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

Luis A. Marcos, Zengmin Yan

International Journal of Infectious Diseases, online first July 10, 2017


* Treatment of choice for Lyme disease remains controversial.
* Bell’s palsy developed despite being on doxycycline.
* Progression of disease may be related to a strong host immune response.
* Prompt clinical response to minocycline needs further investigation.


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:0.3 mg/dL; sedimentation rate:6 mm/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 (red and inflamed) so the patient was prescribed a 7-day course of amoxicillin/clavulonic acid.

Two days later, the rash in right leg increase in size. It was described as 4 cm rash circular with erythematous edges, clearing and central erythema consistent with erythema migrans (EM) (bull’s eye). She was prescribed doxycycline 100 mg 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 12 hours 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 2 cm residual rash. Because of her headaches, a lumbar puncture and brain MRI were recommended. Cerebrospinal spinal fluid analysis revealed only 3 WBCs, protein 30.2 g/dL, glucose 62 mg/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 41 kDa), serum IgG western blot was indeterminate (bands: 41,58 and 93 kDa), CRP remained less than 0.1 mg/dL. MRI of brain showed new increased enhancement involving right facial nerve.

She was discharged on minocycline 100 mg 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.

**Lessons Learned**

*If you are bit by a tick, DO NOT WAIT AROUND!  Even the CDC is NOW stating suspected Tick borne illness to be treated empirically:  That NEW official word has not reached the public or many main stream doctors so it’s up to you to educate people.

*The ER folks and her doctor had their heads in the sand.  When she presented with facial palsy and told them she was bit by a tick – BOOM – treatment should have started that very minute.  Do NOT wait around for lab results!

*Mainstream doctors will prescribe antibiotics for a possible ear infection, but they take a “wait and see” approach with Lyme disease.  Unfortunately amoxicillin isn’t a great drug for LD so it didn’t help this patient.  Few die of ear infections.  Many die of TBI’s.

*Doctors still follow the CDC’s ludicrous and arbitrary EM measurement.

*LD can progress to stage 3 (central nervous system involvement) quickly.  Here’s another case that literally went to stage 3 within hours:

*Minocycline is a fantastic antibiotic that crosses the blood brain barrier:

*Had the doctor and the ER treated her empirically, doxycycline probably would have done the job.

*This shows why doxy alone often doesn’t work.  Time is of the essence. 

*Hopefully this patient was not co-infected.  There is also the possibility of the non-cell wall form of borrelia to lie dormant to reemerge later.  The patient needs follow-up.

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