Early Disseminated Lyme Disease with Multiple Cranial Neuropathy

Introduction: Lyme disease, caused by the spirochete Borrelia burgdorferi and transmitted by the Ixodes tick, encompasses a variety of symptoms across multiple stages. Early localized Lyme disease may present within 1 month of tick bite with erythema migrans, arthralgias, and fever. Disseminated infection typically occurs 3 to 12 weeks later and can cause neurologic symptoms of dizziness, headache, diplopia, cranial neuropathy, cranial nerve (CN) VII palsy, meningitis, encephalopathy, and cardiac arrhythmia or heart block. Late Lyme disease may arise after months or years and is characteristically associated with monoarticular arthritis. Among patients who have cranial neuropathy in early disseminated Lyme disease, 80% have CN VII involvement, but optic and extraocular neuropathy may occur. Clinical Findings: We describe a case of a patient in their 60s who presented with erythema migrans, headache, neck pain, and diplopia, and they were found to have right CN VI palsy. A brain magnetic resonance imaging showed diffuse enhancement of the bilateral oculomotor nerves, trigeminal nerves, abducens nerves, and CN IX/X/XI complexes; patchy enhancement of the right facial nerve; and pachymeningeal enhancement. Clinical Course: Although initial testing for Lyme disease antibodies was negative in serum and cerebrospinal fluid, a repeat serum enzyme-linked immunoabsorbent assay was positive. After a course of intravenous ceftriaxone and methylprednisolone followed by oral doxycycline, their skin lesions, headache, neck pain, and diplopia resolved. Conclusions: Lyme disease may involve multiple CNs and present with diverse neurologic symptoms, even before seroconversion occurs. Our unique case of neuroborreliosis—which presented as headache followed by diplopia, neck pain, and CN VI palsy, with diffuse CN involvement shown on magnetic resonance imaging—responded well to treatment.