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Messner CR, Amara RS. Successful permanent pacemaker explantation after diagnosis and treatment of Lyme carditis complete heart block: a case report. Eur Heart J Case Rep 2023; 7:ytad576. [PMID: 38444881 PMCID: PMC10914342 DOI: 10.1093/ehjcr/ytad576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/07/2023] [Accepted: 11/16/2023] [Indexed: 03/07/2024]
Abstract
Background Lyme carditis (LC) complete heart block (CHB) is typically treated with i.v. antibiotics without requiring permanent pacing. In patients with high degree atrioventricular (AV) block, suspicious index in Lyme carditis (SILC) scoring is highly sensitive for diagnosing LC. Case summary We present a case of CHB where a permanent pacemaker (PPM) was implanted prior to LC diagnosis. Suspicious index in Lyme carditis score was 2 at the time of exam, indicating a low risk for LC. However, per further discussion at follow-up, his score was retroactively increased to an intermediate risk of 4 and Lyme titres returned positive. An outpatient oral antibiotic regimen was given, and 2 months later, the patient had <0.1% V-pacing on interrogation with a subsequent unremarkable event monitor. The pacemaker was removed after considerations ensuring full conduction recovery. The patient is doing well at follow-up > 1 year. Discussion Lyme carditis spontaneous resolution of CHB is common. Once safe extraction parameters have been established, it is appropriate to engage patients without ongoing pacer requirements about explantation of their PPM. For CHB patients without clear aetiology, SILC scoring may be a predictive measure to help prevent unnecessary PPM placement in the future.
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Affiliation(s)
| | - Richard S Amara
- Department of Cardiology, University of Maryland, Baltimore, MD, USA
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2
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Early identification of Lyme disease complications. JAAPA 2023; 36:19-23. [PMID: 36573811 DOI: 10.1097/01.jaa.0000902892.41571.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
ABSTRACT Complications of Lyme disease including Lyme arthritis, Lyme carditis, and Lyme neuroborreliosis, typically occur during the early disseminated and late phases of the disease. Clinicians must maintain a high index of suspicion so they can recognize and treat complications promptly. Early treatment with appropriate antibiotics often leads to improved clinical outcomes.
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Neville DN, Alexander ME, Bennett JE, Balamuth F, Garro A, Levas MN, Thompson AD, Kharbanda AB, Lewander DP, Dart AH, Nigrovic LE. Electrocardiogram as a Lyme Disease Screening Test. J Pediatr 2021; 238:228-232.e1. [PMID: 34265339 DOI: 10.1016/j.jpeds.2021.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine the association between electrocardiographic (ECG) evidence of carditis at the time of Lyme disease evaluation and a diagnosis of Lyme disease. STUDY DESIGN We performed an 8-center prospective cohort study of children undergoing emergency department evaluation for Lyme disease limited to those who had an ECG obtained by their treating clinicians. The study cardiologist reviewed all ECGs flagged as abnormal by the study sites to assess for ECG evidence of carditis. We defined Lyme disease as the presence of an erythema migrans lesion or a positive 2-tier Lyme disease serology. We used logistic regression to measure the association between Lyme disease and atrioventricular (AV) block or any ECG evidence of carditis. RESULTS Of the 546 children who had an ECG obtained, 214 (39%) had Lyme disease. Overall, 42 children had ECG evidence of carditis, of whom 24 had AV block (20 first-degree). Of the patients with ECG evidence of carditis, only 21 (50%) had any cardiac symptoms. The presence of AV block (OR 4.7, 95% CI 1.8-12.1) and any ECG evidence of carditis (OR 2.3, 95% CI 1.2-4.3) were both associated with diagnosis of Lyme disease. CONCLUSIONS ECG evidence of carditis, especially AV block, was associated with a diagnosis of Lyme disease. ECG evidence of carditis can be used as a diagnostic biomarker for Lyme disease to guide initial management while awaiting Lyme disease test results.
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Affiliation(s)
- Desiree N Neville
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Mark E Alexander
- Arrhythmia Service, Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Michael N Levas
- Division of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Amy D Thompson
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - David P Lewander
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Yeung C, Al-Turki M, Baranchuk A. The Value of the Surface ECG for the Diagnosis and Management of Lyme Carditis: A Case Report. Curr Cardiol Rev 2021; 17:5-9. [PMID: 32164515 PMCID: PMC8142371 DOI: 10.2174/1573403x16666200312101751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 01/13/2023] Open
Abstract
Lyme carditis (LC) is an early-disseminated manifestation of Lyme disease, most commonly presenting as a high-degree atrioventricular block (AVB). The degree of AVB can fluctuate rapidly within minutes, and progression to third-degree AVB is potentially fatal if not recognized and managed promptly. However, the AVB in LC is often transient and usually resolves with appropriate antibiotic therapy. LC should be on the differential diagnosis in young patients presenting with new high-degree AVB and factors that increase the index of suspicion for Lyme disease. The Suspicious Index in Lyme Carditis (SILC) score helps clinicians risk-stratify for LC. A systematic approach to the diagnosis and treatment of LC minimizes the unnecessary implantation of permanent pacemakers.
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Affiliation(s)
- Cynthia Yeung
- Department of Medicine, Queen's University, Kingston, ON K7L 2V7, Ontorio, Canada
| | - Mohammed Al-Turki
- Department of Medicine, Queen's University, Kingston, ON K7L 2V7, Ontorio, Canada
| | - Adrian Baranchuk
- Department of Medicine, Queen's University, Kingston, ON K7L 2V7, Ontorio, Canada
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Early Disseminated Lyme Carditis Inducing High-Degree Atrioventricular Block. Case Rep Cardiol 2020; 2020:5309285. [PMID: 32566317 PMCID: PMC7292967 DOI: 10.1155/2020/5309285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 11/24/2022] Open
Abstract
Lyme disease is the most common tick-borne illness in the United States due to Borrelia burgdorferi infection. This case demonstrates a 20-year-old male patient presenting with complaints of annular skin rash, malaise, fever, and lightheadedness after significant outdoor exposure. Physical exam revealed multiple large targetoid lesions on the back and extremities. The rash had raised borders and centralized clearing consistent with erythema migrans chronicum. Electrocardiogram (ECG) revealed a high-degree atrioventricular (AV) block. The patient was started on intravenous ceftriaxone due to clinical suspicion for Lyme carditis. ELISA and Western blot tests were reactive for Lyme IgM and IgG, confirming the diagnosis. The AV block resolved by hospital day four and the patient was discharged with outpatient follow-up. Early identification of disease allowed for effective treatment with no adverse outcomes or sequelae.
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Marx GE, Leikauskas J, Lindstrom K, Mann E, Reagan-Steiner S, Matkovic E, Read JS, Kelso P, Kwit NA, Hinckley AF, Levine MA, Brown C. Fatal Lyme Carditis in New England: Two Case Reports. Ann Intern Med 2020; 172:222-224. [PMID: 31634915 DOI: 10.7326/l19-0483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Grace E Marx
- Centers for Disease Control and Prevention, Fort Collins, Colorado (G.E.M., A.F.H.)
| | - Jillian Leikauskas
- Vermont Department of Health, Burlington, Vermont (J.L., P.K., N.A.K., M.A.L.)
| | - Katherine Lindstrom
- Cape Cod Office of the Chief Medical Examiner, Sandwich, Massachusetts (K.L.)
| | - Erin Mann
- Massachusetts Department of Public Health, Jamaica Plain, Massachusetts (E.M., C.B.)
| | | | - Eduard Matkovic
- Centers for Disease Control and Prevention, Atlanta, Georgia (S.R., E.M.)
| | - Jennifer S Read
- Vermont Department of Health and University of Vermont, Burlington, Vermont (J.S.R.)
| | - Patsy Kelso
- Vermont Department of Health, Burlington, Vermont (J.L., P.K., N.A.K., M.A.L.)
| | - Natalie A Kwit
- Vermont Department of Health, Burlington, Vermont (J.L., P.K., N.A.K., M.A.L.)
| | - Alison F Hinckley
- Centers for Disease Control and Prevention, Fort Collins, Colorado (G.E.M., A.F.H.)
| | - Mark A Levine
- Vermont Department of Health, Burlington, Vermont (J.L., P.K., N.A.K., M.A.L.)
| | - Catherine Brown
- Massachusetts Department of Public Health, Jamaica Plain, Massachusetts (E.M., C.B.)
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Yeung C, Baranchuk A. Diagnosis and Treatment of Lyme Carditis: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 73:717-726. [PMID: 30765038 DOI: 10.1016/j.jacc.2018.11.035] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/13/2018] [Accepted: 11/26/2018] [Indexed: 12/27/2022]
Abstract
The incidence of Lyme disease, a tick-borne bacterial infection, is dramatically increasing in North America. The diagnosis of Lyme carditis (LC), an early disseminated manifestation of Lyme disease, has important implications for patient management and preventing further extracutaneous complications. High-degree atrioventricular block is the most common presentation of LC, and usually resolves with antibiotic therapy. A systematic approach to the diagnosis of LC in patients with high-degree atrioventricular block will facilitate the identification of this usually transient condition, thus preventing unnecessary implantation of permanent pacemakers in otherwise healthy young individuals.
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Affiliation(s)
- Cynthia Yeung
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada. https://twitter.com/yeung2020
| | - Adrian Baranchuk
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada.
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Affiliation(s)
- Douglas Wan
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ont
| | - Adrian Baranchuk
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ont.
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Besant G, Wan D, Yeung C, Blakely C, Branscombe P, Suarez-Fuster L, Redfearn D, Simpson C, Abdollah H, Glover B, Baranchuk A. Suspicious index in Lyme carditis: Systematic review and proposed new risk score. Clin Cardiol 2018; 41:1611-1616. [PMID: 30350436 DOI: 10.1002/clc.23102] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/07/2018] [Accepted: 10/19/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Lyme carditis (LC), an early manifestation of Lyme disease that most commonly presents as high-degree atrioventricular block (AVB), usually resolves with antibiotic treatment. When LC is not identified as the cause of AVB, a permanent pacemaker may be inappropriately implanted in a reversible cardiac conduction disorder. HYPOTHESIS The likelihood that a patient's high-degree AVB is caused by LC can be evaluated by clinical characteristics incorporated into a risk stratification tool. METHODS A systematic review of all published cases of LC with high-degree AVB, and five cases from the authors' experience, was conducted. The results informed the development of a new risk stratification tool, the Suspicious Index in LC (SILC) score. The SILC score was then applied to each case included in the review. RESULTS Of the 88 cases included, 51 (58%) were high-risk, 31 (35.2%) intermediate-risk, and 6 (6.8%) low-risk for LC according to the SILC score (sensitivity 93.2%). For the subset of 32 cases that reported on all SILC variables, 24 (75%) cases were classified as high-risk, 8 (25%) intermediate-risk, and 0 low-risk (sensitivity 100%). Specificity could not be assessed (no control group). Notably, 6 of the 11 patients who received permanent pacemakers had reversal of AVB with antibiotic treatment. CONCLUSION The SILC risk score and COSTAR mnemonic (constitutional symptoms; outdoor activity; sex = male; tick bite; age < 50; rash = erythema migrans) may help to identify LC in patients presenting with high-degree AVB, and ultimately, minimize the implantation of unnecessary permanent pacemakers.
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Affiliation(s)
- Georgia Besant
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Douglas Wan
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Cynthia Yeung
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Crystal Blakely
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Pamela Branscombe
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Laiden Suarez-Fuster
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Damian Redfearn
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Christopher Simpson
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Hoshiar Abdollah
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Benedict Glover
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
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Yeung C, Baranchuk A. Systematic Approach to the Diagnosis and Treatment of Lyme Carditis and High-Degree Atrioventricular Block. Healthcare (Basel) 2018; 6:healthcare6040119. [PMID: 30248981 PMCID: PMC6315930 DOI: 10.3390/healthcare6040119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/21/2018] [Accepted: 09/21/2018] [Indexed: 11/16/2022] Open
Abstract
Lyme carditis (LC) is a manifestation of the early disseminated stage of Lyme disease and often presents as high-degree atrioventricular (AV) block. High-degree AV block in LC can be treated with antibiotics, usually resolving with a highly favorable prognosis, thus preventing the unnecessary implantation of permanent pacemakers. We present a systematic approach to the diagnosis and management of LC that implements the Suspicious Index in Lyme Carditis (SILC) risk stratification score.
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Affiliation(s)
- Cynthia Yeung
- Department of Medicine, Queen's University, Kingston, ON K7L 3N6, Canada.
| | - Adrian Baranchuk
- Department of Medicine, Queen's University, Kingston, ON K7L 3N6, Canada.
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Bourji KI, Newsome T, Meyerhoff J. Rapid complete atrioventricular heart block reversal due to Lyme carditis. J Community Hosp Intern Med Perspect 2018; 8:241-243. [PMID: 30181836 PMCID: PMC6116299 DOI: 10.1080/20009666.2018.1503918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022] Open
Abstract
A 49-year-old man, who presented with new onset dyspnea on exertion and fatigue without clear history of a typical erythema migrans rash, was found to have complete atrioventricular (AV) heart block with positive serology for Lyme disease. A complete stepwise reversal of the AV block was achieved shortly after the initiation of intravenous antibiotic treatment.
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Affiliation(s)
- Khalil I. Bourji
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD, USA
| | - T. Newsome
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD, USA
| | - John Meyerhoff
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD, USA
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Sánchez-Vázquez DR, Márquez MF, Baranchuk A. Afección cardíaca de la enfermedad de Lyme: ¿Por qué México debe de prestar atención a este tema? ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:167-170. [DOI: 10.1016/j.acmx.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 11/24/2022] Open
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Lyme Carditis and High-Degree Atrioventricular Block. Am J Cardiol 2018; 121:1102-1104. [PMID: 29598856 DOI: 10.1016/j.amjcard.2018.01.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/04/2018] [Accepted: 01/09/2018] [Indexed: 11/24/2022]
Abstract
Canada has seen a sixfold increase in Lyme disease since being nationally notifiable in 2009. This is the first Canadian series on Lyme carditis manifested as high-degree atrioventricular block. We report 5 recent cases presented over a 2-year period. The variation of nonspecific presentations requires a high index of suspicion for prompt diagnosis and correct management. Recognizing this early would curtail the progression of conduction disorders and potentially avoid permanent pacemaker implantation.
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Cunha BA, Elyasi M, Singh P, Jimada I. Lyme carditis with isolated left bundle branch block and myocarditis successfully treated with oral doxycycline. IDCases 2017; 11:48-50. [PMID: 29326870 PMCID: PMC5760251 DOI: 10.1016/j.idcr.2017.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 10/27/2022] Open
Abstract
Lyme disease may present with a variety of cardiac manifestations ranging from first degree to third degree heart block. Cardiac involvement with Lyme disease may be asymptomatic, or symptomatic. Atrioventrical conduction abnormalities are the most common manifestation of Lyme carditis. Less common, are alternating right bundle branch block (RBBB) and left bundle branch block (LBBB). We present an interesting case of a young male whose main manifestation of Lyme carditis was isolated LBBB. He also had mild Lyme myocarditis. The patient was successfully treated with oral doxycycline, and his isolated LBBB and myocarditis rapidly resolved.
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Affiliation(s)
- Burke A. Cunha
- Infectious Disease Division Winthrop-University Hospital Mineola, New York, United States
- State University of New York School of Medicine, Stony Brook, New York, United States
| | - Maekal Elyasi
- Infectious Disease Division Winthrop-University Hospital Mineola, New York, United States
- State University of New York School of Medicine, Stony Brook, New York, United States
| | - Prince Singh
- Infectious Disease Division Winthrop-University Hospital Mineola, New York, United States
- State University of New York School of Medicine, Stony Brook, New York, United States
| | - Ismail Jimada
- Infectious Disease Division Winthrop-University Hospital Mineola, New York, United States
- State University of New York School of Medicine, Stony Brook, New York, United States
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Fu Md J, Bhatta L. Lyme carditis: Early occurrence and prolonged recovery. J Electrocardiol 2017; 51:516-518. [PMID: 29275956 DOI: 10.1016/j.jelectrocard.2017.12.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Indexed: 11/16/2022]
Abstract
Lyme carditis is an uncommon manifestation of early disseminated Lyme disease. This case illustrates a 66-year-old male with complaints of fatigue, myalgias, and fever after a tick bite 3days earlier. A large erythema migrans was found on the chest wall. Initial electrocardiogram showed sinus rhythm with second degree 2:1 atrioventricular (AV) block, which progressed to intermittent complete AV block rapidly. He was treated with intravenous ceftriaxone. Over the course of 2-weeks of antibiotic therapy, the intermittent high-grade AV block improved slowly and progressively. This case highlights the importance of timely diagnosis and appropriate management to achieve a favorable prognosis.
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Affiliation(s)
- Jianwei Fu Md
- Department of Cardiology, Zhejiang Provincial People's Hospital, Hangzhou, China; Department of Cardiology, People's Hospital of Hangzhou Medical College, Hangzhou, China.
| | - Luna Bhatta
- Department of Medicine, Division of Cardiology, Suny Upstate University Hospital, Syracuse, NY, USA
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