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System Review

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 bilateral

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 sharp. 

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 reported
   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 twelfth involvement.

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.

Non CNS

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.