Lyme Polyradiculoneuritis Case Report

Lyme Polyradiculoneuritis Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Lyme Polyradiculoneuritis Case Report Thomas Adam Purvis This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8213525/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract We present a challenging case that serves as a cautionary tale pertaining to the appropriate incorporation of electrophysiological assessment of the acute neuromuscular patient. This 64 year-old man presented with acute arm pain and weakness, with electrophysiological assessment suggestive of an acute brachial plexopathy. Subsequent investigation, however, lead to a diagnostic shift to one of a radiculoplexus neuropathy, leading to a revised diagnosis of Lyme Polyradiculoneuritis. This new diagnosis had implications for treatment, and positively affected prognostic trajectory. Knowledge of the limitations of electrophysiological assessment is important for both the neuromuscular specialist and general neurologist. The case also bears educational import for the moderan practice of neurology in the Appalachian region of the United States, as Lyme disease has become endemic to Appalchia as well. Neuromuscular EMG neurophysiology infection case report Full Text The diagnostic differentiaion of the acute neuromuscular patient presents unique and pressing challenges to the neurologist. Misclassifcation of the patient at initial presentation may present a missed opportunity for adequate empiric therapy, and thus negatively impact future clinical trajectory. This diagnostic quandary is compounded by how similarly the “plexopathy” and “polyradiculopathy” patients clinically manifest, and how the “infectious” and “inflammatory” aetiologies can co-masquerade. Electrodiagnostic testing with nerve conduction studies and EMG can be utilized to parse the presenting entity further, but its differentiating power is notoriously limited in the acute setting. The following patient’s presentation lead to an initial formulation of “inflammatory plexopathy”, though subsequent investigation lead to a diagnostic shift to one of “infectious polyradiculopathy” which had important implications for management and prognosis. A 64-year-old man presented to the neurology clinic for consideration of acute onset bilateral arm pain and weakness of sudden onset two weeks prior. On the morning of onset of symptoms, he awoke with excruciating pain in the left shoulder with radiation to the left arm and entire left hand. By the afternoon, he had noticed a similar sensation in his right shoulder, radiating to his right arm. His pain peaked in severity on the first day, causing him significant distress and precluding any functional use of his arms. By the second day, his pain had begun to alleviate somewhat, however he began to notice numbness and weakness in the left more than right arms. While the pain in the arms persisted in moderate severity over the ensuing two weeks, the weakness and dysesthesias worsened. By the time of presentation to the neurology office, he was unable to lift his arms over his head, open jars or bottles, and had lost the ability to use his arms to drive. He denied any new symptoms in his legs, and his walking remained the same. He denied new-onset urinary symptoms, fevers, chills, rash, headache or speech changes. He recalled no antecedent vaccination, illness or infection. His history was also notable for a long-standing history of type 2 diabetes (his most recent Hemoglobin A1C was 8.8%), as well as hypertension and hyperlipidemia. He was a retired welder who spent much of his day outdoors. In his spare time, he would skin and butcher locally hunted deer in rural West Virginia. He was bitten by mosquitos on a recurrent basis. He reported observing many ticks on the deer carcasses he skinned, but took great care to avoid getting bitten himself. His neurological examination was notable for normal mental status and cranial nerves. Assessment of his arms revealed diffuse weakness (4/5 by Medical Research Council grading scale) on bilateral shoulder abduction, elbow flexion and extension, wrist extension, finger abduction and thumb abduction. No weakness was noted in his legs. His deep tendon reflexes were reduced at the knees, absent at the ankles and reduced-to-absent in the arms. Sensory examination revealed reduced sensation to pinprick and vibration in a length-dependent fashion in the legs. There was diffusely reduced sensation in the arms and hands to pinprick, but not in a distribution satisfying the territory of a single nerve or nerve root. The patient underwent electrophysiological testing by nerve conduction studies and electromyography (NCS/EMG) on the same day. Sensory nerve conduction studies revealed no recordable sensory responses over the bilateral median or ulnar nerves. The medial and lateral antebrachial cutaneous and radial sensory responses were reduced in amplitude bilaterally, but approximately symmetrical. Motor nerve conduction studies revealed normal ulnar motor responses, and prolonged distal onset latency responses in the bilateral median nerves. F-wave responses were prolonged on both median and ulnar nerves. Needle EMG demonstrated diffuse, subtle, active denervation throughout the left and right arms in the form of fibrillation potentials, positive sharp waves and fasciculation potentials (Left and right deltoid, biceps, triceps and first dorsal interosseous muscles). The motor unit morphology was normal however recruitment was reduced. Notably, needle examination of the cervical paraspinal muscles revealed no fibrillation potentials, positive sharp waves or fasciculation potentials. Taken in aggregate, the electrodiagnostic assessment suggested bilateral acute brachial plexopathies. The historical elements offered, combined with his medical background of diabetes, made Neuralgic Amyotrophy our top differential diagnosis at this juncture. While conclusion of his workup may have been appropriate at this point, the severity of his condition, the disability inferred, and the progression of his weakness all prompted his investigation to be continued. His exposure history in particular bore consideration for an infectious and potentially treatable etiology to his symptoms. He was directly admitted to the inpatient neurology service from the clinic for an expedited diagnostic workup as well as urgent pain management consultation. Initial serum testing revealed an elevated white count to 16.4, elevated CRP to 16.1, normal ESR of 7, and normal Creatine Kinase of 151. MRI of the brain, cervical spine and brachial plexus, with and without gadolinium contrast, revealed no abnormal enhancement or lesions. CSF testing revealed an elevated white cell count (140 cells/microliter with 95% lymphocytes) and elevated CSF protein (280 mg/dl). CSF bacterial cultures, viral PCR array, and West Nile antibody testing were negative. Serum testing for Lyme IgG and IgM were positive by Western Blot. Lyme antibodies (IgG) were found to be positive in the CSF. In light of these developments, his provisional diagnosis was revised from Neuralgic Amyotrophy to Lyme Polyradiculoneuritis. He was started on doxycycline 100mg twice daily for 14 days with symptomatic improvement in pain and strength. On repeat assessment a year later his arm function had returned, his physical examination revealed return of full strength to confrontation, though he continued to experience moderate aching pains in his shoulders and reduced dexterity in his hands. From the perspective of the patient this was far from an ideal outcome, and he expressed frustration at the lack of sustained recovery as the sequelae of the disease continued to hamper his functionality and quality of life. While the described case is limited in generalizability as a single example, its encountered pearls and pitfalls serve a broader application in wider clinical practice. Neuralgic Amyotrophy, also known as Parsonage Turner syndrome, is an inflammatory condition affecting the nerves of the brachial plexus. An inciting antecedent event is often implied, such as infection, vaccination or surgery [1]. Up to 30% of cases are bilateral [1]. The condition is thought to be monophasic and self-limiting, however steroids may be beneficial for pain in the acute phase [2]. Recovery of function can take years to occur, and may be incomplete [2]. The typical presentation of Neuralgic Amyotrophy is one of excruciating pain in the arm, that eventually yields to sensory and motor dysfunction in the affected limb. Lyme polyradiculoneuritis, also known as Bannwarth syndrome, was previously considered a rare neurological manifestation of Lyme Disease in the United States, more commonly seen in Europe. Cases in the U.S. are becoming more recognized [3,4]. Additionally, Lyme’s disease incidence has increased dramatically in West Virginia over recent years [5,6]. Climate change has been postulated as a reason for this [7]. The spread of the condition from its first-discovered site in Lyme, Connecticut to West Virginia has proposed numerous new challenges to the local population. West Virginian life is steeped in outdoor activites such as hunting, hiking and fishing, and the region is abundant with woodland and wildlife. Practices to prevent Lyme Disease conversely are not as routinely implemented in West Virginia compared to neighbouring states such as New York, Pennsylvania or Connecticut, thus exposure to ticks is likely much higher. The disease has also only been prevalent in West Virginia relatively recently, so the disease may not be considered as routinely in medical practice. Challenges exist however, as overdiagnosis of Lyme’s disease is historically common. The variable presentation and potential for false-positive test results can lead to the erroneous attribution of non-specific or unrelated symptoms as features of Lyme’s disease or “Chronic Lyme”. This can lead to the harmful prescription of long term antibiotic therapy unnecessarily. Our diagnosis of lyme polyradiculoneuritis is based on his fitting clinical presentation, exposure history and supportive laboratory data. Histopathological confirmation via nerve root biopsy may have lent more credence to our conclusions, though from a practical perspective the invasive investigational procedure would have been difficult to justify. Both neuralgic amyotrophy and lyme polyradiculoneuritis can present with marked similarity, both typified by acute-onset severe pain, motor and sensory loss in the arms. Despite this their underlying pathophysiology and management differ greatly. This poses an exceptional challenge to the assessing clinician. An understanding of the limitations of EMG were required in this case to understand that despite the negative paraspinal needle examination a nerve root localization component remained a possibility. Perils exist with over-reliance on EMG, like any other diagnostic modality. Appreciation of the broader clinical context is mandatory to prevent premature diagnostic closure. Furthermore, an understanding of evolving epidemiological trends in the region of practice are imperative to accurately inform differential diagnosis, and prevent missed opportunities to improve prognosis. Declarations Conflict of interest statement/Competing interest statement : The author, Thomas Adam Purvis, has no conflict of interest Funding statement : This work received no funding Funding declaration : not applicable Author contribution statement : I am the sole author of the written manuscript Consent to publish declaration: Informed consent to publish was obtained from the patient subject of the manuscript Experimental protocols : Any experimental protocols would be approved by West Virginia University’s Institutional Review Board (IRB) however in the setting of this case description no experimental protocols were enacted. Ethical statement : The protocol was determined by the West Virginia University IRB in accordance with CFR 46.102(I) as not Human Subject Research. A determination letter is available upon request. Methods : all methods, where applicable, were carried out in accordance with relevant guidelines and regulations Ethical approval : The study was approved by the ethics committee of West Virginia University Institutional Review Board (IRB) Consent to participate : informed consent to participate and publish was obtained from the patient subject to the case discussed Consent to publish : informed consent to participate and publish was obtained from the patient subject to the case discussed Data Acquisition Statement (DAS): All data Generated or Analysed during the current study are included in this published article. Authorship Thomas Adam Purvis is the sole author of the manuscript References Fotios T, Anakwenze O, Vamsi K, Pulos N. Neuralgic Amyotrophy (Parsonage Turner syndrome) , JAAOS 2012 Volume 20 Issue 7. Gstoettner C, Mayer J, Rassam S, et al. Neuralgic Amyotrophy: a paradigm shift in diagnosis and treatment. J Neurol Neurosurg Psychiatry. 2020;91:8. Omotosho YB, Serchan R, Ying G, Shayuk. M A unique Case of Bannwarth syndrome in early disseminated Lyme disease Cureus, 2021, Volume 13, Issue 4. Schwartz AM, Hinckley A, Mead P, Hook, Kugeler K. Surveillance for Lyme disease, United States 2008–2015. MMWR Surveill Summ. 2017;66:22. Rauer S, Kastenbauer S, Hofmann H et al. Guidelines diagnosis Treat Neurol – Lyme neuroborreliosis Ger Med Sci 2020 18. Lyme Disease Data and Surveillance Office of Epidemiology and Prevention Services. 2023 oeps.wv.gov / Lyme . 2 Schwartz AM. Surveillance for Lyme disease—United States, 2008–2015. MMWR Surveillance Summaries. 2017;66(22):1–12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Apr, 2026 Reviews received at journal 30 Mar, 2026 Reviewers agreed at journal 28 Mar, 2026 Reviews received at journal 14 Mar, 2026 Reviewers agreed at journal 07 Mar, 2026 Reviewers invited by journal 19 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Editor invited by journal 16 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 04 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8213525","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":594562308,"identity":"a9385caa-d576-4bd0-8070-d9b7ed9a070f","order_by":0,"name":"Thomas Adam Purvis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYFACxoYDiX9q5AwQIgn4NfAwMDc++NhwzJgULezNhjMbmBM3EK3FXrqxTZp3B1v6dv7DD5h52w4z8LPnGODVwiNzEKjljEzuzhlpBmAtkj1vCGiRSGyT5mFjy91wA+itnDOHGQxuELIFooU53eD8GYgWeyK0AL3fxpxgcCAHqKUCaIsEIS13DjY++HDmmOGGG2kGh/9UpPNInHlWgFcL++z2BwcSKmrkDc4ffvhwhoG1HH978ga8WhgkkNgHQNbiV46uZRSMglEwCkYBVgAAIQ9Hfw/uKMAAAAAASUVORK5CYII=","orcid":"","institution":"West Virginia University","correspondingAuthor":true,"prefix":"","firstName":"Thomas","middleName":"Adam","lastName":"Purvis","suffix":""}],"badges":[],"createdAt":"2025-11-26 13:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8213525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8213525/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103505989,"identity":"100373d6-2412-413a-a9d4-02dc2983f802","added_by":"auto","created_at":"2026-02-26 13:33:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":291948,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8213525/v1/03795f6b-bd00-4ee2-b348-0ed69df2d575.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lyme Polyradiculoneuritis Case Report","fulltext":[{"header":"Full Text","content":"\u003cp\u003eThe diagnostic differentiaion of the acute neuromuscular patient presents unique and pressing challenges to the neurologist. Misclassifcation of the patient at initial presentation may present a missed opportunity for adequate empiric therapy, and thus negatively impact future clinical trajectory. This diagnostic quandary is compounded by how similarly the “plexopathy” and “polyradiculopathy” patients clinically manifest, and how the “infectious” and “inflammatory” aetiologies can co-masquerade. Electrodiagnostic testing with nerve conduction studies and EMG can be utilized to parse the presenting entity further, but its differentiating power is notoriously limited in the acute setting. The following patient’s presentation lead to an initial formulation of “inflammatory plexopathy”, though subsequent investigation lead to a diagnostic shift to one of “infectious polyradiculopathy” which had important implications for management and prognosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA 64-year-old man presented to the neurology clinic for consideration of acute onset bilateral arm pain and weakness of sudden onset two weeks prior. On the morning of onset of symptoms, he awoke with excruciating pain in the left shoulder with radiation to the left arm and entire left hand. By the afternoon, he had noticed a similar sensation in his right shoulder, radiating to his right arm. His pain peaked in severity on the first day, causing him significant distress and precluding any functional use of his arms. By the second day, his pain had begun to alleviate somewhat, however he began to notice numbness and weakness in the left more than right arms. While the pain in the arms persisted in moderate severity over the ensuing two weeks, the weakness and dysesthesias worsened. By the time of presentation to the neurology office, he was unable to lift his arms over his head, open jars or bottles, and had lost the ability to use his arms to drive.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHe denied any new symptoms in his legs, and his walking remained the same. He denied new-onset urinary symptoms, fevers, chills, rash, headache or speech changes. He recalled no antecedent vaccination, illness or infection.\u003c/p\u003e\n\u003cp\u003eHis history was also notable for a long-standing history of type 2 diabetes (his most recent Hemoglobin A1C was 8.8%), as well as hypertension and hyperlipidemia. He was a retired welder who spent much of his day outdoors. In his spare time, he would skin and butcher locally hunted deer in rural West Virginia. He was bitten by mosquitos on a recurrent basis. He reported observing many ticks on the deer carcasses he skinned, but took great care to avoid getting bitten himself.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHis neurological examination was notable for normal mental status and cranial nerves. Assessment of his arms revealed diffuse weakness (4/5 by Medical Research Council grading scale) on bilateral shoulder abduction, elbow flexion and extension, wrist extension, finger abduction and thumb abduction. No weakness was noted in his legs. His deep tendon reflexes were reduced at the knees, absent at the ankles and reduced-to-absent in the arms. Sensory examination revealed reduced sensation to pinprick and vibration in a length-dependent fashion in the legs. There was diffusely reduced sensation in the arms and hands to pinprick, but not in a distribution satisfying the territory of a single nerve or nerve root. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patient underwent electrophysiological testing by nerve conduction studies and electromyography (NCS/EMG) on the same day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSensory nerve conduction studies revealed no recordable sensory responses over the bilateral median or ulnar nerves. The medial and lateral antebrachial cutaneous and radial sensory responses were reduced in amplitude bilaterally, but approximately symmetrical.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMotor nerve conduction studies revealed normal ulnar motor responses, and prolonged distal onset latency responses in the bilateral median nerves. F-wave responses were prolonged on both median and ulnar nerves.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNeedle EMG demonstrated diffuse, subtle, active denervation throughout the left and right arms in the form of fibrillation potentials, positive sharp waves and fasciculation potentials (Left and right deltoid, biceps, triceps and first dorsal interosseous muscles). The motor unit morphology was normal however recruitment was reduced. Notably, needle examination of the cervical paraspinal muscles revealed no fibrillation potentials, positive sharp waves or fasciculation potentials.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaken in aggregate, the electrodiagnostic assessment suggested bilateral acute brachial plexopathies. The historical elements offered, combined with his medical background of diabetes, made Neuralgic Amyotrophy our top differential diagnosis at this juncture. While conclusion of his workup may have been appropriate at this point, the severity of his condition, the disability inferred, and the progression of his weakness all prompted his investigation to be continued. His exposure history in particular bore consideration for an infectious and potentially treatable etiology to his symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHe was directly admitted to the inpatient neurology service from the clinic for an expedited diagnostic workup as well as urgent pain management consultation. Initial serum testing revealed an elevated white count to 16.4, elevated CRP to 16.1, normal ESR of 7, and normal Creatine Kinase of 151.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI of the brain, cervical spine and brachial plexus, with and without gadolinium contrast, revealed no abnormal enhancement or lesions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCSF testing revealed an elevated white cell count (140 cells/microliter with 95% lymphocytes) and elevated CSF protein (280 mg/dl). CSF bacterial cultures, viral PCR array, and West Nile antibody testing were negative.\u003c/p\u003e\n\u003cp\u003eSerum testing for Lyme IgG and IgM were positive by Western Blot. Lyme antibodies (IgG) were found to be positive in the CSF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn light of these developments, his provisional diagnosis was revised from Neuralgic Amyotrophy to Lyme Polyradiculoneuritis. He was started on doxycycline 100mg twice daily for 14 days with symptomatic improvement in pain and strength. On repeat assessment a year later his arm function had returned, his physical examination revealed return of full strength to confrontation, though he continued to experience moderate aching pains in his shoulders and reduced dexterity in his hands. From the perspective of the patient this was far from an ideal outcome, and he expressed frustration at the lack of sustained recovery as the sequelae of the disease continued to hamper his functionality and quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the described case is limited in generalizability as a single example, its encountered pearls and pitfalls serve a broader application in wider clinical practice. Neuralgic Amyotrophy, also known as Parsonage Turner syndrome, is an inflammatory condition affecting the nerves of the brachial plexus. An inciting antecedent event is often implied, such as infection, vaccination or surgery [1]. Up to 30% of cases are bilateral [1]. The condition is thought to be monophasic and self-limiting, however steroids may be beneficial for pain in the acute phase [2]. Recovery of function can take years to occur, and may be incomplete [2]. The typical presentation of Neuralgic Amyotrophy is one of excruciating pain in the arm, that eventually yields to sensory and motor dysfunction in the affected limb.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLyme polyradiculoneuritis, also known as Bannwarth syndrome, was previously considered a rare neurological manifestation of Lyme Disease in the United States, more commonly seen in Europe. Cases in the U.S. are becoming more recognized [3,4]. Additionally, Lyme’s disease incidence has increased dramatically in West Virginia over recent years [5,6]. Climate change has been postulated as a reason for this [7]. The spread of the condition from its first-discovered site in Lyme, Connecticut to West Virginia has proposed numerous new challenges to the local population. West Virginian life is steeped in outdoor activites such as hunting, hiking and fishing, and the region is abundant with woodland and wildlife. Practices to prevent Lyme Disease conversely are not as routinely implemented in West Virginia compared to neighbouring states such as New York, Pennsylvania or Connecticut, thus exposure to ticks is likely much higher. The disease has also only been prevalent in West Virginia relatively recently, so the disease may not be considered as routinely in medical practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChallenges exist however, as overdiagnosis of Lyme’s disease is historically common. The variable presentation and potential for false-positive test results can lead to the erroneous attribution of non-specific or unrelated symptoms as features of Lyme’s disease or “Chronic Lyme”. This can lead to the harmful prescription of long term antibiotic therapy unnecessarily. Our diagnosis of lyme polyradiculoneuritis is based on his fitting clinical presentation, exposure history and supportive laboratory data. Histopathological confirmation via nerve root biopsy may have lent more credence to our conclusions, though from a practical perspective the invasive investigational procedure would have been difficult to justify.\u003c/p\u003e\n\u003cp\u003eBoth neuralgic amyotrophy and lyme polyradiculoneuritis can present with marked similarity, both typified by acute-onset severe pain, motor and sensory loss in the arms. Despite this their underlying pathophysiology and management differ greatly. This poses an exceptional challenge to the assessing clinician. An understanding of the limitations of EMG were required in this case to understand that despite the negative paraspinal needle examination a nerve root localization component remained a possibility. Perils exist with over-reliance on EMG, like any other diagnostic modality. Appreciation of the broader clinical context is mandatory to prevent premature diagnostic closure. Furthermore, an understanding of evolving epidemiological trends in the region of practice are imperative to accurately inform differential diagnosis, and prevent missed opportunities to improve prognosis. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest statement/Competing interest statement\u003c/strong\u003e: The author, Thomas Adam Purvis, has no conflict of interest\u003cbr\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e: This work received no funding\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e: not applicable\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAuthor contribution statement\u003c/strong\u003e: I am the sole author of the written manuscript\u003cbr\u003e\u003cstrong\u003eConsent to publish declaration:\u0026nbsp;\u003c/strong\u003eInformed consent to publish was obtained from the patient subject of the manuscript\u003cbr\u003e\u003cstrong\u003eExperimental protocols\u003c/strong\u003e: Any experimental protocols would be approved by West Virginia University\u0026rsquo;s Institutional Review Board (IRB) however in the setting of this case description no experimental protocols were enacted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e: The protocol was determined by the West Virginia University IRB in accordance with CFR 46.102(I) as not Human Subject Research. A determination letter is available upon request.\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: all methods, where applicable, were carried out in accordance with relevant guidelines and regulations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e: The study was approved by the ethics committee of West Virginia University Institutional Review Board (IRB)\u003cbr\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e: informed consent to participate and publish was obtained from the patient subject to the case discussed\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e: informed consent to participate and publish was obtained from the patient subject to the case discussed\u003cbr\u003e\u003cstrong\u003eData Acquisition Statement (DAS):\u003c/strong\u003e All data Generated or Analysed during the current study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthorship\u003cbr\u003e\u003c/u\u003eThomas Adam Purvis is the sole author of the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFotios T, Anakwenze O, Vamsi K, Pulos N. \u003cem\u003eNeuralgic Amyotrophy (Parsonage Turner syndrome)\u003c/em\u003e, JAAOS 2012 Volume 20 Issue 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGstoettner C, Mayer J, Rassam S, et al. Neuralgic Amyotrophy: a paradigm shift in diagnosis and treatment. J Neurol Neurosurg Psychiatry. 2020;91:8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOmotosho YB, Serchan R, Ying G, Shayuk. \u003cem\u003eM A unique Case of Bannwarth syndrome in early disseminated Lyme disease\u003c/em\u003e Cureus, 2021, Volume 13, Issue 4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwartz AM, Hinckley A, Mead P, Hook, Kugeler K. Surveillance for Lyme disease, United States 2008\u0026ndash;2015. MMWR Surveill Summ. 2017;66:22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRauer S, Kastenbauer S, Hofmann H et al. Guidelines diagnosis Treat Neurol \u0026ndash; Lyme neuroborreliosis Ger Med Sci 2020 18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyme Disease Data and Surveillance Office of Epidemiology and Prevention Services. 2023 \u003cem\u003eoeps.wv.gov\u003c/em\u003e/\u003cem\u003eLyme\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2 Schwartz AM. Surveillance for Lyme disease\u0026mdash;United States, 2008\u0026ndash;2015. MMWR Surveillance Summaries. 2017;66(22):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-neuroscience","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ndev","sideBox":"Learn more about [Neural Development](http://neuraldevelopment.biomedcentral.com/)","snPcode":"13064","submissionUrl":"https://submission.nature.com/new-submission/13064/3","title":"Discover Neuroscience","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neuromuscular, EMG, neurophysiology, infection, case report","lastPublishedDoi":"10.21203/rs.3.rs-8213525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8213525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe present a challenging case that serves as a cautionary tale pertaining to the appropriate incorporation of electrophysiological assessment of the acute neuromuscular patient. This 64 year-old man presented with acute arm pain and weakness, with electrophysiological assessment suggestive of an acute brachial plexopathy. Subsequent investigation, however, lead to a diagnostic shift to one of a radiculoplexus neuropathy, leading to a revised diagnosis of Lyme Polyradiculoneuritis. This new diagnosis had implications for treatment, and positively affected prognostic trajectory. Knowledge of the limitations of electrophysiological assessment is important for both the neuromuscular specialist and general neurologist. The case also bears educational import for the moderan practice of neurology in the Appalachian region of the United States, as Lyme disease has become endemic to Appalchia as well.\u003c/p\u003e","manuscriptTitle":"Lyme Polyradiculoneuritis Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 15:44:14","doi":"10.21203/rs.3.rs-8213525/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T14:33:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T20:23:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294755098379536399356808688943581718939","date":"2026-03-28T14:45:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T12:37:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141580186199248261472924991145576132681","date":"2026-03-07T09:34:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T12:49:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T22:14:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-16T07:37:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T13:25:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Neuroscience","date":"2026-02-04T13:15:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-neuroscience","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ndev","sideBox":"Learn more about [Neural Development](http://neuraldevelopment.biomedcentral.com/)","snPcode":"13064","submissionUrl":"https://submission.nature.com/new-submission/13064/3","title":"Discover Neuroscience","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1f3f1aeb-836c-4dfe-ba59-6de5d63bf16e","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T06:08:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 15:44:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8213525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8213525","identity":"rs-8213525","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}