Can Lyme Disease Mimic Guillain-Barré Syndrome?
Lyme neuroborreliosis can resemble Guillain-Barré syndrome
Weakness, numbness, and facial palsy may initially suggest GBS
A case report highlights why Lyme disease belongs in the differential diagnosis
Can Lyme disease mimic Guillain-Barré syndrome? Yes. Although uncommon, Lyme neuroborreliosis can present with progressive weakness, numbness, facial palsy, abnormal nerve conduction studies, and MRI findings that resemble Guillain-Barré syndrome (GBS).
In a case report by Farr and Bittar, a 33-year-old man was initially treated for presumed Guillain-Barré syndrome after developing ascending weakness, numbness, facial palsy, and respiratory decline. However, he did not improve with intravenous immunoglobulin (IVIG). Further testing revealed Lyme neuroborreliosis, and he improved significantly after treatment with IV ceftriaxone and doxycycline.1
This case illustrates why neurologic Lyme disease should remain in the differential diagnosis when patients present with GBS-like symptoms, especially if they have possible tick exposure, facial palsy, rash, fever, or poor response to standard GBS treatment.
What Is Guillain-Barré Syndrome?
Guillain-Barré syndrome is an immune-mediated disorder in which the body’s immune system attacks peripheral nerves. It can cause progressive weakness, numbness, tingling, loss of reflexes, and, in severe cases, breathing difficulty requiring ventilator support.
GBS often develops after an infection. According to the National Institute of Neurological Disorders and Stroke, symptoms can range from mild weakness to severe paralysis, including inability to breathe independently.2
The Cleveland Clinic notes that in many patients with GBS, symptoms begin within one to six weeks after an illness. GBS may also occur after surgery or, rarely, after vaccination.3
Lyme Neuroborreliosis Presenting Like GBS
Farr and Bittar described a previously healthy 33-year-old man who came to the emergency department with progressive weakness and numbness in both hands and feet. His symptoms began with tingling in the hands and feet, perioral numbness, fever, cough, and a blotchy abdominal rash.
The patient denied a known tick bite, but he frequently spent time in wooded environments while playing disc golf in Ohio.
His neurologic examination revealed several findings that raised concern for Guillain-Barré syndrome:
- Progressive ascending weakness
- Numbness and tingling in the hands and feet
- Bilateral facial palsy
- Reduced reflexes at the knees and ankles
- Decreased sensation below the elbows and up to the knees
These symptoms also overlap with neurologic Lyme disease, particularly when facial palsy, sensory symptoms, and possible tick exposure are present.
Why Doctors Initially Suspected Guillain-Barré Syndrome
The patient’s testing also appeared consistent with Guillain-Barré syndrome.
His spinal fluid showed albuminocytologic dissociation, meaning elevated protein without an elevated white blood cell count. This finding is often associated with GBS.
MRI of the lumbar spine showed enhancement of the cauda equina nerve roots, suggesting an acute inflammatory process.
Electrodiagnostic testing also supported acute inflammatory demyelinating polyneuropathy, a common form of Guillain-Barré syndrome. Findings included prolonged distal motor latency, conduction block, absent F-wave responses, and decreased recruitment on needle electromyography.
Based on these clinical, radiographic, and neurodiagnostic findings, the patient was treated with a five-day course of IVIG for presumed GBS.
Why the Diagnosis Changed
Despite IVIG treatment, the patient’s condition worsened. His respiratory function declined, he required intubation, and later underwent tracheostomy.
By hospital day eight, he had severe weakness in all four limbs and worsening sensory loss. Because he had not improved with standard GBS therapy, clinicians reconsidered the diagnosis.
Additional history became important. The patient had reported outdoor exposure in wooded areas, fever, and a blotchy abdominal rash before the neurologic symptoms began.
Lyme testing was then performed. Serum and cerebrospinal fluid Lyme antibodies were positive. Western blot testing showed positive IgM bands, followed by IgG seroconversion one week later, confirming Lyme disease.
Brain MRI also showed multifocal cranial nerve enhancement involving cranial nerves III, VII, and VIII, supporting widespread leptomeningeal inflammation consistent with Lyme neuroborreliosis.
When Should Lyme Disease Be Considered Instead of Guillain-Barré Syndrome?
Guillain-Barré syndrome remains a neurologic emergency and should be evaluated promptly. However, Lyme disease should be considered in the differential diagnosis when GBS-like symptoms occur in the right clinical setting.
Clinical clues that may point toward Lyme neuroborreliosis include:
- Tick exposure or time spent in wooded or grassy areas
- Residence in or travel to a Lyme-endemic region
- Erythema migrans or another suspicious rash
- Fever or flu-like illness before neurologic symptoms
- Bilateral facial palsy
- Perioral numbness or cranial nerve involvement
- Poor response to IVIG
- Symptoms suggesting Lyme disease facial palsy
In this case, the combination of rash, outdoor exposure, bilateral facial palsy, cranial nerve enhancement, and failure to respond to IVIG supported Lyme neuroborreliosis rather than primary Guillain-Barré syndrome.
How Lyme Disease Was Treated
Once Lyme neuroborreliosis was identified, the patient was treated with IV ceftriaxone and doxycycline for four weeks.
He improved enough to be transferred to a long-term care facility after completing antibiotic treatment. Two weeks later, he was weaned off ventilator support and discharged home.
Eight months after symptom onset, he had recovered significantly. He regained full strength in his upper extremities, with only mild residual weakness in the lower extremities and mild paresthesia in his feet.
What This Case Teaches
This case does not mean that Lyme disease commonly causes Guillain-Barré syndrome. Rather, it shows that Lyme neuroborreliosis can rarely mimic GBS so closely that the initial diagnosis may be incorrect.
The distinction matters because treatment differs. Guillain-Barré syndrome is typically treated with IVIG or plasma exchange, while Lyme neuroborreliosis requires appropriate antibiotic therapy.
When a patient does not respond as expected to GBS treatment, clinicians should reconsider the diagnosis and evaluate for mimics, including Lyme disease when exposure risk or clinical clues are present.
This is one reason Lyme disease misdiagnosis remains an important issue in patients with unusual neurologic presentations.
Frequently Asked Questions
Can Lyme disease mimic Guillain-Barré syndrome?
Yes. Lyme neuroborreliosis can rarely present with weakness, numbness, facial palsy, abnormal nerve conduction studies, and MRI findings that resemble Guillain-Barré syndrome.
Can a tick bite cause Guillain-Barré syndrome?
A tick bite does not typically cause classic Guillain-Barré syndrome directly. However, tick-borne infections such as Lyme disease can sometimes produce neurologic symptoms that resemble GBS and should be considered in the right clinical setting.
What diseases mimic Guillain-Barré syndrome?
Several conditions can mimic Guillain-Barré syndrome, including Lyme neuroborreliosis, spinal cord disorders, myasthenia gravis, botulism, vasculitic neuropathy, metabolic disorders, and other infectious or inflammatory neuropathies.
Can Lyme disease cause weakness and numbness?
Yes. Neurologic Lyme disease may cause weakness, numbness, tingling, radicular pain, facial palsy, and other neurologic symptoms, depending on which nerves are affected.
When should Lyme disease be considered in a patient with suspected GBS?
Lyme disease should be considered when a patient has possible tick exposure, a suspicious rash, facial palsy, fever, residence in an endemic region, cranial nerve involvement, or poor response to standard GBS therapy.
Clinical Takeaway
Guillain-Barré syndrome is a serious neurologic emergency, but Lyme neuroborreliosis can occasionally present with remarkably similar findings.
In patients with progressive weakness, numbness, facial palsy, abnormal nerve studies, or poor response to IVIG, Lyme disease should be considered when there is tick exposure, rash, fever, or residence in an endemic area.
The Farr and Bittar case report shows why Lyme disease belongs in the differential diagnosis of GBS-like illness when clinical clues point toward neuroborreliosis.
Related Articles
Learn more about neurologic Lyme disease, facial palsy, and conditions that may be mistaken for Lyme disease:
Neurologic Lyme Disease
Facial Palsy and Lyme Disease
Lyme Disease Misdiagnosis
Tick Bite Leads to Guillain-Barré Syndrome
Conversion Disorder, Guillain-Barré Syndrome, or Lyme Disease?
References
- Farr J, Bittar J. Neuroborreliosis Presenting as Guillain-Barré Syndrome. Cureus. 2023;15(7):e42322.
- National Institute of Neurological Disorders and Stroke. Guillain-Barré Syndrome.
- Cleveland Clinic. Guillain-Barré Syndrome.
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
I remember only having a rash like this one other time and it was the same summer as the worst “summer flu” ever.
This time, the rash is also on the smalls of my back, and small raised bumps itching between left ring finger and index with one spot appearing randomly in other areas that disappear soon after starting.
All started as an allergy type rash white raised a bit like a bug bites but turn red and to a burning itch such as a nettle burn. The smalls of my back appeared lightly on one side the first day increasing on day 2 and 3 while the stomach rash seems to be subsiding. The tick was negative this time for Lyme but positive for babesia odocoilei. My feet have increased burning, I have developed a slight cough over the day prior to the rash and the next 2 days, sore nose cartridge only on one nostril, cramping of the left hand periodically, bruises on both left and right side hip and outer thy areas along with calf area but all bruises look different.
I was very lethargic 3 days before the rash appeared. The day it appeared, I felt fine otherwise. On the second day, I woke with a sore throat so I tested for covid, which was negative.
After reading this article it reminded me that that first summer flu and the belly rash was the beginning of Ms like symptoms that turned my right side inward.
Since, I have suffered several emergency visits for various issues that do not run in the family.
Heart, stroke, ostioma, adrenal mass, thyroid and parathyroid masses, lung mass, kidney stones as large as 7 mm, with small masses, a tortioned ovarian cyst as large as a soda bottle the nurse described. As well as neurological and physical issues, now also having severe osteoporosis.
Tick-borne diseases are still not looked at in the same way even covid is. The lucky ones get to see doctors and professionals such as in this story, that will go beyond and find root causes to treat with iv.
Only once since my first “summer flu” I felt normal for 3 days and it was after an er visit that I received and iv treatment of an antibiotic that I can only remember started with a c.
For 3 days, in over 15 yrs, I had no pain, no numbness, no mental fog, and could even run!
Keep helping patients for as long as you can and longer…
TBRF/RMSF does more than just mimic Gullian-Barre’, getting a COVID Booster shot caused my GD1b antibodies to be activated, while simultaneously IFA positive for RMSF during serial blood testing over the course of 4 COVID shots.
GD1b antibodies can be activated by a number of conditions
My husband has tested positive for several lyme, co-infections, and viruses – and now suffering from MND mimicking symptoms. Neurologists completely dismissed idea of Lyme and we lost many months, now on an antibiotic protocol but not confident and would like another opinion. Is this an area you are familiar with to treat?
I don’t have many patients with motor neurone disease (MND). They usually stay with neurology. I have had to treat some of them for a persistent tick borne infection to rule out any underlying factors but the results are mixed. I have patients with both Lyme and MND whose Lyme disease symptoms improve which helps their quality of life.