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Steroids for Bell’s Palsy and the ID Doctor

Posted Nov 08 2012 9:10pm

OK, let’s imagine you’ve just gotten a call/email/text from one of your colleagues about Bell’s palsy; he/she is a busy PCP who periodically asks you very reasonable ID questions.

I suspect it went something like this:

COLLEAGUE:  Hi Friendly ID Doctor, quick question — I have a patient with Bell’s palsy — wondering whether to give him steroids.
FRIENDLY ID DOCTOR:  Steroids? Absolutely not! Don’t you know that a host of infectious diseases cause Bell’s palsy, including Lyme, HSV, VZV, HIV, syphilis [and other obscure diagnoses I'm too tired or too forgetful to list]. Have you excluded these?
COLLEAGUE: Well, I just read that the neurologists are recommending steroids …
FRIENDLY ID DOCTOR: I’d get Lyme titers, and start the patient on doxycycline and high-dose valacyclovir. In addition, [insert boilerplate language about the limitations of curbside ID consults here].
COLLEAGUE: But the neurologists say antiviral therapy doesn’t really work. And doxycycline? Why?
LESS-FRIENDLY ID DOCTOR: Never mind — how about you call a neurologist and ask what to do?

Every so often, something comes along that shows that you are absolutely and completely and totally biased in your approach to a problem by your perspective. Whoppingly biased, if that’s a word. I confess that Bell’s palsy is one of those things.

(I didn’t even know that the preferred term is now “Bell palsy”, without the possessive. Sounds weird. I’m sticking with “Bell’s”.)

To me — and probably to most Infectious Diseases specialists — a patient with Bell’s is an ID problem worth solving.

But to the vast majority of the rest of the world, including these new guidelines and the great swath of primary care providers and neurologists, it’s “an acute, peripheral facial paresis of unknown cause.”

Emphasis mine.

And after reading this evidence - based review, I confess that the data supporting the use of steroids for Bell’s palsy are far stronger than those for antiviral agents or, with my New England bias, doxycycline, which was not even mentioned in the guidelines. Oh well.

Nonetheless, for providers who see a new case, especially in the warm months, please humor me — send a Lyme titer. And at least think about those other ID diagnoses that cause Bell’s.

I mean Bell.

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