Ocular flutter as the first manifestation of Lyme disease.

A 33-year-old man with a history of tick bites presented with bursts of involuntary horizontal conjugate saccades, myoclonic head jerks, and truncal ataxia. A cerebral MRI was normal, and no antineuronal antibodies were found (anti-Hu, anti-Yo, anti-Ri). Despite negative serum antibodies for Borrelia burgdorferi, acute neuroborreliosis was suspected because of lymphocytic mild meningitis (19 white cells/mm, protein 0.79 g/L) and apparent intrathecal synthesis of B burgdorferi IgM antibodies (ELISA titers 6.17, normal 0.3), although false-positive IgM serologies can occur in this setting. Intravenous ceftriaxone treatment resulted in dramatic clinical improvement within a few weeks. In ocular flutter, saccadic intrusions are purely horizontal (see video), while in opsoclonus-myoclonus, a similar condition, they are multidirectional.1 Cerebral MRI studies are usually normal,2 lesions involving omnipause neurons in the pons, or the fastigial nucleus in the cerebellum being exceptional.