Late Lyme neuroborreliosis presenting with tremor and gait impairment

A 60-year-old woman presented with a 38-month history of progressive tremor and gait impairment. Examination was consistent with a myeloradiculopathy, cerebrospinal fluid (CSF) analysis was inflammatory and imaging showed meningeal and white matter disease. Revisiting the history identified long periods spent gardening in the months before symptom onset with significant tick exposure. Lyme testing was strikingly positive in serum and CSF: a diagnosis of late Lyme neuroborreliosis was confirmed. There was clinical and radiological response to appropriate antimicrobial treatment with ongoing improvement at follow-up. This case highlights the importance of thorough history taking, a stepwise approach to investigating a complex neurological syndrome and the invaluable input of multiple specialties required to manage such cases.