Multiple cranial nerve palsies as a rare manifestation of Lyme disease: A case report

Lyme disease is a common illness transmitted by ticks and caused by Borrelia bacteria. It can lead to a range of neurological symptoms known collectively as neuroborreliosis. Facial nerve palsy (CN VII) is the most common cranial nerve deficit in Lyme disease, and involvement of multiple cranial nerves is rare. A 74-year-old male with no significant past medical history presented to the emergency department (ED) with symptoms of nausea, vomiting, headache, right-sided facial droop, and diplopia. The patient denied fever, rash, neck rigidity, or extremity deficits. On examination, he exhibited right-sided facial paralysis involving the nasolabial fold, lip, eyebrow, forehead, and eyelid, alongside abducens nerve palsy (CN VI). A CT scan of the head and neck did not reveal any acute processes. The patient's differential diagnosis included posterior fossa lesion, vertebral artery dissection, stroke, multiple sclerosis, and Guillain-Barré syndrome. Given the lack a of clear etiology and the patient's presentation in an endemic area, a Lyme disease panel was ordered, which returned positive. The patient was diagnosed with neuroborreliosis and treated with intravenous ceftriaxone. An emergency physician should consider Lyme disease in their differential diagnosis for patients presenting with cranial nerve palsies after normal imaging studies. Ordering Lyme laboratory testing and initiating treatment in the ED can decrease morbidity and mortality. It is essential to distinguish between Lyme disease and Bell's palsy in patients presenting with a facial cranial nerve palsy as treatment for Lyme disease facial palsies includes antibiotics and avoidance of steroids.