Prefer to read? Read the full written case report here

In this podcast episode, I discuss a 69-year-old man with Lyme disease and double vision from 3rd nerve palsy rather than the more common 7th nerve palsy.

This case was first reported by Dixit and colleagues in the journal Case Reports in Neurological Medicine in 2018.

Patient Presentation

A 69-year-old man was seen in an emergency room in New York City in August complaining of headaches and diplopia. Diplopia is the perception of two images of a single object. Head or brain injury, tumor, stroke, or merely the wrong eyeglass prescription can cause diplopia.

He had a history of type 2 diabetes and hypertension. He had been hiking in a rural area of New York but did not notice a tick bite or rash.

His headache began abruptly one week prior, was localized to the right occipital region, and gradually moved to his right orbit. Within five days, he developed diplopia.

He had double vision when opening both eyes. However, if he covered his right eye, his vision normalized.

He had left-sided 3rd cranial nerve palsy on examination. The 3rd cranial nerve controls the majority of the muscles controlling eye movements. The nerve also controls the upper eyelid muscle and the muscles responsible for pupil constriction.

Diagnostic Testing

He underwent extensive testing. He had abnormal blood tests for Lyme disease with a highly positive Lyme disease titer, 2 of 3 IgM Western blot bands, and 5 of 10 IgG Western blot bands.

His spinal tap showed a highly elevated Lyme disease titer. The Lyme disease titer in his spinal tap would have to be higher than the Lyme disease titer in the blood to be positive.

His diagnosis of Lyme disease was based on pleocytosis in the spinal fluid. A pleocytosis is a high number of white blood cells in the spinal tap. You only need seven white blood cells in the spinal tap to diagnose Lyme disease. He had 74 white blood cells.

Treatment and Outcome

He was treated for oculomotor nerve palsy secondary to Lyme meningitis. He was prescribed acyclovir and four weeks of intravenous ceftriaxone.

His diplopia resolved, and he remained free of symptoms two months after starting treatment.

Clinical Context

Facial nerve palsy is much more common than the 3rd nerve palsy discussed here. Facial nerve palsy, often called Bell’s palsy, affects the 7th cranial nerve. Symptoms of facial nerve palsy are paralysis of the muscles of one side of the face. In rare cases, Lyme disease has been known to occur on both sides of the face.

There are other ocular manifestations of Lyme disease, including conjunctivitis, keratitis, and extraocular muscle palsies.

What Can We Learn From This Case?

Key takeaways from this case of Lyme disease and double vision:

1. Lyme disease can affect the cranial nerves. In this case, the man developed Lyme disease and double vision from 3rd nerve palsy rather than the more common 7th nerve palsy.

2. The 3rd nerve palsy can be successfully treated with antibiotics.

What Questions Does This Case Raise?

1. How often does Lyme disease affect the eyes?

I discussed a wide range of eye problems related to Lyme disease in previous episodes and blog posts. See Growing list of eye problems in Lyme disease and Eye problems in tick-borne diseases other than Lyme.

2. How can Lyme disease with eye involvement be diagnosed if the tests are negative?

This remains a clinical challenge that requires careful evaluation of symptoms, exposure history, and response to treatment.

Treating Tick-Borne Disease

Many patients are complex, as highlighted in this Inside Lyme Podcast series. We need more doctors with skills recognizing tick-borne illness in individuals with Lyme disease and double vision.

We hope that professionals evaluating individuals with Lyme disease and double vision can use this case to remind them to look for tick-borne illnesses and treat accordingly.