We present a case report of 46-year-old man with no medical history, who complained of extreme fatigue, near-syncope, and palpitations. He initially presented in complete heart block. [ncbi.nlm.nih.gov]

Here, we present a case of Lyme carditis presenting with atrial fibrillation, a highly unusual presentation of Lyme carditis. 1. Background Lyme disease is the most commonly reported vector-borne illness in the United States [1]. [hindawi.com]

• Falling

  These sudden cardiac deaths associated with Lyme carditis occurred from late summer to fall, ages ranged from young adult to late 40s, and four patients were men. [ncbi.nlm.nih.gov]

  Passing out, or syncope, is your body’s way of making the heart not have to work against gravity but can also seriously hurt you or somebody else depending on how you fall. [marckatzmd.com]

  If not, they can acquire the bacteria as nymphs and infect other species in the fall of that year. The bacteria are typically transmitted to humans by nymphs. In the fall, the nymphs develop into adults that feed on their third and final host. [pgc.pa.gov]

  At home, clean up fall leaves, create a brush-free zone on porches and walkways, and try to keep the ticks’ favorite meal—deer—out of your space. [pinnaclehealth.org]

• Malaise

  We describe the case of a 37-year-old Caucasian man with a 1-month history of fevers, rash, and malaise who died unexpectedly on the day after he underwent medical evaluation. [ncbi.nlm.nih.gov]

  Snapshot A 16-year-old boy presents to his primary care physician with fatigue, malaise, and a rash. His symptoms began approximately 1 week ago and have progressively worsened. [medbullets.com]

  Presenting symptoms included malaise (71%), presyncope (43%), syncope (29%), palpitations (57%), and dyspnea (43%). 2 patients required temporary pacing for symptomatic bradycardia. [onlinecjc.ca]

  The primary symptoms of stage 2 include intermittent arthritis, cranial nerve palsies and radicular symptoms, atrioventricular (AV) nodal block, and severe malaise and fatigue. [empirestatelymediseaseassociation.org]

  For example, studies have shown that about 20% of patients with new onset Lyme disease only present with fatigue, muscle and joint pain, headache and malaise. [columbia-lyme.org]

• Intravenous Administration

  Intramuscular Antibiotic Therapy: The ISDA guidelines (Wormser, et al., 2006) cite a study (citing Steere, et al. 1985) that suggests that IM administration may be less effective than intravenous administration based upon response rates, although the [aetna.com]

  […] and intramuscular penicillin and intravenous ceftriaxone. [230] [231] The mechanism of tick transmission was also the subject of much discussion. [en.wikipedia.org]

• Anemia

  If not treated, complications can include hemodynamic instability, anemia, http://www.nlm.nih.gov/medlineplus/ency/article/000586.htm ">thrombocytopenia, organ failure, or death. [9] Chronic Fatigue Syndrome Individuals who present with symptoms of significant [physio-pedia.com]

  Variants does not Support a Role in Chronic Lyme Disease Views and Facts About Chronic Lyme Disease from the National Institute of Allergy and Infectious Diseases (NIAID) NIAID Current Portfolio of Basic Research Grants on Lyme Disease Immune hemolytic anemia [aldf.com]

• Abdominal Pain

  He denied chest pain, shortness of breath, presyncope, syncope, nausea, vomiting, diarrhea, constipation, and abdominal pain. He did not notice any tick bites, rash, or joint pain. [amjcaserep.com]

  After 7 months of intensive antimicrobial treatment, her pain improved, but the weakness worsened. She discontinued treatment after developing C. difficile colitis that caused severe abdominal cramps and diarrhea. [scienceblogs.com]

• Heart Block

  RESULTS: Of 207 children with early disseminated Lyme disease, 33 (16%) had carditis, 14 (42%) of whom had advanced heart block, including 9 (27%) with complete heart block. [ncbi.nlm.nih.gov]

  The severity of the heart block can fluctuate rapidly and the progression to complete heart block can be fatal. Importantly, the heart block in Lyme carditis can be transient and usually resolves with antibiotic therapy. [lymedisease.org]

  Of 207 children with early disseminated Lyme disease, 33 (16%) had carditis, 14 (42%) of whom had advanced heart block, including 9 (27%) with complete heart block. [pediatrics.aappublications.org]

• Chest Pain

  We report a case of Lyme carditis in an otherwise healthy male, who presented to the Accident & Emergency Department with chest pain, dizziness and generally symptoms indicating ischaemic heart disease. [ncbi.nlm.nih.gov]

  When this happens, a patient might faint or experience tightness of the chest. Also, heart failure and chest pains are known to occur. [innatoss.com]

  Among Lyme disease cases reported to CDC, second- or third-degree heart block occurs in approximately 1% of patients about whom clinical details are available.[2] Typical symptoms include palpitations, syncope, chest pain, and dyspnea. [medscape.com]

• Insect Bite

  Lyme carditis should be considered in patients aged 50 years or younger with severe conduction abnormalities, particularly if they have a history of being outdoors, an insect bite or a migratory rash. [cmaj.ca]

  Most summer insect bites can be forgotten as soon as the itching fades away. Not so with a bite from a tick harboring the bacteria that cause Lyme disease. [health.harvard.edu]

  Home Treatment for Stings and Insect Bites What Is Lyme Disease? Lyme disease is a bacterial infection that spreads through tick bites. Not all ticks carry Lyme disease. Black-legged ticks, also called deer ticks, are carriers of the disease. [share.upmc.com]

  See section on ‘ Ticks ’ on our Insect Bite Avoidance page. For information on avoiding tick bites in the UK see NHS Inform Avoiding bugs and germs outdoors back to top [fitfortravel.nhs.uk]

• Muscle Weakness

  The commonest symptoms relate to the person feeling unwell, having flu-like symptoms, extreme tiredness, muscle pain, muscle weakness, joint pain, upset digestive system, headache, disturbances of the central nervous system and a poor sleep pattern. [lymediseaseaction.org.uk]

  Other symptoms may include: Abnormal muscle movement Joint swelling Muscle weakness Numbness and tingling Speech problems Thinking (cognitive) problems A blood test can be done to check for antibodies to the bacteria that cause Lyme disease. [medlineplus.gov]

  If the bacteria invade the facial nerve (the seventh cranial nerve), you can develop muscle weakness or paralysis on one or both sides of your face. This palsy is sometimes mistakenly called Bell’s palsy. [healthline.com]

  Muscle weakness Brain swelling ( encephalitis ) causes learning difficulties, confusion, and dementia. Intermittent episodes of arthritis last about a week and usually involve the knee or wrist. [emedicinehealth.com]

• Joint Effusion

  effusions knee and shoulder recurrent acrodermatitis chronica atrophicans "cigarette paper" skin dorsum of hands, feet, knees, elbows in older patients Studies Serum labs WBC normal or elevated ESR, CRP elevated ELISA (sensitive, not specific) 2 steps [orthobullets.com]

• Stroke

  […] other serious cardiovascular manifestations may be present, such as: sinus node disease, marked by alterations to the heart’s “motor” or natural pacemaker, atrial fibrillation, which is a disorganization of the cardiac rhythm that increases the risk of stroke [queensu.ca]

  Prevention) Also in Spanish Lyme Disease Tests (National Library of Medicine) Also in Spanish Lyme Disease Transmission (Centers for Disease Control and Prevention) Neurological Complications of Lyme Disease (National Institute of Neurological Disorders and Stroke [medlineplus.gov]

  National Institute of Neurological Disorders and Stroke. Neurological complications of Lyme disease information page. www.ninds.nih.gov/disorders/lyme/lyme.htm. Accessed December 21, 2013. Krause P, Bicknstedt L. Lyme disease and the heart. [pharmacytimes.com]

  A stroke of bad luck led to a second bout of Lyme in 2008. "I was putting out tick repellent and stepped one foot into the woods right on the edge of our property," Franklin says. [prevention.com]

  He cites, for instance, hormone replacement therapy for post-menopausal women, which was ultimately shown to increase coronary artery disease, stroke, and breast cancer. "A lot of things in medicine would seem to intuitively make sense. [news.nationalgeographic.com]

• Hyperactivity

  As expected, Il10 -/- mice had the lowest bacterial numbers in all three tissues, consistent with a hyperactive immune response and elevated host defense. [journals.plos.org]

• Chorea

  However, family support during flare-ups is recommended for patients with carditis and chorea. AFFECTIONS NERVEUSES DU CŒUR ; CARDITE RHUMATISMALE. NERVOUS AFFECTIONS OF HEART; RHEUMATIC CARDITIS. [context.reverso.net]

Hopefully, the patient gets to the ER quickly, where the ER doctor would perform a cardiac workup and see an aberrant heart rhythm. [bayarealyme.org]

Further workup during the hospital course revealed a twice positive B. burgdorferi IgG and IgM immunoblot (performed at ARUP Laboratories; IgG: bands present: 66, 45, 41, 39, 23, and 18 kDa, IgM: bands present: 41 and 39 kDa). 3. [hindawi.com]

And because of the medical-clinical divide in regard to Lyme disease, insurance covers little to none of her workups and treatment. The disease is debilitating, deflating and downright expensive. [usatoday.com]

• Wide QRS Complex

  Brief asystole, escape rhythm with a wide QRS complex, and fluctuating bundle branch blocks are associated with poorer prognosis (44). [jacc.org]

• Borrelia Burgdorferi

  BELOW: Warthin-Starry stain of decedent heart tissue at 158x magnification demonstrating Borrelia burgdorferi spirochetes (arrow). [acepnow.com]

  The Borrelia burgdorferi sensu lato complex comprises: Borrelia burgdorferi sensu stricto Borrelia afzelii Borrelia garinii Borrelia spielmanii. [ncbi.nlm.nih.gov]

• Prolonged PR Interval

  A repeat ECG showed a first-degree AV block with a markedly prolonged PR interval of greater than 400 ms. Physical exam revealed multiple annular, erythematous, macular lesions with central clearing. (Figures 1 and 2.) [journals.lww.com]

  He was noted to possibly have subtle Brugada pattern on EKG with prolonged PR interval of 252ms. A procainamide challenge was equivocal. He was placed on quinidine for suspected Brugada syndrome. [onlinejacc.org]

  The other 2 patients had improved but still had mildly prolonged PR intervals at short-term follow-up. Thus, Dr. Costello's group states, "A full recovery should be expected with supportive care and antibiotic therapy." [borrelioosifoorumi.net]

  Additionally, on hospital day 2, telemetry monitoring and EKG revealed spontaneous conversion to normal sinus rhythm with a profoundly prolonged PR interval of 460 msec (Figure 3). [hindawi.com]

• Third Degree Atrioventricular Block

  A 44 year old man with third degree atrioventricular block in Lyme carditis had a temporary decrease in heart rate during resolution of the heart block two days after treatment with antibiotics was started. [ncbi.nlm.nih.gov]

  A, ECG at admission showing complete heart block. B, Telemetry demonstrating regression from third-degree atrioventricular block to polymorphic ventricular tachycardia (VT) as the patient began reporting presyncopal symptoms. [ahajournals.org]

  block. 4, 12, 18, 19 A study of 105 patients with Lyme carditis reported that 49 percent had third-degree atrioventricular block, 28 percent had some form of second- or first-degree atrioventricular block, and 23 percent had no conduction abnormalities [aafp.org]

• First-Degree Atrioventricular Block

  He was admitted and over the course of the next few days, his rhythm regressed to Mobitz type I first-degree atrioventricular block and then to normal sinus rhythm. [ncbi.nlm.nih.gov]

  Laboratory findings showed elevated erythrocyte sedimentation rate and C-reactive protein, bilateral temporal artery biopsy results were negative and first degree atrioventricular block was seen on electrocardiogram. [pagepress.org]

  However, they reported that 98% of adults who develop Lyme carditis will develop first degree atrioventricular block, and 58% of those patients are likely to develop complete heart block. [healio.com]

  block. 4, 12, 18, 19 A study of 105 patients with Lyme carditis reported that 49 percent had third-degree atrioventricular block, 28 percent had some form of second- or first-degree atrioventricular block, and 23 percent had no conduction abnormalities [aafp.org]

In most cases the conduction disturbances are reversed by treatment with antibiotics. [ncbi.nlm.nih.gov]

Figure 1A shows the reversal of conduction abnormality after treatment with antibiotics. [cmaj.ca]

The progression of Lyme disease can be prevented with proper diagnosis and initial treatment. [pharmacytimes.com]

The overall prognosis of Lyme carditis seems to be good, although delayed recovery has been described and possible late manifestations have been suggested. [rug.nl]

This case highlights the importance of timely diagnosis and appropriate management to achieve a favorable prognosis. [ncbi.nlm.nih.gov]

Conclusion: Considering Lyme carditis as a differential diagnosis in patients with an AV block of an unknown etiology can result in a timely diagnosis and treatment of Lyme carditis. 1. Forrester, JD, Vakkalanka, JP, Holstege, CP, Mead, PS. [journals.sagepub.com]

However, the criterion standard for confirming myocarditis irrespective of etiology is an endomyocardial biopsy. [amjcaserep.com]

Borrelia burgdorferi as an etiologic agent in chronic heart failure? Scandinavian journal of infectious diseases. [on-lyme.org]

[…] migrans neurological symptoms ( e.g., facial nerve palsy, meningitis, and mononeuritis multiplex) cardiac symptoms ( e.g., carditis) late stage arthritis encephalopathy or polyneuropathy Epidemiology incidence most cases in the northeast and upper midwest Etiology [medbullets.com]

Stanek G., Klein J., Bittner R. and Glogar D. : "Borrelia burgdorferi as an etiologic agent in chronic heart failure?". Scand J Infect Dis Suppl 1991; 77: 85. 68. [jacc.org]

The facts about Lyme disease, from epidemiology to treatment to control Lyme borreliosis, popularly known as Lyme disease, remains the most commonly reported tick-transmitted infection in North America and Europe. [books.google.es]

[…] consultation meeting on Lyme borreliosis surveillance in the European Union held in January 2016 in Stockholm, – having regard to Decision No 2119/98/EC of the European Parliament and of the Council of 24 September 1998 setting up a network for the epidemiological [europarl.europa.eu]

Author Affiliations From the Departments of Pediatrics, Epidemiology of Microbial Diseases, and Investigative Medicine, Yale University Schools of Medicine and of Public Health and Graduate School of Arts and Sciences, New Haven, CT. [nejm.org]

8.6 cases/100,000) adults 55-59 (7.8 cases/100,00) geographic locations northeast, midwest, western US (areas with heavy deer population) Maryland to Maine (Ixodes scapularis) Great Lakes region (Ixodes scapularis) Pacific Northwest (Ixodes pacificus) Pathophysiology [orthobullets.com]

The exact pathophysiology behind the predominant selection of the cardiac conduction system is unclear since cardiac biopsies are rarely available. [innovationsincrm.com]

Pathophysiologically, myocardial biopsy specimens usually show transmural inflammatory infiltrates with characteristic endocardial lymphocytic infiltrates and occasionally spirochetes [7]. Most cases of LC appear to be clinically asymptomatic. [hindawi.com]

1243 Percutaneous Coronary Intervention 1258 Percutaneous Cardiac Procedures 1273 Coronary Artery Bypass Surgery 1290 Approaches to the Patient with Prior Bypass Surgery 1306 Percutaneous Valve Dilatations 1316 Global Pandemic of Heart Failure 1330 Pathophysiology [books.google.es]

[…] can lead to unnecessary implantation of permanent pacemakers in otherwise young and healthy people, which in turn can lead to a lifetime of pulse generator changes and risks of complications such as infection and lead dislodgement.[4] Lyme carditis pathophysiology [bcmj.org]

Atlanta, Georgia. 2 Bacterial Disease Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention, Atlanta, Georgia. [ncbi.nlm.nih.gov]

[…] disseminate info about disseminated Lyme: critical update on Lyme carditis Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention [acepnow.com]

The diagnosis of Lyme carditis (LC), an early disseminated manifestation of Lyme disease, has important implications for patient management and preventing further extracutaneous complications. [jacc.org]

Lyme's carditis may be prevented by starting the antibiotic therapy at the time of the chronic erythema migrans. Upon medication the patient may recover from the carditis without remaining symptoms. [hungary.pure.elsevier.com]