An unusual presentation of Neuro Lyme (P6.308)

OBJECTIVE: Highlight an unusual neurological presentation of Lyme disease.BACKGROUND: Lyme is a multi-system infectious disease with neurological involvement in about 10-15[percnt] of cases.DESIGN/METHODS: Case reportRESULTS:Patient dramatically improved with IV Ceftriaxone.ABSRACT BODY: An 84 year old male presented in August with a two day history of inability to open his right eye. He denied other neurological symptoms, systemic or constitutional symptoms. He lived in North Minnesota and denied recent travel, he did not recall recent illness or skin rash. On exam patient did not appear ill, he was afebrile with no meningeal signs. He was alert but with evidence of cognitive dysfunction, MOCA score was 11/30. Right pupil sparing oculomotor nerve palsy was noted with complete ptosis. Reflexes were absent in the lower extremities on admission and lost in the upper extremities two days later. Strength and tone were intact. Gait was unsteady but normal based. Romberg was absent. He had no rash. Laboratory results revealed: WBC 5,100 cells/µL, creatinine 1.7 mg/dl and CRP of 2.9 mg/L. MRI Brain and MR Angiogram without contrast were unrevealing. Miller Fisher syndrome antibody panel was negative. HIV was negative. Serum Lyme serology showed IgM positive [66, 41 kDa], and IgG negative [41, 39 kDa]). CSF analysis revealed 58 leukocytes (62[percnt] monocyte and 35[percnt] lymphocytes), protein of 129 mg/dl, glucose of 47 mg/dl, 370 erythrocytes and a negative gram stain and culture. Lyme antibody screen (ELISA) in the CSF was positive. CSF VDRL was negative. After a two week course of IV Ceftriaxone, the patient significantly improved in cognition (MOCA score 23/30) and gait, he regained full right eye movements and ptosis improved. He was discharged home from rehab five weeks after admission.CONCLUSIONS: Neuro-Lyme should be suspected with unexplained neurological symptoms and signs in endemic areas. Disclosure: Dr. Tom has nothing to disclose. Dr. Mohamed has nothing to disclose. Dr. Holloway has nothing to disclose.