Brain MRI in a 65-year-old woman with headache, sensory ataxia, and tick exposure revealed leptomeningeal and cranial nerve enhancement and T2-hyperintense symmetrical pontine lesions resembling the “owl-eyes” sign, a radiologic finding described in ischemic or compressive myelopathy (Figure, A–C).1 CSF analysis revealed pleocytosis (163/µL) and intrathecal production of anti-Borrelia IgG (CSF/serum index 21, N < 2). Workup was negative for alternative causes. The patient fully recovered after 21 days of ceftriaxone (Figure, D–F).
MRI before (A–C) and 1 week after (D–F) antibiotic treatment: axial T2 (A and D), coronal FLAIR with gadolinium (B and E), axial T1 with gadolinium (C and F). Initial MRI reveals symmetrical ovoid T2-hyperintense, T1-hypointense pontine lesions, with local (C), leptomeningeal (B) and cranial nerves (not shown) contrast enhancement. Posttreatment MRI shows the absence of contrast enhancement in the lesions.
Radiologic findings in neuroborreliosis include signs of cranial neuritis, meningitis, or stroke.2 In patients presenting with symmetrical T2-hyperintense lesions of the pons, this case supports the inclusion of neuroborreliosis in the differential diagnosis.
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