Presentation
Drooping left mouth corner with trouble holding saliva on that side of the mouth. Symptom onset the day before presentation. Noticed tick bite 4 weeks ago in an endemic region for Lyme disease and tick-borne encephalitis.
Patient Data
The non-contrast CISS scans are unremarkable. There is no mass at the cerebellopontine angle. The post-contrast VIBE scans show increased contrast uptake of the left facial nerve in the IAC and in the facial canal including the geniculate ganglion.
Case Discussion
Increased contrast uptake of the facial nerve along its intracranial course is a classic finding in cases of Bell palsy. Upon presentation, the history of a tick bite in an endemic region seemed to indicate a case of Lyme disease with facial nerve involvement. Facial nerve palsy in neurologic Lyme disease is apparent in about 10% of cases.
Differentiating between idiopathic Bell palsy and Lyme disease-associated facial palsy relies on clinical and lab findings. Patients with Lyme disease often have flu-like symptoms and a specific rash (erythema migrans) at the site of the bite. This patient had a rash but otherwise felt fine. Also, just like in this case, Bell palsy typically involves only one side of the face, whereas Lyme disease can involve one or both sides.
Serologic and cerebrospinal fluid tests were negative for Lyme disease in this patient, pointing to idiopathic facial nerve paralysis (Bell palsy) rather than neurologic Lyme disease. The patient was treated with steroids as well as antibiotics (doxycycline), and his symptoms resolved after two weeks.
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