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Esfandiari N, Beebe-Peat T, Quinlan A, Wagner B, Wark T, Lobel R. Lyme Carditis Complicated by Polymorphic Ventricular Tachycardia and Cardiac Arrest: A Case Report. J Investig Med High Impact Case Rep 2022; 10:23247096221098333. [PMID: 35593429 PMCID: PMC9125101 DOI: 10.1177/23247096221098333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Lyme disease is commonly encountered in endemic areas of the United States harboring the causal organism Borrelia burgdorferi. Lyme carditis can manifest in early disseminated infections, usually as atrioventricular nodal blockade. Timely antibiotic therapy typically suppresses myocardial inflammation and reverses cardiac conduction disturbances. We present a case of a previously healthy male who presented to the emergency department with non-prodromal syncope, multifocal annular rashes, and antecedent inflammatory knee pain and effusion, found to have positive 2-tier Lyme testing and pause-dependent polymorphic ventricular tachycardia leading to cardiac arrest. Lyme carditis occurs in early disseminated infections but rarely leads to cardiac arrest. Acute management is entrained in well-established guidelines for therapy, and together with risk stratification scoring can be considered by emergency care physicians in the workup of undifferentiated syncope with concern for Lyme disease with cardiac involvement.
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Affiliation(s)
- Negar Esfandiari
- Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, USA
| | - Tanesha Beebe-Peat
- Department of Medicine, The University of Vermont Medical Center, Burlington, USA
| | - Anna Quinlan
- Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, USA
| | - Beth Wagner
- Department of Medicine, Central Vermont Medical Center, Berlin, USA
| | - Tyler Wark
- Division of Cardiovascular Medicine, The University of Vermont Medical Center, Burlington, USA
| | - Robert Lobel
- Division of Cardiovascular Medicine, The University of Vermont Medical Center, Burlington, USA
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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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Wolfes J, Ellermann C, Burde S, Leitz P, Bögeholz N, Willy K, Fehr M, Eckardt L, Frommeyer G. Concomitant Treatment with Proton Pump Inhibitors and Cephalosporins Does Not Enhance QT-Associated Proarrhythmia in Isolated Rabbit Hearts. Cardiovasc Toxicol 2020; 20:531-538. [PMID: 32500385 DOI: 10.1007/s12012-020-09577-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Recent results from data mining analyses and reports of adverse drug events suggest a QT-prolonging drug-drug interaction resulting from the combination of distinct proton pump inhibitors and cephalosporins. Therefore, this study aimed at investigating the effect of the suspected QT-prolonging combinations of lansoprazole + ceftriaxone and esomeprazole + cefazolin, respectively. 26 hearts of New Zealand White rabbits were retrogradely perfused and paced at different cycle lengths. After generating baseline data, the hearts were assigned to two groups: In group 1, hearts were treated with 5 µM lansoprazole. Thereafter, 200 µM ceftriaxone was infused additionally. Group 2 was perfused with 10 µM esomeprazole followed by 250 µM cefazolin. In group 1, lansoprazole did not significantly alter QT intervals and APD90. Additional treatment with ceftriaxone significantly shortened QT interval, APD90 and slightly reduced dispersion of repolarization compared to sole lansoprazole infusion. In group 2, esomeprazole led to a significant shortening of the QT interval without altering APD90 or dispersion. Additional treatment with the antibiotic cefazolin further shortened QT interval, APD90 and reduced the dispersion of repolarization. Incidence of ventricular arrhythmias was not significantly altered in both groups. This is the first experimental whole-heart study that investigated the impact of a concomitant treatment with proton pump inhibitors and cephalosporins. In contrast to previous reports, the combination of both agents did not cause QT prolongation but instead shortened QT interval and action potential duration. As a consequence, no triggered activity occurred in the presence of a stable dispersion of repolarization.
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Affiliation(s)
- Julian Wolfes
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany. .,Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, 48149, Münster, Germany.
| | - Christian Ellermann
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sophie Burde
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Patrick Leitz
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Nils Bögeholz
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Kevin Willy
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Michael Fehr
- University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Kannangara DW, Sidra S, Pritiben P. First case report of inducible heart block in Lyme disease and an update of Lyme carditis. BMC Infect Dis 2019; 19:428. [PMID: 31096922 PMCID: PMC6524294 DOI: 10.1186/s12879-019-4025-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background Lyme disease (LD), is the most common vector-borne illness in the US and Europe, with predominantly cutaneous, articular, cardiac and neuro-psychiatric manifestations. LD affects all layers of the heart and every part of the conducting system. Carditis is a less common manifestation of LD. Heart block (HB) as the initial and sole manifestation of LD is rare. Inducible HB has never been reported in LD. We report a case of heart block (HB) inducible with exercise and reversible with rest. Case presentation A 37-year-old male presented to the emergency department after experiencing two episodes of syncope while at work. He presented, with a heart rate of 57 bpm, and the ECG showed sinus bradycardia with first degree AV block. The PR interval was 480 ms (NL 120–200 ms). Physical exam was unremarkable. The cardiologist’s initial impression was vaso-vagal attack. He developed high degree AV block during a stress test for the initial work up, which resolved on cessation of exercise. A similar episode while walking in the hallway, resolved at rest. The high degree AV block appeared inducible with exercise and reversible with rest. His Lyme serology was strongly positive. He was treated with ceftriaxone and doxycycline. After completing treatment, the patient had a normal ECG and returned to work without limitations, doing manual labor. Conclusions Manifestations of Lyme carditis (LC) vary from asymptomatic and symptomatic electrocardiographic changes and heart block (HB) reversible with treatment, to sudden death. HB as the sole and initial presentation of LC is rare. There have been no reports of inducible HB in LD. Here we present a case of inducible and reversible high degree HB in a case of LC and an update of literature. Exercise and stress testing should be avoided in suspected cases of LC until resolution of carditis. Lyme carditis should be suspected in individuals with cardiac manifestations in an endemic area, particularly in the younger patients with no other etiology evident.
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Affiliation(s)
- Don Walter Kannangara
- St Luke's University Health Network, Warren Campus, 185 Roseberry Street, Phillipsburg, NJ, 08865, USA.
| | - Sindhu Sidra
- St Luke's University Health Network, Warren Campus, 185 Roseberry Street, Phillipsburg, NJ, 08865, USA
| | - Patel Pritiben
- St Luke's University Health Network, Warren Campus, 185 Roseberry Street, Phillipsburg, NJ, 08865, USA
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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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Scheffold N, Herkommer B, Kandolf R, May AE. Lyme carditis--diagnosis, treatment and prognosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:202-8. [PMID: 25838022 DOI: 10.3238/arztebl.2015.0202] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 01/08/2015] [Accepted: 01/08/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND There are 60,000 to 100,000 new cases of borreliosis in Germany each year. This infectious disease most commonly affects the skin, joints, and nervous system. Lyme carditis is a rare manifestation with potentially lethal complications. METHODS This review is based on selected publications on the clinical manifestations, diagnosis, and treatment of Lyme carditis, and on the authors' scientific and clinical experience. RESULTS Lyme carditis is seen in 4% to 10% of all patients with Lyme borreliosis. Whenever the clinical suspicion of Lyme carditis arises, an ECG is mandatory for the detection or exclusion of an atrioventricular conduction block. Patients with a PQ interval longer than 300 ms need continuous ECG monitoring. 90% of patients with Lyme carditis develop cardiac conduction abnormalities, and 60% develop signs of perimyocarditis. Borrelia serology (ELISA) may still be negative in the early phase of the condition, but is always positive in later phases. Cardiac MRI can be used to confirm the diagnosis and to monitor the patient's subsequent course. The treatment of choice is with antibiotics, preferably ceftriaxone. The cardiac conduction disturbances are usually reversible, and the implantation of a permanent pacemaker is only exceptionally necessary. There is no clear evidence at present for an association between borreliosis and the later development of a dilated cardiomyopathy. When Lyme carditis is treated according to the current guidelines, its prognosis is highly favorable. CONCLUSION Lyme carditis is among the rarer manifestations of Lyme borreliosis but must nevertheless be considered prominently in differential diagnosis because of the potentially severe cardiac arrhythmias that it can cause.
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Affiliation(s)
- Norbert Scheffold
- Internal Medicine Department I, Department of Cardiology, Memmingen Medical Center, affiliated teaching center of the LMU Munich, Internal Medicine Department I, Department of Cardiology, München-Pasing Medical Center, affiliated teaching center of the LMU Munich, Department of Molecular Pathology, Institute of Pathology and Neuropathology, University Hospital of Tübingen
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Pseudoseizures in a preadolescent: does this case have a bite? Pediatr Emerg Care 2012; 28:691-5. [PMID: 22766586 DOI: 10.1097/pec.0b013e31825d21ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a preadolescent girl with acquired complete heart block most likely caused by viral myocarditis. The diagnosis was supported by endomyocardial biopsy and several immunohistological panels. A temporary pacemaker was used, and the child responded well to therapy with full recovery of cardiac conduction.
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Costello JM, Alexander ME, Greco KM, Perez-Atayde AR, Laussen PC. Lyme carditis in children: presentation, predictive factors, and clinical course. Pediatrics 2009; 123:e835-41. [PMID: 19403477 DOI: 10.1542/peds.2008-3058] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to identify predictive factors for Lyme carditis in children and to characterize the clinical course of these patients. METHODS We reviewed all cases of early disseminated Lyme disease presenting to our institution from January 1994 through July 2008, and summarized the presentation and course of those patients with carditis. A case-control study was used to identify predictive factors for carditis. Controls were patients with early disseminated Lyme disease without carditis. RESULTS Of 207 children with early disseminated Lyme disease, 33 (16%) had carditis, 14 (42%) of whom had advanced heart block, including 9 (27%) with complete heart block. The median time to recovery of sinus rhythm in these 14 patients was 3 days (range: 1-7 days), and none required a permanent pacemaker. Four (12%) of 33 patients with carditis had depressed ventricular systolic function, 3 (9%) of whom required mechanical ventilation, temporary pacing, and inotropic support. Complete resolution of rhythm disturbances and myocardial dysfunction occurred in 24 (89%) of 27 patients for whom follow-up data were available. Most patients with carditis also had other systemic Lyme involvement. By using multivariate logistic regression analysis, we found that children >10 years of age, those with arthralgias, and those with cardiopulmonary symptoms were more likely to have carditis. CONCLUSIONS The spectrum of presentation for children with Lyme carditis is broad, ranging from asymptomatic, first-degree heart block to fulminant myocarditis. Variable degrees of heart block are the most common manifestation and occasionally require temporary pacing. Transient myocardial dysfunction, although less common, can be life-threatening. Advanced heart block resolves within 1 week in most cases. In children with early disseminated Lyme disease, older age, arthralgias, and cardiopulmonary symptoms independently predict the presence of carditis.
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Affiliation(s)
- John M Costello
- Harvard Medical School, Division of Cardiac Intensive Care, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Bader 600, Boston, MA 02115, USA.
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Rostoff P, Gajos G, Konduracka E, Gackowski A, Nessler J, Piwowarska W. Lyme carditis: epidemiology, pathophysiology, and clinical features in endemic areas. Int J Cardiol 2009; 144:328-33. [PMID: 19328565 DOI: 10.1016/j.ijcard.2009.03.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 03/04/2009] [Indexed: 10/21/2022]
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Abstract
Cardiovascular manifestations of Lyme disease were first reported nearly 30 years ago. This article describes Lyme carditis, its epidemiology, pathophysiology, methods of diagnosis, and treatment options.
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Affiliation(s)
- Airley E Fish
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Abstract
PURPOSE OF REVIEW Lyme disease is endemic to areas in both Europe and the United States and the incidence is increasing. Despite published guidelines, controversy persists about its diagnosis and management in patients who do not meet strict diagnostic criteria. This review summarizes important recently published studies and recommendations for the diagnosis and management of Lyme disease. RECENT FINDINGS Recent comprehensive guidelines have been published for the diagnosis and management of pediatric Lyme disease. In addition, recent studies may help physicians differentiate between Lyme and aseptic meningitis, as well as show the poor sensitivity of cerebrospinal fluid polymerase chain reaction. Controversy continues about the diagnosis and management of "chronic Lyme disease", despite the current medical literature. Recently published studies in the US have also better described southern tick-associated rash illness, an entity that may present a similar clinical picture to Lyme disease. Guidelines have also been published on the management and diagnosis of other tick-borne illnesses often seen as co-infections with Lyme disease. Finally, case reports have been published describing new cardiac manifestations associated with Lyme disease. SUMMARY Controversies persist about the diagnosis and management of Lyme disease. Recently published guidelines and primary research can aid clinicians in diagnosing Lyme properly.
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Affiliation(s)
- Eric Hoppa
- Division of Emergency Medicine, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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