DOI: 10.12890/2025_005034

Lyme neuroborreliosis as initial expression of Lyme disease in an elderly patient

Authors

  • Emidio Mata Department of Cardiology, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal
  • Bárbara Lage Garcia Department of Cardiology, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal
  • André Pereira Department of Internal Medicine, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal
  • Joana Rego Department of Internal Medicine, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal
  • Flávia Santos Department of Internal Medicine, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal
  • Carlos Fernandes Department of Internal Medicine, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal
  • Jorge Cotter Department of Internal Medicine, Unidade Local de Saúde de Alto Ave, Guimarães, Portugal

emidiomata@hotmail.com

Keywords

Lyme disease, Lyme neuroborreliosis, Borrelia infections, Lyme meningoencephalitis

Abstract

Background: Lyme disease (LD) is a multisystemic infection caused by Borrelia burgdorferi and transmitted by Ixodes ticks, affecting the skin, nervous system, heart and joints. Neuroborreliosis (LNB), a nervous system manifestation of LD, occurs in 10–15% of cases and may present with neurological symptoms at varying stages.
Case description: We present the case of an 84-year-old man, admitted to the emergency department following a seizure, with fever and oropharyngeal erythema. After the administration of penicillin for presumed tonsillitis, a generalised skin rash developed and spontaneously resolved after 4 hours. Within 24 hours, two well-defined round erythematous lesions were observed on the neck and shoulder. Due to new onset of confusion and lethargy a lumbar puncture was performed, revealing polymorphonuclear pleocytosis, elevated protein levels and normal glucose. An empirical ceftriaxone course was started for suspected neuroborreliosis. Neuroborreliosis was diagnosed based on the clinical presentation of fever and neurological changes, with supporting cutaneous manifestations and compatible Borrelia burgdorferi serology. The initial rash was interpreted as a Jarisch–Herxheimer reaction, and the two skin lesions were classified as erythema migrans. After completing treatment, the patient made a full recovery.
Conclusion: This case underscores the diagnostic complexity of LNB as an initial manifestation of LD, particularly in elderly patients. Early neurological symptoms, often preceding classic cutaneous signs, may lead to diagnostic delays. This highlights the importance of maintaining clinical suspicion for LD, given the limitations of serological and cerebrospinal fluid (CSF) testing. Prompt recognition and intervention are essential to prevent progression and ensure favourable outcomes.

View the entire article

Downloads

References

  1. Goldman L, Cooney KA, editors. Goldman-Cecil Medicine. 27th ed. New York: Elsevier Health Sciences; 2021.
  2. Factsheet about Borreliosis European Centre for Disease Prevention and Control [updated 6 Mar 2016]. [accessed 2024 Aug 5]. Available from: https://www.ecdc.europa.eu/en/borreliosis/facts/factsheet.
  3. Koedel U, Fingerle V, Pfister HW. Lyme neuroborreliosis-epidemiology, diagnosis and management. Nat Rev Neurol 2015;11:446–456.
  4. Santos FV, Cipriano A, Abreu MA, Andrade C, Sarmento-Castro R. Neuroborreliose Tardia num Estudante em Programa Erasmus. [Late Neuroborreliosis in an Erasmus Programme Student]. Acta Med Port 2018;31:509–511.
  5. Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s Principles of Internal Medicine. 21st ed. New York: McGraw-Hill Education; 2022.
  6. Mygland A, Ljøstad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I; European Federation of Neurological Societies. EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Eur J Neuro 2010;17:8–16, e1–4.
  7. Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Care Res (Hoboken) 2021;73:1–9.
  8. Cook MJ. Lyme borreliosis: a review of data on transmission time after tick attachment. Int J Gen Med 2015;8:1–8.
  9. Schneider C, Gielen J, Röth P, Albrecht P, Schroeter M, Fink GR, et al. Quantitative serological antibody testing for suspected neuroborreliosis. J Neurol 2020;267:1476–1481.
  10. Clinical Testing and Diagnosis for Lyme Disease Centers for Disease Control and Prevention. [accessed 2024 Aug 5]. Available from: https://www.cdc.gov/lyme/hcp/diagnosis-testing/?CDC_AAref_Val=https://www.cdc.gov/lyme/diagnosistesting/index.html.
  11. Aguero-Rosenfeld ME, Nowakowski J, Bittker S, Cooper D, Nadelman RB, Wormser GP. Evolution of the serologic response to Borrelia burgdorferi in treated patients with culture-confirmed erythema migrans. J Clin Microbiol 1996;34:1–9.
  12. Dhakal A, Sbar E. Jarisch–Herxheimer reaction 2022 [updated 24 Apr 2023]. [accessed 2024 Aug 5]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557820/.

Published

2025-01-17

Issue

Vol. 12 No. 2 (2025)

Categories

How to Cite

1.
Mata E, Lage Garcia B, Pereira A, Rego J, Santos F, Fernandes C, et al. Lyme neuroborreliosis as initial expression of Lyme disease in an elderly patient. EJCRIM [Internet]. 2025 Jan. 17 [cited 2026 Nov. 3];12(2). Available from: https://ejcrim.com/index.php/ejcrim/article/view/5034

Most read articles by the same author(s)