The case of a 38‐year‐old man with transient right arm weakness and dysarthria

interACTN Case #40: Available: https://interactn.org/2024/06/10/case-4738-year-old-man-with-transient-right-arm-weakness-and-dysarthria/ A 38-year-old Caucasian male with a history of tobacco use and alcohol use disorder presented to the emergency department with sudden onset transient right upper extremity numbness, weakness, and dysarthria. He was tachycardic to the 110–120 s with otherwise normal vital signs. General and neurologic physical examinations were normal. He was admitted to the stroke unit where further history revealed fatigue for the preceding 6 months and migratory arthralgia for the preceding month. Six months prior to presentation, the patient spent 2 months living in a tent in rural Michigan. He denied any interval history of tick bites, rash, fevers, chills, or headaches. He underwent typical stroke workup including transthoracic echocardiogram, lipid panel, hemoglobin A1c, and arterial hypercoagulability markers which were unremarkable. Serologic workup was notable for WBC 11.8 K/μL, ESR 99 mm/h, RF 38 IU/mL, CRP 3.6 mg/dL, and positive C-ANCA. The patient also had positive serum borrelia antibody screen with confirmatory testing pending. CSF studies demonstrated 92 WBC/mcL (94% lymphocytes), glucose 35 mg/dL, protein 97 mg/dL, 9 RBC/mcL, and IgG index of 1.49 with 3 O-bands. Several days later, confirmatory serum Borrelia burgdorferi test (modified two-tier test methodology) was positive. Ten days after presentation, Lyme antibody index (CSF/serum antibody ratio) was elevated at 1.5. Intravenous Ceftriaxone 2g Q24H was administered for 21 days. Antiplatelet therapy with aspirin 81 mg was continued indefinitely. Per Blanc and colleagues' proposed criteria in 2007,1 our patient satisfies all aspects supporting the diagnosis of Lyme neuroborreliosis (LNB). The criteria necessitate the presence of four of the following five items to diagnose LNB: "(1) no past history of neuroborreliosis, (2) positive CSF ELISA serology, (3) positive anti-Borrelia antibody index, (4) favorable outcome after specific antibiotic treatment, and (5) and no other etiologic diagnosis." Given this particular presentation, we diagnosed our patient with CNS vasculitis secondary to LNB.