Lyme Neuroborreliosis: Manifestations of a Rapidly Emerging Zoonosis

A, Summary of reported cases of Lyme disease in the United States. There is 1 dot within the county of residence for each reported case. Note the widespread diversity of cases correlating with the prevalence of infected Ixodes species in different geographic areas. Courtesy of the Centers for Disease Control. B, The beige-shaded areas indicate the geographic distribution of recorded clinical cases of Lyme borreliosis. The colored ellipses indicate the distribution of the various Borrelia subspecies. Fig 2B is reprinted with permission from Nature Publishing Group.¹⁰⁸

Erythema migrans rash with the typical target appearance that is virtually diagnostic of Lyme disease.

Facial neuritis. A 48-year-old woman with headache and peripheral right facial palsy. Prominent enhancement of the fundal tuft and labyrinthine segment of the seventh cranial nerve on postinfusion axial T1 (A) and coronal spoiled gradient-recalled sequences (B). The patient had CSF pleocytosis, Lyme-positive EIA, and Western blot (IgM and IgG) in serum and CSF. Resolution occurred with intravenous ceftriaxone therapy.

Evolving cranial neuritis. A 71-year-old woman with headache, malaise, fever, and diplopia. Initial coronal postcontrast T1 MR imaging (A and B) with enhancing bilateral third and fifth cranial nerves. C, Nine days later, she developed left facial palsy with enhancing fundal tuft and labyrinthine and tympanic segments of the seventh cranial nerve. The patient had CSF pleocytosis with positive Lyme-EIA and Western blot in both serum and CSF and CSF Lyme PCR-negative findings. Resolution occurred with intravenous ceftriaxone therapy.

A 50-year-old woman with a history of tick bite and erythema migrans rash treated with doxycycline, who had recurrent erythema migrans rash with headache, fever, nausea, and nuchal rigidity. The patient had CSF pleocytosis with positive Lyme serum EIA and IgM Western blot and negative Lyme antibodies in the CSF. Gradual symptomatic improvement occurred following intravenous ceftriaxone therapy. There has been stable MR imaging for 5 years. Sagittal (A and B) and axial (C) fluid-attenuated inversion recovery images show arcuate and confluent subcortical white matter involvement and callososeptal interface involvement remarkably similar to that in MS, but without involvement of the periventricular white matter.

A 74-year-old man with 2-year cognitive decline and memory loss. The patient had Lyme-positive serum EIA and Western blot (IgG and IgM) and CSF pleocytosis with CSF positive Lyme IgM and IgG antibodies. The patient improved with intravenous ceftriaxone therapy. The “dot-dash” callososeptal interface (A) and periventricular distribution of involvement (B) would be routinely ascribed to a demyelinating process.

A 56-year-old woman with neck, bilateral shoulder, and bilateral arm pain. In 2 weeks, she subsequently developed left facial palsy and positive serum EIA and Western blot (IgM and IgG) and CSF Lyme IgG and IgM antibodies. Complete resolution of symptoms occurred with oral doxycycline. Postcontrast sagittal and axial T1-weighted MR images show diffuse thin uniform cervical spinal cord leptomeningeal enhancement without apparent root or ganglion enhancement.