THE TRAVELLING TICK: NEUROLOGICAL MANIFESTATIONS IN LATE TICK-BORNE ILLNESS P Devulapalli, MD, C Michael, MD, O Alawale, MD Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA
INTRODUCTION Infections caused by Borrelia burgdorferi, predominantly seen in the Northeast, are categorized into three main stages: early localized, early disseminated, and late. Depending on the stage, various organ involvements are seen, including the skin, joint, cardiac, and nervous systems. Specifically, Lyme meningitis can manifest as headaches, neck stiffness, and visual impairment. CASE: A 45-year-old woman with type II diabetes mellitus and hypertension initially presented for evaluation by Ophthalmology, given complaints of progressively worsening blurry vision for the past two years. The patient noted over the past few months, she had developed bilateral peripheral vision loss, intermittent headaches, lightheadedness, and photophobia. MRI of the Head-Orbits was obtained to investigate her painless vision loss and showed scattered punctate nonspecific T2 hyperintensities of the bifrontal subcortical white matter. Given the patient’s age this was less likely to be microvascular ischemic changes, and the distribution of the lesions was not typical of demyelinating disease. It was recommended that vasculitis and Lyme disease be ruled out, for which the workup included: ANA, ANCA, CBC, ESR, CRP, CMP, FTA- Abs, RPR, Echo, Carotid doppler, LP, and Lyme antibodies. Though the vasculitis workup was negative, the Lyme IgM western blot was positive. On referral to Infectious Disease, the patient admitted to a tick bite in 2016 while living in rural Shreveport, Louisiana, and was uncertain of treatment. Of note, physical findings were negative for Brudzinski and Kernig signs. Subsequently, the lumbar puncture was consistent with Lyme meningitis with pleocytosis. The patient was treated for four weeks with intravenous ceftriaxone. DISCUSSION: Despite Lyme disease being a rare condition in the Southern states, this case emphasizes the importance of keeping Lyme meningitis as a possibility. Given the majority of patients develop skin manifestations, rarely does Lyme meningitis present solely as a neurological manifestation. While symptoms can be very nonspecific, CSF findings can be just as variable, prompting focus on the less abrupt onset of symptoms and findings of pleocytosis in CSF.
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