Pediatric Pearl

Lyme-Related Palsy or Bell Palsy Diagnosis

  • The Research

    In this retrospective cohort study, pediatric neurologists at Children’s Hospital of Philadelphia (CHOP) reviewed the presentation and diagnosis of 306 children aged 1 to 18 years who presented in the CHOP care network in Southeast Pennsylvania from 2013 to 2018 with a unilateral peripheral seventh nerve palsy. As is typical even within a Lyme disease-endemic area, the majority of these children (68%) were ultimately diagnosed with a Bell palsy, while 27% were diagnosed with Lyme-related facial palsy, and 5% with other diagnoses. The authors looked for clinical features that might be useful in distinguishing the 2 conditions at presentation.

    The Results

    Two features seemed most helpful in separating Bell palsy from Lyme-related facial palsy: seasonality and presence of a systemic prodrome. While Bell palsy did not show a particular seasonal distribution, 93% of patients with Lyme-related facial palsy presented in the months between June and November. While only 6% of patients with Bell palsy presented with a preceding systemic prodrome, 55% of patients with Lyme-related facial palsy had at least 3 of the following symptoms in the preceding 6 weeks: fever, headache, malaise, arthralgias, and myalgias. The ability to distinguish the 2 conditions may lead to earlier appropriate treatment, as Bell palsy is generally treated with systemic steroids, while Lyme-related facial palsy requires antibiotic therapy.

    What’s the Take Home?

    When I worked in an endemic area in New Jersey, I would always send a Lyme titer in any child who presented with a peripheral facial nerve palsy. Armed with the data from this study, I would most likely change my approach to a child presenting in winter or spring without a systemic prodrome. In such a patient, I would likely treat with steroids at presentation and consider not sending Lyme titers. The purpose of antibiotic therapy in Lyme-related facial palsy is to prevent the development of late Lyme disease and I would typically await the results of Lyme titers before starting antibiotics. Ongoing prospective trials of the efficacy of corticosteroids in Bell palsy will hopefully clarify the role of early steroid treatment in these children. Even though the authors of the current trial did not find an effect on overall recovery rate, I will continue to treat these children while awaiting the results of these prospective trials.

     

    References:

    1. Guez-Barber D, Swami SK, Harrison JB, McGuire JL. Differentiating Bell's palsy from Lyme-related facial palsy. Pediatrics. 2022;149(6):e2021053992. doi:10.1542/peds.2021-053992
    2. Kimberlin DW, Barnette ED, Lynfield R, Sawyer MH; Committee on Infectious Diseases; American Academy of Pediatrics. Red Book: 2021-2024 Report on the Committee on Infectious Diseases. Pediatrics. 2022:488. doi:10.1542/9781610025782

    Scott T. Vergano, MD, is a pediatrician in the Department of Pediatrics, Children’s Hospital of the King’s Daughters, Norfolk Virginia.