Can Lyme Disease Cause Vasculitis? A Case of Recurrent Stroke

Rare neurologic complication of Lyme disease
How cerebral vasculitis can lead to recurrent ischemic stroke
Why Lyme neuroborreliosis should be considered in unexplained stroke

Can Lyme disease cause vasculitis? Although rare, Lyme neuroborreliosis has been associated with cerebral vasculitis, an inflammatory condition affecting blood vessels in the brain that can lead to ischemic stroke. This case highlights why Lyme disease should remain in the differential diagnosis for patients with recurrent unexplained strokes, even when routine testing is unrevealing.

Can Lyme disease cause cerebral vasculitis?

Cerebral vasculitis is an uncommon manifestation of Lyme neuroborreliosis. Inflammation of cerebral blood vessels may reduce blood flow to the brain, resulting in ischemic stroke. According to published reports, cerebral vasculitis occurs in only about 0.3% to 1% of patients with Lyme neuroborreliosis, making it an uncommon but important diagnosis to recognize.

In their article, “A Case Report of Unilateral Cerebral Vasculitis in Adults: Keep in Mind Lyme Neuroborreliosis,” Riescher and colleagues describe a 58-year-old man who experienced recurrent strokes caused by Lyme neuroborreliosis despite having no cardiovascular risk factors and an initially unrevealing neurologic evaluation.

Patient experienced recurrent strokes

The patient presented with sudden right brachiofacial weakness. Although he partially recovered, facial weakness persisted. CT angiography of the cervical and intracranial vessels was normal without stenosis, occlusion, or aneurysm.

He was diagnosed with a cryptogenic stroke and treated with aspirin, atorvastatin, and perindopril.

Two months later, he developed sudden aphasia.

“Burgdorferi-induced cerebral vasculitis is thought to be a very rare manifestation of Lyme neuroborreliosis. But it must nonetheless be considered in the differential diagnosis of unexplained recurrent and/or multiple strokes.”

MRI demonstrated a new ischemic infarction within the left middle cerebral artery territory together with evidence of an older infarct. Anticoagulation was initiated and prolonged cardiac monitoring was performed.

Symptoms progressed over the following year

Despite treatment, the patient continued to deteriorate over the following months. He developed:

• Paresthesias involving the right hand and foot
• Headaches
• Profound fatigue
• Psychomotor slowing
• Unsteady gait
• Progressive right leg weakness

Thirteen months after his initial stroke, brain MRI demonstrated additional acute ischemic lesions involving the anterior cerebral artery and middle cerebral artery territories.

Routine neurologic testing remained unrevealing. Lyme serologic testing, however, was strongly positive by ELISA and confirmed by Western blot.

Doxycycline led to clinical improvement

The patient was treated with one month of doxycycline.

“The patient experienced no further stroke after four weeks of doxycycline treatment.”

Within weeks, he reported marked improvement in fatigue, dizziness, and right arm paresthesias.

Only after treatment did the patient recall sustaining a tick bite approximately two years before his first stroke, accompanied by an erythema migrans rash. He had never developed Lyme arthritis or significant musculoskeletal pain.

Clinical perspective

Stroke caused by Lyme disease is uncommon in clinical practice. However, this case illustrates that Lyme neuroborreliosis should remain on the differential diagnosis when patients experience recurrent unexplained ischemic strokes, particularly when conventional vascular and cardiac evaluations are unrevealing. A history of tick exposure may not become apparent until careful questioning, and cerebrospinal fluid findings may occasionally be normal despite active infection.

Bottom line

This report expands the recognized spectrum of neurologic Lyme disease by demonstrating that cerebral vasculitis may present with recurrent ischemic strokes even without cerebrospinal fluid pleocytosis. Although rare, Lyme disease should be considered in selected patients with unexplained recurrent stroke, especially in endemic regions or when there is a history of tick exposure.

Frequently Asked Questions

Can Lyme disease cause vasculitis?

Yes. Lyme neuroborreliosis has rarely been associated with cerebral vasculitis, an inflammatory condition affecting blood vessels in the brain. Although uncommon, it can lead to ischemic stroke.

Can Lyme disease cause recurrent strokes?

Rarely. Published case reports describe recurrent ischemic strokes caused by cerebral vasculitis associated with Lyme neuroborreliosis.

Can Lyme disease cause stroke-like symptoms?

Yes. Lyme neuroborreliosis can produce facial weakness, speech difficulty, numbness, weakness, dizziness, and other neurologic symptoms that may resemble stroke.

Does a normal spinal tap rule out Lyme neuroborreliosis?

No. Although cerebrospinal fluid abnormalities are common, this case demonstrates that Lyme neuroborreliosis with cerebral vasculitis can occasionally occur without CSF pleocytosis.

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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