Lyme Neuroborreliosis: A Diagnostic Headache

Abstract

Case 1: A 4-year-old girl presented to our emergency department (ED) during the height of summer with 5 days of left-sided facial droop, which spared the forehead. The patient also complained of severe fatigue, 1 week of frontal headaches, urinary retention, intermittent erythematous rash around her eyes and behind her knees, and an increase in night terrors. Three days before admission, she was seen by her pediatrician, who sent Lyme serologies and empirically started amoxicillin given that the patient lived in an endemic area. She notably had no known history of tick bite or rash. Lyme serologies returned negative, so the patient was referred into our ED. The patient had 2 previous admissions to the neurology service 2 weeks and 3 weeks before the current presentation. The first presentation was for complaints of fever, urinary dribbling despite normal fluid intake, and bilateral lower extremity pain and weakness. Laboratory data including complete blood cell count (CBC) were within normal limits except for mildly elevated inflammatory markers of erythrocyte sedimentation rate of 32 mm/h and C-reactive protein (CRP) of 2.6 mg/dL. The patient improved overnight with supportive care, and the patient’s symptoms were attributed to a viral process. Outpatient lumbar magnetic resonance imaging (MRI) was scheduled to evaluate for tethered cord, and the patient was discharged. The next week, the patient presented for her second admission with cough, fatigue, intermittent urinary dribbling and retention, and an erythematous rash around her eyes. Inflammatory markers were slightly improved (erythrocyte sedimentation rate 27 mm/hr, CRP 0.8 mg/dL). Lumbar MRI was normal. The patient again improved with supportive care and was discharged with a diagnosis of a viral upper respiratory infection. There was particular concern on the patient’s third presentation given her continued fatigue, urinary retention, and new-onset headaches and night terrors. Physical examination in the …