This case involved a 25-year-old woman who experienced progressive numbness and tingling, beginning in her torso and eventually affecting her entire body. Over a four-week period, her neurological symptoms worsened, including a decrease in her reflexes (hyporeflexia), prompting her to seek care at a neurology clinic. Notably, she lacked the hallmark features typically associated with Lyme disease.

Instead, her clinical presentation was dominated by decreased reflexes (hyporeflexia) and sensory disturbances. Symptoms initially localized to the hypogastric region gradually radiated to her back and extremities.

“The numbness and tingling began on the right side of her stomach and radiated to her back and later spread to her entire body. The tingling was not associated with any burning or pins-and-needles sensation,” the authors wrote.¹

Alarming Progression of Symptoms

The symptoms significantly impaired her daily functioning, including her ability to care for her child.

“She especially became alarmed when she could not hold her toddler anymore and ended up dropping the child secondary to her numbness and tingling,” the authors reported.

Neurological Findings

A motor examination revealed:

• Decreased muscle tone, more pronounced in the upper limbs (3/5 strength) than in the lower limbs (4/5 strength)
• Hyporeflexia in the biceps, triceps, patellar, and Achilles tendons

Diagnostic Workup

A lumbar puncture revealed an elevated protein concentration in cerebrospinal fluid (148 mg/dL; normal range: 15–60 mg/dL), suggesting central nervous system involvement. The diagnosis of Lyme disease was confirmed via Western blot testing.

Comparison to Logigian and Steere’s Findings

This case contrasts with findings from the 1990 study by Logigian and Steere published in The New England Journal of Medicine, which evaluated 27 patients with chronic neurologic Lyme disease. In that study, 25 of 27 patients (93%) had normal CSF results, including normal protein levels and no pleocytosis.²

This discrepancy underscores a key point: while CSF abnormalities may support the diagnosis of neurologic Lyme disease, their absence does not rule it out. The variability in neurological presentations highlights the importance of clinical judgment.

Treatment and Outcome

The patient was initially treated with intravenous ceftriaxone for three days, followed by oral doxycycline. Her response to treatment was both rapid and substantial. Upon discharge:

• She regained full spontaneous movement in all extremities.

• Her gait had normalized.

“At the time of discharge, the patient was able to move all extremities spontaneously and ambulate with a normal gait,” the authors noted.

Four Key Discussion Points

1. Neurological Manifestations of Lyme Disease

This case reinforces the importance of recognizing the diverse neurological presentations of Lyme disease. As shown in the Logigian and Steere study, the absence of CSF abnormalities is not uncommon in chronic neurologic Lyme. Clinicians should consider Lyme disease even when classic signs are absent.

2. Role of Lumbar Puncture in Diagnosis

Although this patient had elevated CSF protein levels, many patients with neurologic Lyme disease may have normal CSF results. This highlights the need to use a combination of clinical history, physical exam, and serological testing to make the diagnosis.

3. Timely Diagnosis and Treatment

Despite a delay in diagnosis, the patient responded well to antibiotics. The treatment regimen—IV ceftriaxone followed by oral doxycycline—is effective in managing Lyme neuroborreliosis.

4. Impact on Quality of Life

The patient’s neurological symptoms significantly affected her ability to care for her child. Early recognition and treatment are vital to restoring function and preserving quality of life.

Conclusion

Timely diagnosis and treatment of Lyme neuroborreliosis can lead to excellent outcomes, even in patients with atypical presentations. This case emphasizes the importance of clinical awareness and early intervention in restoring function and providing reassurance.

References

1. Semy R, et al. Lyme Disease Presenting With Interesting Neurological Features of Weakness and Hyporeflexia: A Case Report.
2. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990;323:1438–1444.