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Images in Neurology
April 2009

Bilateral Facial Palsy in Neuroborreliosis

Arch Neurol. 2009;66(4):534-535. doi:10.1001/archneurol.2009.4

A 54-year-old forest worker experienced bilateral facial weakness. A few days later, he presented with an almost complete facial palsy without any disturbances of taste, hearing, or sensation. He had a marked Bell phenomenon (Figure). He was diagnosed some years before with Lyme disease without any clinical symptoms and was treated with oral antibiotics. Meanwhile, he received some new tick bites. A lumbar puncture revealed a lymphocyte count of 77/μL and an elevated protein level of 2.5 g/L. Serological testing revealed positive IgG results, a negative IgM borreliosis titer on an enzyme-linked immunosorbent assay, and multiple bands on Western blotting, suggestive of either remnants of an earlier asymptomatic contact with borrelia or a late or very recent infection with still-absent IgM antibodies. In cerebrospinal fluid, IgM antibodies were negative and the IgG antibody index was 1.4. Serological testing results for tick-borne encephalitis, listeriosis, cytomegalovirus, herpes virus, varicella-zoster virus, and human immunodeficiency virus were all negative. A cranial magnetic resonance image was normal. Lyme neuroborreliosis was clinically diagnosed and the patient was treated with intravenous ceftriaxone sodium. The symptoms gradually subsided. The only remaining symptom is the inability to play the hunting horn.