A 69-year-old man residing in Upstate NY presented with painful double vision, eyelid swelling, conjunctival chemosis, and left facial numbness. He did not report tick bites. Physical examination revealed left VII palsy, eye proptosis, and ophthalmoplegia. There was no rash or fever. Orbit and brain MRI (Figure 1) revealed asymmetric enlargement and enhancement of the left extraorbital muscles with orbital fat infiltration, compatible with orbital myositis.1 Lyme immunoglobulin (Ig) G/IgM antibody was positive which was confirmed by Lyme immunoblot assay. CSF analysis revealed lymphocytic pleocytosis and elevated protein. CSF cytology and flow cytometry were negative for malignant cells. Thyroid-stimulating hormone, thyroxine, and antithyroid peroxidase antibodies were unremarkable. Sarcoidosis, IgG4-related disease, autoimmune, and other infectious workups were unrevealing. The patient received IV ceftriaxone with significant improvement and with near resolution of the symptoms after 1 month. A follow-up MRI after 2 months showed improvement of the above findings (Figure 2).
