Abstract
Aim: To describe an unusual case presentation of INO associated with possible Lyme disease. Methods: This is a case report of a 30 year old man who presented to the emergency department complaining of right orbital pain, double vision and an inability to look to the left. He was seen by the ophthalmologist and neurologist and reported worsening symptoms of a frontal headache and difficulties in walking. He had a history of tick bites and a consequent rash 2 months earlier. There was no vomiting, limb weakness or fever and also no significant history of trauma. Results: On examination visual acuity was 6/9 in the eye; pupils, fundus and discs were normal. Orthoptic assessment revealed a right/alternating exotropia with diplopia and right INO was confirmed on ocular movement testing. Vertical nystagmus was also noted on upgaze. Convergence was normal. He was diagnosed with a right internuclear ophthalmoplegia with intact convergence. CT scan and MRI were normal and so he was commenced on ceftriaxone 2 mg IV once daily for probable neuroborreliosis which after 3 days was switched to oral doxycycline 100 mg for 2 weeks. Tests for Lyme disease proved inconclusive. Four weeks later the patient was reassessed and his INO had resolved. Conclusion: Diagnosis of Lyme disease should be considered for sudden onset internuclear ophthalmoplegia. Internuclear ophthalmoplegia (INO) as the first sign of neuroborreliosis is extremely rare. To our knowledge there is only one other documented case of an adult patient with an isolated INO.
Highlights
Internuclear ophthalmoplegia (INO) is a lesion of the medial longitudinal fasciculus resulting in a palsy of the medial rectus and a dissociated gaze-evoked nystagmus in the abducting eye
The neurological disorders found in Lyme disease are collectively referred to as neuroborreliosis, which occurs in two forms: the acute or early stage, and the chronic stage with symptoms persisting for more than 6 months
To our knowledge there has been only one reported case of an adult patient presenting with an isolated internuclear ophthalmoplegia as the only clinical symptom of early neuroborreliosis.[4]
Summary
Internuclear ophthalmoplegia (INO) is a lesion of the medial longitudinal fasciculus resulting in a palsy of the medial rectus and a dissociated gaze-evoked nystagmus in the abducting eye. The commonest cause of unilateral INO in the younger patient is multiple sclerosis (MS). Other causes such as tumours are rarely purely unilateral. Lyme disease is a tick-borne illness caused by spirochete Borrelia burgdoferi, first described in 1975.2,3 The disease is charaterized by a broad variety of symptoms ranging from neurological, dermatological, cardiac and rheumatological signs. Often this wide variety can lead to a late diagnosis of the disease. Diagnosis and treatment of the disease is of extreme importance as serious complications such as meningitis and encephalitis can result
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