Diplopia as the Sole Symptom of Lyme Borreliosis

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Lyme Borreliosis (LB) is the most common human tick-borne disease in the Northern Hemisphere. The illness usually begins with erythema migrans, followed by neurologic or cardiac abnormalities and finally arthritis. Ocular complications have been reported, including conjunctivitis, keratitis, uveitis, oculomotor palsies, papilloedema and others, but they have been rarely described in literature as unique clinical feature of disease. Herein, the case of a 53-year-old Caucasian woman with diplopia as the sole symptom of LB. No other systemic symptoms were detected, leading to an initial misdiagnosis. Undergoing to detailed investigation, our patient actually had serology positive for Borreliosis. Two months after antibiotic and orthoptic treatment, diplopia definitively disappeared. These results confirm the theory that an appropriate drug therapy associated with an effective orthoptic rehabilitation has made possible a quick restoration of binocular vision, achieving a good quality of life. This case demonstrates the importance of considering LB as part of the differential diagnosis of patients with isolated cranial nerve palsies, stressing the importance of the orthoptic intervention. 

Lyme Borreliosis (LB) is the most frequently infectious multi system disorder worldwide. The prevalence of LB is estimated to be 20-100 cases per 100,000 persons in the United States and 100-155 cases per 100,000 persons in Europe. The disease is transmitted following exposure to a tick bite carrying the spirochete Borrelia Burgdorferi. It typically begins with an erythematous rash (erythema migrans), but patients can develop also cardiac anomalies (4- 8%), neurologic compromise (11%) and arthritis (45-60%). Literature also reports common ocular manifestation, such as conjunctivitis, keratitis, uveitis, oculomotor palsies, papilloedema, papillitis, accompanied by ophthalmological symptoms among pain, visual impairment, photophobia, myodesopsia, diplopia and lack of accommodation. LB diagnosis is highly likely based upon appropriate serology and clinical manifestations. Symptoms generally disappear with antibiotic treatment that generally lasts less than 4 weeks, although the length of therapy could vary according to disease course. Ocular LB is probably underdiagnosed due to a difficult serologic diagnosis, as well as its various and soft ophthalmological symptoms. This case presents a 53-year-old Caucasian woman affected by an isolated paralytic strabismus originally caused by LB. The clinical findings, limitated to diplopia, have lead to a late diagnosis since an isolated abducens nerve palsy does not represent a specific features of Borreliosis.