Uncommon Neuro-Ophthalmologic Findings in Pediatric Lyme Disease

Lyme disease (LD) is the most prevalent tick-borne illness in the United States and Europe, caused by a spirochete transmitted through the bite of an infected Ixodes tick. In this report, we present a case of disseminated Lyme disease in a four-year-old female who presented with constitutional symptoms and a recurrent, migratory erythema migrans-like rash for one month. The subsequent onset of eye deviation and vision complaints prompted referral, which revealed bilateral optic nerve edema and a left abducens nerve (CN VI) palsy. Cerebrospinal fluid analysis demonstrated an elevated Lyme antibody index, pleocytosis, and an elevated intracranial pressure of 40 cm H₂O. These findings are consistent with Lyme neuroborreliosis based on European Federation of Neurological Societies (EFNS) guidelines. The patient was treated with prednisolone eye drops, ceftriaxone, acetazolamide for intracranial hypertension, and doxycycline. Follow-up examination demonstrated clinical resolution of CN VI palsy and papilledema. This case highlights the importance of maintaining a high index of suspicion for Lyme disease in pediatric patients with neurologic or ocular symptoms following systemic or dermatologic findings suggestive of early Lyme disease. The rapid improvement of uncommon ocular manifestations further illustrates the potential role of timely inpatient evaluation and therapy.