Dumic and colleague first discussed this case in the journal IDCases in 2019.
“A previously healthy 25-year-old man presented with inability to urinate and frequent falls associated with bilateral lower extremity weakness and numbness.” wrote the authors.
Two weeks earlier, he described a red circumferential rash. His rash was approximately 10 cm in diameter, which is about 4 inch in diameter. The CDC only requires a 5 cm rash to diagnose Lyme disease criteria, which is about 2 inches.
He lived in Wisconsin, USA, with extensive exposure to ticks. He lived next to the woods, hiked, camped, and fished, and has two dogs. He had no recent history of a tick bite.
He also developed a mild, intermittent headache, mild neck stiffness, and thought he had a fever. Flu-like symptoms have commonly been reported in Lyme disease.
Did he get treated for Lyme disease? No.
The rash disappeared within a week without treatment. The erythema migrans rash of Lyme disease often clears without treatment.
His condition took a turn for the worse. “Five days prior to admission, he developed urinary retention as well as progressive numbness and weakness in his lower extremities.” wrote the authors. He was also not able to move his bowels.
His sensory deficit progressed from “left foot numbness to the upper thorax right below the nipple line anteriorly and below the shoulder blades posteriorly.” write the authors.
He began to fall due to the weakness of both legs and problems with his gait.
His physical examination revealed several findings. He had weakness of both legs, mild spasticity in both knees, increased reflexes in his legs, a diminished sensation in his legs, and a Babinski sign of the left foot.
A positive Babinski sign occurs when a doctor stimulates the bottom of the foot. The big toe bends up and back to the top of the foot, and the other toes fan out. This can mean there is some problem with the nervous system.
He had evidence suggestive of myelitis on an MRI “MRI of the cervical and thoracic spine revealed T2 signal hyperintensity in the central spinal cord gray matter at C5, C6 and T3 to T9 levels suggestive of myelitis.” write the authors. They use the term suggestive as a T2 signal hyperintensity can be from other causes. Myelitis refers to inflammation of the spinal cord.
He had strong evidence of an inflammatory process in his spinal fluid as measured by a pleocytosis in his spinal fluid. These are white cells in his spinal fluid. His antibody test for Lyme disease was negative.
His PCR for Lyme disease was positive. They were able to confirm PCR tests were positive for Lyme disease using a molecular detection test at the Mayo Medical Laboratories.
He was diagnosed and treated for acute transverse myelitis.
TRANSVERSE MYELITIS AND LYME DISEASE
The man’s motor, sensory, and autonomic dysfunction were typical of acute transverse myelitis. Autonomic dysfunction is a part of the nervous system that regulates internal organs such as the heart, stomach and intestines. The autonomic nervous system is composed of the Sympathetic and Parasympathetic system. It has also been called the fight-or-flight response. The man was unable to control his bowels and bladder.
OUTCOME
He was treated for Lyme disease with IV ceftriaxone. He also was treated with an intravenous antiviral medicine, Acyclovir, for two days until the spinal tap PCR was positive. Finally, he was treated with the steroid methylprednisolone 1 g IV daily for three days.
“He showed gradual improvement in gait, motor and sensory functions of his lower extremities along with a resolution of neurogenic bowel.” wrote the authors.
The authors added, “he continues to need intermittent self-catheterization for neurogenic bladder.”
This is not the first case of transverse myelitis and Lyme disease patients according to the authors. Their search revealed six other cases of neurologic Lyme disease associated with acute transverse myelitis.
What can we learn from this cases?
- Acute transverse myelitis can occur in Lyme disease.
- The spinal tap in Lyme disease can present with a high white count, also called pleocytosis, and still have a negative antibody test.
- A positive PCR test was able to confirm Lyme disease in this patient.
- The man’s acute transverse myelitis and Lyme disease improved with antibiotic treatment.
What questions does these cases raise?
- How often does transverse myelitis occur in Lyme disease?
- Would the man have been treated for Lyme disease if the PCR test at the Mayo had been negative?
- Would the man no longer need intermittent self-catheterization for neurogenic bladder if he were treated with more than a single one-month course of intravenous ceftriaxone?</li
- Were there other autonomic issues not described by the authors?</li
TREATING TICK-BORNE DISEASE IN MY PRACTICE
In my practice, each individual requires a careful assessment. That is why I order a broad range of blood tests for other illnesses in addition to tick-borne infections. I also arrange consultations with specialists as needed.
Many patients are complex, as highlighted in this Inside Lyme Podcast series.
We need more doctors with skills recognizing a tick-borne illness in an individual with acute transverse myelitis and Lyme disease. We hope that professionals evaluating individuals with acute transverse myelitis can use this case to remind them to look for tick-borne illnesses and treat accordingly.
Inside Lyme Podcast Series
This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube. As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts. Sign up for our newsletter to keep up with our cases.
References:
- Dumic I, Vitorovic D, Spritzer S, Sviggum E, Patel J, Ramanan P. Acute transverse myelitis – A rare clinical manifestation of Lyme neuroborreliosis. IDCases. 2019;15:e00479.
- Kenney MJ, Ganta CK. Autonomic Nervous System and Immune System Interactions. Compr Physiol. 2014 July ; 4(3): 1177–1200.
Madison Area Lyme Support Group 