A rare presentation of clinically diagnosed lyme disease with probable neuroborreliosis, septic shock, and bone marrow suppression: a case report

Abstract Background Lyme disease is rarely considered in critically ill patients from regions not routinely recognised as endemic. Severe presentations including septic shock, central nervous system involvement, and bone marrow suppression may therefore be difficult to recognise, particularly when laboratory confirmation is incomplete. Case presentation A 60-year-old man from an inland province of northern China was admitted to the intensive care unit with four months of relapsing fever, acute delirium, respiratory distress, and septic shock. During admission, he developed recurrent high-grade fever with migratory erythematous rashes. Collateral history revealed a tick bite approximately 15 months earlier, followed by an expanding erythematous lesion compatible with erythema migrans. Cerebrospinal fluid showed markedly elevated opening pressure (>30 cmH2O), lymphocytic pleocytosis, elevated protein, and a normal CSF-to-serum glucose ratio, consistent with aseptic meningitis. Bone marrow aspiration showed pure red cell aplasia and megakaryocyte maturation arrest. Blood, urine, and cerebrospinal fluid cultures were negative, and metagenomic next-generation sequencing did not identify alternative pathogens. Lyme serology showed isolated IgM positivity with IgG negativity. Confirmatory two-tier testing and CSF Borrelia antibody testing were unavailable in our centre. This patient was therefore classified as clinically diagnosed Lyme disease with probable neuroborreliosis. Treatment with ceftriaxone and doxycycline was followed by defervescence and haematological recovery. At follow-up several weeks after discharge, the patient was afebrile, fully alert, and oriented. Conclusions This case highlights an unusual severe presentation of clinically diagnosed Lyme disease with probable neuroborreliosis, intracranial hypertension, septic shock, and bone marrow suppression. Geographic origin should not preclude diagnostic consideration. In critically ill patients with unexplained fever, cytopenias, and dynamic cutaneous lesions, careful tick exposure history and bedside dermatological assessment may prove decisive where laboratory testing is inconclusive.