Lyme Disease (& W/U of Facial Palsy)

Residence in, or travel to, endemic area in tick season:
   — Northern VA, MD, DL, NJ, PA, eastern NY, New England; WI, MN
  • Forests
  • Also suburbs of Boston, NYC, Phila.
  • mid-May to late-July
   ** rarely  occurs elsewhere in US
   ** epidemiology in Europe is different
 
CN7 Palsy occurs during the “Early Disseminated” Stage:
  • Mid-June to Dec.
SYMPTOMS
**  Seek Erythema Migrans rash (or Hx thereof in June through August)
**  Bilateral Palsy is certainly Lyme in endemic area
**  Other Sx of “Early Disseminated Lyme”:
  • Migratory Arthralgias
  • Conjunctivitis
  • Multiple Erythema Migrans lesions
  • Meningeal Sx (H/A, stiff neck)
  • Radiculopathy / Peripheral neuropathy
  • Cerebellar Ataxia (rare)
  • Carditis (A-V Block, often asymptomatic)
** Should Obtain EKG for heart block
  • Long 1° (>300 msec), any 2° or 3°, need CCU & IV Tx
DIAGNOSIS:  Antibodies to Borrelia burgdorferi (ELISA / IFA; Western Blot)
  • If negative = No Lyme Disease
  • If positive: confirm with Western Blot IgM and IgG
    IgM is diagnostic of “Early Disseminated Lyme”
  • Note  —  Many residents of endemic areas are IgG Pos. from prior asymptomatic infection

WHO TO TREAT ORALLY (vs.  I.V.)

* Isolated CN7 Palsy can get p.o. Tx
  • Non-specific arthralgias, conjunctivitis, mild HA still OK
* Severe headache / Severe stiff neck warrant LP
  • Maybe most useful to R/O other illnesses
  • Lyme CSF:  ↑ lymphs (~90%, median count 160), ↑ protein
  • BUT Early Lyme w/o neuro involvement may have abnl CSF
  • Uncertain if IV Tx is better than p.o. in aseptic meningitis

* Other Neuro Sx (radiculopathy, ataxia, neuropathy) probably warrant IV.

Dx & Treat Facial Palsy for Lyme Empirically:
  • Children
  • Other Sx “Early Disseminated” above

If awaiting antibody results, Tx for idiopathic “Bell’s” while pending

SEE ALSO —  Our overview of Lyme Disease (with pix) and posting Bell’s Palsy.

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