Nicholas M. Tranchitella, MD
Resident Physician
UPMC
Pittsburgh, Pennsylvania, United States
Jesse Champi, MD
Resident Physician
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States
Mary Ann Miknevich, M.D.
Clinical Assistant Professor / Associate Residency Program Director, Dept. of PMR
University of Pittsburgh Medical Center (UPMC)
Pittsburgh, Pennsylvania, United States
Lyme Neuroborreliosis
Case Description:
An independent 72-year-old male presented to his physician with diffuse back pain, anorexia, and severe constipation for one month. A metabolic workup revealed hyponatremia to 122, requiring hospitalization and treatment with colonoscopy-guided disimpaction and fluid restriction. While hospitalized, he developed numbness and tingling in a stocking/glove distribution but was discharged when sodium normalized. He then developed asymmetric pain, numbness, and weakness affecting his right face and contralateral trunk. Further workup was notable for Lyme serum antibodies, and he was started on doxycycline. Upon referral for electrodiagnostic testing (EDx), physical examination was significant for four-limb hyporeflexia and notable trunk weakness requiring a walker to ambulate. EDx revealed active denervation in the bilateral thoracic and lumbar paraspinals and reduced sensory nerve action potential (SNAP) amplitudes in the lower extremities, consistent with thoracolumbar polyradiculopathy and diffuse axonal sensory polyneuropathy.
Discussions:
The differential diagnosis for asymmetric truncal and extremity neurologic symptoms includes diabetic polyradiculopathy, lumbosacral plexopathy, critical illness neuropathy, mononeuritis multiplex, and acquired polyradiculopathy, such as Lyme neuroborreliosis (LNB). This patient’s presentation was a rare form of LNB, with evidence of early constipation, back pain, hyponatremia, and subsequent asymmetric facial, truncal, and extremity neurologic symptoms. EDx classically shows a primarily axonal polyneuropathy with reduction in SNAP amplitudes and conduction velocity, often with active denervation throughout the paraspinal musculature consistent with polyradiculopathy, as seen in this patient.
Conclusions:
LNB can manifest with rare patterns of lab abnormalities and neurologic symptoms. EDx is important to narrow the differential and can show polyradiculopathy as well as length-dependent polyneuropathy. LNB is confirmed with positive serum Lyme antibody titers and is treated with doxycycline. As physiatrists, LNB is an important form of acquired polyradiculopathy to keep on the differential, as early diagnosis limits chronic disease progression, permanent neurologic symptoms, and loss of function.
