Transverse myelitis and Lyme disease: a rare neurologic case
Acute spinal cord inflammation and Lyme disease
Neurologic dysfunction can include weakness, sensory loss, and autonomic symptoms
Diagnosis and treatment may affect long-term recovery
I will be discussing a 25-year-old man with transverse myelitis and Lyme disease. “He showed gradual improvement in gait, motor and sensory functions of his lower extremities along with a resolution of neurogenic bowel,” wrote the authors. They added, “He continues to need intermittent self-catheterization for neurogenic bladder.”
Transverse myelitis Lyme disease cases are uncommon but clinically important because neurologic Lyme disease can involve the spinal cord, autonomic nervous system, and sensory pathways.
Although uncommon, transverse myelitis Lyme disease cases raise important questions because spinal cord inflammation may occasionally be part of Lyme neuroborreliosis.
Lyme neuroborreliosis can affect the meninges, cranial nerves, peripheral nerves, spinal cord, and autonomic nervous system, leading to varied neurologic presentations.
href=”https://danielcameronmd.com/author/danielcameron/” rel=”author”>Dr. Daniel Cameron
Dumic and colleagues first discussed this case in the journal IDCases in 2019.
“A previously healthy 25-year-old man presented with inability to urinate and frequent falls associated with bilateral lower extremity weakness and numbness,” wrote the authors.
Two weeks earlier, he described a red circumferential rash. His rash was approximately 10 cm in diameter, roughly 4 inches. The CDC surveillance definition uses a 5 cm rash criterion.
He lived in Wisconsin with extensive tick exposure. He lived next to woods, hiked, camped, fished, and had two dogs. He did not recall a tick bite.
Failure to recall a tick bite does not exclude Lyme disease because many patients with tick-borne illness never identify the original exposure.
He also developed a mild intermittent headache, mild neck stiffness, and possible fever. Flu-like symptoms are commonly reported in Lyme disease and are reviewed further in Lyme disease symptoms.
The rash disappeared within a week without treatment. Erythema migrans can clear even without antibiotics.
His condition then worsened.
“Five days prior to admission, he developed urinary retention as well as progressive numbness and weakness in his lower extremities,” wrote the authors.
He also lost bowel control.
Progressive weakness, sensory changes, urinary retention, and gait instability may suggest ascending spinal cord involvement and warrant urgent neurologic evaluation.
His sensory deficit progressed from left foot numbness upward to the thorax below the nipple line anteriorly and below the shoulder blades posteriorly.
He developed falls because of bilateral leg weakness and gait impairment.
Neurologic findings suggesting spinal cord involvement
His examination demonstrated weakness in both legs, mild spasticity, increased reflexes, diminished sensation, and a positive Babinski sign.
A positive Babinski sign may suggest dysfunction involving the central nervous system.
How Lyme disease may affect the spinal cord
MRI showed evidence concerning for spinal cord inflammation.
“MRI of the cervical and thoracic spine revealed T2 signal hyperintensity in the central spinal cord gray matter at C5, C6 and T3 to T9 levels suggestive of myelitis.”
Myelitis refers to inflammation involving the spinal cord.
Spinal MRI abnormalities in Lyme myelitis may include inflammatory lesions, cord signal abnormalities, or findings overlapping with other inflammatory neurologic disorders.
Spinal cord lesions in Lyme disease remain uncommon and require correlation with clinical findings, exposure history, and laboratory evaluation.
He also had inflammatory spinal fluid with pleocytosis despite negative Lyme antibody testing.
His PCR testing for Lyme disease was positive and confirmed using molecular testing through Mayo Medical Laboratories.
Diagnosing neurologic Lyme disease can be challenging because laboratory testing and spinal fluid findings do not always align perfectly with clinical presentations. Related diagnostic limitations are discussed in why Lyme tests medicine differently.
Conditions that may resemble Lyme myelitis
Transverse myelitis has many causes. Multiple sclerosis, autoimmune disease, viral infections, neuromyelitis optica spectrum disorders, and other inflammatory conditions may also present with weakness, numbness, and bladder dysfunction.
Exposure history, examination findings, imaging, laboratory testing, and clinical evolution help narrow the differential diagnosis.
Transverse myelitis and autonomic dysfunction
The patient’s motor, sensory, and autonomic dysfunction were consistent with acute transverse myelitis.
Autonomic dysfunction affects internal organ regulation including bowel, bladder, heart rate, blood pressure, gastrointestinal function, and temperature regulation.
His inability to control bowel and bladder function demonstrates how spinal cord inflammation can affect autonomic pathways. Additional discussion is available in autonomic dysfunction and Lyme disease.
Neurologic Lyme disease may also involve brain fog, sensory symptoms, balance problems, and autonomic dysfunction beyond the spinal cord itself. Additional discussion is available in neurologic Lyme disease.
Coinfections and overlapping tick-borne illnesses may further complicate neurologic presentations and recovery patterns in some patients. Additional discussion is available in Lyme coinfections.
Outcome after treatment
He was treated with intravenous ceftriaxone.
He initially received acyclovir until spinal fluid PCR testing supported Lyme disease.
He also received methylprednisolone 1 g IV daily for three days.
“He showed gradual improvement in gait, motor and sensory functions of his lower extremities along with a resolution of neurogenic bowel.”
The authors added, “he continues to need intermittent self-catheterization for neurogenic bladder.”
Recovery after neurologic Lyme disease can vary considerably depending on timing of diagnosis, severity, and residual neurologic injury. Additional discussion is available in recovery from Lyme disease.
The authors identified six additional reports linking Lyme neuroborreliosis with acute transverse myelitis.
Clinical questions raised by this case
- How frequently does transverse myelitis occur in Lyme disease?
- Would treatment have been delayed without PCR confirmation?
- Would prolonged neurologic recovery have changed with alternative treatment strategies?
- Were additional autonomic manifestations present but underreported?
Frequently Asked Questions
Can Lyme disease cause transverse myelitis?
Yes. Case reports describe Lyme neuroborreliosis presenting with spinal cord inflammation, weakness, sensory loss, and autonomic dysfunction.
What symptoms suggest transverse myelitis in Lyme disease?
Symptoms may include weakness, gait problems, numbness, bowel dysfunction, bladder dysfunction, sensory changes, and abnormal reflexes.
Can Lyme testing be negative in neurologic Lyme disease?
Testing may occasionally be challenging. Clinical history, examination findings, spinal fluid studies, imaging, and exposure history may all contribute to diagnosis.
Does autonomic dysfunction occur with Lyme myelitis?
Yes. Bowel dysfunction, urinary retention, and neurogenic bladder may reflect involvement of autonomic pathways.
Can transverse myelitis from Lyme disease be permanent?
Recovery varies. Some individuals improve substantially after treatment, while others may experience persistent neurologic or autonomic symptoms.
What tests help diagnose Lyme myelitis?
Diagnosis may involve neurologic examination, MRI imaging, spinal fluid analysis, Lyme testing, exposure history, and evaluation for alternative causes of myelitis.
Can Lyme disease cause urinary retention?
Yes. Neurologic Lyme disease involving the spinal cord or autonomic nervous system may contribute to urinary retention, bladder dysfunction, or bowel symptoms in some cases.
Clinical Takeaway
Acute transverse myelitis is an uncommon but important neurologic manifestation that may occur in Lyme disease.
Spinal cord involvement may lead to weakness, sensory changes, gait impairment, and autonomic dysfunction affecting bowel and bladder function.
Spinal cord inflammation, autonomic dysfunction, and progressive neurologic symptoms following tick exposure warrant careful evaluation because early recognition may influence recovery.
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References
- Dumic I, Vitorovic D, Spritzer S, Sviggum E, Patel J, Ramanan P. Acute transverse myelitis – A rare clinical manifestation of Lyme neuroborreliosis. IDCases. 2019;15:e00479.
- Kenney MJ, Ganta CK. Autonomic nervous system and immune system interactions. Compr Physiol. 2014;4(3):1177-1200.
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
Dr. Daniel Cameron, if you could get any test or sequential tests what would they be? as a practicer is the patient presentation stronger evidence then done testing? Ty Eric
There are a wide range of tests being developed. I hope they help.
Thank you for all the interesting article’s–I learn from them.
Your patient,
Andrea Jackson- Massachusetts.
Thanks for all your support.