HPI

16 y/o female p/w L sided facial droop and L eyelid weakness

Onset 1 night ago, numbness/tingling in L lip, today noticed drooling from L lip after drinking fluids, weakness w/ closing L eyelid

No recent travel or exposure to wooded areas, no sexual hx, no pmh, dx w/ strep 5 days prior by pediatrician, taking amox

Physical exam

BP 143/75, HR 71, T 98.8 F, RR 18, O2 100%

PERLLA, EOMI, L Sided facial droop, L eye ptosis, Lid lag, L eyelid weakness, Decreased movement of L forehead

Otherwise Strength 5/5 in UE’s and LE’s, reflexes normal, Sensation intact, gait normal, Romberg negative, no dysmetria, speech normal

L external ear canal revealed a small black insect, immobile, appears latched onto canal, scant amount of dried blood around insect 

DDX

Bell’s palsy

Tick Paralysis 

CVA

Workup

Peds Neuro and Peds ID consulted recommended following:

Removal of tick

Labs- IGM/IGG titer

Started on doxycycline and prednisone

Clinical course

Tick was killed and removed w/ copious irrigation of L external ear canal w/ isopropyl alcohol using a 10cc syringe and 16-gauge catheter

lidocaine ineffective against ticks

Abx and steroids were prescribed, patient instructed to continue abx and steroids, f/u w/ peds neuro

On neuro follow had improvement of eye weakness, continued with facial droop so valacyclovir was added 

Take home points

Must be thorough w/ history and physical exam for patient’s w/ bell’s palsy- look for rash, vesicles, etc. 

Neuro exam must be complete to r/o CVA as cause of paralysis 

Otitis media, HSV, Varicella Zoster, CMV, EBV, Rubella, Lyme Disease, HIV, Guillain-Barre, Influenza, and mumps are common culprits in ped’s pts w/ bells palsy 

Doxycycline = standard treatment for Lyme’s disease, doxy can be used in children < 8 y/o if used for <21 days, otherwise amoxicillin may be used 

Always obtain Lyme serology