CASE REPORT Painful Hallucinations and Somatic Delusions in a Patient With the Possible Diagnosis of Neuroborreliosis Karl-Ju¨rgen Ba¨r, MD,* Thomas Jochum,* Frank Ha¨ger, MD,* Winfried Meissner, MD,† and Heinrich Sauer, MD* Abstract: Neuroborreliosis has become the most frequently recognized tick-borne infection of the nervous system in Europe and the United States. In addition to dermatological, cardiac, articular, and neurologic manifestations, psychiatric disorders such as depression, panic attacks, and schizophrenia-like psychosis can also arise. We report on a 61-year-old woman who developed a severe pain syndrome following several tick bites. She was diagnosed with neuro- borreliosis; she received various courses of antibiotics over several years, but without any clinical improvement in her condition. Her eventual admission to a psychiatric ward due to mental symptoms and neuroleptic treatment led to a dramatic improvement of her pain symptoms. However, increasing delusions disclosed a psychotic epi- sode, which ceased over time. We discuss therapeutic difficulties and psychiatric complications in the absence of a clear-cut diagnosis of neuroborreliosis. Although this patient might have suffered from late- onset schizophrenia with painful hallucinations right from the start of her disease, the case highlights psychiatric complications that might be associated with neuroborreliosis. Key Words: diagnosis, neuroborreliosis, pain, psychosis, schizo- phrenia (Clin J Pain 2005;21:362–363) N euroborreliosis, a manifestation of infection with the spirochete Borrelia burgdorferi, has become the most frequent recognized tick-borne infection of the nervous system in Europe and the United States. 1 Although dermatological, cardiac, articular, and neurologic manifestations are well rec- ognized in Lyme disease, psychiatric complications such as depression, panic attacks, and schizophrenia-like psychosis may also arise. 2 Neuroborreliosis is often associated with pain syndromes. Thus, psychiatric consultation might be neces- sary to evaluate mental problems or disorders, either arising through the infection per se, or in secondary course, partic- ularly for depression. The aim of this report is to describe difficulties in diagnosing and managing a case with an uncertain neuroborreliosis and severe pain syndrome. In particular, psychiatric aspects of clinical management in such patients shall be addressed. CASE REPORT We report the case of a 61-year-old woman with a diagnosis of borreliosis, who was referred to the liaison psychiatrist for con- sultation. At the time, she was seen at our interdisciplinary pain clinic complaining of severe pains on both arms, shoulders, back, and both legs, which had lasted for 2 years. On psychiatric interview, she was severely depressed and reluctant to talk. Her thoughts were exclu- sively engaged with her numerous sensations of pain. The patient was convinced that she suffered from neuroborreliosis and that previous treatments had failed to eradicate bacteria completely. Moreover, she was sure that the bacteria would now ruin her nervous system in the gastrointestinal tract. She scored maximum pain ratings on several scales, including the visual analogue scale. Review of her history showed that the patient had sustained a severe pain syndrome for 2 years following several tick bites. Although no erythema migrans or other skin manifestations had been observed, she increasingly suffered from diffuse, persistent pains in various parts of her body. AWestern blot for specific proteins such as IgG 41 kDa had been positive, as well as for IgM 60 kDa. In contrast, common antigen for borrelia burgdorferi and serology for Treponema pallidum, as well as antibodies for herpes zoster virus (HZV), varicella zoster virus (VZV), Epstein-Barr virus (EBV), and cyto- megalovirus (CMV), and tests for antinuclear antibody (ANA) had been negative. She had been diagnosed with neuroborreliosis and received various courses of antibiotics, including doxycycline and ceftriaxone. The patient had sought help at several institutions, including specialist practices and clinics. However, none of the therapeutic attempts significantly improved her clinical status. There was no other relevant psychiatric or medical history. Due to clinical presentation, a reported suicide attempt, and persisting suicidal ideation, she was admitted to a psychiatric ward. Several blood investigations were repeated. On this occasion, tests did not reveal abnormalities such as antibodies against Borrelia burgdorferi and Treponema pallidum. However, in Western blot analysis, IgG was reactive to 41 kDa flagellin and IgM was incomplete reactive to the 60 kDa common antigen. Electroenceph- alogram (EEG), cerebrospinal fluid (CSF), and cranial magnetic resonance imaging (MRI) were unremarkable. Electroneurographic investigations showed entirely normal somatosensory evoked poten- tials and no signs of peripheral neuropathy. The preliminary diagnosis of a depressive episode with delusion and somatization of unknown origin (infectious or primarily psychotic) was established and antidepressive treatment with clomip- ramine (100 mg daily) and neuroleptic medication (olanzapine 15 mg daily) was started. Received for publication April 24, 2002; revised July 5, 2003; second revision October 18, 2003; accepted January 10, 2004. From the *Department of Psychiatry, Friedrich-Schiller-University of Jena, Jena; and †Department of Anesthesiology, Friedrich-Schiller-University of Jena, Jena, Germany. Reprints: K. J. Ba¨r, MD, Klinik fu¨r Psychiatrie, Philosophenweg 3, Jena 07743, Germany (e-mail: karl-juergen.baer@med.uni-jena.de). Copyright Ó 2005 by Lippincott Williams & Wilkins 362 Clin J Pain  Volume 21, Number 4, July/August 2005