Bell Palsy From Lyme Meningitis
RIVA KAMAT, MD
Figure A 10-year-old girl presented with left-sided Bell palsy as the first manifestation of Lyme disease.When she closed her eyes without smiling, her left eye remained partially open . For comparison,the patient is shown smiling with her eyes open and with her eyes closed .
LYME DISEASEThe incidence of pediatric Lyme disease is highest among children aged 5 to 9 years.1 The clinical manifestations of Lyme disease are divided into 3 stages . Early localized disease usually manifests as erythema migrans, typically at the site of the tick bite. Lyme neuroborreliosis–neurological involvement caused by infection with the spirochete Borrelia burgdorferi–is usually characterized as early disseminated disease. Common features of early disseminated disease include headaches, seizures, meningitis, meningoencephalitis, focal neurological signs, and ataxia.2 Manifestations of late disease may occur months to years after the initial infection if antimicrobial therapy was not given in the early stages of disease.1
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I Have Written In The Past About How Lyme Disease Can Seem Like Other Illnesses Can Bells Palsy Be An Indicator Of Lyme Infection
Most recently, I wrote about how Lyme can be misdiagnosed as Alzheimers. Bells palsy is a relatively rare condition. There are about 200,000 known cases per year in the United States. Some cases are not as serious as others. Bells palsy results in muscle weakness in half of the face. Those suffering from the condition, might notice pain in their ear. Vision can also be affected. More often, Bells palsy results in the inability to open or close the eyelids, or control facial expressions on one side of the face. There is usually noticeable facial drooping. Bells palsy can also result in sensitivity to taste and smell. It is treated with anti-viral medication and steroids, but often resolves on its own within a few months. Bells palsy is said to rarely occur more than one time. But what if it does?
Lyme Disease With Bilateral Facial Palsy Formally Known As Bells Palsy
Bells palsy has been described as an early complication of Lyme disease. Doctors have since reserved the term Bells palsy for facial nerve palsy due to a virus. More recently doctors use the term facial palsy in patients diagnosed with Lyme disease.
Less than 2% of facial palsy cases are bilateral.¹ Unlike unilateral facial palsy, it is often caused by a serious underlying systemic disease and therefore warrants urgent medical intervention, wrote Yang and Dalal in their article Bilateral Facial Palsy: A Clinical Approach.²
A previously healthy 10-year-old boy presented in late August with a one-day history of bilateral facial palsy and an otherwise normal neurological examination, wrote Piche-Renaud and colleagues.²
Three weeks prior to presentation, he experienced an evanescent rash on his chest with a spike of fever, they added. There was no history of a tick bite although the family was aware of ticks in southeastern Canada where they live.
A brain MRI showed bilateral symmetric enhancement of cervical cranial nerve roots consistent with bilateral facial palsy. The brain MRI also revealed involvement of other and multiple cranial nerves including the oculomotor , trigeminal , abducens , facial , vestibulo-cochlear , vagus and hypoglossal .
The boy was treated with the steroid methylprednisolone and IVIG without success.
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How Is Bells Palsy Managed Or Treated
Bells palsy improves without treatment. Still, your healthcare provider may recommend one or more of these therapies for symptom relief and a faster recovery:
- Oral corticosteroids, such as prednisone, decrease nerve swelling and may help you regain facial movement faster. This treatment is most effective when you start it within 48 hours of noticing symptoms.
- Antiviral medications, such as acyclovir for herpes, may speed recovery, although its unclear how much benefit they provide. This treatment works best when combined with oral corticosteroids.
- Eye care is very important. Eyedrops, including artificial tears, soothe dry, irritated eyes. If your eyelid wont close, you may need to wear an eye patch to protect the eye from irritants and injuries.
- Functional facial plastic surgery procedures are options for people who dont recover to help correct facial asymmetry and assist with eyelid closure.
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Signs Of Lyme Disease
Lyme disease symptoms may begin anywhere from days to weeks following exposure and often vary greatly between individuals. Many patients do not even recall being bitten by a tick.
The most common symptom is a target-like rash that moves around the body. However, many patients do not notice or develop a rash. In these cases, laboratory testing is needed for a diagnosis.
Other symptoms might include fever, chills, headache, fatigue, neck stiffness or muscle aches. In late stages, some patients also develop arthritis.
Because Lyme disease is caused by bacteria that can affect the nervous system, it can sometimes cause dysfunction of the facial nerve .
About five percent of patients with Lyme disease will develop some degree of sudden facial weakness , where one or both sides of the face droop. Known as Lyme disease-associated facial palsy, this tends to occur seven to 21 days after tick exposure in infected patients. Anyone who experiences sudden facial palsy should be urgently assessed by a physician to establish the appropriate diagnosis.
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Lyme Disease Bells Palsy And Facial Paralysis: What Is The Best Treatment Option
There may be times when Lyme disease occurs due to a bacterial infection that can be treated with antibiotics. Or, there may be instances when other treatment options are required to address a patients symptoms. Regardless, testing is necessary to ensure a patient can receive an accurate Lyme disease diagnosis. From here, a doctor can identify a safe, effective treatment designed to deliver long-lasting symptomatic relief.
Appropriate treatment forLyme disease Bells palsyor other facial palsy symptoms is crucial. Inone study, researchers found patients dealing with Lyme disease-related facial palsy faced a higher risk of severe long-term outcomes when treated using the same regimen as Bells palsy patients.
Those who experience facial paralysis symptoms should consult with a doctor immediately. At this time, a doctor can determine if these symptoms are related to facial paralysis. The doctor also can find out if a patient is coping with Bells palsy or facial palsy and treat the condition accordingly.
Clinical Questions And Evidence Review
An initial list of relevant clinical questions for these guidelines was created by the whole panel for review and discussion. The final set of clinical questions was approved by the entire committee. All outcomes of interest were identified a priori and explicitly rated for their relative importance for decision making. Each clinical question was assigned to a pair of panelists.
Evidence summaries for each question were prepared by the technical team from Tufts Medical Center. The risk of bias was assessed by the technical review team using the Cochrane risk of bias tool for randomized controlled trials , the Newcastle-Ottawa scale for nonrandomized studies and QUADAS-2 tool for diagnostic test accuracy studies . The certainty in the evidence was initially determined for each critical and important outcome, and then for each recommendation using the GRADE approach for rating the confidence in the evidence . Evidence profile tables and quality of evidence were reviewed by the guideline methodologists . The summaries of evidence were discussed and reviewed by all committee members and edited as appropriate. The final evidence summaries were presented to the whole panel for deliberation and drafting of recommendations. Literature search strategies, PRISMA flow diagrams detailing the search results, data extraction and evidence profiles tables, and additional data, such as meta-analysis results when appropriate, can be found in the supplementary materials .
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Lyme Disease And Bells Palsy Diagnosis
Laboratory tests are commonly used to diagnose Lyme disease. These tests require a blood sample from a patient.
Initially, a blood test is taken to determine if a patient is dealing with Lyme disease. If a patient tests negative for Lyme disease, no further testing is required. However, if a patient tests positive or the initial test results are unclear, a second test is used to verify Lyme disease is present.
Lab tests are also used to diagnose Bells palsy or other forms of facial paralysis. A neurologic and ear, nose, and throat evaluation are also performed. Other tests that may be completed include a test of a patients ability to produce tears, computed tomography scan, magnetic resonance imaging exam, and electromyography or electroneurography .
Comprehensive testing is key to accurately diagnose Lyme disease and Bells palsy. These conditions can occur in combination with one another or separately, and testing ensures a patient can find out if one or both are present. Following testing, a patient can pursue treatment options that deliver long-lasting symptomatic relief.
Bells Palsy Occurrence As A Symptom Of Lyme Disease
FirstCare Medical Center treats several Lyme disease sufferers daily. Lyme disease is a tick borne illness prevalent in the northeast and present, to at least some extent, in most or all states. Symptom presentation varies widely among patients, which is one of many complicating factors in diagnosis.
A circular or bulls-eye rash is a lyme disease symptom that is fairly widely known, but the rash is not always in a visible location and can be missed by doctors and patients alike, and does not occur in all patients. Fewer than half of infected patients likely experience a rash, though estimates range from 27 to 80%.
A far more obvious symptom of Lyme disease for some patients is a partial facial paralysis called Bells palsy. This condition is not always caused by Lyme disease, but can be a very strong indication of the disease.
As with Lyme disease itself, Bells palsy brings many complicated symptoms beyond the visible ones.
Visible symptoms include:
Facial droop on one side of the face, similar in appearance to a strokeOccasional drooling on the paralyzed side of the faceVarying degrees of uncontrollable tearing of the affected eyeInability to form normal facial expressions during recoveryInability to close affected eye
Common symptoms that are not visible include:
Reference:Johnson, Lorraine, JD, MBA. How many of those with Lyme disease have the rash? Estimates range from 27-80%. LYMEPOLICYWONK. Lymedisease.org, April 2014. Web. 21 July 2014.
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Disclosure And Management Of Potential Conflicts Of Interest
The Lyme conflict of interest review group consisting of 2 representatives from IDSA, AAN, and ACR were responsible for reviewing, evaluating, and approving all disclosures. All members of the expert panel complied with the consensus IDSA/AAN/ACR process for reviewing and managing conflicts of interest, which required disclosure of any financial, intellectual, or other interest that might be construed as constituting an actual, potential, or apparent conflict, regardless of relevancy to the guideline topic. Thus, to provide transparency, IDSA/AAN/ACR required full disclosure of all relationships. The assessment of disclosed relationships for possible COI by the IDSA/AAN/ACR review group was based on the relative weight of the financial relationship and the relevance of the relationship . For more information on allowable and prohibited relationships, please review Table 1 and Table 2. In addition, the IDSA/AAN/ACR adhered to Section 7 of the Council for Medical Specialty SocietiesââCode for Interactions with Companiesâ . The COI review group ensured that the majority of the panel and each cochair was without potential relevant conflicts . Each of the cochairs and all members of the technical team were determined to be unconflicted. See the notes section for disclosures reported to IDSA/AAN/ACR.
Lyme Disease And Facial Weakness: What You Should Know
Monday, Aug 6, 2018
Did you know that a tick bite can sometimes cause facial paralysis? Dr. Nate Jowett of the Facial Nerve Center at Mass. Eye and Ear breaks down Lyme disease associated-facial palsy and what you need to know to make sure you get the right treatment.
Ticks are those small, pesky bugs known for carrying Lyme disease, a bacterial infection transmitted through the bite of an infected tick. The CDC estimates that blacklegged ticks, or deer ticks, infect more than 300,000 Americans with Lyme disease each year.
Lyme disease is prevalent in New England, and it can be challenging to diagnose, said Nate Jowett, MD, a specialist in the Facial Nerve Center at Mass. Eye and Ear. Its important for those at risk to know the potential symptoms especially those who venture into wooded or grassy areas.
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Getting The Right Treatment
Lyme disease-associated facial palsy may look a lot like Bells palsy another cause of sudden facial weakness. But the two conditions are not the same.
Though more research is needed, a recent study from Mass. Eye and Ear suggests that patients with Lyme disease-associated facial palsy might develop worse long-term outcomes when treated with the same regimen used to treat patients with Bells palsy.
Since Lyme disease is a bacterial infection, it requires antibiotic therapy. Bells palsy is believed to be caused by a virus, and therefore is typically treated with corticosteroids and antivirals.
In some cases of acute facial palsy, physicians will prescribe antibiotics, corticosteroids and antiviral medications while awaiting lab results for Lyme disease, said Dr. Jowett. While good evidence supports the use of corticosteroids in Bells palsy, their role as an add-on therapy for Lyme disease-associated facial palsy is currently unclear.
Patients with Lyme disease-associated facial palsy and Bells palsy often experience different symptoms:
Canada Communicable Disease Report
CCDR Highlights summarize the latest evidence on infectious diseases from recent articles in the Canada Communicable Disease Report, a peer-reviewed online journal published by the Public Health Agency of Canada. This highlight was prepared by Dr Patricia Huston, a family physician, public health physician, and Editor-in-Chief of the Canada Communicable Disease Report.
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How Does Bells Palsy Affect Pregnancy
For unknown reasons, pregnant women are three times more likely to develop Bells palsy than women who arent expecting. The condition typically occurs during the third trimester. You may be more likely to develop Bells palsy while pregnant if you have preeclampsia or gestational diabetes.
If your symptoms are severe, your healthcare provider may recommend treatment. Certain treatments, such as oral corticosteroids, may increase your risk of giving birth prematurely before the 37th week of pregnancy. Your healthcare provider can discuss treatment risks and benefits with you.
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Etiology And Differential Diagnosis
Bells palsy is believed to be caused by inflammation of the facial nerve at the geniculate ganglion, which leads to compression and possible ischemia and demyelination. This ganglion lies in the facial canal at the junction of the labyrinthine and tympanic segments, where the nerve curves sharply toward the stylomastoid foramen. Classically, Bells palsy has been defined as idiopathic, and the cause of the inflammatory process in the facial nerve remains uncertain. Recently, attention has focused on infection with herpes simplex virus type 1 as a possible cause because research has found elevated HSV-1 titers in affected patients. However, studies have failed to isolate viral DNA in biopsy specimens, leaving the causative role of HSV-1 in question.4,5
Many conditions can produce isolated facial nerve palsy identical to Bells palsy. Structural lesions in the ear or parotid gland can produce facial nerve compression and paralysis. Other causes of peripheral nerve palsies include Guillain-Barré syndrome, Lyme disease, otitis media, Ramsay Hunt syndrome , sarcoidosis, and some influenza vaccines. Although these conditions can present as isolated facial nerve palsies, they usually have additional features that distinguish them from Bells palsy.
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Lyme Disease And Bells Palsy: New Considerations For Differential Diagnosis
byTimothy Sellati, P.h.D.on March 28, 2022
Neurological disorder resulting from COVID-19 may confound Lyme disease diagnosis.
Bells palsy is a non-progressive neurological disorder of one of the facial nerves . Bells palsy is fundamentally a clinical diagnosis with no specific laboratory test to confirm the disorder.1 This disorder is characterized by the sudden onset of facial paralysis that may be preceded by a slight fever, pain behind the ear on the affected side, a stiff neck, and weakness and/or stiffness on one side of the face. Paralysis results from decreased blood supply and/or compression of the 7th cranial nerve. This compression can be caused by inflammation of the tissue around the nerve. Approximately 40,000 individuals are diagnosed with Bells palsy in the US each year, affecting males and females in equal numbers.
The exact cause of Bells palsy is not known, however, bacterial infections ,1 and viral infections ,2 immune disorders and neuropathies , are frequently implicated as a cause.
Neurological Lyme Disease and Bells Palsy
COVID-19 and Bells Palsy
Since the time frames for onset of Bells palsy associated with Lyme disease and SARS-CoV-2 infection or COVID-19 vaccination overlaps, it is important for front-line physicians to be aware that when faced with differentially diagnosing a patient that presents with Bells palsy they should consider:
Does Bells Palsy From Lyme Go Away
About 5% of Lyme sufferers experience facial palsy. It can occur within a few weeks of a bite from an infected tick. This might look like Bells palsy, but it is not the same. Facial paralysis caused by Lyme infection should not be treated the same as Bells palsy. The bacterial infection of Lyme disease is treated with antibiotics. Facial paralysis caused by early onset Lyme can go away with quick diagnosis and treatment. It might take a few weeks or a few months to fully recover from facial palsy, even after treatment of Lyme is complete.
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