Article Type : Case Report
Title : A Rare Presentation of Bilateral Bell’s Palsy in Lyme Disease: A Case Report
Abstract : Introduction: Bilateral Bell’s palsy is an uncommon neurological presentation. While most cases of facial nerve palsy are idiopathic, infectious causes such as Lyme disease should be considered, especially in endemic areas.
Case Presentation: A 35-year-old male presented with acute bilateral facial weakness without antecedent trauma. Neurological examination confirmed bilateral lower motor neuron facial palsy. Cerebrospinal fluid analysis and serology were positive for Borrelia burgdorferi, establishing the diagnosis of Lyme neuroborreliosis.
Intervention: The patient received intravenous ceftriaxone for 21 days and a short course of corticosteroids. Evidence supports antibiotic therapy for Lyme neuroborreliosis (intravenous or oral depending on severity), though the benefit/harm of adjunctive corticosteroids remains controversial.
Outcome: The patient showed progressive improvement and achieved complete recovery within 8 weeks. Early antibiotic therapy is associated with favorable outcomes.
Conclusion: Bilateral Bell’s palsy may be the first manifestation of Lyme disease. Early diagnosis and timely treatment are critical to avoid long-term neurological deficits.
Introduction : Bell’s palsy, an idiopathic lower motor neuron facial nerve palsy, typically presents unilaterally. Bilateral facial paralysis is rare and accounts for a very small fraction of facial nerve palsies; it should prompt urgent evaluation for secondary causes such as Guillain–Barré syndrome, sarcoidosis, HIV, leukemia, or Lyme disease. [1-7] Lyme disease, caused by Borrelia burgdorferi sensu lato and transmitted via Ixodes ticks, may present with diverse neurological features including meningitis, radiculoneuritis, and cranial neuropathies (facial nerve palsy). Neurologic involvement has been reported in a notable minority of untreated cases and is reversible in most patients who receive timely antibiotic therapy. [3,4,8]
Case Presentation : A 35-year-old male, previously healthy, presented with a 3-day history of sudden bilateral facial weakness. He reported difficulty closing his eyes, drooping of both corners of the mouth, impaired speech articulation, and inability to blow air. There was no preceding trauma, ear pain, or known tick bite; no erythema migrans was reported.
Examination: Vital signs were stable. Neurological examination revealed bilateral lower motor neuron type facial palsy (House-Brackmann grade IV on both sides) with preserved limb power, reflexes, and sensation. No meningismus, cerebellar signs, or other cranial nerve deficits were noted.
Investigations:
• Routine blood tests (CBC, electrolytes, liver and renal function) were within normal limits.
• HIV and syphilis serologies were negative.
• CSF analysis: lymphocytic pleocytosis (110 cells/µL), elevated protein (98 mg/dL), normal glucose. CSF testing and serum serology (ELISA with confirmatory Western blot) were positive for Borrelia burgdorferi. Positive CSF findings and serum serology supported a diagnosis of Lyme neuroborreliosis. [3,9]
• MRI brain with contrast excluded demyelinating lesions and intracranial structural pathology.
Timeline
Date (Day) Event
Day 0 Onset of bilateral facial weakness
Day 3 Hospital admission, neurological exam performed
Day 4 CSF analysis and Lyme serology returned positive
Day 5 IV ceftriaxone initiated + short tapering course of oral corticosteroids
Week 2 Partial improvement in eye closure and speech
Week 4 Significant resolution of facial weakness
Week 8 Complete recovery (House-Brackmann grade I bilaterally)
Discussion : Intervention
The patient was treated with intravenous ceftriaxone 2 g once daily for 21 days. Eye-protective measures (lubricating drops, night patching) and facial physiotherapy were initiated. A short tapering course of oral corticosteroids was given early in the course; note that the literature is mixed about benefits versus potential harms of steroids in Lyme-associated facial palsy. [5,6,10]
Outcome
The patient demonstrated steady recovery. At 4 weeks, near-complete function returned; by 8 weeks facial nerve function was fully restored with no synkinesis or residual deficits reported on clinic follow-up. This favorable outcome aligns with reports that most patients treated promptly for Lyme neuroborreliosis recover facial function. [3,4]
Discussion
Bilateral facial nerve palsy is an uncommon presentation that typically indicates an underlying systemic or infectious disorder rather than idiopathic Bell’s palsy. In Lyme-endemic regions, Lyme disease is an important consideration because cranial nerve VII involvement is a recognized manifestation and can be bilateral either simultaneously or sequentially. [1,2,9]
Key points from the literature:
1. Epidemiology and clinical pattern: Facial nerve palsy has been described in patients with Lyme disease and is sometimes bilateral; case series report sequential bilateral involvement in a subset of patients. [2,9,11]
2. Diagnosis: Diagnostic workup should include CSF examination, serologic testing for Borrelia (two-tier testing where available), and neuroimaging to exclude structural causes in atypical presentations. CSF pleocytosis and intrathecal antibody production support neuroborreliosis. [3,9]
3. Antibiotic therapy: For Lyme neuroborreliosis, guidelines and reviews support antibiotic therapy (oral doxycycline for many cases of cranial neuropathy or intravenous ceftriaxone for more severe CNS involvement). Duration ranges typically from 10–28 days depending on clinical severity and site of infection; many clinicians use 14–21 days for CNS involvement. [3,4,8]
4. Corticosteroids: The role of corticosteroids in Lyme-associated facial palsy is controversial. While steroids are beneficial for idiopathic Bell’s palsy, some observational studies and reviews suggest possible worse long-term facial function when steroids are added to antibiotics in Lyme-associated facial palsy; other analyses find no clear benefit or harm. Randomized data are limited and the topic remains debated. [5,6,10,12]
5. Prognosis: With timely diagnosis and appropriate antibiotic therapy, most patients regain facial nerve function; delayed treatment can increase the risk of persistent deficits. Long-term outcomes in children and adults vary across studies but generally are favorable with early therapy. [3,4,13]
This case contributes to the literature by illustrating an acute bilateral presentation with CSF-confirmed Borrelia infection and complete recovery after intravenous antibiotic therapy. Given the mixed evidence on adjunctive steroids, clinicians should weigh the risks and benefits and prioritize prompt antimicrobial therapy when Lyme neuroborreliosis is suspected.
Bilateral Bell’s palsy should prompt evaluation for systemic and infectious causes. Lyme disease can present with bilateral facial palsy and should be considered, particularly in endemic areas or when CSF findings suggest neuroborreliosis. Prompt antibiotic therapy (intravenous or oral depending on involvement) is associated with favorable recovery; the use of corticosteroids remains controversial and should be individualized.
1. Jain V, Sood RG, Forster A, et al. Bilateral Facial Paralysis: Case Presentation and Review. Ann Emerg Med. 2006;47(5):e8–e12. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC1924702/.
2. Marques A, Torgerson PR, et al. Characteristics and outcome of facial nerve palsy from Lyme neuroborreliosis. J Infect Dis. 2022; (PMC article). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8791801/.
3. Garcia-Monco JC, Benach JL. Lyme Neuroborreliosis: Clinical Outcomes, Controversy, and Recommendations. Front Neurol. 2019; (review). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7025284/.
4. Wormser GP, et al. Outcome of facial palsy from Lyme disease in prospectively studied patients. Clin Infect Dis. 2018; (summary/analysis).
5. Jowett N, Banks CA, Knox CJ, Hadlock TA. Steroid use in Lyme disease–associated facial palsy is associated with worse outcomes: A review. Laryngoscope. 2017;127(6):1451–1458. PubMed PMID: 27598389.
6. Avellan S, et al. Adjunctive corticosteroids for Lyme neuroborreliosis peripheral facial palsy: systematic review. Clin Infect Dis. 2021; PMID: 33905494.
7. Ozkara B, et al. Bilateral Facial Paralysis. Eur J Med Investig. 2018; (pdf review).
8. Centers for Disease Control and Prevention (CDC). Clinical Care and Treatment of Neurologic Lyme Disease. U.S. CDC guidance. Updated Mar 5, 2025. Available from: https://www.cdc.gov/lyme/hcp/clinical-care/neurologic-lyme-disease.html.
9. Collignon S, et al. An atypical presentation of Lyme disease (a case report). PubMed. 2024;38974695.
10. McEntire CRS. FACE DROPS: Lyme disease–associated facial palsy vs Bell palsy commentary. Neurol Clin Pract. 2025.
11. Cheng G, et al. Case Report: A Typical Lyme Disease With Uncommon Bilateral Facial Palsy — case and literature review. J Clin Med Case Rep. 2024; (PMC). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11466348/.
12. Karlsson S, et al. The FACE trial rationale: corticosteroid treatment for pediatric facial palsy including LNB. BMC Pediatr. 2021.
13. Long-term Clinical Outcome After Lyme Neuroborreliosis in Children. Pediatrics. 2012;130(2):262–269. (publication on outcomes).