Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
BMC Infectious Diseases
Published in: BMC Infectious Diseases 1/2019

Open Access 01-12-2019 | Tick | Case report

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

Authors: Don Walter Kannangara, Sindhu Sidra, Patel Pritiben

Published in: BMC Infectious Diseases | Issue 1/2019

Login to get access

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.
Literature
1.
2.
Scheffold N, Herkommer B, Kandolf R, May AE. Lyme Carditis. Dtsch Arztebl. 2015;112:202–8.
3.
Klein J, Stanek G, Bittner R, Horvat R, et al. Lyme borreliosis as a cause of myocarditis and heart muscle disease. Eur Heart J. 1991;12 Suppl D:73–5.CrossRefPubMed
4.
Bergler-Klein J, Ullrich R, Glogar D, Stanek G. Lyme borreliosis and cardiomyopathy. Wien Med Wochenschr. 1995;145:196–8.PubMed
5.
Cepelová J. Lyme carditis—rare cause of dilated cardiomyopathy and rhythm disturbances. Vnitr Lek. 2008;54:430–3.PubMed
6.
Konopka M, Kuch M, Braksator W, Walczak E, et al. Unclassified cardiomyopathy or Lyme carditis? A three-year follow-up. Kardiol Pol. 2013;71:283–5.CrossRefPubMed
7.
Plocarová K. Inflammatory Borrelia – associated dilated cardiomyopathy. Vnitr Lek. 2013;59:1107–10.PubMed
8.
Bruyn GAW, Koning JDE, Reijsoo PM, Hoogkamp-Korstanje JAA. Lyme pericarditis leading to tamponade. Rheumatology. 1994;33:862–6.CrossRef
9.
Gasser R, Horn S, Reisinger E, Fischer L, et al. First description of recurrent pericardial effusion associated with Borrelia burgdorferi infection. Int J Cardiol. 1998;64:309–10.CrossRefPubMed
10.
Rudenko N, Golovchenko M, Mockráček A, Piscunová N, et al. Detection of Borrelia bissettii in cardiac valve tissue of a patient with endocarditis and aortic valve stenosis in the Czech Republic. J Clin Microbiol. 2008;46:3540–3.CrossRefPubMedPubMedCentral
11.
Kameda G, Vieker S, Hartmann J, Niehues T, et al. Diastolic heart murmur, nocturnal back pain, and lumbar rigidity in a 7-year old girl: an unusual manifestation of Lyme disease in child hood. Case Rep Pediatr. 2012;2012:976961.PubMedPubMedCentral
12.
Hidri N, Barraud O, de Martino S, Garnier F, et al. Lyme endocarditis. Clin Microbiol Infect. 2012;18:E531–2.CrossRefPubMed
13.
Patel LD, Schachne JS. Lyme carditis: a case involving the conduction system and the mitral valve. R I Med J. 2017;100:17–20.
14.
CDC morbidity and mortality report (MMWR). Three sudden cardiac deaths associated with Lyme carditis, vol. 62; 2013. p. 993–6.
15.
Yoon EC, Vail E, Kleinman G, Lento PA, et al. Lyme disease: a case report of a 17- year-old male with fatal Lyme carditis. Cardiovasc Pathol. 2015;24:317–21.CrossRefPubMed
16.
17.
Steere AC, Malawista SE, Bartenhagen NH, Spieler PN, et al. The clinical spectrum and treatment of Lyme disease. Yale J Biol Med. 1984;57:453–61.PubMedPubMedCentral
18.
Hofthuis A, Arend SM, Davids CJ, Tukkie R, et al. General practitioner reported incidence of Lyme carditis in the Netherlands. Neth Heart J. 2015;23:533–8.CrossRef
19.
Robinson ML, Kobayashi T, Higgins Y, Calkins H, et al. Lyme carditis. Infect Dis Clin N Am. 2015;29:255–68.CrossRef
20.
Kwit NA, Nelson CA, Max R, Mead PS. Risk factors for clinician-diagnosed Lyme arthritis, facial palsy, carditis, and meningitis in patients from high-incidence states. Open Forum Infect Dis. 2017;5:ofx254.PubMedPubMedCentral
21.
Woolf PK, Lorsung EM, Edwards KS. Electrocardiographic findings in children with Lyme disease. Pediatr Emerg Care. 1991;7:334–6.CrossRefPubMed
22.
Koene R, Boulware DR, Kemperman M, Konety SH, et al. Acute heart failure from Lyme carditis. Circulation. 2012;5:e24–6.PubMed
23.
Župan Ž, Mijatović D, Medved I, Kraljić S, et al. Successful treatment of fulminant Lyme myocarditis with mechanical circulatory support in a young male adult: a case report. Croat Med J. 2017;58:185–93.CrossRefPubMedPubMedCentral
24.
Clinckaert C, Bidgoli S, Verbeet T, Attou R, et al. Peri-operative cardiogenic shock suggesting acute coronary syndrome as initial manifestation of Lyme carditis. J Clin Anesth. 2016;35:430–3.CrossRefPubMed
25.
Jensen TB, Dalsgard D, Johansen JB. Cardiac arrest due to torsades pointes ventricular tachycardia in a patient with Lyme carditis. Ugeskr Laeger. 2014; 25:176(35).
26.
Khalil S, Padala SK, Hui CM, Steckman DA, et al. Lyme carditis in the fast lane: from alternating bundle branch block to asystole in 12 hours. Conn Med. 2015;24:317–21.
27.
Cunningham MEA, Doroshow OL, Moak JP. Junctional ectopic tachycardia secondary to myocarditis associated with sudden cardiac arrest. Heart Rhythm case Rep. 2016;3:124–8.CrossRef
28.
Cary NRB, Fox B, Wright DJ, Cutler SJ, et al. Fatal Lyme carditis and endodermal heterotopia of the atrioventricular node. Postgrad Med. 1990;66:134–6.CrossRef
29.
Muehlenbachs A, Bollweg BC, Schultz TJ, Forrester JD, et al. Cardiac tropism of Borrelia burgdorferi: an autopsy study of sudden cardiac death associated with Lyme carditis. Am J Pathol. 2016;186:1195–205.CrossRefPubMed
30.
Steere AC, Batsford WP, Weinberg WP. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Int Med. 1980;93:8–16.CrossRefPubMed
31.
Van der Linde MR. Lyme Carditis: clinical characteristics of 105 cases. Scand J Infect Dis Suppl. 1991;77:81–4.PubMed
32.
Afari ME, Marmoush F, Rehman MU, Gorsi U, et al. Lyme carditis: an interesting trip to third degree heart block and back. Case Rep Cardiol. 2016;2016:5454160.PubMedPubMedCentral
33.
Tumminello R, Glaspey L, Bhamidipati A, Sheehan P, Patel S. Early disseminated Lyme disease masquerading as mononucleosis: a case report. J Emerg Med. 2017;53:e133–5.CrossRefPubMed
34.
Shah R, Kanzaria M. A case series of Lyme carditis complete heart block. The Medicine Forum. 2012;13:article 4.
35.
Dobbs LB, Mugmon MA. Wenckebach responsive to cephalosporins- it must be Lyme carditis. J community Hosp Intern Med Perspect. 2013;3:3–4.
36.
Lee S, Singla M. An unrecognized rash progressing to Lyme carditis: important features and recommendations regarding Lyme disease. Am J Ther. 2016;23(2):e566–9.CrossRefPubMed
37.
38.
39.
Kashou AH, Braiteh N, Kashou HE. Reversible atrioventricular block and the importance of close follow-up: two cases of Lyme carditis. J Cardiol Cases. 2018;17:171–4.CrossRefPubMedPubMedCentral
40.
Van der Linde MR, Crijns HJ, de Koning J, Hoogkamp-Korstanje JA, et al. Range of atrioventricular conduction disturbances in Lyme borreliosis: a report of four cases and review of other published reports. Br Heart J. 1990;63:162–8.CrossRefPubMedPubMedCentral
41.
Greenberg YJ, Brennan JJ, Rosenfeld L. Lyme myocarditis presenting as fascicular tachycardia with underlying complete heart block. J Cardiovasc Electrophysiol. 1997;8:323–4.CrossRefPubMed
42.
43.
Bacino L, Gazzarata M, Siri G, Cordone S, et al. Complete atrioventricular block as the first clinical manifestation of a tick bite (Lyme disease). G Ital Cardiol (Rome). 2011;12:214–6.
44.
Wenger N, Pellaton C, Bruchez P, Schläpfer J. Atrial fibrillation, complete atrio-ventricular block and escape rhythm with bundle-branch block morphologies: an exceptional presentation of Lyme carditis. Int J Cardiol. 2012;160:e12–4.CrossRefPubMed
45.
Shah P, Mithwala P, Bajaj S, Virk H, et al. Third-degree heart block as initial presentation of Lyme disease. Acta Cardiol. 2015;70:744–5.CrossRefPubMed
46.
Timmer SAJ, Boswijk DK, Kimman GP, Germans T. A case of reversible third-degree AV block due to Lyme carditis. J Electrocardiol. 2016;49:519–21.CrossRefPubMed
47.
48.
Patel KP, Farjo PD, Juskowich JJ, Hama AA, et al. Early-onset Lyme carditis with concurrent disseminated erythema migrans. Am J cardiovasc Dis. 2017;7:53–6.PubMedPubMedCentral
49.
Cunha BA, Elyasi M, Singh P, Jimada I. Lyme carditis with isolated left bundle branch block and myocarditis successfully treated with oral doxycycline. I D cases, vol. 11; 2017. p. 48–50.
50.
Franck H, Wollschläger H. Lyme carditis and symptomatic sinus node dysfunction. Z Kardiol. 2003;92:1029–32.CrossRefPubMed
51.
Oktay AA, Dibs SR, Friedman H. Sinus pause in association with Lyme carditis. Texas Heart Inst J. 2015;42:248–50.CrossRef
52.
Tanksley GW, Playe SJ. Lyme carditis: from asymptomatic first-degree heart block to dilated cardiomyopathy. Emerg Med News. 2005;27:14–6.CrossRef
53.
Frank DB, Patel AR, Sanchez GR, et al. Junctional tachycardia in a child with Lyme carditis. Pediatr Cardiol. 2011;32:689–91.CrossRefPubMed
54.
Vlay SC, Pervan JP, Elias J, Kane PP, et al. Ventricular tachycardia associated with Lyme carditis. Am Heart J. 1991;121:1558–60.CrossRefPubMed
55.
Abraham S, Reddy S, Abboud J, Jonnalagadda K, et al. Brief, recurrent, and spontaneous episodes of loss of consciousness in a healthy young male. Int Med Case Rep J. 2010;3:71–6.CrossRefPubMedPubMedCentral
56.
Seslar SP, Berul CI, Burklow TR, Cecchin F, et al. Transient prolongation of QT interval in Lyme disease. J Pediatr. 2006;148:692–7.CrossRefPubMed
57.
Welsh EJ, Cohn KA, Nigrovic LE, Thompson AD, et al. Electrocardiographic abnormalities in children with Lyme meningitis. J Pediatric Infect Dis Soc. 2012;1:293–8.CrossRefPubMed
58.
Michalski B, Umpierrez De RA. Lyme carditis buried beneath the ST-segment elevations. Case Rep Cardiol. 2017;2017:9157625.PubMedPubMedCentral
59.
Kannangara DW, Patel P. Report of non-Lyme erythema migrans rashes from New Jersey with a review of possible role of tick salivary toxins. Vector borne Zoonotic dis. 2018;18:641–52.CrossRefPubMed
60.
Vujisić-Tesić B, Simin N, Petrović M, Vasiljević Z, et al. The role of echocardiography in the evaluation of cardiac damage in Lyme disease. Glas Srp Akad Nauka Med. 1993;43:241–3.
61.
Palacek T, Kuchynka P, Hulinska D, Schramlova J, et al. Presence of Borrelia burgdorferi in endomyocardial biopsies in patients with new-onset unexplained dilated cardiomyopathy. Med Microbiol Immunol. 2010;199:139–43.CrossRef
62.
Kubánek M, Šramko M, Berenová D, Hulinská D, et al. Detection of Borrelia burgdorferi sensu lato in endomyocardial biopsy specimens in individuals with recent-onset dilated cardiomyopathy. Eur J Heart Fail. 2012;14:588–96.CrossRefPubMed
63.
Lalosevic D, Lalosevic V, Stojsic-Milosavljevic A, Stojsic C. Borrelia-like organism in heart capillaries of patient with Lyme disease seen by electron microscopy. Int J Cardiol. 2010;145:e96–8.CrossRefPubMed
64.
Alpert LI, Welch P, Fischer N. Gallium-positive Lyme disease myocarditis. Clin Nucl Med. 1985;10:617.CrossRefPubMed
65.
Veluvolu P, Balian AA, Goldsmith R, Gallant TE, et al. Lyme carditis. Evaluation by GA-67 scan and MRI. Clin Nucl Med. 1992;17:823.CrossRefPubMed
66.
Kimball SA, Janson PA, L Raia PJ. Complete heart block as the sole presentation of Lyme disease. Arch Int Med. 1989;149:1897–8.CrossRef
67.
Metadata
Title
First case report of inducible heart block in Lyme disease and an update of Lyme carditis
Authors
Don Walter Kannangara
Sindhu Sidra
Patel Pritiben
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Infectious Diseases / Issue 1/2019
Electronic ISSN: 1471-2334
DOI
https://doi.org/10.1186/s12879-019-4025-0

Other articles of this Issue 1/2019

BMC Infectious Diseases 1/2019 Go to the issue

Correction

Correction to: Nasopharyngeal carriage of Streptococcus pneumoniae in children under 5 years of age before introduction of pneumococcal vaccine (PCV10) in urban and rural districts in Pakistan

Research article

Molecular characterization of Blastocystis subtypes in HIV-positive patients and evaluation of risk factors for colonization

Research Article

Comparing alternative cholera vaccination strategies in Maela refugee camp: using a transmission model in public health practice

Research article

Revisiting area risk classification of visceral leishmaniasis in Brazil

Case report

Dermatoscopy for the rapid diagnosis of Talaromyces marneffei infection: a case report

Research article

Different mechanisms of two anti-anthrax protective antigen antibodies and function comparison between them

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24 to hear Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits