Objective: We report two cases of encephalomyelitis due to Lyme disease with cerebellar ataxia and autonomic symptoms, which presented with a rapidly progressive MSA-like phenotype.

Background: There are different stages and manifestations of Lyme disease, ranging from Erythema migrans, early neuroborreliosis with painful polyradiculitis to meningoencephalitis (1). Early recognition and treatment of the disease is essential to prevent sequalae.

Method: Case reports.

Results: A 74-year old man and a 57-year old women presented with rapid progressive gait ataxia (male patient was more severely affected), jerky postural and action tremor and dizziness over eight months. Both also suffered from fatigue, night sweats, weight loss and urinary tract dysfunction. The female patient additionally presented with migraine-like headache and hearing loss.

Brain MRI studies showed signal alterations in the mesencephalon and thalamus (f) and mild atrophy in that region (m). A lymphocytary pleocytosis and elevated protein were found in the cerebrospinal fluid of both patients. Intrathecal synthesis of borrelia specific antibodies confirmed the diagnosis of Lyme disease in both cases. Intravenous treatment with ceftriaxone over four weeks lead to an almost complete recovery.

Conclusion: These cases illustrate that encephalomyelitis due to Lyme disease may present as a rapidly progressive MSA-C look alike. The rapid deterioration of symptoms as well as additional systemic features such as weight loss and night sweats pointed to an alternative diagnosis than MSA-C in our cases. Early recognition of entities which mimic typical neurodegenerative disorders, but which are treatable, is essential to not delay the necessary treatment.

References: (1) Ross Russell AL, Dryden MS, Pinto AA, Lovett JK. Lyme disease: diagnosis and management. Pract Neurol. 2018 Dec;18(6):455-464. doi: 10.1136/practneurol-2018-001998. Epub 2018 Oct 3. PMID: 30282764.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/lyme-disease-presenting-as-a-rapidly-progressive-msa-c-look-alike/