Can Lyme Disease Cause Bilateral Facial Palsy?

Bilateral facial palsy is a rare neurologic complication of Lyme disease
Early disseminated Lyme disease may affect both sides of the face
Facial weakness may occur even without a recalled tick bite

Bilateral facial palsy (paralysis or weakness on both sides of the face) is extremely rare and can be caused by autoimmune conditions, infections such as Lyme disease, or trauma.¹

Bilateral facial palsy due to Lyme disease has rarely been reported in the literature.

A recent article by Cheng and colleagues entitled Case Report: A Typical Lyme Disease With Uncommon Neurologic Presentation¹ describes a patient who presented with bilateral facial palsy.

For a broader overview of neurologic manifestations, visit our Neurologic Lyme Disease hub.

Patient Presented With Rash, Headache, and Facial Weakness

The 32-year-old man was admitted to the emergency department with a rash, headache, and right-sided facial weakness.¹

He initially developed a large rash on his abdomen, followed several days later by similar rashes on his legs, trunk, and wrists.¹

“We present a rare case of bilateral facial palsy in Lyme disease due to Borrelia burgdorferi infection,” the authors wrote.¹

“One day before presentation, the patient had difficulty in closing the right eyelid and had drooling from the right corner of the mouth when drinking water,” according to the authors.¹

Tick Bite Was Not Recalled

The patient lived in a wooded area but could not recall a tick bite.¹

While awaiting Lyme disease test results, he was treated empirically with doxycycline.

He later tested positive for Lyme disease.¹

This case highlights how neurologic Lyme disease may occur even when patients do not remember a tick exposure.

Lyme disease facial palsy is sometimes initially labeled as Bell’s palsy, particularly when patients do not recall a tick bite or rash.

Unlike classic idiopathic Bell’s palsy, bilateral facial palsy often has an identifiable underlying cause. Lyme disease is considered one of the leading infectious causes of bilateral facial nerve palsy and may require a different diagnostic and treatment approach.¹

For more on atypical presentations, visit our Lyme Disease Misdiagnosis article.

Bilateral Facial Palsy Improved With Treatment

After 17 days of treatment, the patient’s erythema migrans rashes and bilateral facial palsy had resolved.¹

“Although facial nerve palsy is not an uncommon neurologic presentation in the early disseminated stage of the disease, the majority are unilateral. In fact, bilateral facial palsy is an extremely rare condition,” the authors point out.¹

Early recognition and treatment may improve neurologic recovery.

How Lyme Disease Facial Palsy Differs From Bell’s Palsy

Facial weakness is often initially attributed to viral Bell’s palsy.

However, bilateral facial palsy is far less likely to be idiopathic and more likely to have an identifiable cause, including Lyme disease.¹

Unlike classic Bell’s palsy, Lyme-associated facial palsy may occur with:

• bilateral facial weakness
• erythema migrans rash
• headache
• neurologic symptoms
• possible tick exposure
• other systemic symptoms

The distinction is clinically important because Lyme-associated facial palsy requires a different evaluation and treatment approach.

The article also notes that corticosteroids are not recommended for Lyme disease-associated facial nerve palsy, which differs from standard Bell’s palsy treatment recommendations.¹

Frequently Asked Questions

Can Lyme disease cause bilateral facial palsy?

Yes. Although uncommon, Lyme disease may cause weakness or paralysis affecting both sides of the face during early disseminated infection.¹

Is facial palsy common in Lyme disease?

Facial nerve palsy is a recognized neurologic manifestation of Lyme disease, though most cases are unilateral rather than bilateral.

Can Lyme disease be mistaken for Bell’s palsy?

Yes. Lyme disease facial palsy may initially resemble Bell’s palsy, especially in patients without a known tick bite or erythema migrans rash.

How is Lyme disease facial palsy different from Bell’s palsy?

Bell’s palsy is typically idiopathic and unilateral, whereas Lyme disease facial palsy may occur with rash, headache, neurologic symptoms, or bilateral facial weakness. Lyme-associated facial palsy also requires different evaluation and treatment considerations.¹

Can Lyme disease facial palsy improve with antibiotics?

Many patients improve with appropriate antibiotic treatment, particularly when therapy is started early.

Can neurologic Lyme disease occur without a known tick bite?

Yes. Some patients with neurologic Lyme disease do not remember a tick bite or classic rash.

Why is bilateral facial palsy important clinically?

Bilateral facial palsy is rare and may indicate underlying neurologic or infectious disease requiring prompt evaluation.

Clinical Takeaway

Bilateral facial palsy is an uncommon but important neurologic manifestation of Lyme disease.

This case highlights how early disseminated Lyme disease may present with bilateral facial weakness, rash, and headache even without a recalled tick bite.

Clinicians should consider Lyme disease in patients presenting with bilateral facial palsy, especially in endemic areas.

Related Articles

These related articles explore facial palsy, neurologic Lyme disease, delayed diagnosis, and atypical neurologic presentations.

Patient With Facial Palsy From Lyme Disease Fails Treatment
Facial Nerve Dysfunction After Treatment for Lyme Disease
Facial Paralysis Due to Lyme Disease Initially Attributed to a Virus
Delayed Lyme Disease Diagnosis
Lyme Disease Symptoms Guide

Reference

1. 1. 1. Cheng G, Parkash N, Daniel A, Marur S. Case Report: A Typical Lyme Disease With Uncommon Neurologic Presentation. J Community Hosp Intern Med Perspect. 2024 Sep 9;14(5):101-105.

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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