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]

• Pain

  She denied fever, rash, muscle pain, or joint pain. Providers in the urgent care facility diagnosed the patient with anxiety and prescribed clonazepam. No electrocardiogram (ECG) was performed. The following day, the patient collapsed and died. [acepnow.com]

  Two weeks later an erythema of 8 cm in diameter, spreading peripherally as well as painful inguinal lymphadenitis developed at the site of the bite with transient arthralgia and myalgia in the region of the waist and left lower limb. [hungary.pure.elsevier.com]

  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]

  According to a 1985 report published in the Annals of Internal Medicine, he died 18 hours after being taken to the hospital with chills, muscle pain and other symptoms. [eu.poughkeepsiejournal.com]

  The joint pain of Lyme disease is called migratory arthralgia, which translates to joint pain that moves. Lyme disease can also cause chronic inflammation of the nerves (neuropathy) and brain (encephalopathy). [everydayhealth.com]

• Inflammation

  When you see the suffix “-itis”, it denotes inflammation – often caused by an infection. So, carditis literally means inflammation of the heart. When a Borrelia infection enters the body, we know from animal studies that it disseminates quickly. [bayarealyme.org]

  An autopsy found that he also suffered from heart inflammation. • A patient who died from cardiac arrest caused by Lyme myocarditis or heart inflammation. [eu.poughkeepsiejournal.com]

  Cardiac magnetic resonance imaging (MRI) revealed inflammation around the AV node (Fig. 4 ). Lyme carditis was confirmed after Western blot revealed Borrelia burgdorferi antibodies. [intjem.biomedcentral.com]

  Lyme Disease Skin Fever Chills Swollen glands Stiff neck Muscle and joint pain Headache Fatigue Poor appetite Joint inflammation Nerve pain Facial nerve disorders Meningitis Myopericarditis Heart palpitations Eye inflammation Confusion bacterium Borrelia [nm.org]

• Swelling

  Swelling of the Heart Patients with Lyme disease may also experience a swelling of the heart, which is called myopericarditis. [livestrong.com]

  Months/years after bite Approximately 60% of patients who go untreated may begin to have bouts of arthritis, with severe joint pain and swelling. Large joints are most often affected, particularly the knees. [chesco.org]

  They came down with symptoms, including muscle pain, tenderness, swelling and weakness. • A 31 year-old male farm worker in Great Britain — the only geographical reference in the four articles — who tested positive for Lyme disease on his first screening [eu.poughkeepsiejournal.com]

  Their continued swelling of the joints and pain is thought to be perpetuated by their own immune system’s autoimmune condition. [hopkinsarthritis.org]

• Chills

  According to a 1985 report published in the Annals of Internal Medicine, he died 18 hours after being taken to the hospital with chills, muscle pain and other symptoms. [eu.poughkeepsiejournal.com]

  Lyme Disease Skin Fever Chills Swollen glands Stiff neck Muscle and joint pain Headache Fatigue Poor appetite Joint inflammation Nerve pain Facial nerve disorders Meningitis Myopericarditis Heart palpitations Eye inflammation Confusion bacterium Borrelia [nm.org]

  Fever, chills, myalgia and headache are common. Meningeal involvement may follow. Central nervous system and other complications may occur weeks or months after the onset of illness. Arthritis may develop up to 2 years after onset. [who.int]

  Early phases of Lyme disease present with flu-like symptoms, such as chills, fever, and muscle pain. In the early phase of Lyme disease, one specific presentation is an Erythema Migrans rash. This is described as a bull’s eye-type rash. [pharmacytimes.com]

  Other symptoms may include fever, headache, chills, fatigue, joint pains, muscle ache and swollen glands. The rash gradually gets better over weeks. [fitfortravel.nhs.uk]

• Weakness

  They came down with symptoms, including muscle pain, tenderness, swelling and weakness. • A 31 year-old male farm worker in Great Britain — the only geographical reference in the four articles — who tested positive for Lyme disease on his first screening [eu.poughkeepsiejournal.com]

  Had a tick bite and develop weakness, numbness, tingling, or heart problems. Symptoms of Lyme disease, especially if you may have been exposed to ticks. Take precautions to avoid tick bites. Be extra careful during warmer months. [medlineplus.gov]

  These problems include meningitis (an inflammation of the membranes covering the brain and spinal cord), facial weakness (Bell’s palsy) or other problems with nerves of the head, and weakness or pain (or both) in the hands, arms, feet and/or legs. [mass.gov]

  Minnesota 4 Wisconsin 4 Virginia 4 Maryland 2 Pennsylvania 2 Presentation location Hospital 71 Outpatient clinic 25 Missing 4 Associated presenting symptoms Erythema migrans rash 44 Syncope 40 Fever 36 Lightheadedness/dizziness 33 Dyspnea 33 Lethargy or weakness [academic.oup.com]

  Symptoms If you are infected with Lyme disease, you may experience: Fever Tiredness/weakness Headache Joint and muscle pain A skin rash called erythema migrans, also known as a bulls-eye or target-shaped rash Early symptoms usually begin three to 30 days [nyc.gov]

• 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]

• Cardiomegaly

  Cardiovascular manifestations of Lyme disease often occur within 21 days of exposure and include fluctuating degrees of atrioventricular (AV) block, acute myopericarditis or mild left ventricular dysfunction and rarely cardiomegaly or fatal pericarditis [ncbi.nlm.nih.gov]

  The most frequent symptom was atrioventricular block, more unusual were other arrhythmias, nonspecific ECG alterations, cardiomegaly and pericarditis. [prohealth.com]

  Thirteen patients had evidence of more diffuse cardiac involvement: electrocardiographic changes compatible with acute myopericarditis (11 patients), radionuclide evidence of mild left ventricular dysfunction (five of 12 patients tested), or frank cardiomegaly [annals.org]

  In a case report published in 2012 in The Medicine Forum, researchers reported that complications include atrioventricular block, myocarditis, mild left ventricular dysfunction and rare instances of cardiomegaly or fatal pericarditis, but that most symptoms [healio.com]

• Cutaneous Manifestation

  It is a disease with early and late cutaneous manifestations plus involvement of the nervous system, heart, eye, and joints in variable combinations. The disease was formerly known as lyme arthritis and first discovered at old lyme, connecticut. [icd10data.com]

  Compared to the cutaneous, arthritic, and neurological manifestations of Lyme disease, Lyme carditis is a relatively rare manifestation, with reported prevalence of 1.5% to 10.0% in the United States and 0.3% to 4.0% in Europe among adult patients with [bcmj.org]

  […] and non-cutaneous manifestations of Lyme borreliosis PLoS One 2013 8 e64110 42 Different genospecies of Borrelia burgdorferi are associated with distinct clinical manifestations of Lyme borreliosis Clin Infect Dis 1993 17 708 17 43 The clinical assessment [academic.oup.com]

  Serologic testing is the mainstay of laboratory diagnosis for patients with extra cutaneous manifestations of Lyme disease. [physio-pedia.com]

  Evidence supports the use of Food and Drug Administration (FDA)-approved serologic tests, such as an EIA, followed by Western blot testing, to diagnose extra-cutaneous manifestations of Lyme disease. [aetna.com]

• Myalgia

  Two weeks later an erythema of 8 cm in diameter, spreading peripherally as well as painful inguinal lymphadenitis developed at the site of the bite with transient arthralgia and myalgia in the region of the waist and left lower limb. [hungary.pure.elsevier.com]

  This case illustrates a 66-year-old male with complaints of fatigue, myalgias, and fever after a tick bite 3days earlier. A large erythema migrans was found on the chest wall. [ncbi.nlm.nih.gov]

  Abstract Presenting an interesting case of a patient who complained of myalgias, fatigue, headache, jaw claudication and scalp tenderness. Patient’s physical examination was unremarkable. [pagepress.org]

  Although fever and cough resolved after the first 3 days of his illness, his fatigue, malaise, and myalgia persisted. [amjcaserep.com]

  Fever, chills, myalgia and headache are common. Meningeal involvement may follow. Central nervous system and other complications may occur weeks or months after the onset of illness. Arthritis may develop up to 2 years after onset. [who.int]

• 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]

• Fear

  Her story was in the back of my mind as I traveled, and I relayed it through fearful tears to my doctor. I remember the soft touch of his hand as he laid a reassuring palm on my forehead. “Ohhh, how awful,” he said. “Of course you were worried. [globallymealliance.org]

  It was the scenario I’d always feared. My kidneys started to fail. I was in and out of the hospital. I developed restless body syndrome. I couldn’t sit. I couldn’t lie down. [nymag.com]

  This is an illness that has been minimized, underestimated, and politicized to the point that doctors fear treating it aggressively with a cheap, common drug: antibiotics. [earthisland.org]

  But patient advocates fear this does not give the condition the recognition it deserves. To its credit, WHO accepted 14 Lyme-related conditions in the new ICD, compared to just four in the previous edition. [blogs.scientificamerican.com]

• Denial

  I knew it wasn’t denial. If I’m open with my doctor and tell him I’m feeling worse I don’t expect that response. I researched the success rate of Lyme disease testing. [nymag.com]

  Reading between the lines, one can imagine that this woman might have been in denial over her diagnosis, given that ALS is a relentless and terminal disease with no good treatment that arrests the progress of the disease, leaving supportive care as the [scienceblogs.com]

• Neurologic Manifestation

  manifestations 100 98 87 100 Multiple erythema migrans lesions 43 98 89 79 Late Arthritis or neurologic manifestations 100 98 94 100 Table 3. [aafp.org]

  The role of these antibodies in the pathogenesis of the neurologic manifestations of Lyme disease is unknown. [antimicrobe.org]

  Compared to the cutaneous, arthritic, and neurological manifestations of Lyme disease, Lyme carditis is a relatively rare manifestation, with reported prevalence of 1.5% to 10.0% in the United States and 0.3% to 4.0% in Europe among adult patients with [bcmj.org]

  […] same or different joints Possible neurological and cognitive manifestations occur due to effects on the central and peripheral nervous systems. [canada.ca]

• Ataxia

  […] involvement, affecting up to 15 percent of untreated patients, can include lymphocytic meningitis, cranial neuropathies (primarily unilateral, but rarely bilateral, facial nerve palsy), motor or sensory radiculoneuropathy, mononeuritis multiplex, cerebellar ataxia [aafp.org]

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]