Bilateral Facial Palsy and Lyme Disease: A Rare but Serious Presentation

Bilateral facial palsy Lyme disease is an uncommon but important clinical presentation.

Less than 2% of facial palsy cases are bilateral. Unlike unilateral facial palsy, bilateral involvement is more often associated with systemic disease and requires urgent evaluation.

A Child With Sudden Bilateral Facial Palsy

A previously healthy 10-year-old boy presented with a one-day history of bilateral facial palsy and an otherwise normal neurological examination.

Three weeks earlier, he had experienced a transient rash on his chest along with a fever.

There was no reported tick bite, although the family lived in a region where ticks were known to be present.

Imaging Revealed Extensive Cranial Nerve Involvement

Brain MRI showed bilateral symmetric enhancement of cervical cranial nerve roots.

Multiple cranial nerves were involved, including:

• Oculomotor (III)
• Trigeminal (V)
• Abducens (VI)
• Facial (VII)
• Vestibulocochlear (VIII)
• Vagus (X)
• Hypoglossal (XII)

Clinical concern: widespread cranial nerve involvement suggests a systemic neurologic process.

Initial Treatment Failed

The child was initially treated with steroids (methylprednisolone) and IVIG without improvement.

This lack of response prompted further evaluation.

The Diagnosis: Lyme Disease

Six days later, the child was diagnosed with Lyme disease.

He was treated with intravenous ceftriaxone for four weeks.

The bilateral facial palsy resolved completely with antibiotic therapy.

Clinical Takeaway

Bilateral facial palsy should prompt evaluation for systemic causes—including Lyme disease—especially in endemic areas.

This case highlights how Lyme disease can present without a known tick bite and with neurologic symptoms that mimic other conditions.

Key question: Could Lyme disease explain bilateral facial palsy when initial treatments fail?

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