Can hyperreflexia be a symptom of Lyme disease?

Hyperreflexia is Not a Typical Symptom of Lyme Disease

Hyperreflexia is not typically associated with Lyme disease, which more commonly causes hyporeflexia or normal reflexes in its neurological manifestations. Based on current clinical guidelines, Lyme disease's neurological manifestations primarily include meningitis, cranial neuropathy (particularly facial nerve palsy), and radiculoneuropathy, which typically present with normal or reduced reflexes rather than hyperreflexia 1.

Neurological Manifestations of Lyme Disease

The neurological manifestations of Lyme disease can be categorized as:

Early Neurologic Lyme Disease

• Meningitis with headache and mild neck stiffness
• Cranial neuropathy (especially facial nerve palsy)
• Radiculoneuropathy (pain and sensory disturbances)
• Mononeuropathy multiplex

Late Neurologic Lyme Disease

• Peripheral neuropathy (typically with reduced reflexes)
• Encephalopathy with cognitive impairment
• Rarely, encephalomyelitis

Reflex Patterns in Lyme Disease

When Lyme disease affects the nervous system, the pattern typically involves:

• Normal or reduced reflexes: Particularly in cases of peripheral neuropathy or radiculopathy 1
• Asymmetric weakness: Often seen in radiculoneuropathies 2
• Axonal polyneuropathy: Characterized by distal paresthesias and often reduced reflexes 3

Hyperreflexia, which indicates upper motor neuron involvement with increased deep tendon reflexes, is not a characteristic finding in Lyme disease. Hyperreflexia is more commonly associated with:

• Multiple sclerosis
• Spinal cord compression
• Stroke
• Amyotrophic lateral sclerosis
• Other conditions affecting upper motor neurons

Diagnostic Considerations

If a patient presents with hyperreflexia and there is concern for Lyme disease:

1. Consider alternative diagnoses for the hyperreflexia
2. Look for other typical manifestations of Lyme disease (erythema migrans rash, arthritis, etc.)
3. In endemic areas, test for Lyme disease only if there are other supporting clinical or epidemiological features

The 2020 IDSA/AAN/ACR guidelines specifically recommend against routine testing for Lyme disease in patients with neurological syndromes that are not typical for Lyme disease 1.

Clinical Pearls and Pitfalls

• Key pitfall: Attributing hyperreflexia to Lyme disease may lead to missed diagnosis of the true cause
• Important consideration: If a patient has both hyperreflexia and suspected Lyme disease, investigate for two separate conditions
• Diagnostic approach: For suspected neurologic Lyme disease, use two-tier testing with ELISA followed by Western blot
• Treatment decision: Neurologic Lyme disease typically requires treatment with doxycycline, ceftriaxone, cefotaxime, or penicillin G for 14-21 days 1

In summary, while Lyme disease can cause various neurological manifestations, hyperreflexia is not typically among them. When encountering hyperreflexia, clinicians should pursue other diagnostic possibilities even in Lyme-endemic regions.