Lyme Disease Mistaken for Shingles: A Case Report

Quick Answer: Lyme disease can be mistaken for shingles when patients present with rash and nerve pain. If symptoms do not improve with antiviral treatment, Lyme disease should be considered—especially in endemic areas.

Lyme disease can sometimes be mistaken for shingles when patients present with rash and severe nerve pain. Hansen and colleagues describe a case illustrating this pattern of Lyme disease misdiagnosis: a 62-year-old man with abdominal pain and rash who was initially treated for shingles but later diagnosed with Lyme disease.

Both Lyme disease and shingles can produce rash and neuropathic pain, which may complicate diagnosis when symptoms occur outside classic patterns.

Initial Presentation

The patient was admitted to the emergency department complaining of epigastric pain that had been ongoing for four to five weeks. “He described a constant pain with episodic worsening,” Hansen writes. The pain began with a rash in the man’s right upper quadrant.

Physicians considered several diagnoses. The patient had a history of migraines, anxiety, colon polyps, and gastroesophageal reflux disease (GERD). Imaging also revealed small gallbladder stones, though these were not considered acute.

Misdiagnosis and Failed Treatment

The man was diagnosed with shingles and prescribed acyclovir and pregabalin. Despite treatment, he remained ill. His pain increased and “he developed additional symptoms including nausea, lethargy, decreased appetite, constipation, decreased size and force of the urinary stream, and a 5–7 kg weight loss,” Hansen writes.

Imaging and laboratory tests were negative and the patient was discharged. However, one week later he was readmitted because “his general practitioner did not find it reasonable that his anxiety could explain his current symptoms,” Hansen notes.

Correct Diagnosis: Lyme Disease

The man lived in an area endemic for Lyme disease. Although he did not recall a recent tick bite, he reported previous tick exposure. Physicians ordered Lyme disease serologic testing.

Because his Borrelia burgdorferi IgG titers were markedly elevated and he had a history of tick bites and rash, a lumbar puncture was performed. The results were positive.

The 62-year-old man was diagnosed with Lyme disease. His symptoms, except for fatigue, resolved after a three-week course of intravenous ceftriaxone.

“His weight is now normalized and he has no problems with constipation,” Hansen explains. “The abdominal pain is almost gone. His main problem is fatigue, but this is gradually improving.”

The authors note that atypical clinical presentations of Lyme disease can occur, including gastrointestinal manifestations related to autonomic dysfunction, as was seen in this case. Neurologic involvement can also contribute to atypical presentations, as discussed in neurologic Lyme disease.

Why Lyme Disease Can Be Mistaken for Shingles

Lyme disease can affect multiple body systems including the nervous system and autonomic pathways. When symptoms include rash and nerve pain, the condition may resemble shingles or other neurologic disorders. Because Lyme disease presentations can evolve gradually, recognition may be delayed if early symptoms mimic more common conditions.

Frequently Asked Questions

Can Lyme disease be mistaken for shingles?
Yes. Both conditions can cause rash and nerve pain, which can lead to diagnostic confusion when Lyme disease presents with atypical symptoms.

How can doctors tell the difference between Lyme disease and shingles?
Shingles typically causes a dermatomal rash and usually improves with antiviral treatment. Lyme disease may involve tick exposure, neurologic symptoms, and positive serologic testing.

What should you do if shingles treatment isn’t working?
If symptoms persist or worsen despite antiviral treatment, physicians may consider Lyme disease testing, particularly in endemic regions or when there is possible tick exposure.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

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