Lyme Neuroborreliosis With Acute Encephalopathy Despite Early Antibiotic Therapy: A Case Report

BACKGROUND Lyme disease is a tick-borne infection caused by spirochetes of the Borrelia burgdorferi sensu lato species complex (Bb). Lyme neuroborreliosis occurs in up to 15% of untreated Lyme disease cases and most commonly presents with painful radiculitis, cranial nerve palsy, and meningitis; progression to encephalitis occurs in approximately 3.3% to 9% of cases. Lyme neuroborreliosis can develop despite appropriate antibiotic therapy of early Lyme disease. Diagnosis of Lyme neuroborreliosis is based on a combination of compatible neurological symptoms, serologic evidence of Lyme disease, and cerebrospinal fluid (CSF) abnormalities, which can include measurement of a Bb CSF: serum antibody index. CASE REPORT We describe an 84-year-old man who developed acute encephalopathy after removal of a dead tick from under his right eyelid. Initial symptoms included periorbital swelling and right-sided facial nerve palsy. Early treatment with doxycycline was completed. His illness subsequently progressed to encephalopathy, characterized by agitation, hallucinations, and ataxia. Diagnostic evaluation revealed CSF lymphocytic pleocytosis, positive Lyme serologies, and cranial nerve enhancement on magnetic resonance imaging. The patient improved following treatment with ceftriaxone followed by a 21-day course of doxycycline, and received a diagnosis of probable Lyme neuroborreliosis. Anti-GFAP-1 antibodies were detected in CSF, but were believed to be non-contributory given clinical recovery in the absence of immunomodulatory therapy. CONCLUSIONS This case highlights a rare presentation of probable Lyme neuroborreliosis complicated by acute encephalitis despite early doxycycline treatment. The need for specific CSF testing is underscored along with the difficulties in diagnosis even with ideal testing.