What better place to serve a reminder to check the psychological
psychiatric aspects of this disease. Is your patient a workaholic etc etc.
What aspects present of stress, anxiety, depression or even psychosis.
Work carefully through a CNS review paying
particular attention to cranial nerves and of course test where appropriate
Cranials - Losses are unlikely to be equally
My comments on the nerves in my case load would be
along these lines
1 an occasional patient notes a hypersensitivity to
some or many smells. More, on reflection, will note it has not been as
2 Visual contrast sensitivity (See Dr Shoemakers
test by Googling CVS test) seems to be the initial primary loss and is
almost universal. Many a patient has reported repeated visits to get the
eyes checked an no abnormality found. Otherwise I rarely find abnormality. However "LD can
include conjunctivitis, ocular myalgias, keratitis, episcleritis, optic
neuritis, pars planitis, uveitis, iritis, transient or permanent blindness,
temporal arteritis, vitritis and periorbital edema (Jacqueline MS; Ibid).
Horner's syndrome, ocular myasthenia gravis, and an Argyll-Robertson pupil
are also reported. Optic neuritis has been observed to become recurrent or
intractable after treatment with steroids."
I lifted this statement
from a very interesting article about
LD showing it has been around for many generations - not what a lot of
us had been led to believe.
3,4 and 6 look for weakness, double vision etc.
Check for pain on movement though this may be attributable to
leptomeningeal LD, particularly if there is photophobia.
5 Some will report taste changes a
uniform loss of taste - everything is bland. Sometimes a salty taste is
Now we come to the divisions of the trigeminal. I often see all
3 involved simultaneously, and sometimes divisions 2 and 3. Symptoms can be
described as brief (hours) or weeks on end.
7 Lyme is a known cause of Bells Palsy - not the
only one of course. Like cranial 5 sx can be brief or protracted. Ask also
about fasciculations of muscles.
The rest of the cranial nerves are outstandingly
involved in Australia. I have no real explanation.
8 Hyperacusis. Balance disturbance and gait
disturbance. Question vertigo episodes and distinguish from presyncope. Do a
Romberg test plus sharpened version. The patient with 8th involvement wont last 10 seconds
and a sharpened test is impossible.
9 10 11 - I tend to group these together for
assessment of tongue pharynx and anterior neck, though one patient had
marked tetanus of the tongue on one side before treatment. Whether it is pain,
swallowing or articulation difficulty, problems are very common. Consider
the role of the vagus in presyncope etc. But bear in mind Lyme can cause
conduction defect in myocardium as well.
12 The accessory. never in all my years of medical
practice did I ever find an abnormality here. Suddenly symptoms of pain,
creaking neck, muscle stiffness, post aural pain can be attributed to
How does all this cranial nerve involvement stack
up. many nerves will be involved and this is the key to excluding a host of
neurological disorders including MS which will only effect a couple of
cranials at most at the one time. The dd for multiple cranial nerve
involvement is Sarcoid the the autoimmune neurological disorders.
At autopsy Borrelia have been found widespread in
all possible tissues. Enough said, and this explains why it is now being
called the second great imitator.