Atypical Lyme Disease Symptoms: When the Diagnosis Is Delayed
Symptoms can appear one by one.
And that can delay diagnosis.
Atypical Lyme disease symptoms can make diagnosis difficult—especially when they evolve over time.
As noted in a case report, Lyme disease can present with a mix of symptoms that develop consecutively, obscuring the clinical picture.
Clinical concern: when symptoms don’t appear all at once, the diagnosis is often missed.
An Unusual Presentation
A 69-year-old man presented with abdominal pain and hyponatremia—a condition in which sodium levels in the blood are abnormally low.
Four weeks earlier, he had noticed a rash on his elbow that resolved within a week.
He then developed a range of symptoms:
- Decreased appetite and anorexia
- Abdominal fullness
- Constipation
- Chills, headache, fatigue, and muscle aches
Clinical pattern: symptoms appeared gradually and affected multiple systems.
Diagnosis and Early Treatment
Testing for Lyme disease returned positive, and the patient was started on intravenous ceftriaxone.
However, the clinical picture continued to evolve.
Neurologic and Autonomic Symptoms Emerge
Several days after starting treatment, the patient developed:
- Bell’s palsy (facial nerve paralysis)
- Urinary retention requiring catheterization
Clinical insight: Lyme disease can involve the autonomic nervous system, leading to dysfunction across multiple organ systems.
A Jarisch–Herxheimer Reaction
Two days after initiating antibiotics, the patient developed worsening symptoms:
- Tachycardia
- Weakness
- Fever
- Diaphoresis
These findings were consistent with a Jarisch–Herxheimer reaction, rather than cardiac complications.
The patient was switched to intravenous doxycycline.
Understanding the Role of SIADH
The patient’s hyponatremia was attributed to a syndrome of inappropriate antidiuretic hormone secretion (SIADH).
SIADH causes the body to retain excess water, diluting sodium levels in the blood.
Clinical implication: autonomic and neurologic involvement in Lyme disease may contribute to electrolyte disturbances.
Full Recovery with Treatment
At three months, the patient’s symptoms had resolved completely.
Outcome: even complex, multisystem presentations can improve with appropriate treatment.
Why This Case Matters
This case highlights an unusual combination of symptoms:
- Hyponatremia (SIADH-like syndrome)
- Constipation
- Urinary retention
- Facial nerve palsy
Clinical pattern: autonomic dysregulation can be a key feature of neurologic Lyme disease.
Because these symptoms are uncommon and develop sequentially, they can delay recognition.
Clinical Takeaway
Atypical Lyme disease symptoms may include autonomic dysfunction, electrolyte abnormalities, and evolving neurologic signs.
Clinicians should maintain a high index of suspicion when patients present with unexplained multisystem symptoms—even if they do not fit the classic Lyme presentation.
Key question: Could a mix of gastrointestinal, neurologic, and autonomic symptoms point to Lyme disease?
Related Articles:
Gastrointestinal symptoms in Lyme disease
Autonomic dysfunction and pain
Abdominal pain and constipation in Lyme disease
Reference:
- Leone M, et al. SIADH, urinary retention, constipation, and Bell’s palsy in Lyme disease. Case Rep Nephrol. 2022.
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
Why is Lyme not listed as a debilitating desease with Social security disability?
Listed
Social Security does not appear to approve disability due to a disease. They focus on the disability caused by a disease.
Hello Dr Cameron,
I have a chronic Lyme, with Bartonella henselae 1/512 and Babesia 1/64 IGG positive, i’m from France. I became ill since two years, and I was given doxycycline and amoxicillin, it got better but new symptoms appeared afterwards… Every two weeks, many red scratches (not stretch marks) appear in several places on my body and often precede the symptoms; I also have trouble swallowing, and abdominal pain that comes and goes, arbitrarily. A few months ago, ventricular extrasystoles appeared, but the cardiological examinations are normal for the moment. I follow you regularly from France, I met you through Laura Arnal, and I would have liked to consult you but I’m so far away… I was advised to take ceftriaxone intravenously, but I never took it, because at the beginning I was doing a lot of herx. Today I no longer herx, but the symptoms that I described to you are moving and migrating everywhere (leg pain on Monday, neck pain on Tuesday.) Which shows, in my opinion, that I don’t I’m not in Post Lyme Syndrome, but still in active disease.
What can I do, I want to do this IV cure (over 21 days) but I don’t know if it will be beneficial to me (I have no comorbidities and I have already had intramuscular ceftriaxone so I don’t think I’m allergic.
Thank you very much for your work and your investment, I wish you the best.
Respectfully.
Naim Merzouki
I am sorry to hear you are still ill. I am unable to make any recommendations without an examination. I advise my patients that 3 weeks of IV Rocephin may not be enough. I also advise them to be treated for Babesia. There is no IV for Babesia.
I’m scheduled for back fusion Nov 14 th. I’ve been treated for Lyme twice with coinfections. DX with Neuro Lyme by Spinal Tap and positive titers. I’m concerned about the Anesthesia as I’ve had heart issues since Lyme. Mostly Vacoscyncope with irregular heart rate.
Still have many symptoms. Does this put me at a higher risk for this surgery?
I have been to your conferences in Scottsdale AZ at our Lyme conferences
I have patients who have benefited from additional antibiotic treatment for the remaining symptoms. I have found that Lyme disease can exaggerate the severity of the pain. I am planning on a blog discussing a recent article on anesthesia. The article discusses the need for a cardiac evaluation. https://www.aana.com/docs/default-source/aana-journal-web-documents-1/lyme-disease-and-anesthesia-considerations-december-2017.pdf?sfvrsn=5c4041b1_6
I was very ill with Lyme’s in 2019 with just about all the symptoms and Bell Palsy. When Covid started in 2020, my breathing became so bad I was given supplemental oxygen and have been on it since. I am in about 3 stage emphasema, and every so often I have exacerbations of what I always thought was the emphasema, but could I have Chronic Lyme’s Desease? Yesterday, I felt so bad and in the evening I took my first Doxycycline for my emphasema already being on 25 mg. a day of prednisome. Today I woke and was a changed person. It’s a wow day, and feeling so much better. Could it still be Lyme’s flaring up? How would I find out?
I have patients with more than one illness. I hope you find treatment for Lyme helps you.
Help! 15 months ago my husband became very ill with lyme disease symptoms. We recognized them from the tick bite that gave him Lyme 12 years ago and almost killed him. We immediately went to urgent care and got 2 weeks supply of doxicillin and the pain and swelling subsided and he felt fine. Except that, his memory suddenly had huge gaps in it from the past and he couldn’t remember what he had done 3 days ago. We have gone to 3 doctors, including a neurologist for help and explained the Lyme disease to them. After a ct scan and mri they all prounced him perfectly well with no problems visible in the brain nor was there any sign of Lyme in his bloodwork. They dismissed my accounts of his constant memory loss as “selective memory”. They are so wrong. He is aware of the memory problems and they are slowly getting worse and we don’t know what to do or where to go for help. We live in a remote rural area in Ne Oklahoma so there isn’t a major medical facility anywhere close. What do we do?
I have Lyme disease patients with processing issues that are difficult to detect. Brain fog has also been described that is difficult to assess
I was diagnosed with Lyme disease after a long standing infection over 10 years. I was treated with various ABX, got very sick during the process, Herxhimer very intense it did get me feelin better but never the same. It’s been over 20 years since diagnosis and my health has never been the same . Always battling , whole body pain arthritic joint pain my back is a mess with degenerative disc disease and a total hip replacement which I wonder if due to lyme Anxeirty that can snow ball into a complete weakness and feeling like im going to collasp so many issues I’m at a loss. . my lyme Dr. says I still have bartonella . I recently tried methylene blue but could not tolerate the stuff. I’m at a loss as to where to go with all this. And continue to watch my health fail. And suggestions.. How long does it take to get in to see you. I’ve spent thousands and thousands on treatment I’m running on empty..
I am sorry to hear you have been through so much. You are certainly welcome to contact my office 914 666 4665 if you have any questions.