Complete heart block due to Lyme carditis in two pediatric patients and a review of the literature

Complete heart block associated with hepatitis A infection in a female child with fatal outcome

Hepatitis A virus (HAV) infection can cause extra-hepatic manifestations like myocarditis. An 8-year-old female with HAV infection presented with fever, abdominal pain, vomiting, and icterus. She developed viral myocarditis with complete AV dissociation on ECG and was treated with a temporary pacemaker, but her condition worsened, and she died. Hepatitis A viral infection can be associated with viral myocarditis and complete heart block that can lead to cardiogenic shock and death eventually.

Host transcriptome response to Borrelia burgdorferi sensu lato

The host immune response to infection is a well-coordinated system of innate and adaptive immune cells working in concert to prevent the colonization and dissemination of a pathogen. While this typically leads to a beneficial outcome and the suppression of disease pathogenesis, the Lyme borreliosis bacterium, Borrelia burgdorferi sensu lato, can elicit an immune profile that leads to a deleterious state. As B. burgdorferi s.l. produces no known toxins, it is suggested that the immune and inflammatory response of the host are responsible for the manifestation of symptoms, including flu-like symptoms, musculoskeletal pain, and cognitive disorders. The past several years has seen a substantial increase in the use of microarray and sequencing technologies to investigate the transcriptome response induced by B. burgdorferi s.l., thus enabling researchers to identify key factors and pathways underlying the pathophysiology of Lyme borreliosis. In this review we present the major host transcriptional outcomes induced by the bacterium across several studies and discuss the overarching theme of the host inflammatory and immune response, and how it influences the pathology of Lyme borreliosis.

Chest palpitations in a teenager as an unusual presentation of Lyme disease: case report

BACKGROUND

The incidence of Lyme disease (LD) in North America has increased substantially in the past two decades. Concomitant with the increased incidence of infection has been an enhancement in the recognition of LD complications. Here, we report a case of Lyme carditis complicated by heart block in a pediatric patient admitted to our children's hospital. What is unique about this case is that the complaint of chest palpitations is an infrequent presentation of LD, and what it adds to the scientific literature is an improved understanding of LD in the pediatric population.

CASE PRESENTATION

The patient was a 16-year-old male who presented with the main concerns of acute onset of palpitations and chest pain. An important clinical finding was Erythema migrans (EM) on physical exam. The primary diagnoses were LD with associated Lyme carditis, based on the finding of 1st degree atrioventricular heart block (AVB) and positive IgM and IgG antibodies to Borrelia burgdorferi. Interventions included echocardiography, electrocardiography (EKG), and intravenous antibiotics. The hospital course was further remarkable for transition to 2nd degree heart block and transient episodes of complete heart block. A normal sinus rhythm and PR interval were restored after antibiotic therapy and the primary outcome was that of an uneventful recovery.

CONCLUSIONS

Lyme carditis occurs in < 5% of LD cases, but the "take-away" lesson of this case is that carditis can be the presenting manifestation of B. burgdorferi infection in pediatric patients. Any patient with suspected Lyme carditis manifesting cardiac symptoms such as syncope, chest pain, or EKG changes should be admitted for parenteral antibiotic therapy and cardiac monitoring. The most common manifestation of Lyme carditis is AVB. AVB may manifest as first-degree block, or may present as high-grade second or third-degree block. Other manifestations of Lyme carditis may include myopericarditis, left ventricular dysfunction, and cardiomegaly. Resolution of carditis is typically achieved through antibiotic administration, although pacemaker placement should be considered if the PR interval fails to normalize or if higher degrees of heart block, with accompanying symptoms, are encountered. With the rising incidence of LD, providers must maintain a high level of suspicion in order to promptly diagnose and treat Lyme carditis.

Advanced Heart Block in Children with Lyme Disease

BACKGROUND

The clinical course of children with advanced heart block secondary to Lyme disease has not been well characterized.

OBJECTIVE

To review the presentation, management, and time to resolution of heart block due to Lyme disease in previously healthy children.

METHODS

An IRB approved single-center retrospective study was conducted of all patients < 21 years old with confirmed Lyme disease and advanced second or third degree heart block between 2007 and 2017.

RESULTS

Twelve patients (100% male) with a mean age of 15.9 years (range 13.2-18.1) were identified. Six patients (50%) had mild to moderate atrioventricular valve regurgitation and all had normal biventricular function. Five patients had advanced second degree heart block and 7 had complete heart block with an escape rate of 20-57 bpm. Isoproterenol was used in 4 patients for 3-4 days and one patient required transvenous pacing for 2 days. Patients were treated with 21 days (n = 6, 50%) or 28 days (n = 6, 50%) of antibiotics. Three patients received steroids for 3-4 days. Advanced heart block resolved in all patients within 2-5 days, and all had a normal PR interval within 3 days to 16 months from hospital discharge.

CONCLUSION

Symptomatic children who present with new high-grade heart block from an endemic area should be tested for Lyme disease. Antibiotic therapy provides quick and complete resolution of advanced heart block within 5 days, while steroids did not appear to shorten the time course in this case series. Importantly, no patients required a permanent pacemaker.

Suspicious index in Lyme carditis: Systematic review and proposed new risk score

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.

A 15-Year-Old Male With Wide Complex Tachyarrhythmia

A 15-year-old male presented with exertional syncope and was found to be in an unstable regular wide complex tachyarrhythmia (WCT). After a trial of antiarrhythmic medication, his clinical condition declined, necessitating synchronized cardioversion. Although he noted symptomatic improvement after cardioversion, he was found to be in third-degree heart block. The patient was transported by rotor wing aircraft to a pediatric cardiac intensive care unit where he was ultimately diagnosed with Lyme disease. He was treated with a course of intravenous antibiotics, his heart block resolved, and he was discharged home with a good neurologic outcome.

Manifestations of Lyme carditis

The first data of Lyme carditis, a relatively rare manifestation of Lyme disease, were published in eighties of the last century. Clinical manifestations include syncope, light-headedness, fainting, shortness of breath, palpitations, and/or chest pain. Atrioventricular (AV) electrical block of varying severity presents the most common conduction disorder in Lyme carditis. Although is usually mild, AV block can fluctuates rapidly and progress from a prolonged P-R interval to a His-Purkinje block within minutes to hours and days. Rarely, Lyme disease may be the cause of endocarditis, while some studies and reports, based on serological and/or molecular investigations, have suggested possible influence of Borrelia burgdorferi on degenerative cardiac valvular disease. Myocarditis, pericarditis, pancarditis, dilated cardiomyopathy, and heart failure have also been described as possible manifestations of Lyme carditis. The clinical course of Lyme carditis is generally mild, short term, and in most cases, completely reversible after adequate antibiotic treatment.

Peroperative cardiogenic shock suggesting acute coronary syndrome as initial manifestation of Lyme carditis

Carditis can complicate Lyme disease in an estimated <5% of cases, and cardiogenic shock and severe cardiac arrhythmias are described with electrocardiographic abnormalities that could be suggestive of coronary manifestations. We report a case of severe persistent biventricular heart failure complicated by cardiac arrhythmias as initial manifestation of a Lyme disease developing peroperatively electrocardiographic abnormalities suggesting acute transmural myocardial infarction.

Third-degree heart block associated with lyme carditis: review of published cases

Lyme carditis is an uncommon manifestation of Lyme disease that most commonly involves some degree of atrioventricular conduction blockade. Third-degree conduction block is the most severe form and can be fatal if untreated. Systematic review of the medical literature identified 45 published cases of third-degree conduction block associated with Lyme carditis in the United States. Median patient age was 32 years, 84% of patients were male, and 39% required temporary pacing. Recognizing patient groups more likely to develop third-degree heart block associated with Lyme carditis is essential to providing prompt and appropriate therapy.

Asymptomatic complete atrioventricular block in a 13-year-old girl

Atrioventricular (AV) block is a delay or an interruption in the transmission of an impulse from atria to ventricles due to an anatomic or a functional impairment in the conduction system. Atrioventricular block may be congenital or acquired. Electrocardiographic screening of asymptomatic school-aged children (median, 12.4 years) in Japan found the prevalence of a third-degree AV block to be 2 per 100,000. We report a case of asymptomatic complete AV block of unknown etiology in a 13-year-old child who did not require pacemaker placement. The importance of recognizing an asymptomatic complete AV block in the pediatric population, the classification and controversies of pacemaker placement, and the complications of pacemaker placement are discussed.

Arrhythmogenic causes of chest pain in children

Although cardiac causes of chest pain in children are infrequent, arrhythmias are implicated in most cardiac related cases. The most common arrhythmias associated with chest pain are supraventricular tachycardias, but more ominous rhythms, such as ventricular tachycardia or bradycardias, can manifest as chest pain. Investigation of all children with chest pain suspected of arrhythmia should include detailed history and physical examination and a 12- or 15-lead electrocardiogram. In some cases echocardiogram, 24-hour Holter monitoring, exercise stress testing, or other cardiac evaluations may be indicated. Children with a history of cardiac disease or cardiac surgery are particularly at risk for arrhythmias and may experience chest pain in association with their arrhythmias.

Asymptomatic, transient complete heart block in a pediatric patient with Lyme disease

Lyme Disease, caused by the spirochete Borrellia burgdorferi, is the most common vector-borne disease in the United States. Clinically, it primarily affects the skin, joints, nervous system, and heart. Lyme carditis occurs in 4%-10% of adults with Lyme disease. Transient variable-level atrioventricular blocks, occurring in 77% of adults with Lyme carditis, are the most common cardiac manifestation. Up to 50% of Lyme carditis patients may develop complete heart block. The incidence of Lyme carditis in the pediatric population is not well established. We present a pediatric patient with a transient asymptomatic complete heart block resulting from Lyme carditis, an under-recognized complication of Lyme disease in the pediatric population.

[Update on pediatric cardiology and congenital heart disease]

The fields of pediatric cardiology and congenital heart disease have experienced considerable progress in the last few years, with advances in new diagnostic and therapeutic techniques that can be applied at all stages of life from the fetus to the adult. This article reviews scientific publications in a number of areas that appeared between August 2007 and September 2008. In developed countries, congenital heart disease is becoming increasingly prevalent in nonpediatric patients, including pregnant women. Actions aimed at preventing coronary heart disease must be started early in infancy and should involve the promotion of a healthy diet and lifestyle. Recent developments in echocardiography include the introduction of three-dimensional echocardiography and of new techniques such as two-dimensional speckle tracking imaging, which can be used for both anatomical and functional investigations in patients with complex heart disease, including a univentricular heart. Progress has also occurred in fetal cardiology, with new data on prognosis and prognostic factors and developments in intrauterine interventions, though indications for these interventions have still to be established. Heart transplantation has become a routine procedure, supplemented in some cases by circulatory support devices. In catheter interventions, new devices have become available for the closure of atrial or ventricular septal defects and patent ductus arteriosus as well as for percutaneous pulmonary valve implantation. Surgery is also advancing, in some cases with hybrid techniques, particularly for the treatment of hypoplastic left heart syndrome. The article ends with a review of publications on cardiomyopathy, myocarditis and the treatment of bacterial endocarditis.

Lyme carditis in children: presentation, predictive factors, and clinical course

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.