Abstract
In 2018, 23,558 confirmed cases and 10,108 probable cases of Lyme disease were reported in the United States, with 96% of all cases coming from 14 states. Lyme carditis is well described, occurring in less than 1% of Lyme disease. High-grade heart block is uncommon in early disseminated Lyme disease. In Lyme carditis due to sinus node dysfunction and/or high grade atrioventricular block, the pulse rates are significantly lower which can lead to syncope. This can happen in the setting of an unstable ventricular escape rhythm with pulse rates ranging around 30 beats per minute or lower. In patients with low cardiovascular reserve, high-degree AV block can cause sudden death. Here we describe a rare case of profound bradycardia in disseminated Lyme disease. The patient’s only two symptoms are bradycardia and jaw pain. He lacks erythema migrans, neurological symptoms or syncope - despite having high-degree AV block. Initially prescribed doxycycline 100mg BID, his PR interval begins to normalize, but once a Lyme titre was positive for IgM (p41, p39, p23) and IgG (p66, p45, p41, p39, p23, p18), the patient was switched to 2g ceftriaxone IV Q 24h, per Infectious Disease Society of America (IDSA) guidelines. After several days he feels better and was discharged home to complete antibiotics and wear a cardiac event monitor. Lyme disease has three distinct stages that include early localized infection, early disseminated disease, and late infection. At the time of Lyme carditis diagnosis, common symptoms include erythema migrans, malaise, polyarthritis, Bell’s palsy and other neurological symptoms - all of which were lacking in our patient. The prognosis for Lyme carditis is generally good, despite disagreement over the incidence of persistent B. burgdorferi infection. This patient’s unique presentation of Lyme carditis is further evidence of variability in cardiac symptoms depending on one’s immunological and physiological ability to combat acute spirochete infection.
Highlights
Lyme carditis most commonly presents as high-degree AV block and is well described, occurring in less than 1% of Lyme disease cases [1]
Borrelia burgdorferi is a spirochete transmitted by the bite from I. scapularis tick [2]
Per Infectious Disease Society of America (IDSA) guidelines, the patient was switched to 2g ceftriaxone IV every 24h once suspected Lyme carditis was confirmed by immunohistochemical testing
Summary
Lyme carditis most commonly presents as high-degree AV block and is well described, occurring in less than 1% of Lyme disease cases [1]. While visiting his primary care physician (PCP) to discuss the isolated findings of jaw pain and mildly elevated troponin, the patient was noted to have sinus conduction delay on EKG, with a PR-interval of 160 milliseconds (Figure 1). Per Infectious Disease Society of America (IDSA) guidelines, the patient was switched to 2g ceftriaxone IV every 24h once suspected Lyme carditis was confirmed by immunohistochemical testing After several days he reported feeling better and was discharged with the remaining course of antibiotics and a portable cardiac event monitor
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