A previously healthy 43‐year‐old man from northwestern Wisconsin presented to his local medical center with 3 days of generalized malaise, arthralgias, low‐grade fever, and constant left‐sided chest pain, worse with deep inspiration and lying flat. An initial electrocardiogram was concerning for ST‐segment elevation. Troponin was elevated at 0.8 ng/mL. Because of concern for a STEMI, he was airlifted to Regions Hospital (St. Paul, MN), where emergent cardiac catheterization showed normal coronary arteries. Echocardiography (ECG) showed right and left ventricular hypokinesis with a left ventricle ejection fraction of 40%. The patient was discharged home on lisinopril and metoprolol for treatment of nonischemic cardiomyopathy. Twelve days later, he experienced 2 syncopal episodes, preceded by transient lightheadedness and followed by loss of consciousness for about 1 minute. Emergency medical services noted a heart rate of 38. ECG now showed complete heart block with junctional bradycardia and long ventricular pauses; he was again transferred to Regions Hospital. The patient subsequently gave a history of diffuse arthralgias and fatigue, which he previously attributed to overexertion. He also noted spending long periods in the woods. Physical exam showed persistent bradycardia, stable blood pressure, no clinical evidence of heart failure, and 2 large, erythematous, annular lesions on the patient's back. With a clinical picture suspicious for Lyme disease, empiric treatment with ceftriaxone was initiated. Notably, transient fever and diffuse erythematous lesions with central clearing consistent with erythema migrans developed after the first dose of ceftriaxone. Lyme serologies and Western blot later returned positive. A repeat echocardiogram, done 8 days after the initial study, showed interval normalization of left ventricular function. Over the course of 9 days of cef‐triaxone therapy, symptoms resolved, and cardiac conduction reverted in a stepwise manner, from complete heart block to a Mobitz type I second‐degree AV block and ultimately to a first‐degree AV block. He was discharged on an additional 21 days of doxycycline.
This case demonstrates an unusual presentation of Lyme carditis, in that the patient initially had cardiomyopathy that was then followed by complete heart block. Lyme disease is caused by the tick‐borne spirochete Borrelia burgdorferi; cardiac manifestations occur in up to 10% of affected patients. Of those, palpitations occur in 69%, conduction defects in 19%, myocarditis in 10%, left ventricular failure in 5%, and pericarditis in 2%. Approximately three fourths of patients with cardiac involvement from Lyme disease have an erythema migrans rash; half are febrile. Most patients have complete resolution of symptoms with appropriate treatment.
The diagnosis of Lyme carditis should be considered in patients presenting with new cardiac symptoms, conduction abnormalities, or left ventricular dysfunction, particularly when fever, myalgias, or rash are present and/or a history is suggestive of tick exposure in an endemic area.
R. Donahue ‐ none; D. Ries ‐ none
To cite this abstract:Donahue R, Ries D. The North Woods: Heart‐Stopping Beauty? An Unusual Case of Lyme Carditis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 265. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/the-north-woods-heartstopping-beauty-an-unusual-case-of-lyme-carditis/. Accessed March 29, 2020.