A case study presented at the 2021 North American Neuro-Ophthalmology Society (NANOS) Annual Meeting demonstrates that, even in regions where ticks are not endemic, aseptic meningitis from Lyme disease can occur. The study was presented by University of Kentucky College of Medicine researchers Kaitlin E. Smith, MD, and Padmaja Sudhakar, MD. 

One of the diagnostic challenges is that antibodies for Borrelia burgdorferi, the bacteria responsible for the disease, may not be evident in the cerebrospinal fluid (CSF) until week 4 of the disease.

The 25-year-old patient in this review arrived at the emergency department with a 2-week history of fever at night, headaches, and neck stiffness. Because symptoms did not include rash or joint pain, and the patient did not think she was exposed to a tick, physicians ordered extensive testing. 

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Lumbar puncture revealed an elevated opening pressure of 34 cmH2O, lymphocytic pleocytosis with 297 of 313 nucleated cells, and increased protein level. Serum bloodwork was positive for B. burgdorferi immunoglobulin M (IgM), but Immunoglobulin G (IgG) negative, and Western blot equivocal. Magnetic resonance venography (MRV) displayed “bilateral transverse sinus stenosis.” An ophthalmic consult was ordered, finding 20/20 visual acuity and unremarkable dilated fundus examination. The diagnosis was Lyme meningitis and courses of oral and intravenous antibiotics were prescribed.

The patient presented back to the hospital with continued fever and headache, as well as tinnitus, blurred vision, and difficulty focusing, 2 weeks after being discharged. A new ophthalmic evaluation with fundus exam revealed “inferior pole nerve fiber layer thickening and blurred margin.” A repeated lumbar puncture showed a higher opening pressure of 50 cmH2O, but improved lymphocytic pleocytosis and normal protein. MRV still showed bilateral transverse sinus stenosis. Physicians maintained their initial diagnosis, and with 1 antibiotic change, she completed the treatment.

As found in the patient’s 2 neuro-ophthalmology follow-up visits, she responded well to treatment. Optical coherence tomography images demonstrated a healthy retinal nerve fiber layer, with no papilledema detected. Further, the most recent lumbar puncture exhibited normal opening pressure, nucleated cell count, and protein level. No other cause for meningitis was found.

Investigators noted that the appearance of intracranial hypertension was unusual for Lyme disease in an adult. They added that untreated Lyme disease impacts the nervous system only 10% to 15% of the time. “To ensure appropriate work-up and treatment, all clinicians, including those in non-endemic areas, should include it on the differential for aseptic meningitis,” according to the researchers. “If serology is not initially positive, but there is high suspicion, repeat testing could be obtained.”


Smith KE, Sudhakar P. A little Lyme to go with the pandemic time. Presented at: North American Neuro-Ophthalmology Society Annual Meeting; February 20-23, 2021. Poster 35.

This article originally appeared on Ophthalmology Advisor