Lyme Carditis: An Interesting Trip to Third-Degree Heart Block and Back

Afari, Maxwell Eyram; Marmoush, Fady; Rehman, Mobeen Ur; Gorsi, Umama; Yammine, Joseph

doi:10.1155/2016/5454160

Cited by 6 publications

(10 citation statements)

References 8 publications

(9 reference statements)

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“…Another 34 articles were removed for: not in English, not a case report/series, or not reporting high‐degree AVB . The final 74 articles reported on 88 cases relevant to this study ).…”

Section: Resultsmentioning

confidence: 99%

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

Besant

Wan

Yeung

et al. 2018

Clinical Cardiology

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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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“…Another 34 articles were removed for: not in English, not a case report/series, or not reporting high‐degree AVB . The final 74 articles reported on 88 cases relevant to this study ).…”

Section: Resultsmentioning

confidence: 99%

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

Besant

Wan

Yeung

et al. 2018

Clinical Cardiology

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“…Cardiac involvement has been reported with B.burgdorferi ss (US cases), B garinii, B afzelli [12] and B bissettii [10]. Patients with CHB (Complete heart block) due to LC may have erythema migrans [32, 36, 37, 47, 48, 58] or other manifestations such as joint involvement [8]. Basic investigations include the history of possible tick exposure, laboratory testing, a 12-channel electrocardiogram, 24-h Holter monitor, chest x-ray, and echocardiography [2].…”

Section: Discussionmentioning

confidence: 99%

“…Progression of first-degree heart block to second degree and then to complete heart block without treatment has been reported. Regression of complete heart block to second degree, then first degree followed by complete resolution with treatment is also known [32]. Inducible heart block in Lyme disease has not been reported.…”

Section: Discussionmentioning

confidence: 99%

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First case report of inducible heart block in Lyme disease and an update of Lyme carditis

2019

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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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“…Conduction disturbances are the most common manifestations of LC, presumably due to endocardium inflammatory infiltrates of the conduction system, and it can present with multiple levels of AV blocks with higher prevalence of third-degree then second-degree and first-degree, which are 49%, 16%, and 12%, respectively [7]. In a systematic review, Forrester et al reviewed a total of 45 cases of complete AV block due to LC, 40% of these cases required transvenous pacing, and in all other cases the median time to achieve complete resolution to normal sinus rhythm or improvement to first-degree block was 6 days (range 1–42) [8]. Although the stepwise complete reversal of the complete AV block in LC has been shown in several case reports [9–11], only few reports have shown a quick reversal to normal sinus rhythm within days.…”

Section: Discussionmentioning

confidence: 99%