Single dose of doxycycline for Lyme disease led to poor outcome for 61-year-old man

Ever wonder what the outcome might be if a patient were prescribed a single dose of oral doxycycline for Lyme disease? Not so good, according to a case report by Ebner and colleagues from the Mayo Clinic in Rochester, Minnesota. [1]

In the January 2018 issue of the British Medical Journal, the authors describe the case of a 61-year-old man who complained to his primary care physician and multiple emergency room personnel that he was having severe shooting pain over his scalp, neck and back.

“The degree of discomfort from his hair moving was so extreme he elected to shave his head to provide some relief,” writes Ebner. The man also presented with non-radiating back pain and bilateral dorsal arm paresthesias.

He reported having “three distinct large circular red lesions, one with a central clearing,” writes Ebner. However, his serologic and spinal tap results were normal.

The man had been exposed to ticks, “working outside optimizing the landscape for white tailed deer,” states Ebner. He had also been exposed to at least 30 ticks in 1 day, but did not recall a tick bite.

The initial doctors did not prescribe the treatment regime of at least 3 weeks of antibiotics, as recommended by both the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS).

Instead, the man was prescribed a single dose of doxycycline 200 mg. And physicians attempted to manage his symptoms with pain medications. “He had been up-titrated on gabapentin with minimal response and started on a narcotic for pain control,” the authors explain.

For the next 6 weeks, the man continued suffering with severe pain, worsening paresthesias, and right-sided cranial nerve VII palsy.

His repeat spinal tap was abnormal for lymphocytosis, elevation of protein, 6 oligoclonal bands, and a positive ELISA and IgG and IgM immunoblot. Physicians then diagnosed him with early Lyme neuroborreliosis and prescribed a 28-day course of intravenous ceftriaxone.

“After completion of antibiotic therapy, the patient reported feeling significantly improved,” explains Ebner. He did, however, continue to have some weakness on the right side of his face, along with intermittent back pain that was managed with gabapentin.

The 61-year-old man might have avoided 6 weeks of pain and suffering, narcotics, a repeat spinal tap, intravenous antibiotics, weakness of his face in the lower motor neuron pattern and back pain if he had been treated with at least 3 weeks of antibiotics, instead of a single dose of doxycycline.

Related Articles:

Single dose of prophylactic treatment of a tick bite only prevents a Lyme rash

Case report: persistent pain and fatigue after treatment for Lyme disease

At least 50% of patients with Lyme neuroborreliosis remain ill years after treatment


  1. Ebner D, Smith K, DeSimone D, Sohail MR. Cranial neuropathy and severe pain due to early disseminated Borrelia burgdorferi infection. BMJ Case Rep. 2018;2018.

36 Replies to "Single dose of doxycycline for Lyme disease led to poor outcome for 61-year-old man"

  • Justine
    07/19/2022 (10:07 am)

    Hello Dr. I have recently travelled back from Romania and was bitten by a tick the third day there. I went to go get tested two weeks after bitten and my tests came back negative, however I was determined to go back to testing as I started developing a rash around that area. One month after bitten I had positive result come back and went to go get treatment. The area I was in was very unaware of the risks that some ticks may carry. This made it difficult to get a doctor to prescribe me some doxycline but I was able to finally get some after a month and a half and began taking 100 mg / day. I had a total of 20 pills given however after all my research I saw the suggested 200 mg / day instead. I am on day 9 – should I begin taking 2/day now and is there anything else I should be aware of? Planning on getting a check up this week but I would greatly appreciate your opinion. Thanks

    • Dr. Daniel Cameron
      07/21/2022 (7:31 am)

      I typically prescribe 100 mg of doxycycline twice a day for a month for my patients with followup to determine response to treatment. I have had to change therapy or treat for a co-infection in some patients. Finally, I also assess them for other illnesses unrelated to a tick.

  • George Dunn
    06/29/2021 (12:07 am)

    Hi Dr. C!

    I was bit by a tick, never saw the actual tick but shortly thereafter developed the bulls eye rash. I also had high fever (105) and chills and thought it was COVID. At the ER, the infectious disease doctor told me that I had classic Lyme, as I had the rash and it was estimated that I was bit about a week ago. IgM test confirmed it.
    I was immediately started on 100mg of Doxy twice a day for 4 weeks. I was asymptotic on day 3 of Doxy.

    Do you have confidence in the 30 day 100mg x 2 times a day regimen?

    I ask because I have a work colleague who is challenging me to step up to the 8 week of Doxy 200mg x twice a day regimen, which is what he was prescribed for his bite a few years back.

    Thank you


    • Dr. Daniel Cameron
      06/29/2021 (6:51 am)

      I have Lyme disease patients who have remained well after 4 weeks of doxycycline. I advise my patients to return at 4 weeks before completing treatment to evaluate how they are responding to treatment and to evaluate for other tick borne co-infections. Researchers have not typically evaluated than 4 weeks of treatment. I have treated longer than a month on a case by case basis with success.

  • Wendy Marino
    06/10/2021 (2:28 pm)

    I’m a bit confused and pretty concerned. Should I take 200mg of doxycycline Hyclate up to 72hrs after bite (that would be late tonight) under these conditions? —I had what looks exactly like a nymph or larve black legged tick (deer) (poppy seed size) bite that I removed fairly easily from my back. It did not look look engorged and got the whole thing out intact. Bite site is itchy and small pink raised bump. I had been mowing and believe was only on there for 8 or so hours or less. I sent it off for testing today. I am confused bc further testing may not be accurate if I take it, yet really want to prevent anything if possible. I am in Norwalk, CT. Thank you so much!!!

  • Aaron
    03/09/2021 (12:59 pm)

    Dr. Cameron, thanks for being so vigilant in treating this often misunderstood illness. I just returned from western NC yesterday and discovered a female black legged tick feasting on my calve just under my sock. It was likely not attached for more than 36 hours but wasn’t sure to be honest. Despite knowing what to do, I panicked and pulled it off. I did get the head but not sure about the mouth (pinchers). I have sent off the tick to be tested but my doctor (friend) prescribed the single dose of 200mg doxycycline as a prophylaxis (assuming the tick was positive). Would you advise taking it now (about 24 hours post removal) or waiting for the pathology on the tick to start a more aggressive treatment. First tick bite and I’m a bit of a medical worrier. Thanks for all that you do!

    • Dr. Daniel Cameron
      03/09/2021 (5:19 pm)

      A single dose of doxycycline is effective at preventing a tick bite but not other manifestations. I typically watch or treat for 3 to 4 weeks with follow-up

      • Aaron
        03/09/2021 (5:40 pm)

        Thank you! Would it be better for me to wait for the pathology on the tick to start treatment or take the 200mg doxycycline now and wait to hear back to decide what to do next?

        • Dr. Daniel Cameron
          03/10/2021 (8:11 am)

          I advise my patients to take the doxycycline at the time of the bite they are comfortable with a single bite.

  • Dorcas Sandness
    02/14/2021 (4:42 am)

    Thank you Dr. C. I am a physician who has worked in Virginia, Mississippi, California, Indiana and Arkansas. When I first worked in Virginia around 10 years ago now, I ordered a Lyme test on a patient in the ER and the medical director laughed at me saying they didn’t have much of it there and he never ordered it. I said well, I was from Arkansas and we had it there, and the symptoms seemed consistent. Well, the test came back positive and he came and talked to me. He became proactive about changing the practice in the State and now not only do they recognize it exists, but require ER doctors to inform people about it and give them information about the lack of sensitivity of the testing. I always prescribe 3 weeks for presumed lyme with 1/2 that time with amoxicillin and 1/2 w/doxy if children. In Mississippi, I saw multiple patients with it, but again, huge denial among the Internal medicine, and even family practice population. Here in Arkansas, it depends where you work, but it can be difficult to get treatment, understanding, information and testing anywhere in the US (may be why it was published in the BMJ). I believe the hunting industry, which is huge, somehow has a role in this. Nonetheless, I have a telebusiness, now, and am happy to help if anyone is in those states, and needs care. Text or call 479 926 8000 for more information. Thank you Dr. C. I follow you closely, appreciate that you investigate and write with the patient as the first priority. Your effort and knowledge is greatly appreciated.

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