Case report: Lyme neuroborreliosis triggers multiple strokes

In their article, “A case report of unilateral cerebral vasculitis in adults: keep in mind Lyme neuroborreliosis,” Riescher and colleagues examine the case of a 58-year-old man “with recurrent strokes in the same vascular territory without CSF pleocytosis, reflecting an unusual first manifestation of [Lyme neuroborreliosis].”¹

The authors point out that cerebral vasculitis is reported in only 0.3–1% of all Lyme neuroborreliosis cases, and unilateral or focal vasculitis have only rarely been described, almost exclusively in children.

In this case report, the patient, who had no medical history or cardiovascular risk factors, was admitted to the hospital with sudden right brachiofacial weakness. According to the authors, “He recovered partially, but facial palsy persisted.”

He was referred to the stroke unit but a neurological and general examination was normal.

“Cervical and intracranial CT angiography did not show any abnormalities such as stenosis, occlusion, or dilatation,” the authors wrote.

The man was diagnosed with cryptogenic stroke and prescribed aspirin (160  mg), atorvastatin (80 mg), and perindopril at 2 mg daily.

Two months later, the man exhibited sudden aphasia.

“Burgdorferi-induced cerebral vasculitis is thought to be a very rare manifestation of [Lyme neuroborreliosis]. But it must nonetheless be considered in the differential diagnosis of unexplained recurrent and/or multiple strokes.”

“MRI revealed a new and recent ischemic lesion in the left MCA territory visible on DWI, and another older lesion in the anterior cerebral artery (ACA) territory,” the authors wrote.

The patient was prescribed an oral anticoagulant and a cardiac monitor was inserted.

Over the next several months, the patient developed new symptoms including paresthesia (tingling sensation) in the right hand and foot, headaches, extreme weakness and lack of energy, psychomotor retardation, and unsteadiness.

Thirteen months after his first symptom appeared, he developed paresis (muscle weakness) in his right leg.

“A brain MRI showed a new recent ischemic lesion in the left cingulate cortex on DWI in the left ACA territory as well as other new lesions in the left MCA territory (in the frontal lobe),” the authors wrote.

Additional neurological testing was normal. However, Lyme disease testing was “highly positive” on ELISA and confirmed by Western blot.

The man was successfully treated with a one-month course of doxycycline.

“The patient experienced no further stroke after four weeks of doxycycline treatment.”

“In the following weeks, the patient reported dramatic improvement, with disappearance of his asthenia, dizziness, and right arm paresthesia,” the authors wrote.

The patient later reported that he had a tick bite 2 years prior to his first stroke, along with an erythema migrans rash but he never developed arthritis or pain.

Authors Conclude:

• “Our patient stood out because he had recurrent ischemic strokes for more than one year (at least four episodes), without other associated symptoms, involving the ICA territory only, and without CSF pleocytosis, which is thought to be highly suggestive of LNB.”
• “Burgdorferi-induced cerebral vasculitis is thought to be a very rare manifestation of [Lyme neuroborreliosis]. But it must nonetheless be considered in the differential diagnosis of unexplained recurrent and/or multiple strokes.”
• “This case report reminds clinicians that it can occur without a history of a clear tick bite or erythema migrans, and cranial or peripheral neuritis and that the CSF examination can be normal.”