Neuroborreliosis with enhancement of the third, fifth, sixth, and twelfth cranial nerves.

7-year-old girl presented with a one-week history of diplopia. On examination, left abducens nerve palsy was found. There was no clinical evidence of meningitis or of involvement of cranial nerves other than the abducens nerve. C-reactive protein and white blood cell count were normal. Magnetic resonance imaging (MRI) showed enhancement of 3 rd , 5 th , 6 th , and 12 th cranial nerves (Fig. 1); there were no focal brain lesions. Lumbar puncture showed monocytic pleocytosis and increased protein. CSF-Polymerase chain reaction was positive for Borrelia burgdorferi and negative for herpes simplex, varicella zoster, enterovirus and Epstein-Barr virus. Clinical improvement occurred after two weeks of intravenous treatment with Ceftriaxone 2 g per day. To our knowledge, there is no previous report on involvement of 6th and 12th cranial nerves in neuro borreliosis. Neuroborreliosis usually involves 3 rd , 5 th and 7 th cranial nerves (Hildenbrand et al., 2009); erythema migrans is present in 89 % of children (Sood et al., 2006). Our take home message is the following: as neuroborreliosis is a potentially treatable condition, this diagnosis should be considered whenever MRI shows multiple cranial nerve involve ment, despite the absence of clinical or labora tory evidence of active infection and despite involvement of some of the unusually involved cranial nerves.