Recurrent Lyme Disease: Old or New Infection?

Lakshmi Ganapathi, MBBS; Neeraj Surana, MD, PhD


October 21, 2013

Evaluation and Diagnosis

On examination, the patient was noted to have neck stiffness and a left cranial nerve VII lower motor neuron palsy. The rest of his neurologic examination and physical examination were unremarkable. A complete blood count, differential, lumbar puncture, and other laboratory tests revealed the following:

  • White blood cell (WBC) count: 5500 cells/μL

  • Hemoglobin 15.7 g/dL

  • Hematocrit 45.8%

  • Platelet count: 232,000 cells/μL

  • Differential: 60% neutrophils, 35% lymphocytes, and 5% monocytes

  • Lumbar puncture:

    • Clear cerebrospinal fluid (CSF) with an elevated opening pressure of 25 cm H2O

    • CSF total protein: 125.6 mg/dL, glucose: 53 mg/dL, and elevated WBC count of 198 cells/mm3 (8% neutrophils and 92% lymphocytes)

    • Gram stain of CSF: negative

    • CSF culture: no growth

    • Polymerase chain reaction (PCR) of CSF for HSV 1 and 2: negative

  • Serum Lyme enzyme-linked immunosorbent assay (ELISA): positive

  • Western blot analyses for Lyme immunoglobulin (Ig)M and IgG: positive (3/3 bands positive for IgM and 10/10 bands positive for IgG)

The patient was diagnosed with Lyme meningitis and treated with 28 days of intravenous ceftriaxone, during which time his symptoms resolved.

Two Years Later...

Two years later, the patient presents with a 1-day history of a rash on his right thigh that looks like a bull's eye (erythematous rash with a central clearing; Figure). He states that the rash is in roughly the same location as his rash of 2 years earlier. He denies any tick bites, but he has again had multiple, recent hiking trips in Massachusetts.

Figure. Patient's rash.


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