Neuroborreliosis Presenting as Guillain-Barré Syndrome

Abstract

Lyme disease (LD) is the most common vector-borne disease in the United States. The early localized disease presents with erythema migrans and nonspecific constitutional symptoms. A neurological manifestation of LD (neuroborreliosis) is only seen in 10-15% of LD cases, and it typically presents as cranial neuritis or painful radiculitis. We report a case of a 33-year-old male who presented with progressive ascending bilateral lower extremities weakness with paresthesia in hands and feet following an upper respiratory tract infection and an abdominal rash. Cerebrospinal fluid (CSF) analysis revealed albuminocytologic dissociation. An electrodiagnostic study showed prolonged distal motor latency, conduction block, and absent F-wave response. Magnetic resonance imaging of the lumbar spine revealed enhancement of the cauda equina nerve roots. After a lack of improvement with intravenous immunoglobulin for presumed Guillain-Barré syndrome (GBS), Lyme serologies were sent and showed positive Lyme antibodies in serum and CSF as well as positive western blot IgM followed by IgG seroconversion a week later. The patient was started on IV ceftriaxone and doxycycline for four weeks with significant improvement in his symptoms. This is a rare case of LD presenting as GBS. Lyme can have diverse neurologic manifestations and should be considered in the differential diagnosis of GBS in the appropriate settings.

Keywords: albuminocytologic dissociation; ascending paralysis; borrelia burgdorferi; demyelination; guillain-barré syndrome; guillain-barré syndrome (gbs); lyme disease; neuroborreliosis; tick; western blot.

Figure 1. Magnetic resonance scan of the lumbar spine (T1 weighted)

Diffuse nerve root enhancement of the cauda equina with mild thickening. A: sagittal pre-contrast; B: sagittal post-contrast.

Figure 2. Motor nerve conduction study

Prolonged distal motor latency in the left peroneal motor study with conduction block in the left median and ulnar nerves. APB: abductor pollicis brevis; ADM: abductor digiti minimi; EDB: extensor digitorum brevis; NCS: nerve conduction study.

Figure 3. F-wave responses

Absence of left peroneal, tibial, and median F-wave responses after repetitive supramaximal stimulations.

Figure 4. Axial brain MRI (contrast-enhanced T1-weighted) using cranial nerve protocol

Multifocal abnormal cranial nerve enhancement involving cranial nerve III bilaterally (A and B) as well as cranial nerves VII/VIII in the internal auditory canals (C and D).