In Lyme disease with neurological symptoms such as Bell's palsy or AV block, what is the recommended treatment?

• A. IV Ceftriaxone for 28 days
• B. Oral Doxycycline for 21 days
• C. IV Penicillin for 14 days
• D. Oral Azithromycin for 7 days

Answer: (A)

Neurologic involvement in Lyme disease means the infection has disseminated to the nervous system, so antibiotics must reach the central nervous system effectively. Intravenous ceftriaxone is preferred because it penetrates the CNS well and is reliably active against Borrelia burgdorferi. The typical approach is 2 g IV daily for about 28 days, which addresses neurologic manifestations such as Bell’s palsy and conduction abnormalities like AV block. IV penicillin G is a valid alternative if ceftriaxone isn’t suitable, usually given for 14–28 days. Oral doxycycline or azithromycin are not ideal for neuroborreliosis due to poorer CNS penetration and less evidence of efficacy in central nervous system infection, though they may be used for non-neurologic or mild cases when IV therapy isn’t possible.