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.