Can Lyme disease cause acute neurological sequelae?

Acute Neurological Sequelae of Lyme Disease

Yes, Lyme disease can cause significant acute neurological sequelae, including meningitis, cranial neuropathy (especially facial nerve palsy), and radiculopathy, which typically occur within weeks to months after initial infection. 1

Common Acute Neurological Manifestations

Peripheral Nervous System Involvement

• Cranial neuropathies: Most commonly facial nerve palsy (unilateral or bilateral)
• Radiculopathy: Sharp radiating pain along nerve roots
• Mononeuropathy multiplex: Multifocal involvement of anatomically unrelated nerves 1, 2

Central Nervous System Involvement

• Lymphocytic meningitis: Characterized by headache, neck stiffness, and photophobia
• Encephalomyelitis: Rare but serious parenchymal inflammation of brain and/or spinal cord 1
• Increased intracranial pressure: May present with papilledema or sixth cranial nerve palsy 1

Diagnostic Approach

1. Serological testing:

   • Two-tier testing with ELISA followed by Western blot
   • Most patients with neurologic Lyme disease are seropositive 1, 2

2. CSF analysis when CNS involvement is suspected:

   • Lymphocytic pleocytosis (typically <10% polymorphonuclear leukocytes)
   • Elevated protein
   • Evidence of intrathecal antibody production to B. burgdorferi 1

3. Clinical differentiation from viral meningitis:

   • Lyme meningitis patients typically have:
     • Longer duration of illness (median 17 days vs 2 days)
     • Less likely to be febrile
     • Often have concurrent erythema migrans, cranial nerve palsy, or papilledema 1

Treatment of Acute Neurological Lyme Disease

Meningitis or Radiculopathy

• Adults: Ceftriaxone 2g IV once daily for 14 days (range 10-28 days) 1
• Alternatives:
  • Cefotaxime or penicillin G IV
  • Doxycycline 200-400 mg/day in 2 divided doses orally for 10-28 days (for β-lactam intolerant patients) 1, 2

Children

• Preferred: Ceftriaxone or cefotaxime IV
• Alternative: Penicillin G IV
• For children ≥8 years: Doxycycline 4-8 mg/kg/day in 2 divided doses (max 100-200 mg per dose) 1

Isolated Cranial Nerve Palsy

• Can be treated with oral antibiotics (same as for erythema migrans)
• Recovery rates appear similar regardless of treatment 1

Special Considerations

Management of Increased Intracranial Pressure

• While intracranial pressure typically responds to antibiotic therapy, additional measures may be needed:
  • Serial lumbar punctures
  • Corticosteroids or acetazolamide in select cases
  • CSF shunting (rare cases with vision loss) 1

Treatment Response

• Headache, stiff neck, and radicular pain typically begin to subside by the second day of therapy
• Complete resolution of symptoms often occurs within 7-10 days of treatment initiation 3
• Motor deficits may take longer to resolve (approximately 7-8 weeks) 3

Pitfalls and Caveats

1. Diagnostic challenges:

   • Neurologic manifestations can be nonspecific; laboratory support for diagnosis is required in the absence of erythema migrans 1
   • Consider convalescent serology in initially seronegative patients with strong clinical suspicion

2. Treatment considerations:

   • Doxycycline is contraindicated in pregnancy, lactation, and children <8 years 1, 4
   • Duration of therapy (10-14 days) has been associated with favorable outcomes; longer courses are generally unnecessary 1

3. Consider coinfections:

   • Evaluate for coinfection with Babesia microti or Anaplasma phagocytophilum in patients with:
     • More severe initial symptoms than typical for Lyme disease alone
     • High-grade fever persisting >48 hours despite appropriate antibiotics
     • Unexplained leukopenia, thrombocytopenia, or anemia 1, 4

Early recognition and appropriate treatment of neurological manifestations of Lyme disease are essential to prevent progression to chronic neurological complications and improve patient outcomes.