Neurogenic Bladder in Lyme Disease
A 32-year-old male was hospitalized owing to bilateral ptosis, dysphagia, lower extremity weakness, and voiding difficulty. He was a Taekwondo master and his medical history was unremarkable. The patient informed that he had been admitted to another hospital due to an episode of sudden bilateral lower extremity weakness followed by bilateral ptosis and dysphasia two month prior to the admission. At that time, brain, cervical, and lumbar magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction studies (NCS) and cerebrospinal fluid (CSF) examination were performed which revealed no abnormal findings. Clear causes for his condition were not identified and he was discharged after being instructed to manage severe urinary retention with clean intermittent catheterization. The bilateral ptosis and spastic paraparesis were somewhat relieved 2 weeks later, but the voiding dysfunction remained.\nHowever, the symptoms were relapsed; bilateral ptosis was 2 weeks before; bilateral lower extremity weakness was 1 week before; dysphasia was 3 days before the admission. Neurological examinations revealed no other cranial nerve palsy apart from bilateral ptosis and dysphasgia. Spastic paraparesis was observed (dorsiflexion: Medical Research Council [MRC] grade 4, plantar flexion: MRC grade 4+) and both patellar and Achilles tendon reflexes were increased bilaterally. Babinski's sign and ankle clonus reflex were observed on both sides. Upper extremity muscle strength, sensation and neurologic tests showed normal results. The patient's blood pressure, pulse rate, respiratory rate, and temperature were all normal. He complained of mild dyspnea during the admission and developed respiratory failure several days later which required endotracheal intubation.\nBlood tests showed the patient's white blood cell concentration to be 7,760/mL (neutrophil, 63%) and erythrocyte sedimentation rate to be 28 mm/hr. Serological test results for hepatitis B, human immunodeficiency virus and syphilis and autoantibody test results for cytomegalovirus, herpes simplex virus 1-2, toxoplasmosis, tumor markers (alpha-fetoprotein, careinoembryonal antigen, prostate-specific antigen, and carbohydrate antigen 19-9), paraneoplastic autoantibody and other autoantibodies were all negative. Cerebrospinal fluid (CSF) analysis revealed no evidence of inflammation with negative results for viruses, tuberculosis, and fungi and oligoclonal bands were absent. Brain and lumbar MRI was performed but no abnormal findings were found. EMG test results were normal; NCS showed decreased velocity in the bilateral superficial peroneal nerves, but there were no other abnormal findings. Acetylcholine receptor antibody was negative and there were no remarkable findings in repetitive nerve stimulation and neostigmine tests.\nThe patient was expectorating large amounts of sputum and third-generation cephalosporin (ceftriaxone 2 g/day) was administered to treat his pneumonia. The dyspnea and dysphagia were relieved 9 days after the treatment was commenced.\nIt was learned that the patient was positive for indirect immunofluorescence antibody (immunoglobulin M, 1:16; immunoglobulin G, 1:128) tests and Western blot tests for B. burgdorferi. These tests were repeated in 4 week time and confirmed positive results which suggested Lyme disease. He was treated with 2 g of intravenous ceftriaxone for 4 weeks and his condition was markedly improved although his voiding dysfunction remained without any improvement. A routine urine analysis showed no abnormal findings except for minor hematuria (urine red blood cells, 1-4/HPF), and there was no bacterial growth in a urine culture. When 300 mL of sterile distilled water was injected into the bladder for a urodynamic study, the patient felt micturition desire without an increase in intravesical pressure, suggesting detrusor areflexia (). Results of pudendal nerve sensory evoked potential tests and anal sphincter EMG, conducted 3 months after the admission, were normal; however, bulbocavernosus reflex tests showed delayed responses (right, 58.6 ms; left, 68.2 ms). Thus, demyelinating lesions at S2-S4 regions were suspected. Even after 4 months from the onset of the symptom, the patient's voiding dysfunction has not been relieved and clean intermittent catheterization is still required to manage the problem.