A 27-year-old woman comes to the emergency department after waking with new left-sided facial weakness. She has also had headaches over the last 10 days that are throbbing, 4 of 10 in intensity, located "all over" her head, and associated with photophobia but no nausea. She has had no double vision, limb weakness, numbness, difficulty swallowing, or recent head trauma, but she does note some malaise and mild neck stiffness.
The patient has a history of migraines but says her current headaches are different in quality and more persistent. She has seasonal allergies and takes over-the-counter antihistamines as needed. She traveled to India 4 months ago and is currently living with her grandparents in Connecticut for the summer. She is single and does not use tobacco, alcohol, or illicit drugs.
Temperature is 37 C (98.6 F) , blood pressure is 130/80 mm Hg, pulse is 80/min and regular, and respirations are 15/min. BMI is 30 kg/m². Mucous membranes are dry. Neurologic examination shows slight nuchal rigidity and photophobia. Cranial nerve testing reveals a decreased corneal reflex on the left as well as upper and lower left-sided facial weakness. The remainder of the physical examination is unremarkable.
Which of the following is the most likely complication if this patient's condition is left untreated?

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11ec193a_9621_1238_853d_97c73ff50c1a_MD0002_00 This patient who currently resides in Connecticut has evidence of facial nerve palsy (unilateral facial weakness, impaired corneal reflex) and likely meningitis (headache, photophobia, nuchal rigidity), raising suspicion for early disseminated Lyme disease. Lyme disease is a tick-borne illness endemic to the northeastern United States. Manifestations typically arise in 3 progressive clinical stages: northeastern United States Early localized disease - A few weeks of viral-like symptoms and a spreading, annular rash (erythema migrans).Early disseminated disease - Several weeks or months later, patients can develop acute arthralgias, carditis (eg, atrioventricular block), and neurologic disease (eg, facial nerve palsy, meningitis).Late Lyme disease - Late symptoms usually occur months or years after the initial inoculation. The most common manifestation is intermittent or persistent arthritis in >1 large joints (particularly the knee). More serious neurologic disease such as Lyme encephalopathy can also occur. Early localized disease - A few weeks of viral-like symptoms and a spreading, annular rash (erythema migrans). Early localized disease - A few weeks of viral-like symptoms and a spreading, annular rash (erythema migrans). erythema migrans Early disseminated disease - Several weeks or months later, patients can develop acute arthralgias, carditis (eg, atrioventricular block), and neurologic disease (eg, facial nerve palsy, meningitis). Early disseminated disease - Several weeks or months later, patients can develop acute arthralgias, carditis (eg, atrioventricular block), and neurologic disease (eg, facial nerve palsy, meningitis). Late Lyme disease - Late symptoms usually occur months or years after the initial inoculation. The most common manifestation is intermittent or persistent arthritis in >1 large joints (particularly the knee). More serious neurologic disease such as Lyme encephalopathy can also occur. Late Lyme disease - Late symptoms usually occur months or years after the initial inoculation. The most common manifestation is intermittent or persistent arthritis in >1 large joints (particularly the knee). More serious neurologic disease such as Lyme encephalopathy can also occur. Although Lyme disease usually progresses in a stepwise fashion, there can occasionally be manifestations of multiple stages at the same time. Patients can also have symptoms of early disseminated or late Lyme disease without having manifestations of previous stages. (Choice B) Lyme carditis generally occurs within a few months of infection and is considered a manifestation of early disseminated Lyme disease. The most common finding is atrioventricular conduction block, but patients can also occasionally develop myopericarditis. Chronic dilated cardiomyopathy is rare. (Choice C) Lower extremity paraplegia and meningitis can be seen with tuberculosis infections of the central nervous system. Although this patient did travel to a TB-endemic country (India), central nervous system tuberculosis is much less common than Lyme disease and rarely causes facial nerve palsy. (Choice D) Seizures are more common with encephalitis (eg, herpes encephalitis) than with meningitis. Lyme disease is not typically associated with an increased risk of seizures. (Choice E) Conjunctivitis is seen in approximately 10% of cases of early disseminated Lyme disease. Other ocular manifestations are rare. Late Lyme disease is most likely to cause arthritis, not vision loss. Educational objective: The manifestations of Lyme disease are typically categorized into 3 progressive stages. Early localized infection is marked by a viral-like syndrome and erythema migrans. Weeks or months later, patients can develop signs of early disseminated disease such as arthralgias, carditis (eg, atrioventricular block), and nervous system abnormalities (eg, facial nerve palsy, meningitis). Late Lyme disease is typically associated with intermittent or persistent arthritis in >1 large joints (particularly the knee). __________ References: Lyme disease: Part I. Advances and perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/21414493) Lyme disease: Part II. Management and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/21414494)

A 27-Year-Old Woman Comes to the Emergency Department After Waking