PerampaAIAN
Annals of Indian Academy of Neurology
  Users Online: 522 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size

Table of Contents
LETTER TO THE EDITOR
Year : 2021  |  Volume : 24  |  Issue : 6  |  Page : 990-991
 

Bilateral facial palsy in neuroborreliosis


1 Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post-Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
2 Department of Neuromedicine, R.G Kar Medical College & Hospital, Kolkata, West Bengal, India

Date of Submission30-Jun-2020
Date of Acceptance23-Jul-2020
Date of Web Publication10-Apr-2021

Correspondence Address:
Alak Pandit
Department of Neuromedicine, Bangur Institute of Neurosciences, 52/1A Shambhu Nath Pandit Street, Kolkata - 25, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_698_20

Rights and Permissions

 



How to cite this article:
Das S, Dutta A, Sarkar P, Dubey S, Lahiri D, Pandit A, Gangopadhyay G, Ray BK. Bilateral facial palsy in neuroborreliosis. Ann Indian Acad Neurol 2021;24:990-1

How to cite this URL:
Das S, Dutta A, Sarkar P, Dubey S, Lahiri D, Pandit A, Gangopadhyay G, Ray BK. Bilateral facial palsy in neuroborreliosis. Ann Indian Acad Neurol [serial online] 2021 [cited 2022 Jun 25];24:990-1. Available from: https://www.annalsofian.org/text.asp?2021/24/6/990/313550




Sir,

Bilateral facial nerve palsy (FNP) is an uncommon entity (incidence of 1 per 5,000,000) accounting for 0.3%–2% of all facial palsies. Simultaneous bilateral FNP (involving both the sides within 4 week period) commonly shares a myriad of serious etiological correlation, of which infection, metabolic, neoplastic, autoimmune diseases, and multiple sclerosis are often considered as commoner association, making it an ominous sign necessitating thorough evaluation.[1],[2] We encountered two cases of Lyme disease with bilateral FNP from eastern India.

A 27-year-old male initially presented elsewhere with acute onset, painless left lower motor neuron (LMN) FNP manifested in the form of food getting stuck in the left vestibule of the mouth, drooling of saliva from left angle of mouth, facial deviation to the right on attempted smile along with visible rolling of eyeballs upward on attempted closure of the left eye. He was put on steroids without significant improvement; 27 days later, he developed right LMN FNP and presented to us [Figure 1]. Another 25-year-old male, presented to our care after 2 weeks of acute onset, painless bilateral LMN FNP, both sides having simultaneous onset.
Figure 1: Patient on attempted smiling with bilateral facial palsy

Click here to view


Both the patients had no other cranial nerve, motor, sensory, autonomic symptoms. No other systemic symptoms, comorbidities, or recent travel. No skin lesions were seen. Neurological examination showed bilateral LMN FNP along with loss of taste sensation in the anterior two-thirds of tongue, with normal cognition, no meningeal, other cranial nerve, motor, sensory, or autonomic involvement. Deep tendon reflexes were 2+ in all four limbs.

Complete blood count, metabolic parameters, chest radiography, serum angiotensin-converting enzyme levels, and nerve conduction study were normal. HIV antibody and venereal disease research laboratory testing were negative. Magnetic resonance imaging of brain revealed no significant abnormality. Cerebrospinal fluid analysis was normal in the first case (C1), and showed lymphocytic pleocytosis (cell-45/μL, 90% mononuclear, Protein-58 mg/dL) in the second case (C2). Borrelia IgM (EIA) was positive in high titres, IgG (EIA) was negative in C1, while both were positive in high titres in C2. Confirmation with western blot could not be done due to logistic implications.

Both our patients received oral doxycycline for 21 days and showed complete recovery within a month without any new onset neuro deficit.

India is not known to be endemic for Lyme and has no systemic data. However, recently high seroprevalence of 19.9% and 13% was documented in population-at-risk from southern and northern India, respectively, casting doubts on its rarity in India.[3] The eight reported cases of neuroborreliosis are largely from north India. Meningitis occurred in five of them including one case with hypoglycorrhachic chronic meningitis, and was the commonest presentation. Neuroretinits occurred in two, while one had meningoencephalitis. Only one of the eight cases had unilateral LMN FNP as a part of craniospinal meningitis. The fact that six of the cases did not have any other system involvement and none reporting erythema chronicum migrans highlights the importance of high index of suspicion in the absence of usual manifestations while diagnosing neuroborreliosis.[3],[4],[5]

Neurological manifestations are seen in up to 15% of patients with untreated borreliosis. It occurs mostly in early, disseminated infection and can affect all parts of neuro-axis. The classical triad includes meningitis, cranial neuritis, and radiculoneuritis. Cranial meningoradiculitis is commoner in younger population, and a painful spinal meningoradiculitis in elderly.[6],[7],[8],[9]

FNP accounts for three-quarters of Lyme associated cranial neuropathy. It could be related to direct invasion by spirochete or damage related to indirect immune mechanism. Although it has an excellent prognosis, there is marked paresis at onset. Bilateral involvement commonly develops consecutively within a median interval of 3 days, often has an excessively higher incidence of associated clinical meningoencephalitis, and has a greater incidence of mild dysfunction and late recovery following treatment. However, one of our cases had developed contralateral FNP nearly 4 weeks later, none had associated meningoencephalitis, and both had recovered completely. Although common in endemic areas, bilateral FNP in Lyme has never been reported from India, while sequential involvement of bilateral FNP as presenting manifestation is unheard of globally.[6],[7],[8],[9],[10]

Lyme disease as previously thought may not be so uncommon in India. This case report highlights the importance to consider Lyme in the light of corroborative clinical scenario, which can greatly aid in timely treatment and thus prevent long-term complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Arias G, Nogués J, Mañós M, Amilibia E, Dicenta M. Bilateral facial nerve palsy: Four case reports. ORL J Otorhinolaryngol Relat Spec 1998;60:227-9.  Back to cited text no. 1
    
2.
Pothiawala S, Lateef F. Bilateral facial nerve palsy: A diagnostic dilemma. Case Rep Emerg Med 2012;2012:458371.  Back to cited text no. 2
    
3.
Babu K, Murthy K, Bhagya M, Murthy P, Puttamallesh V, Ravi V. Seroprevalence of Lymes disease in the Nagarahole and Bandipur forest areas of South India. Indian J Ophthalmol 2020;68:100-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Prasad VSV, Sharawat IK, Saini L, Dekate PSR, Penchala S, Varma DR. Acute flaccid paralysis: Intravenous immunoglobulin is not the drug of choice always! Indian J Pediatr 2018;85:1139-40.  Back to cited text no. 4
    
5.
Farmania R, Jauhari P, Chakrabarty B, Gulati S. Chronic meningitis with persistent hypoglycorrhachia: An unusual presentation of Lyme's disease. Neurol India 2019;67:563-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Halperin JJ. Nervous System lyme disease. Vol. 29. Infectious Disease Clinics of North America. W.B. Saunders; 2015. p. 241-53.  Back to cited text no. 6
    
7.
Oschmann P, Dorndorf W, Hornig C, Schäfer C, Wellensiek HJ, Pflughaupt KW. Stages and syndromes of neuroborreliosis. J Neurol 1998;245:262-72.  Back to cited text no. 7
    
8.
Méreaux J-L, Hébant B, Magne N, Quesney G, Lefaucheur R. Bilateral facial palsy in an older person. Age Ageing 2020:afaa082. doi: 10.1093/ageing/afaa082.  Back to cited text no. 8
    
9.
Owens J, Filatov A, Husain-Wilson S. Guillain-Barre syndrome, neuroborreliosis, or both. Cureus 2020;12:e7823.  Back to cited text no. 9
    
10.
Facial Paralysis in Lyme Disease Clark_et_al-1985-The_Laryngoscope.pdf [Internet]. [cited 2020 Jun 12]. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1288/00005537-198511000-00009.  Back to cited text no. 10
    


    Figures

  [Figure 1]



 

Top
Print this article  Email this article

    

 
   Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (494 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed448    
    Printed22    
    Emailed0    
    PDF Downloaded58    
    Comments [Add]    

Recommend this journal