Pediatric Bilateral Facial Paralysis: An Unusual Presentation of Lyme Disease.

Pediatric bilateral facial nerve paralysis (FNP) is a rare condition, representing less than 2% of all cases of FNP. The differential diagnosis of FNP is extensive (ranging from infectious, traumatic, neurologic, to idiopathic) and often can present as a diagnostic challenge. In contrast to unilateral presentation, bilateral FNP presents as a manifestation of serious systemic conditions, including meningitis (infectious and neoplastic), brain stem encephalitis, Guillain-Barre syndrome, sarcoidosis, Lyme disease, human immunodeficiency virus infection, leukemia, and vasculitis. In the evaluation of a child who presents with bilateral FNP, history plays the utmost role in the diagnosis. A history of rash consistent with erythema chronicum migrans, recent tick exposure, or travel to a Lyme disease-endemic area is highly suggestive that the facial paralysis is a result of Lyme disease. It is also important to recognize that Lyme disease is emerging as the most common infectious etiology of bilateral FNP in the pediatric population. In this case report, we describe a 16-year-old boy who presented to the emergency department with complaints of headache and bilateral FNP, an unusual presentation of Lyme disease.