Cardiovascular Disease: Student/Resident Case Report Poster - Cardiovascular Disease I |

Lyme Carditis: A Presentation Without Erythema Migrans FREE TO VIEW

Bisma Alam, MD; Geetanjali Johri, MD; Kegan Jessamy, MD; Kan Liu, MD
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SUNY Upstate Medical University, Syracuse, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):94A. doi:10.1016/j.chest.2016.08.102
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SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Lyme disease is a systemic illness caused by the spirochete Borrelia burgdorferi which utilizes the Ixodes tick as its vector. Cardiac manifestations are one of the most variable and often can be fatal and occur in 4-10% of untreated cases of Lyme disease. The most common manifestation is first and second-degree heart block, while third degree heart block is a more serious, and less common phenomenon. Fortunately, this illness is generally reversible when the diagnosis is made and early treatment is initiated.

CASE PRESENTATION: A 25 year old male presented with complaints of paroxysmal dizziness and extreme dyspnea on exertion. He also denied any recent rash over his body, joint swelling, or neck stiffness. Family history was significant for two first cousins with HOCM, one of which had died from the condition. Patient travelled to Maine recently. Patient was bradycardic to a rate of 27-30 bpm. Blood pressure, temperature, and respiratory rate were within normal limits. Physical examination was unremarkable except for bradycardia. EKG showed third degree heart block. A transvenous pacemaker was placed. Patient was started on IV ceftriaxone for suspicion of Lyme carditis. After two days of therapy the Lyme titers had returned preliminarily positive and were later confirmed with Western blot.

DISCUSSION: Lyme disease is one of the most prevalent causes of reversible heart block in the United States. It is due to direct invasion of the myocardium by B. burgdorferi. It may be accompanied or preceded by other hallmark signs of Lyme disease including erythema migrans, arthritis, and facial palsy. AV block occurs due to host inflammatory response towards spirochetes in cardiac tissue. There is high risk of sudden cardiac death if there is a delay in diagnosis and initiation of therapy. A limiting factor in early diagnoses of Lyme carditis is the frequent lack of associated erythema migrans which is found in majority of cases.

CONCLUSIONS: Carditis, specifically third degree heart block, is an uncommon manifestation of Lyme disease, but also the deadliest. Healthcare workers, specifically in regions of high-incidence Lyme disease, should be mindful of patients who present with cardiac symptoms, even those without common manifestations of Lyme disease. Prompt recognition and early therapy are key to prevent fatal complications.

Reference #1: Fish A, Pride Y, Pinto D. Lyme carditis. Infectious Disease Clinics Of North America. June 2008;22(2):275.

Reference #2: Oktay A, Dibs S, Friedman H. Sinus Pause in Association with Lyme Carditis. Texas Heart Institute Journal / From The Texas Heart Institute Of St. Luke's Episcopal Hospital, Texas Children's Hospital. June 1, 2015;42(3):248-250.

Reference #3: Forrester J, Mead P. Third-degree heart block associated with lyme carditis: review of published cases. Clinical Infectious Diseases: An Official Publication Of The Infectious Diseases Society Of America. October 2014;59(7):996-1000.

DISCLOSURE: The following authors have nothing to disclose: Bisma Alam, Geetanjali Johri, Kegan Jessamy, Kan Liu

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