Definite neuroborreliosis with atypical antibody-profiles: a case report

According to European Academy of Neurology guidelines, a positive Borrelia burgdorferi antibody index is required for diagnosing definite Lyme neuroborreliosis. Exceptions to the typical antibody production may be seen in the earlier phases of Lyme neuroborreliosis and in immunocompromised patients with Lyme neuroborreliosis, which can present diagnostic challenges.

We present four Norwegian immunocompetent patients (three male patients aged 52, 61 and 64 years old and one female patient aged 52 years) with neurological symptoms typical of Lyme neuroborreliosis and pleocytosis but a negative or incalculable Borrelia burgdorferi antibody index. A positive PCR for Borrelia burgdorferi DNA in cerebrospinal fluid confirmed the diagnosis of Lyme neuroborreliosis for all four patients.

Our cases demonstrate that Lyme neuroborreliosis patients with symptom duration for several weeks and a well-functioning immune system can present with atypical antibody profiles. Consequently, we suggest that in cases with pleocytosis and symptoms compatible with Lyme neuroborreliosis but negative Borrelia burgdorferi antibody index, one should consider supplementary laboratory testing to confirm the diagnosis.