Bilateral facial paralysis: case presentation and discussion of differential diagnosis

Bilateral facial paralysis is a rare condition and therefore represents a diagnostic challenge. We report the case of a 34-year-old healthy woman with sequential bilateral facial paralysis as a sole manifestation of sarcoidosis. She initially presented with an isolated left sided Bell's palsy without any symptoms to suggest alternative diagnoses. Within a month there was progression to peripheral facial paresis on the contra lateral side, prompting a diagnosis of Lyme disease. Her physical examination and chest x-ray did not reveal any clinical evidence of sarcoidosis. After failing to respond to an empiric trial of intravenous ceftriaxone for a presumptive diagnosis of Lyme disease, computed tomography scan of the chest was ordered which demonstrated bilateral hilar lymphadenopathy. Bronchoscopic biopsy confirmed a diagnosis of sarcoidosis. The patient then made a complete recovery on steroid therapy. We discuss the differential diagnosis of facial diplegia and focus on the clinical presentation, diagnosis and treatment of neurosarcoidosis.