Three females and one male between the ages of 52 – 61 presented with severe back pain and peripheral cranial nerve 7 palsy during Summer 2018 in the Appalachian region of West Virginia. The back pain preceded the facial palsy by 2-3 weeks. Two patients reported a history of a tick bite, and one had a targetoid rash. Three patients were previously misdiagnosed with Bell’s palsy, myofascial pain syndrome or musculoskeletal pain.

In all cases, lumbar puncture was significant for elevated protein and lymphocytic pleocytosis and serum Western blot Lyme IgM was reactive. Cranial nerve or spinal nerve root enhancement was seen in 3 out of 4 patient MRIs. The clinical symptoms, serum and CSF values, and imaging findings were consistent with CNS Lyme in all four patients. All were treated with a 21-day course of intravenous Ceftriaxone with no further complications.      

This cluster of cases raises suspicion that BWS is more common than previously suspected. Our cases were consistent with previous case series presenting with severe back pain followed by facial or other cranial nerve palsy a few weeks later. This constellation of symptoms should prompt investigation for neuroborreliosis, especially in Lyme endemic areas, although lack of awareness of BWS often leads to delayed diagnosis and treatment. Further studies are needed to determine a true incidence of BWS in the United States.