LYME CARDITIS: A RARE CASE OF ABORTED SUDDEN CARDIAC ARREST

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lyme disease (LD) is the most common tick-borne disease in the US. Cardiac involvement occurs in up to 8% of untreated cases. (1) Even though only eleven cases of fatal Lyme carditis (LC) were reported worldwide between 1985 and 2019, it can be life-threatening. (2) We present a rare case of LC leading to cardiac arrest who was successfully saved. CASE PRESENTATION: A young healthy male from the Ohio river valley presented in July after a syncopal episode. He had fever, rash, and malaise for two weeks before admission. There was no personal or family history of cardiac illness. Vitals and cardiac auscultation were normal, but he had multiple erythematous patches over the abdomen. Initial labs were only positive for mild troponin elevation. Electrocardiogram (EKG) showed complete heart block (CHB) with right bundle branch block (RBBB). He was placed on telemetry monitoring and doxycycline was started for tick-borne infection. On the same day of admission, he had a cardiac arrest with pulseless ventricular tachycardia and return of spontaneous circulation after resuscitation. Extensive testing to evaluate the cause of cardiac arrest was pursued. Echocardiography and cardiac MRI did not reveal any structural anomaly and CT coronary angiography showed normal anatomy with patent vasculature. Serologies were positive for LD which was confirmed with Western blot. He was treated for LC with ceftriaxone resulting in resolution of CHB and RBBB by day fifteen of hospitalization. DISCUSSION: LD is caused by Borrelia burgdorferi and is transmitted by Ixodes tick. Most cases occur in June-July and show male predominance. It is classically divided into three stages. The second stage is an early disseminated phase characterized by ≥2 erythema migrans lesions along with cardiac or nervous system involvement. Within days to weeks of tick bite, the spirochetes can invade cardiac tissue via the bloodstream, causing LC. Atrio-ventricular block is the most common cardiac manifestation which can fluctuate or can rapidly progress to CHB. (3) Other cardiac complications include peri-myocarditis, ventricular arrhythmias and infrequently involves the valves or the coronary vessels. Antibiotics can prevent cardiac complications but very rarely they can progress to be life threatening. (1) This case emphasizes the need for continuous cardiac monitoring in a patient with LC and a high risk of decompensation despite treatment. CONCLUSIONS: Keeping a high suspicion and thorough examination especially in a young patient from an endemic area with unexplained cardiac abnormalities can be vital. This case highlights the fact that the disease can progress rapidly despite antibiotics. Intensive inpatient cardiac monitoring must be pursued until the conduction abnormalities are no longer life-threatening. REFERENCE #1: Haddad FA, Nadelman RB. Lyme disease and the heart. Front Biosci. 2003 Sep 1;8:s769-82. doi: 10.2741/1065. PMID: 12957829. REFERENCE #2: Centers for Disease Control and Prevention. Lyme Carditis at: https://www.cdc.gov/lyme/treatment/lymecarditis.html. Assessed on 4/28/2021 REFERENCE #3: Yeung C, Baranchuk A. Diagnosis and Treatment of Lyme Carditis: JACC Review Topic of the Week. J Am Coll Cardiol. 2019 Feb 19;73(6):717-726. doi: 10.1016/j.jacc.2018.11.035. Erratum in: J Am Coll Cardiol. 2019 Nov 26;74(21):2709-2711. PMID: 30765038. DISCLOSURES: No relevant relationships by James Bradley, source=Web Response No relevant relationships by Harsimran Brar, source=Web Response No relevant relationships by William Smith, source=Web Response