Phrenic nerve palsy as the sole manifestation of Lyme disease

Lyme disease is a tick borne spirochete infection caused by Borrelia burgdorferi that may present with multisystem involvement. It can affect both the central and peripheral nervous systems. The classical triad of Lyme neuroborreliosis called Bannwarth’s syndrome includes lymphocytic meningitis, cranial neuropathy and radiculoneuritis. An ever increasing number of peripheral neuropathies have been associated with Lyme borreliosis. We present here an asymptomatic 57-year-old man with right sided diaphragmatic paralysis noted on a chest radiograph performed pre-operatively prior to a total knee replacement surgery. Lyme serology came back positive. Our case is unique as phrenic nerve palsy was the sole clinical manifestation of Lyme disease and it emphasis that Lyme disease be considered in the differential diagnosis of otherwise unexplained phrenic nerve palsy specially in patients residing in endemic areas.