Lyme neuroborreliosis in a critically ill patient

Lyme neuroborreliosis (LNB) is a nervous system infection caused by the species of the spirochete Borrelia. A woman, with a history of right facial palsy, was admitted to the physical and rehabilitation medicine (PRM) unit for the rehabilitation of presumed sequalae of aneurism rupture and neuromuscular weakness related to critical illness. She presented in the PRM unit with flaccid quadriparesis, right facial nerve paresis, bulbar paresis, aphonia, dysphagia, and hypoactive deep-tendon reflexes. Electromyography (EMG) revealed multifocal neuropathy and serologic tests revealed positive for Borrelia (IgG). The patient was treated with 2 weeks of intravenous ceftriaxone with a marked improvement in the following days. LNB diagnosis was made due to the clinical presentation, positive Borrelia serology, and great improvement with targeted therapy. Neuromuscular weakness related to critical illness was the main differential diagnosis; however, weakness in bulbar and facial musculature and the EMG findings were not consistent with this diagnosis.