P3.210: Neuroborreliosis: Don’t turn a blind eye

Introduction: Lyme disease is the most frequently transmitted tick-borne infection in the US. About 20% of patients with early disseminated Lyme disease present with neuroborreliosis. For pediatric patients presenting with neurologic complaints, Lyme testing is often required to exclude differential diagnosis.

Case Description: A 12‐year‐old male presented with diplopia and abnormal eye movement. About two weeks before this presentation, the patient reported abdominal pain, nausea, vomiting, fever, neck stiffness, and headaches. He developed diplopia a few days later with associated periorbital erythema and edema. All symptoms subsided except for the headaches and diplopia. The patient was from Illinois and traveled to Ohio for an outdoor summer camp. He did not recall any tick bites. On admission, his neurological exam was notable for loss of right eye abduction. On skin exam, he had multiple erythematous annular macules on the bilateral arms and left chest. Initial labs, including CBC, BMP, and liver panel, were unremarkable. MRI findings showed thickening and abnormal enhancement of the visualized cisternal segments of the bilateral cranial nerves II, V through X, and flattening of bilateral optic discs suggestive of papilledema. His history, presentation, and recent travel prompted Lyme IgM and IgG testing, which were both positive and led to the diagnosis of early disseminated Lyme disease. He completed a 21-day course of doxycycline with mild persistent right eye symptoms and was prescribed a second 21-day course of doxycycline with resolution of diplopia and headaches.

Discussion: In 2022, approximately 63,000 cases of Lyme disease were reported to the US Centers for Disease Control and Prevention. Children are more likely exposed to Lyme disease due to low adherence to protective measures. The clinical course of Lyme disease is divided into three stages. Stage II, early disseminated Lyme disease, occurs 3 to 10 weeks after a tick bite. Clinical features can include multiple erythema migrans lesions, neurological symptoms, migratory arthralgia, or cardiac symptoms. During this stage, Lyme testing is often required to exclude differential diagnosis. About 20% of patients present with neuroborreliosis. Pediatric neuroborreliosis presents predominately with facial nerve palsy and subacute meningitis. Although neuroborreliosis rarely presents with oculomotor nerve palsies, the abducens nerve is affected in 3% of all cases. The gold standard for definitive diagnosis of neuroborreliosis is the detection of anti-Borrelia burgdorferi IgM and IgG in the CSF. MRI can assist in localizing the pathology and the extent of inflammation.

Conclusion: Diagnosing Lyme disease can be challenging as symptoms can be similar to other common childhood diseases and have a wide variety of neurologic complaints. This case highlights a unique presentation of oculomotor nerve palsies as the main clinical manifestation of neuroborreliosis and emphasizes the importance of considering Lyme disease in pediatric patients who present with neurological symptoms.