We describe a case report of an elderly patient who had presented with acute onset of atypical lower extremity pain and gait dysfunction, and was ultimately diagnosed with Lyme arthritis. Case report: A 70-year-old male presented with a chief complaint of 10 days of lower back and bilateral lower extremity pain. He described sudden onset of intense, sharp bilateral anterior thigh pain radiating to the medial calves intermittently and without paresthesia, bowel or bladder incontinence, fevers,

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... shes or weight change. His gait was found to be antalgic and slow. Strength, sensation, and reflexes were intact in both legs. X-ray imaging of bilateral hips revealed mild osteoarthritis bilaterally. An MRI of the bilateral hips showed bilateral hip effusions with synovial proliferation and degenerative labral tearing. He underwent a fluoroscopically guided bilateral injection with each hip, and clear, straw-colored synovial fluid was aspirated from the left hip. He gave additional history following the injection of being treated for Lyme disease 4 months prior to the onset of his leg pain, for which he previously completed 2 weeks of doxycycline. Fluid analysis revealed elevated nucleated cell count and positive serology for multiple Borrelia-specific bands, consistent with Lyme arthritis. He was subsequently treated with a 4 week course of doxycycline. As of 18 months later, his pain has improved significantly. Conclusion: Patients with antibiotic refractory Lyme disease that continue to have chronic symptoms, including arthritis and synovitis, after appropriate antibiotic therapy may benefit from treatment with anti-inflammatory medications, disease-modifying anti-rheumatic drugs (DMARD) or synovectomy.