Progression of Lyme disease to Bell’s Palsy despite treatment with doxycycline

A 54 year-old healthy woman presented to the emergency department with a right sided facial paralysis. About 3 weeks ago, she woke up and noticed an attached engorged tick in her right lower extremity. A week later, she noticed a mild to moderate right jaw pain which progressed to a severe right facial pain so she visited her doctor.
On physical, II to XII cranial nerve examination was unremarkable. Doppler ultrasound did not show any vascular abnormalities in temporal artery. Her inflammatory markers were within normal limits (C-reactive protein:0.3mg/dL; sedimentation rate:6mm/h). Further brain imaging by MRI reveled no abnormalities. Lyme serology (antibodies against purified VlsE-1 and PepC10 antigens) was negative (index value 0.6;?0.90 negative). Complete blood count and metabolic panel were within normal limits.
Only objective physical finding was a right erythematous ear canal so the patient was prescribed a 7-day course of amoxicillin/clavulonic acid. Two days later, the rash in right leg increased in size. It was described as 4cm rash circular with erythematous edges, clearing and central erythema consistent with erythema migrans (EM) (bull's eye).
She was prescribed doxycycline 100mg orally twice a day. Five days later went to see a neurologist due to worsening right facial shooting pain. Patient had minimal gastrointestinal side effects from the antibiotic and continued taking it every 12hours without interruption. Physical exam revealed face symmetric, numbness in right chin in nerve distribution.
She was diagnosed with possible Lyme cranial neuritis. Doxycycline was continued and pregabalin was started. On day #10 of doxycycline, she woke up and noticed that her right face was paralyzed and unable to close the right eye so she went to the local emergency department. The EM was improved from 4 to 2cm residual rash.
Because of her headaches, a lumbar puncture and brain MRI were recommended.
Cerebrospinal spinal fluid analysis revealed only 3 WBCs, protein 30.2g/dL, glucose 62mg/L, Lyme serology pair CSF fluid O.D.=0.114 (borderline), serum Lyme serology pair O.D.=0.409 (reactive), serum IgM western blot was positive (bands present: 23 and 41kDa), serum IgG western blot was indeterminate (bands: 41,58 and 93kDa), CRP remained less than 0.1mg/dL. MRI of brain showed new increased enhancement involving right facial nerve (Fig. 1).
She was discharged on minocycline 100mg orally twice a day for 21 days. Two days later, her right side headaches improved significantly. The facial paralysis completely resolved after 1 week. At 3 months follow-up, she recovered completely without any complications.
Source: By LA Marcos and Z. Yan Z. Progression of Lyme disease to Bell's Palsy despite treatment with doxycycline.  Int J Infect Dis. 2017 Jul 10. pii: S1201-9712(17)30182-0. doi: 10.1016/j.ijid.2017.07.004. [Epub ahead of print]

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