What are the causes and treatments of paresthesia in the face due to infectious diseases?

Lyme Disease: A Key Infectious Cause of Facial Paresthesia

Lyme disease is the most important infectious cause of facial paresthesia to consider, particularly in endemic areas, as it can cause facial nerve palsy in up to 25% of cases and requires specific antibiotic treatment for optimal outcomes. 1

Clinical Presentation of Lyme Disease with Facial Involvement

Lyme disease is caused by the spirochete Borrelia burgdorferi and transmitted by tick bites. When it affects the nervous system (neuroborreliosis), it commonly presents with:

• Facial nerve palsy: Unilateral or bilateral facial weakness/paralysis, often with associated paresthesia
• Timing pattern: Most cases occur during summer months in endemic areas 2
• Associated symptoms:
  • Erythema migrans (bull's-eye rash) in approximately 70% of patients 2
  • Systemic symptoms like fever, headache, fatigue
  • Painful radiculopathy (nerve root pain) in some patients 3
  • Meningitis symptoms (headache, neck stiffness)

Key Distinguishing Features

• Bilateral involvement: Lyme disease accounts for a high percentage of bilateral facial palsies, which are rare in Bell's palsy 4
• Seasonal pattern: Higher incidence in summer months when tick activity is highest 2
• Geographic consideration: More common in endemic areas (Northeast, Upper Midwest, Pacific Northwest in the US) 1
• Paresthesia distribution: Can affect the face and extend to limbs in a "stocking-glove" pattern in late disease 1

Diagnostic Approach

1. Clinical assessment: Thorough history focusing on:

   • Recent tick exposure
   • Presence of erythema migrans rash
   • Timing of symptom onset
   • Travel to endemic areas
   • Associated neurological symptoms

2. Laboratory testing:

   • Two-tier serologic testing (ELISA followed by Western blot) for B. burgdorferi 1
   • In endemic areas, Lyme disease serology should be performed for patients with facial paralysis 1
   • CSF analysis if meningitis is suspected (lymphocytic pleocytosis, elevated protein)

3. Neurophysiologic testing: Can help document peripheral nerve involvement and monitor treatment response 5

Treatment Protocol

Antibiotic Therapy

For facial nerve involvement in Lyme disease:

• First-line treatment: Oral antibiotics for 2-4 weeks 3

  • Doxycycline 100mg twice daily for adults
  • Amoxicillin for children or pregnant women

• For severe cases: Intravenous antibiotics (ceftriaxone) for 2-4 weeks 3

  • Particularly for cases with CSF involvement or severe neurological manifestations

Important Treatment Considerations

• Timing: Early treatment is crucial for preventing progression to late neurologic Lyme disease 1
• Corticosteroids: Unlike Bell's palsy, corticosteroids alone are not recommended for Lyme-associated facial palsy 2
• Duration: Treatment beyond 4 weeks carries substantial risk with minimal additional benefit 3
• Prognosis: Excellent recovery rate (>99%) with appropriate antibiotic treatment 4

Eye Protection

For patients with impaired eye closure due to facial nerve involvement:

• Artificial tears during the day
• Lubricating ointment at night
• Eye patch or tape to ensure complete closure during sleep 1

Potential Complications if Untreated

• Progression to late neurologic Lyme disease
• Development of peripheral neuropathy with persistent paresthesias 5
• Encephalopathy with cognitive dysfunction 1
• Post-Lyme disease syndrome with persistent symptoms despite treatment 1

Clinical Pearls

• Always consider Lyme disease in cases of facial palsy occurring in summer months in endemic areas
• Bilateral facial palsy is rare in Bell's palsy but more common in Lyme disease
• The presence of paresthesia along with facial weakness should raise suspicion for Lyme neuroborreliosis
• Antibiotics are the mainstay of treatment, and most patients recover completely with appropriate therapy

Lyme disease represents a treatable cause of facial paresthesia and paralysis that requires specific antibiotic therapy rather than the corticosteroid approach used for Bell's palsy.