ABSTRACT
Lyme disease is a tick-borne bacterial infection caused primarily by three pathogenic species of spirochete Borrelia (B. burgdorferi, B. afzelii, and B. garinii). It has a wide range of clinical manifestations ranging in severity. Although, it is generally divided into three phases: early localized, early disseminated, and late disease. Certain cases do not follow the same order described in standard books like Harrison's. Thus, it is vital to establish a chronological timeline when establishing the diagnosis. Here, we describe a 25-year-old female with numbness and tingling that began in her torso and then spread to her entire body. Physical examination revealed diminished motor reflexes and power, but the diagnosis of neuroborreliosis with monoradiculitis was only established with positive laboratory antibody evaluation and lumbar puncture. The patient's symptoms resolved quickly with a four-day inpatient course of IV ceftriaxone followed by 10 days of oral doxycycline.
ABSTRACT
Lyme disease, caused by a tick-borne spirochete, Borrelia burgdorferi, is the most common vector-borne disease in the United States. Clinical manifestations can include erythema migrans, carditis, facial nerve palsy, or arthritis. A rare complication of Lyme disease is hemidiaphragmatic paralysis. The first case of this complication was documented in 1986, and since then, there have been 16 case reports associating hemidiaphragmatic paralysis with Lyme disease. This is a case of a patient found to be in atrial flutter likely resulting from left hemidiaphragmatic paralysis as a complication of Lyme disease. The patient was a 49-year-old male recently diagnosed with Lyme disease who was treated with a 10-day course of doxycycline and who presented with dyspnea and chest pain. He appeared in acute distress with tachypnea and tachycardia to 169 beats/minute but was not hypoxic. Electrocardiogram (EKG) showed atrial flutter with a rapid ventricular response (RVR). The patient was sent to the emergency department and was treated with intravenous (IV) metoprolol, followed by an IV diltiazem drip, and ultimately converted to normal sinus rhythm. Chest X-ray demonstrated an elevated left hemidiaphragm. Due to concern for Lyme carditis causing tachyarrhythmia, the patient was started on IV ceftriaxone 2 g daily. A transthoracic echocardiogram showed no valvular abnormalities and a normal ejection fraction, thus indicating a low likelihood of carditis. The patient was transitioned to oral doxycycline for an additional 17 days. During the hospital course, a fluoroscopic chest sniff test confirmed the left hemidiaphragmatic paralysis. A chest X-ray completed after two months showed persistent elevation of the left hemidiaphragm and the patient continued to have mild dyspnea. The main lesson from this case is to consider hemidiaphragmatic paralysis as a possible complication of Lyme disease.
ABSTRACT
Lyme disease is a zoonotic infection increasing in prevalence across the United States. While the recognition of its classic clinical signs is sufficient to establish the diagnosis in the early stages, the diagnosis of Lyme neuroborreliosis (LNB) may be challenging and the diagnostic approaches may have to be tailored. We report a rare case of early disseminated LNB presenting with features of Banwarth syndrome in the form of painful radiculoneuritis, motor weakness, and facial palsy in a middle-aged female who presented to an Upstate New York Hospital during summer. Lyme antibody testing was found to be positive at a level of 11.70 by enzyme immunoassay and Western Blot was IgM positive with three out of three reactive borrelial proteins. Lumbar puncture was not performed per the patient's preference. Otherwise, the laboratory workup along with MRI of the brain and cervical spine were grossly unremarkable. The patient was treated with a four-week course of oral doxycycline with resolution of all her symptoms. The diagnostic value of lumbar puncture in certain presentations of LNB remains controversial and is further discussed in this review.