Hello, and welcome to another Inside Lyme Podcast. I am your host Dr. Daniel Cameron. In this episode, I’ll be discussing a case involving a man in his 70’s who had an abrupt onset of involuntary body movements, including jerks in his left arm. The man was initially dismissed as having a functional disorder, when in fact, his involuntary body movements was due to Lyme disease.
Li and colleagues described this case, entitled “Lyme neuroborreliosis presenting as spinal myoclonus” in the journal BMJ Case Rep.. [1]
While visiting the Czech Republic, the man developed a large round erythematous rash on his left arm. He also removed a tick from his thigh. Doctors prescribed amoxicillin and the rash resolved within 3 days.
Three weeks later, the man was evaluated at a clinic in Canada for radicular pain down his left arm. His symptoms progressed, which included involuntary body movements in multiple limbs. “Within 1 week, these jerks progressed to his contralateral arm and bilateral legs as well as the trunk, consistent with propriospinal myoclonus,” the authors explain.
Propriospinal Myoclonus (PSM) is an extremely uncommon movement disorder characterized by myoclonic jerks, writes Verma and colleagues,2 adding that “PSM has sometimes been dismissed as psychogenic in some cases.”
Multiple Emergency Room Visits
The man, who presented to multiple emergency rooms, was given Pregabalin to treat his pain. Doctors diagnosed the patient with a functional disorder.
During this third visit to the emergency room, the man was finally diagnosed with Lyme disease. Laboratory tests were positive for Lyme disease by IgM EIA and Lyme IgM Western blot.
He subsequently tested positive for Borrelia afzelli. His spinal tap revealed an elevated protein with a lymphocytic pleocytosis. His MRI showed abnormal patchy cauda equina nerve root enhancement and anterior spinal cord enhancement at C5–C6.
The patient was treated successfully for Lyme disease with 7 weeks of oral and intravenous antibiotics.
This is not the first case of propriospinal myoclonus. Propriospinal myoclonus was described in a 60-year-old woman following a tick bite and erythema migrans, the authors write. However, a spinal tap later revealed she was positive for Borrelia burgdorferi antibodies.
Editor’s note: This is a good example of a Lyme disease patient being dismissed as having a psychogenic or functional disorder instead of being recognized as involuntary body movements lyme disease. The authors published a photo of the rash which was clearly a typical erythema migrans (EM) rash. The initial 3-day course of antibiotics would not be expected to be effective in treating Lyme disease.
The following questions are addressed in this episode:
- What is radicular pain?
- Can involuntary body movements be a symptom of Lyme disease?
- The patient was treated briefly for the rash. Your thoughts?
- What is propriospinal myoclonus?
- This movement disorder is often dismissed as a psychogenic illness?
- What is the significance of a diagnosis of psychogenic illness?
- The patient wasn’t diagnosed with Lyme disease until his 3rd ED visit?
- How do you interpret the laboratory tests?
- What are your thoughts about this patient’s treatment?
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- Thanks for listening to another Inside Lyme Podcast. You can read more about these cases in my show notes and on my website @DanielCameronMD.com. As always, it is your likes, comments, reviews, and shares that help spread the word about Lyme disease. Until next time on Inside Lyme.
Please remember that the advice given is general and not intended as specific advice as to any particular patient. If you require specific advice, then please seek that advice from an experienced professional.
Inside Lyme Podcast Series
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References:
- Li X, Kirschner A, Metrie M, Loeb M. Lyme neuroborreliosis presenting as spinal myoclonus. BMJ Case Rep. Dec 29 2019;12(12)doi:10.1136/bcr-2019-233162
- Verma R, Praharaj HN, Raut TP, Rai D. Propriospinal myoclonus: is it always psychogenic? BMJ Case Rep. Jul 29 2013;2013doi:10.1136/bcr-2013-009559
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