1157

Abstract

Case Reports: A 46 year old male with no medical history was brought to the emergency room for evaluation of confusion. He had recent head aches and on day of presentation became combative. On arrival, he was very aggressive and biting requiring restrains and intubation. Initial concern was for drugs of abuse but testing was negative. Family noted recent contact with bats causing concern for rabies. Lumbar puncture(LP) found 370 WBCs with 98% lymphocytes, normal glucose, and high protein. He was initially placed on broad spectrum anti-microbials including acyclovir, doxycycline, and rabies immunoglobulin and vaccine. Family also reported tick and mosquito exposures so Arboviruses, West Nile, and tickborne diseases were also considered. The health department was contacted for possible rabies infection. Nape of neck skin biopsy, saliva, blood, and CSF fluid were sent to the CDC for rabies testing. Head MRI was normal. All blood, CSF cultures, and rabies testing were negative except for Lyme IgM serologies. Diagnosis of severe Lyme encephalomenigitis was made and antibiotics were changed to ceftriaxone. With therapy, repeat LP showed improved pleocytosis and protein counts. His mental status improved and was extubated. He was discharged at baseline mental status with a thirty day course of ceftriaxone. Lyme disease is a tickborne illness caused by spirochetes of the genus Borrelia. In the U.S., most cases are due to B. burgdorferi. All pathogenic species: B. burgdorferi, B. afzelii, and B. garinii occur in Europe[1]. It is very rare for Lyme disease to cause acute encephalomenigitis in the U.S. which is more common in Europe caused by B. garinii[2]. Our case is unique as he had no skin or rheumatologic signs of Lyme disease, only neurologic manifestations. This case emphasizes the importance for ICU physicians to take a detailed history and be aware of uncommon presentations of Lyme disease.