For 36 hours, a 75-year-old woman had experienced weakness of the right side of the face. She was unable to close the right eye and drooled from the right side of the mouth. There was no weakness, numbness, or tingling of the extremities. The patient's medications included insulin for type 2 diabetes, furosemide and spironolactone for hypertension, aspirin, alendronate, calcium, vitamin D, and tramadol for occasional pain from osteoarthritis.
Dr Steven Manuli of Elizabeth City, NC, writes that the results of a CT scan ruled out stroke and tumor of the temporal bone; the history and physical examination findings were not consistent with Ramsay Hunt syndrome, acoustic neuroma, or Guillain- Barré syndrome. Close examination of the patient's head revealed decreased wrinkling of the forehead when the eyebrows were raised. Central causes of facial weakness spare the forehead because the frontalis muscle derives inervation from both hemispheres of the brain.
Bell's palsy was diagnosed. Bell's palsy can be the initial sign in Lyme disease. In a vaccine trial, 1 (0.4%) of 269 patients presented with facial palsy.1 In this patient, testing for Lyme antibodies yielded negative results. Since 80% of patients recover within several weeks or months, observation was considered sufficient for this patient; the facial palsy resolved after 6 weeks. Corticosteroids may be helpful in some patients.