Case Presentation: A 67-year-old male presented with progressive bilateral upper extremity weakness, diplopia and neck pain of 1 week duration. Patient noted to have bilateral facial droop, weakness and areflexia of both upper extremities on physical exam. He reported having fevers and bloody diarrhea a few months prior to presentation. Magnetic resonance imaging (MRI) of the brain and cervical spine did not reveal any acute findings. MRI of lumbar spine showed diffuse enhancement of the cauda equina. Lumbar puncture demonstrated elevated protein with albuminocytologic dissociation and mild pleocytosis. Patient was empirically started on intravenous immunoglobulin to treat presumed atypical acute inflammatory demyelinating polyradiculoneuropathy (AIDP) with no improvement of condition. Patient reported having a tick bite 2 months prior to presentation on further investigation. Serum lyme IgM was positive with confirmatory western blot, and cerebrospinal fluid studies reactive for lyme IgG. Electromyography testing showed asymmetric subacute cervical polyradiculopathy in all tested nerve roots of the upper extremity without evidence of demyelination. Patient was diagnosed with polyradiculoneuritis secondary to neuroborreliosis (Bannwarth syndrome) which was treated with intravenous ceftriaxone with improvement of condition.

Discussion: Lyme disease is a tick-borne illness caused by the spirochete Borrelia burgdorferi. It is known to cause early localized, early disseminated, and late disease with different clinical manifestations based on timing of infection. We have a case of Bannwarth syndrome which is an early disseminated presentation of Lyme Disease causing acute radiculoneuritis reported in only 3 percent of cases here in the United States. Bannwarth Syndrome is an uncommon presentation of early disseminated Lyme disease which can occur within weeks to months of initial infection. The syndrome is characterized by painful radiculoneuritis with associated muscular weakness, sensory deficits, and decreased reflexes in the affected distribution. Cranial nerve involvement is common. Bannwarth syndrome is more commonly seen in Europe, although this may be due difference in recognition of the syndrome rather than a true difference in frequency. Serologic testing for lyme disease is highly sensitive and specific which helps establish the diagnosis. Additional neuroimaging, lumbar puncture, and electromyography may help exclude other possible conditions such as AIDP.

Conclusions: This case highlights the need to have a high index of suspicion for this condition in patients presenting with acute painful radiculoneuritis which would facilitate inquiry regarding history of tick exposure with serologic testing for diagnosis.