Development of bilateral facial nerve palsies while receiving doxycycline for early disseminated Lyme disease.

Background: Disease progression is uncommon in patients diagnosed with Lyme disease who receive appropriate therapy. Here we report a case of a patient developing bilateral facial nerve palsies while receiving oral doxycycline therapy for early disseminated Lyme disease and review the literature of similar cases. Case report: A 58-year-old previously healthy male from the mid-Atlantic area in the U.S. presented with a multifocal erythematous rash consistent with erythema migrans after international travel. His clinical presentation and two-step Lyme-serology testing confirmed a diagnosis of Lyme disease. Four days into initiation of doxycycline therapy, he developed bilateral facial weakness including difficulty raising the corners of his mouth and lifting his eyebrows bilaterally. He experienced neurologic improvement with ongoing antimicrobial therapy with ceftriaxone and subsequent doxycycline and had complete recovery 7 weeks later. Conclusion: This case describes an uncommon presentation of neuroborreliosis with bilateral facial palsies which developed after initiation of treatment of early disseminated Lyme disease. The manifestations in this case may be due to host immune reaction as seen in other spirochetal diseases. The findings resolved with continued therapy. In our review of the literature, we identified three additional cases of neuroborreliosis which progressed on treatment but also had eventual resolution of signs and symptoms. Clinicians should be aware that facial palsies rarely can occur on therapy for Lyme disease but do not necessarily imply a worse prognosis.