Lyme disease is caused by Borrelia burgdorferi acquired from a bite of an infected Ixodes tick. The most common neurologic complications are cranial neuritis (facial nerve palsy), meningitis, and polyradiculopathy. Here we present a patient who progressed to meningitis despite completing appropriate guideline-directed treatment for cranial neuritis.

A 60-year-old lady with PMH of migraine headaches was seen for worsening migraine. The patient complained of a headache, that was different from her usual episodes of migraine, associated with neck stiffness for the past 3 days and blurry vision. She was recently diagnosed with Lyme cranial neuritis and was treated with Doxycycline 200 mg for 14 days by her PCP. The exam was remarkable for left-sided LMN facial palsy and slight blurring of the nasal aspect of the disc and grade I papilledema. The patient was admitted. CSF studies showed elevated total nucleated cells and protein. Lyme IgM was positive. Infectious diseases were consulted, and a workup for plasmodium, babesia, Trypanosoma, microfilaria, and viral meningitis was negative. The patient was treated with as 14 days course of IV ceftriaxone, and her symptoms resolved completely. 

The IDSA recommends that oral doxycycline is as efficacious as IV ceftriaxone, cefotaxime, and penicillin G for 14 days in patients with Lyme disease-associated meningitis and cranial neuropathy. However, the evidence behind the use of Doxycycline is based on 2 studies done in Sweden. Borrelia afzelii, B. garinii, and B. bavariensis are the prevalent strains in Europe, and B. burgdorferi is prevalent in USA. Our patient, despite receiving oral doxycycline, continued to worsen, and eventually was completely treated with IV ceftriaxone. This questions whether the usage of oral doxycycline is as efficacious as IV antibiotics for neuroborreliosis in the USA. Further studies investigating oral doxycycline are needed in the U.S to answer this.