What is the recommended treatment for a patient who developed neuropathy after a tick bite several months ago without resolution in symptoms?

Treatment of Persistent Neuropathy Following Tick Bite

For a patient with neuropathy persisting several months after a tick bite, initiate a 2-4 week course of intravenous ceftriaxone for presumed late Lyme neuroborreliosis, as neurologic manifestations require parenteral antibiotics rather than oral therapy. 1, 2

Diagnostic Confirmation Before Treatment

At several months post-tick bite, prophylactic antibiotics are no longer indicated—management depends entirely on whether clinical manifestations of Lyme disease are present. 2

Serologic testing strategy:

• Use two-tier testing with ELISA followed by Western blot confirmation if positive or equivocal. 2
• At 6 months post-exposure, IgG antibodies should be present if infection occurred, as antibody responses develop over weeks. 2
• Focus on IgG results rather than IgM, as IgM antibodies may be absent at this late stage (only 10-40% positive in late disease). 2
• Do not test asymptomatic patients, as this leads to false positives and inappropriate treatment. 2

Neurologic evaluation:

• Test for Lyme neuroborreliosis if the patient presents with meningitis, painful radiculoneuritis, mononeuropathy multiplex, acute cranial neuropathies, or evidence of spinal cord inflammation. 2
• Use serum antibody testing rather than PCR or culture of cerebrospinal fluid (CSF) or serum for neurologic symptoms. 2
• CSF analysis may reveal elevated protein content or mild pleocytosis even when PCR is negative. 3

Treatment Algorithm Based on Manifestations

For confirmed Lyme neuroborreliosis:

• Administer intravenous antibiotics for 2-3 weeks: ceftriaxone, cefotaxime, or penicillin G. 2
• This applies to neurologic manifestations including peripheral neuropathy, radiculopathies, and cranial nerve palsies. 4

If peripheral neuropathy without CNS involvement:

• Consider oral doxycycline 100 mg twice daily for 28 days as an alternative to IV therapy for isolated peripheral neuropathy. 1, 2
• Amoxicillin 500 mg three times daily for 28 days or cefuroxime axetil 500 mg twice daily for 28 days are alternatives if doxycycline is contraindicated. 1, 2

Symptomatic Management

For neuropathic pain control:

• Pregabalin is FDA-indicated for management of neuropathic pain and can be used adjunctively regardless of etiology. 5
• This addresses symptom control while antibiotics target the underlying infection. 5

Critical Clinical Pitfalls

Avoid these common errors:

• Do not rely on IgM antibodies alone at 6 months, as IgM may be falsely positive or absent in late disease. 2
• Do not test the tick itself, as presence of B. burgdorferi in the tick does not reliably predict clinical infection. 1, 2
• Do not prescribe prolonged antibiotic courses for nonspecific symptoms like fatigue or fibromyalgia without objective evidence of active infection. 2
• Do not delay treatment while waiting for serologic confirmation if clinical suspicion is high, though at several months post-bite, acute treatment urgency is less critical than in early disease. 2

Alternative Diagnoses to Consider

If serologic testing is negative:

• Peripheral neuropathies may occur a long interval from tick bite and are not always preceded by other forms of Lyme disease. 4
• Consider other tick-borne infections such as rickettsial diseases, which can cause sub-acute neuropathy following tick bites with symptoms persisting 3-26 months after onset. 3
• Approximately 20% of patients with persistent symptoms after tick exposure show signs of autoimmunity, suggesting a multifactorial etiology. 6
• Co-infection with tick-borne encephalitis should be considered in endemic regions, as distal peripheral neuropathy can occur with double infection. 7

Monitoring Response to Treatment

Expected clinical course:

• Clinical improvement should be obtained after treatment with antibiotics, which confirms the diagnosis of neuroborreliosis. 4
• Lack of response to appropriate antibiotic therapy suggests either an alternative diagnosis or post-treatment sequelae requiring symptomatic management rather than additional antibiotics. 6
• Quality of life scores are typically significantly below general population norms in patients with persistent symptoms after tick exposure. 6