her weakness improved significantly.
At her two-week follow-up visit, she reported complete resolution of facial weakness and pain with marked improvement in arm strength.
The Lumbar Puncture Controversy
“Lyme neuroborreliosis remains a challenging diagnosis and often warrants spinal fluid analysis, particularly in the context of acute meningitis,” the authors wrote.
However, whether to perform a lumbar puncture in patients with facial palsy and peripheral neurologic symptoms remains controversial.
Guidelines differ on whether cerebrospinal fluid analysis should be routinely performed or individualized based on the clinical scenario.
Limitations of CSF Testing
Cerebrospinal fluid testing has several limitations.
An increase in white blood cells in the CSF (pleocytosis) may occur in Lyme neuroborreliosis but can also be seen in many other neurologic conditions.
Detection of Borrelia burgdorferi antibodies in CSF can be helpful. However, interpretation requires comparing CSF and serum antibody levels using a CSF-to-serum antibody index.
Polymerase chain reaction (PCR) testing for B. burgdorferi DNA in CSF may occasionally be positive but has limited sensitivity.
Some studies have reported low sensitivity of spinal fluid testing. For example, only 1 of 27 patients with neurologic Lyme disease had CSF pleocytosis in one study, and that increase was minimal.
Other biomarkers such as CXCL13 have also been studied as potential CSF indicators of Lyme neuroborreliosis.
To Lumbar Puncture or Not to Lumbar Puncture?
A lumbar puncture may help rule out alternative diagnoses. However, the authors emphasized that the decision should be individualized.
“The need for a lumbar puncture in suspected cases of Lyme neuroborreliosis remains a clinical decision that must be tailored to the specific situation,” they wrote.
When the clinical presentation and serologic findings strongly suggest Lyme neuroborreliosis, treatment may proceed even without spinal fluid confirmation.
Questions Addressed in This Podcast Episode
- What is neurologic Lyme disease?
- What neurologic findings did this patient present with?
- What is Bannwarth syndrome?
- What is a lumbar puncture?
- How accurate is CSF testing?
- What CSF findings occur in neurologic Lyme disease?
- What are the limitations of CSF testing?
- How should clinicians decide whether to perform a lumbar puncture?
Thanks for listening to another Inside Lyme Podcast. The information discussed is general medical information and should not substitute for individualized care from an experienced clinician.
Thank you for this broadcast Dr. Cameron. It seems that even three diagnostic positives were not enough to get a correct treatment. If we consider suspected spider bite, as I once had just before the start of all my symptoms, that should also be a confirmation.
Lest we diagnose to death, there must be moore education about treatment. Specifically reducing the firewalls between allopathic and naturopathic, pharmacy and politics.
When these fiefdoms begin talk WITH each other, to work on what works, only then will patients with late, stage Boriella and co-infections can begin to have hope.