Subacute Transverse Myelitis Caused by Borrelia Infection

Subacute transverse myelitis is a rare but serious neurologic complication that can occur with Lyme disease. The condition results from inflammation of the spinal cord and can be triggered by infections, including Borrelia burgdorferi, the bacterium responsible for Lyme disease.

This rare complication falls within the broader spectrum of neurologic Lyme disease, which can affect the brain, spinal cord, and peripheral nerves.

Subacute transverse myelitis damages or destroys myelin, the insulating substance that surrounds nerves in the brain and spinal cord. Immune disorders, vascular disease, and other inflammatory conditions may also trigger the syndrome.¹

Can Lyme disease cause transverse myelitis?

Although uncommon, Lyme neuroborreliosis can cause inflammation of the spinal cord resulting in transverse myelitis. In these cases, infection with Borrelia burgdorferi may trigger immune-mediated damage to myelin and disrupt nerve signaling.

Case reports have documented patients with spinal cord lesions and neurologic symptoms that improved after antibiotic treatment for Lyme disease.

Opielka reports that infectious or parainfectious causes account for approximately 12% of transverse myelitis cases. Borrelia burgdorferi is one of the infectious agents associated with the condition. However, in nearly 40% of cases the cause remains unknown.

Symptoms of transverse myelitis

Typical symptoms associated with transverse myelitis include:

• bilateral or unilateral limb weakness
• sensory disturbances
• autonomic dysfunction affecting bladder or bowel control

Approximately one-third of patients with transverse myelitis report having a febrile illness shortly before the onset of neurologic symptoms.

Diagnostically challenging case

The authors describe the case of a 23-year-old woman who was admitted to the hospital because of hand tremors and paresthesia (burning or prickling sensations) extending to her forearms. She did not exhibit upper arm weakness.

The patient also experienced severe pain in the mid-cervical region and had suffered from nausea and vertigo for three months before hospitalization.

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She experienced transient episodes of double vision when looking at distant objects and reported a two-day fever several months before admission. She did not recall a tick bite.

“The clinical presentation of our patient was diagnostically challenging,” the authors write.

The only possible indicator of a tick-borne illness was a brief febrile episode followed by symptoms of neck stiffness and pain. Additionally, a significant amount of time had elapsed between the onset of symptoms and hospitalization.

Tests indicate elevated intracranial pressure

Examination revealed bilateral papilloedema (optic disc swelling caused by increased intracranial pressure) and diffuse thickening of the retinal nerve fiber layer in all quadrants.

“Blurred optic margins and several flame-like peripapillary hemorrhages were observed in both eyes,” writes Opielka.

Nerve conduction studies revealed radiculopathy affecting the nerve roots of both peroneal nerves and the right median nerve. Sensory neuropathy was also detected in both sural nerves and the right median nerve.

Routine blood tests were normal, but Western blot testing for Lyme disease was positive.

MRI findings reveal spinal cord inflammation

MRI imaging demonstrated longitudinally extensive enlargement of the spinal cord spanning more than three segments, primarily from the C3 to C6/C7 level.

The images also showed a hyperintense spindle-shaped lesion within the central portion of the spinal cord.

An MRI of the optic nerves revealed bilateral protrusion of the optic nerve heads, slight vertical tortuosity of both optic nerves, and hyperintense perioptic nerve sheaths.

According to the authors, these findings suggested elevated intracranial pressure.

Lyme infection triggers subacute transverse myelitis

Cerebrospinal fluid (CSF) testing detected antibodies against Borrelia burgdorferi.

“The titers of anti-Bb IgM and IgG antibodies were significantly increased,” the authors write.

The patient was diagnosed with subacute transverse myelitis caused by Lyme neuroborreliosis.

She received a 28-day course of intravenous ceftriaxone and her symptoms completely resolved.

“Our patient presented typical manifestations of subacute transverse myelitis with segmental swelling and enlargement of the spinal cord,” the authors explain.

The patient also displayed a less common manifestation of Lyme neuroborreliosis—optic nerve involvement.

Clinical takeaway

When patients present with spinal cord inflammation, limb weakness, or unexplained sensory disturbances, Lyme disease should remain in the differential diagnosis, particularly in regions where Lyme disease is endemic.

Conclusion

Clinicians should consider subacute transverse myelitis when evaluating patients with suspected Lyme neuroborreliosis. Optic nerve symptoms may also accompany neurologic Lyme disease and should not be overlooked.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

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