Bilateral Facial Palsy, Lyme Disease, and Bell’s Palsy
Bilateral facial weakness is uncommon
Lyme disease can affect the facial nerves
Early diagnosis may improve outcomes
Bilateral facial palsy is rare and may signal an underlying systemic illness. Lyme disease is one important cause of bilateral facial nerve palsy, particularly in endemic areas where tick exposure is common.
Many patients search for Bell’s palsy and Lyme disease because facial weakness is often first recognized as Bell’s palsy. However, bilateral facial palsy affecting both sides of the face is much less common and should prompt evaluation for other causes including Lyme disease.
Can Lyme Disease Cause Bilateral Facial Palsy?
Yes. Lyme disease can affect the facial nerve and may lead to unilateral or bilateral facial weakness. While single-sided facial palsy is more common, bilateral facial paralysis should raise suspicion for neurologic involvement.
These presentations may overlap with neurologic Lyme disease, especially when accompanied by headaches, fever, meningitis symptoms, or additional neurologic findings.
Why Bilateral Facial Palsy Is Different From Typical Bell’s Palsy
Less than 2% of facial palsy cases are bilateral. Unlike classic Bell’s palsy, bilateral facial nerve involvement is more likely to be associated with an underlying condition.
Causes that may be considered include:
- Lyme disease
- Guillain-Barré syndrome
- Sarcoidosis
- Viral infections
- Autoimmune disease
- Central nervous system disorders
Because symptoms overlap with other neurologic conditions, bilateral facial weakness may contribute to Lyme disease misdiagnosis.
Pediatric Case: Bilateral Facial Palsy in a Child With Lyme Disease
A published case described a previously healthy 10-year-old boy who presented with bilateral facial palsy and multiple cranial nerve abnormalities.
Three weeks before presentation, he experienced fever and a transient rash. There was no known tick bite history.
MRI demonstrated enhancement involving several cranial nerves including:
- Facial nerve (VII)
- Trigeminal nerve (V)
- Abducens nerve (VI)
- Vestibulocochlear nerve (VIII)
- Additional cranial nerve involvement
Initial treatment with steroids and IVIG did not improve symptoms. After Lyme disease was diagnosed, treatment with intravenous ceftriaxone led to resolution of bilateral facial nerve palsy.
Children with Lyme disease may present differently than adults, making early diagnosis challenging. Learn more about pediatric Lyme disease.
Symptoms That May Accompany Lyme Facial Palsy
Facial paralysis from Lyme disease may occur alongside other symptoms including:
- Headache
- Fever
- Neck stiffness
- Fatigue
- Dizziness
- Sensory symptoms
- Rash
- Multiple cranial neuropathies
When multiple symptoms appear together, clinicians may need to consider delayed Lyme disease diagnosis as a risk factor for prolonged illness.
Frequently Asked Questions
Can Lyme disease cause Bell’s palsy?
Yes. Lyme disease is a recognized cause of facial nerve palsy and may present as unilateral or bilateral facial weakness.
Is bilateral facial palsy common in Lyme disease?
No. Bilateral facial palsy is uncommon but is considered an important neurologic presentation when it occurs.
Can Bell’s palsy affect both sides of the face?
Facial weakness involving both sides of the face is unusual and should prompt evaluation for underlying causes including Lyme disease.
Do children get bilateral facial palsy from Lyme disease?
Yes. Pediatric cases have been reported, although bilateral involvement remains uncommon.
What other symptoms occur with Lyme facial palsy?
Headaches, fever, fatigue, meningitis symptoms, dizziness, and other neurologic findings may occur alongside facial weakness.
Clinical Takeaway
Bilateral facial palsy is rare and deserves careful evaluation when it occurs.
Facial weakness affecting both sides of the face—particularly when accompanied by neurologic symptoms—should raise suspicion for Lyme disease in endemic regions.
Related Articles
These related articles explore pediatric presentations, delayed diagnosis, persistent symptoms, and recovery after Lyme disease.
Post-Treatment Lyme Disease Syndrome
Delayed Lyme Disease Diagnosis
Persistent Lyme Disease
Lyme Disease Symptoms Guide
Recovery From Lyme Disease
References
- Piche-Renaud PP, Branson H, Yeh EA, Morris SK. Lyme disease presenting with multiple cranial neuropathies on MRI. IDCases. 2018;12:117-118.
- Yang A, Dalal V. Bilateral Facial Palsy: A Clinical Approach. Cureus. 2021;13(4):e14671.
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
That is incredible! Were there prolonged effects of either the Lyme disease or from the treatment?
The boy did well according to the authors
Would being bit in eye make lyme go to the brain were 1 month of antibiotics won’t work?