A case of Lyme neuroborreliosis without erythema migrans

A 56-year-old man was sustained ticks at the left axilla and flank. He did not have a rash. About 3 months after the tick bites, he developed back pain, right leg weakness, right abducens nerve palsy, and left facial palsy. Western blot analysis for serum IgM and IgG antibodies against Borrelia were positive. We diagnosed Lyme borreliosis. The patient was treated with antibiotics and steroids, and the symptoms improved. Our findings demonstrate that, even if erythema migrans is not obvious, neuroborreliosis should be considered when neurological signs, such as multiple cranial nerve palsies, are present.