Can Lyme Disease Cause Transverse Myelitis? A Rare Neurologic Complication

Transverse myelitis is a rare complication of Lyme neuroborreliosis
Symptoms may include back pain, weakness, sensory changes, and bladder dysfunction
Published case reports describe improvement after antibiotic treatment

Lyme disease can rarely affect the spinal cord and lead to transverse myelitis. This inflammatory neurologic condition may cause severe back pain, muscle spasms, numbness, weakness, abnormal reflexes, and bowel or bladder dysfunction.

The clinical signs and symptoms depend on the region of the spinal cord involved, explain Kaiser and colleagues in the case report, “Lyme myelopathy: Case report and literature review of a rare but treatable disorder.” [1]

Transverse myelitis has a broad differential diagnosis. Potential causes include demyelinating conditions, infections, autoimmune disorders, malignancies, vascular injury, and nutritional deficiencies.

Because the symptoms and MRI findings are not specific to Lyme disease, clinicians may initially suspect conditions such as multiple sclerosis, neuromyelitis optica, spinal cord compression, autoimmune myelitis, or a viral infection.

How often is transverse myelitis associated with Lyme disease?

Transverse myelitis is an uncommon manifestation of neurologic Lyme disease. More typical presentations of Lyme neuroborreliosis include meningitis, facial nerve palsy, painful radiculitis, and other cranial or peripheral neuropathies.

Facial nerve palsy, Lyme meningitis, and painful radiculitis remain considerably more common than spinal cord involvement.

Earlier reviews identified approximately 25 cases of Lyme-associated myelitis. A 2026 report noted that fewer than approximately 50 to 70 cases had been described in the medical literature. [2]

The rarity of published cases does not mean Lyme disease should be excluded automatically. It may remain an important consideration when myelitis develops in a patient with compatible exposure, symptoms, laboratory findings, or residence in an endemic region.

A recalled tick bite or erythema migrans rash is not required. In the original literature review by Kaiser and colleagues, only a minority of reported patients recalled a recent tick bite or described an erythema migrans or other rash.

Severe thoracic back pain followed by neurologic symptoms

In the journal Multiple Sclerosis and Related Disorders, Kaiser and colleagues described a 56-year-old man who developed transverse myelitis associated with Lyme disease.

The man was an avid gardener living in Pennsylvania. He initially developed right-sided back and flank pain that felt as though he had been “punched in the kidney.” Numbness and tingling subsequently spread across his abdomen.

Doctors initially suspected herpes zoster without a rash, sometimes called zoster sine herpete. However, his illness progressed despite seven days of treatment with the antiviral medication famciclovir.

This progression illustrates why severe Lyme disease pain, particularly when accompanied by sensory, motor, reflex, or bladder abnormalities, may require a broader neurologic evaluation rather than being attributed solely to a musculoskeletal condition.

Symptoms of Lyme-associated transverse myelitis

The patient’s symptoms and examination findings included:

• abdominal and back muscle spasms
• tactile allodynia, in which light touch was painful
• formication, or a skin-crawling sensation
• a band-like sensation around the thorax
• chills
• urinary hesitancy
• incomplete bladder emptying
• severe pain that caused him to writhe
• decreased light touch, pinprick, and temperature sensation across thoracic dermatomes
• allodynia to light touch
• hyperreflexia, including brisk patellar reflexes
• a jaw jerk
• absent superficial abdominal reflexes

The sensory abnormalities formed a suspended sensory level between approximately T6 and T10 on the right and T7 and T11 on the left.

Severe thoracic or flank pain may precede more recognizable spinal cord findings. However, back pain by itself is common and does not establish transverse myelitis or Lyme neuroborreliosis. Concern increases when pain occurs with weakness, numbness, a defined sensory level, abnormal reflexes, gait changes, or bowel and bladder dysfunction.

MRI findings in Lyme-associated transverse myelitis

An MRI of the patient’s thoracic spine showed an expansile T2 hyperintensity extending from approximately T7 through T10. The longitudinally extensive spinal cord abnormality was consistent with acute transverse myelitis.

MRI abnormalities in Lyme-associated myelitis may involve the cervical or thoracic spinal cord. Published cases have described both small focal lesions and longitudinally extensive lesions involving several spinal segments. [1-4]

These findings are not unique to Lyme disease. Similar spinal cord abnormalities may be seen with inflammatory, infectious, vascular, metabolic, or demyelinating disorders. MRI findings must therefore be interpreted together with the clinical presentation, cerebrospinal fluid results, laboratory testing, and exclusion of alternative diagnoses.

How is Lyme-associated transverse myelitis diagnosed?

The diagnosis is not based on a positive Lyme blood test alone. Because Lyme antibodies may reflect prior exposure, clinicians correlate laboratory findings with the patient’s neurologic syndrome, MRI findings, cerebrospinal fluid analysis, and exclusion of alternative diagnoses.

A careful evaluation may include:

• a detailed neurologic examination
• MRI of the spinal cord and, when indicated, the brain
• serologic testing for Lyme disease
• cerebrospinal fluid analysis
• assessment for intrathecal production of Borrelia-specific antibodies
• testing for other infectious causes
• evaluation for autoimmune and demyelinating disorders
• assessment for spinal cord compression, vascular injury, malignancy, and nutritional deficiencies

Cerebrospinal fluid in reported cases often demonstrates lymphocytic pleocytosis and elevated protein. Intrathecal production of Borrelia-specific antibodies may provide additional support for the diagnosis of Lyme neuroborreliosis.

In the Kaiser case, the diagnosis was supported by myelopathic symptoms and examination findings, thoracic spinal cord abnormalities on MRI, positive Lyme serology, intrathecal synthesis of Lyme antibodies, and substantial improvement following antibiotic therapy.

A 2026 report described two additional patients with subacute myelitis attributed to Lyme neuroborreliosis. Both had inflammatory cerebrospinal fluid with lymphocytic pleocytosis, elevated protein, and intrathecal synthesis of Borrelia burgdorferi-specific antibodies. One patient had a focal cervical lesion, while the other had a longitudinally extensive thoracic lesion. [2]

Neither the absence of a known tick bite nor the absence of an erythema migrans rash reliably excludes Lyme disease. The diagnosis should nevertheless remain clinically grounded and should account for the possibility of unrelated positive serology, prior exposure, and competing neurologic conditions.

The broader Lyme disease symptom pattern, exposure history, timing of illness, neurologic examination, laboratory evidence, and imaging findings must be considered together.

Conditions that can resemble Lyme-associated myelitis

Symptoms of transverse myelitis may overlap with several other conditions, including:

• multiple sclerosis
• neuromyelitis optica spectrum disorder
• myelin oligodendrocyte glycoprotein antibody-associated disease
• acute disseminated encephalomyelitis
• viral myelitis
• spinal cord compression
• spinal cord infarction
• autoimmune inflammatory disease
• vitamin B12 or copper deficiency
• malignancy or paraneoplastic disease
• herpes zoster, including zoster without a visible rash

This differential diagnosis is particularly important because corticosteroids or other immunosuppressive treatments may be considered for inflammatory myelitis before an infectious cause has been identified.

Treatment of Lyme-associated transverse myelitis

The patient initially experienced some pain relief with corticosteroids and antiviral treatment. Approximately two weeks after hospitalization, testing supported a diagnosis of Lyme disease.

He was treated with a three-week course of intravenous ceftriaxone. His symptoms nearly completely resolved following treatment.

The authors recommended considering Lyme disease testing during the evaluation of acute transverse myelitis when the clinical and epidemiologic circumstances are appropriate. Identifying an infectious cause may uncover a potentially treatable form of myelopathy.

Additional cases of Lyme-associated transverse myelitis

Several additional reports illustrate the range of symptoms, diagnostic findings, and outcomes associated with this rare complication.

Two women with cervical and thoracic myelitis

In 2026, Rončević Filipović and colleagues reported two women with subacute myelitis attributed to Lyme neuroborreliosis. One was a 76-year-old woman with lower-extremity weakness, gait impairment, urinary retention, and a focal cervical spinal cord lesion. The other was a 55-year-old woman with leg pain, thoracic sensory symptoms, left-leg weakness, bilateral facial palsy, and a longitudinally extensive thoracic lesion from approximately T5 through T8. [2]

Both patients initially received corticosteroids because inflammatory myelitis was suspected. After cerebrospinal fluid testing confirmed intrathecal production of Borrelia-specific antibodies, they were treated with intravenous ceftriaxone. Both experienced marked clinical improvement and regression of the spinal cord abnormalities on follow-up MRI.

One patient later developed worsening gait, paresthesias, urinary retention, and MRI signal changes at the previously affected level. This finding underscores that improvement may be substantial without guaranteeing complete or permanently stable recovery.

Rapid improvement in upper-extremity weakness

Chohan and colleagues described a 62-year-old man who developed progressive weakness and poor coordination involving both arms. He did not have a known erythema migrans rash or typical flu-like illness. MRI showed cervical cord abnormalities, while cerebrospinal fluid testing demonstrated marked lymphocytic inflammation and Lyme antibodies. [3]

The man received 28 days of intravenous ceftriaxone. His muscle strength began improving within two days, and he recovered full measured strength in both upper extremities within four days. He was discharged for rehabilitation while completing antibiotic therapy.

Leg weakness, a sensory level, and neurogenic bladder

Dumic and colleagues reported a previously healthy 25-year-old man who developed erythema migrans, headache, neck stiffness, leg weakness, numbness, urinary retention, constipation, and gait instability. [4]

MRI showed spinal cord abnormalities at cervical and thoracic levels. Serum Lyme antibodies were negative, but Borrelia burgdorferi DNA was detected in cerebrospinal fluid by PCR. The patient received intravenous ceftriaxone and corticosteroids.

His gait, leg strength, sensation, and bowel function improved. However, neurogenic bladder persisted and required intermittent self-catheterization. This case provides an important reminder that neurologic improvement may be incomplete even when other symptoms respond to treatment.

Can Lyme myelitis improve with treatment?

Many published case reports describe meaningful clinical improvement after antibiotic treatment, frequently accompanied by partial or substantial regression of spinal cord abnormalities on follow-up MRI. However, case reports cannot establish how often complete recovery occurs.

Recovery may depend on the location and extent of spinal cord inflammation, the severity of the initial neurologic injury, the time to diagnosis, the underlying cause, and whether permanent tissue damage has occurred.

Motor strength and gait may improve while sensory symptoms, bladder dysfunction, pain, or other neurologic deficits persist. Rehabilitation, physical therapy, bladder management, pain treatment, and continued neurologic follow-up may therefore remain necessary.

A 2025 systematic review and meta-analysis found an increased burden of neurologic and musculoskeletal manifestations among patients with Lyme disease, although the included studies were heterogeneous and the analysis was not designed to determine the frequency of transverse myelitis specifically. [5]

Frequently Asked Questions

Can Lyme disease cause transverse myelitis?

Yes. Lyme neuroborreliosis can rarely involve the spinal cord and produce transverse myelitis. Published reports describe cervical and thoracic spinal cord inflammation associated with sensory, motor, reflex, and autonomic abnormalities.

Can Lyme disease cause severe back pain?

Lyme disease may be associated with back or radicular pain, but back pain is common and usually has other causes. Severe thoracic back pain accompanied by weakness, numbness, a sensory level, abnormal reflexes, or bladder dysfunction warrants prompt neurologic evaluation.

What symptoms suggest transverse myelitis?

Symptoms may include weakness, numbness, tingling, a band-like sensation around the torso, muscle spasms, abnormal reflexes, difficulty walking, urinary retention, constipation, or loss of bowel and bladder control. The pattern depends on the spinal cord level affected.

How is Lyme-associated transverse myelitis diagnosed?

Diagnosis typically requires a compatible neurologic syndrome, spinal MRI findings, Lyme disease testing, cerebrospinal fluid analysis, and careful exclusion of alternative infectious, autoimmune, structural, vascular, and demyelinating conditions.

Does Lyme transverse myelitis appear on an MRI?

It may. Published cases describe T2-hyperintense spinal cord lesions that may be focal or extend across several cervical or thoracic segments. MRI findings are not specific to Lyme disease and must be interpreted with clinical and laboratory evidence.

Can Lyme disease cause urinary retention?

Urinary retention has been reported in several cases of Lyme-associated transverse myelitis. It can occur when spinal cord inflammation disrupts the nerves involved in bladder control, but urinary retention has many other possible causes and requires prompt medical evaluation.

Can Lyme myelitis be reversed?

Substantial improvement has been reported following antibiotic treatment, and MRI abnormalities may regress. Recovery is not always complete, however, and some patients may continue to experience sensory symptoms, gait problems, pain, or bladder dysfunction.

Clinical Takeaway

Transverse myelitis is a rare but potentially serious manifestation of Lyme neuroborreliosis. It may present with severe back or flank pain, muscle spasms, sensory changes, weakness, abnormal reflexes, gait impairment, and bowel or bladder dysfunction.

Lyme disease should not be assumed to be the explanation for every case of transverse myelitis. The diagnosis requires a compatible clinical presentation, appropriate laboratory and cerebrospinal fluid evidence, MRI findings, and a careful evaluation for competing causes.

Published case reports suggest that timely recognition and antibiotic treatment may lead to substantial neurologic and radiologic improvement, although some patients are left with residual deficits.

Related Articles

These articles provide additional information about neurologic manifestations and complications of Lyme disease:

Chronic inflammatory demyelinating polyneuropathy case resolved with antibiotics
What happens in the brain of neurologic Lyme disease patients who remain ill?
Lyme meningitis presenting as parkinsonism reversed with ceftriaxone

References

1. Kaiser EA, George DK, Rubenstein MN, Berger JR. Lyme myelopathy: Case report and literature review of a rare but treatable disorder. Mult Scler Relat Disord. 2019;29:1-6.
2. Rončević Filipović M, Ćužić D, Cekinović Grbeša Đ. Acute transverse myelitis as a manifestation of Lyme neuroborreliosis: Two cases. IDCases. 2026;45:e02662.
3. Chohan M, Rana D, Hafez N. Rare case of acute transverse myelitis associated with Lyme neuroborreliosis. IDCases. 2022;27:e01422.
4. Dumic I, Vitorovic D, Spritzer S, Sviggum E, Patel J, Ramanan P. Acute transverse myelitis: A rare clinical manifestation of Lyme neuroborreliosis. IDCases. 2019;15:e00479.
5. Bushi G, Balaraman AK, Gaidhane S, et al. Lyme disease associated neurological and musculoskeletal symptoms: A systematic review and meta-analysis. Brain Behav Immun Health. 2025;43:100931.

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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