Abstract
Objective To discuss a rare presentation of bilateral facial nerve palsy in a 32 year old Australian female with Lyme neuroborreliosis, SARS-CoV-2 and positive Epstein-Barr virus (EBV) serology.
Case A 32 year old female presented to the emergency department with a right sided, lower motor neuron (LMN) facial palsy in the setting of a recent viral upper respiratory tract infection. Magnetic resonance imaging of the brain showed enhancement of the right facial nerve. She was diagnosed with Bell’s palsy and given a short course of oral prednisone. She re-presented 11 days later having developed a left sided LMN facial palsy. Serum EBV viral capsid antigen (VCA) IgM was equivocal in the setting of both VCA and nuclear antigen IgG positivity.
Further history revealed a recent SARS-CoV-2 infection and travel to the USA and Canada. Cerebrospinal fluid (CSF) analysis showed a lymphocytosis but negative EBV polymerase chain reaction. She was treated with further steroids and antiviral therapy. Her travel to Borrelia endemic areas prompted empiric treatment with doxycycline and testing which confirmed a diagnosis of Lyme neuroborreliosis with positive Borrelia IgG and IgM. Immunoblot was positive in both serum and CSF. The patient has made a near-complete recovery.
Conclusion Bilateral Bell’s palsy has been reported with Lyme neuroborreliosis, SARS-CoV-2 and EBV infection previously, but this is the first case to report co-infection. This case highlights the importance of tailoring investigations to the clinical context and serves to remind clinicians of the value of a travel history.
