Lyme Myelopathy: Acute Transverse Myelitis as a Treatable Cause

Lyme disease is a rare but important—and potentially reversible—cause of acute transverse myelitis.

Clinical signs and symptoms of acute transverse myelitis (ATM) depend on the region of the spinal cord involved, explain Kaiser and colleagues in a recent case report,

“Lyme myelopathy: Case report and literature review of a rare but treatable disorder.”

ATM may result from demyelinating disease, infections, autoimmune conditions, malignancy, vascular injury, or nutritional deficiencies.

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How Common Is Lyme-Associated Acute Transverse Myelitis?

Lyme disease has been documented as a cause of acute transverse myelitis, but it remains rare.

Only 25 cases have been reported in the medical literature.

Notably:

• Only 3 patients reported an erythema migrans rash
• Only 5 recalled a recent tick bite

This highlights that Lyme myelopathy may occur without classic early Lyme disease signs.

For a broader neurologic overview, see neurologic Lyme disease.

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Case Report: Lyme Myelopathy in a 56-Year-Old Man

A 56-year-old man from Pennsylvania developed severe right-sided back and flank pain, described as feeling “punched in the kidney,” followed by progressive neurologic symptoms.

Initial diagnosis was suspected herpes zoster without rash. However, symptoms worsened despite antiviral therapy.

Signs and Symptoms

• Abdominal and back muscle spasms
• Tactile allodynia
• Formication (skin-crawling sensation)
• Band-like thoracic pain
• Urinary hesitancy and incomplete voiding
• Hyperreflexia and abnormal neurologic reflexes
• Segmental sensory loss across the thorax

MRI revealed an “expansile T2 hyperintensity” involving the thoracic spinal cord (T7–10), consistent with acute transverse myelitis.

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Diagnosis and Treatment

The patient initially experienced partial relief with corticosteroids and antiviral therapy.

Two weeks later, Lyme disease was confirmed through laboratory testing.

He was treated with a 3-week course of intravenous ceftriaxone, resulting in near-complete resolution of symptoms.

Including Lyme disease testing in the evaluation of acute transverse myelitis may identify a treatable cause of neurologic disease.

Learn more about Lyme disease testing limitations and when additional evaluation may be needed.

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Clinical Perspective

This case highlights a critical point: Lyme disease can present as a reversible neurologic disorder—even when initial symptoms mimic other conditions.

Failure to recognize Lyme myelopathy may delay appropriate treatment.

In endemic areas, clinicians should consider Lyme disease in the differential diagnosis of acute transverse myelitis, particularly when no clear cause is identified.

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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