To Lumbar Puncture or Not to Lumbar Puncture: A Case of Lyme Neuroborreliosis

Lyme disease is a zoonotic infection increasing in prevalence across the United States. While the recognition of its classic clinical signs is sufficient to establish the diagnosis in the early stages, the diagnosis of Lyme neuroborreliosis (LNB) may be challenging and the diagnostic approaches may have to be tailored. We report a rare case of early disseminated LNB presenting with features of Banwarth syndrome in the form of painful radiculoneuritis, motor weakness, and facial palsy in a middle-aged female who presented to an Upstate New York Hospital during summer. Lyme antibody testing was found to be positive at a level of 11.70 by enzyme immunoassay and Western Blot was IgM positive with three out of three reactive borrelial proteins. Lumbar puncture was not performed per the patient's preference. Otherwise, the laboratory workup along with MRI of the brain and cervical spine were grossly unremarkable. The patient was treated with a four-week course of oral doxycycline with resolution of all her symptoms. The diagnostic value of lumbar puncture in certain presentations of LNB remains controversial and is further discussed in this review.