Small fiber neuropathy in Lyme disease and COVID-19

person with neuropathy due to lyme disease rubbing their foot

Small fiber neuropathy (SFN) is a disorder that affects the small sensory cutaneous nerves, resulting in unusual sensations such as tingling, pins-and-needles and numbness. Some patients may experience burning pain or coldness and electric shock-like brief painful sensations. In most patients, these symptoms start in the feet and progress upwards.¹

Small fiber neuropathy with autonomic and sensory dysfunction has been described in Lyme disease patients. In fact, a small study suggests that SFN may be a viable biomarker of post-treatment Lyme disease syndrome, particularly for patients whose main symptoms involve sensory issues.²

In their article, “Resolution of Pain in the Absence of Nerve Regeneration in Small Fiber Neuropathy Following Treatment of Lyme Disease,” the authors describe the case of an 83-year-old woman with a 4-year history of diffuse burning pain in her face, arms, and legs, and muscle spasms in the legs.³

Lyme disease causes small fiber neuropathy in an elderly woman. Complete resolution of symptoms after antibiotic treatment.

Lyme disease testing was positive. “She was then treated with a 40-day course of oral antibiotics for Lyme disease with complete resolution of her neuropathic symptoms.”

“Painful small fiber neuropathy may be a manifestation of Lyme disease,” the authors suggest. “Antibiotic treatment of Lyme disease can result in resolution of the neuropathic pain symptoms.”

Small fiber neuropathy and COVID-19

Now, small fiber neuropathy is being recognized in patients with COVID-19.

Investigators describe the clinical presentation of SFN associated with COVID-19 in two patients.4

Patient 1

A 52-year-old man, who contracted SARS-CoV-2, developed moderate respiratory problems (shortness of breath and productive cough).

“About 3 weeks later, he began to experience burning pain in the feet that spread up to the knees that was associated with imbalance and falls,” the authors explain.

“The pain would wake him at night, impacted his functional capacity, and was associated with allodynia.” (Note: Allodynia is the experience of pain from stimuli that typically is not painful, for example, light touch.)

He was diagnosed with small fiber neuropathy based on symptoms and test results.

The patient’s symptoms were “most compatible with a small fiber-predominant sensory neuropathy unmasked by COVID-19 infection.”

His neuropathic symptoms improved with gabapentin, and a topical lidocaine cream improved his neuropathic symptoms.

Patient 2

A 67-year-old woman with a 10-year history of mild acral tingling and burning pain had been diagnosed with small fiber neuropathy associated with psoriatic arthritis, based upon biopsy results.

Her symptoms had been stable for 10 years until she contracted SARS-CoV-2 and developed severe burning pain in her hands and feet.

“She presented 6 months later with persistent symptoms and occasional orthostasis.”

Her examination and test results supported a diagnosis of small fiber neuropathy.

“This is an example of a chronic pre-morbid sensory and small fiber-predominant autonomic neuropathy exacerbated by COVID-19 infection,” the authors write.

This study was observational and “cannot draw reliable conclusions regarding causative relationships or underlying mechanisms.”

  1. Johns Hopkins Medicine. Neurology and Neurosurgery.
  2. Novak P, Felsenstein D, Mao C, Octavien NR, Zubcevik N. Association of small fiber neuropathy and post treatment Lyme disease syndrome. PLoS One. 2019;14(2):e0212222. doi:10.1371/journal.pone.0212222
  3. Resolution of Pain in the Absence of Nerve Regeneration in Small Fiber Neuropathy Following Treatment of Lyme Disease (P06.228) Naomi Feuer, Armin Alaedini Neurology Feb 2013, 80 (7 Supplement) P06.228;
  4. Shouman K, Vanichkachorn G, Cheshire WP, et al. Autonomic dysfunction following COVID-19 infection: an early experience. Clin Auton Res. Apr 16 2021;doi:10.1007/s10286-021-00803-8

7 Replies to "Small fiber neuropathy in Lyme disease and COVID-19"

  • Nicole
    09/23/2021 (7:43 pm)

    can sfn remit with antibiotics

    • Dr. Daniel Cameron
      09/24/2021 (7:50 am)

      In 1990, Logigian and colleagues described axonal sensory neuropathy in Lyme disease. some of their patients improved. I have seen some patients whose SFN has improved with antibiotics.

  • Adriana
    07/29/2021 (1:23 am)

    Yes, my daughter is dealing with severe neuropathic pain that started during treatment with antibiotics and still last after finishing. She has been prescribed with gabapentin and lipoic acid for the pain. Also she is being tested for SFN and doctors are considering IVIG as well. She still is positive for Lyme on the bands but not with the PCR. Doctors (neuro & reuma) are not sure if continuing antibiotics will benefit her at all. How long a patient should receive antibiotics when PCR is negative but bands are still positive, considering the side effects?

    • Dr. Daniel Cameron
      07/29/2021 (7:25 am)

      I often have Lyme disease patients with a negative PCR and neuropathy who do well with antibiotic treatment. I have some patients who fail antibiotic treatment for neuropathy. I ask my patients to continue working with their neurologist if their neuropathy persists. Some have benefited from IVIG.

      • ed
        08/06/2021 (3:30 pm)

        Hi dr Cameron,
        I have first the diagnose Sarcoidose, later small fiber neuropathy and 8 years later TBD.
        The TBD is a big struggle in the lyme world.

        Iam extremely tired with pain also.
        Lot of brainfog.
        Muscle pain and bone pain.
        Sleap problems.
        Dry mouth and tong. Burn mouth syndrom.

        Also are mine Interleukine very high

        Best regards,

  • Cynthia Blakemore
    07/28/2021 (2:16 pm)

    That is exactly what I am dealing with. None of my MD’s even mentioned Lyme when they were examining me. The tingling started a bit and when it was evident all the time, I got a referral to the neurologist. He called it sensory neuropathy. Said to come back in 6 months (to see if it was getting worse or not). It is continual and no, I am not going back as I can’t see how they will have a fix anyway.

  • Sue Rameaka
    07/28/2021 (1:40 pm)

    My original Lyme symptom was muscle inflammation with terrible pain in head, neck and shoulder. After months of severe pain, I was finally put on Steroids to manage what doctors thought was Polymyalgia Rheumatica (PMR). Oddly enough, the Rheumatologist took a Lyme test and it was totally CDC, all bands positive. Once, I started Doxy, and then a round of IV ceftriaxone, I developed terrible nerve pain, numbness on my left side from headaches, face, neck shoulder, back, sacro and left leg.
    Unfortunately, all the antibiotics have not relieved this neuropathy or the pain on my left side. Had Shingles twice since Lyme diagnosis which may be causing some nerve pain as well.
    Somehow, I tested positive again for Lyme and Babesia last month – no bite, no rash. I’m on second round of Doxy, Azithromycin and Atovaquone. This new treatment has intensified the nerves and I’m absolutely miserable. Maybe herxing?

    Has anyone had nerve pain that still persists after antibiotic treatment? Treatment and/or Detox?

Join the Lyme Conversation
(Note: comments are moderated. You will see your comment after it has been reviewed.)

Some html is OK