Unilateral phrenic nerve lesion in Lyme neuroborreliosis

We report an 87-years old huntsman with unilateral phrenic nerve palsy as a consequence of Lyme neuroborreliosis.Although Lyme neuroborreliosis is a rare cause of diaphragmatic weakness, it should be considered in the differential workup because of its potentially treatable nature.Lyme neuroborreliosis (LNB) is the neurological manifestation of the systemic infection caused by the spirochete Borrelia burgdorferi (BB) sensu lato. Clinical features of LNB are diverse and differ among European and American patients, most probably because of differences in the distribution of Borrelia species in Europe and North America [1,2]. The most common neurological manifestation of LNB in European adults is polyradiculoneuritis (Bannwarth’s syndrome) [3], which typically occurs in patients older than 50 years, while in younger patients a meningitic syndrome of LNB is common [4]. Although several studies indicate that severe paralysis may occur in LNB [1], diaphragmatic weakness as a symptom of LNB is rare [2]. Here we report a case of LNB leading to a reduction of vital capacity and severe dyspnoea as a consequence of unilateral paralysis of the diaphragm.An 87-years old huntsman presented with severe headache, shooting left-sided thoracic pain, fatigue and vertigo. Neurological examination revealed partial dysfunction of the right abducens nerve. During the course of the disease a right facial palsy, with dysarthria and dysphagia as a consequence of facial weakness developed. Although the patient reported multiple previous tick bites, he had never noticed an erythema migrans. Brain magnetic resonance imaging (MRI) without and with contrast medium was unremarkable. The cerebrospinal fluid (CSF) analysis revealed a lymphocytic pleocytosis (129 cells/μl), an elevated lactate level of 2,6 mmol/l, a protein level of 1324 mg/l and an intrathecal Borrelia burgdorferi (BB)-IgG antibodies synthesis (BB-specific antibody index for IgG 5.0 and for IgM 0.8). BB-PCR of CSF was negative. The