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Electrocardiographic progression of acute Lyme disease
American Journal of Emergency Medicine 35 (2017) 1040.e5–1040.e6
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Electrocardiographic progression of acute Lyme disease Laiden Suarez Fuster, Enes Elvin Gul, Adrian Baranchuk ⁎ Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
a r t i c l e
i n f o
Article history: Received 2 January 2017 Received in revised form 26 February 2017 Accepted 28 February 2017
a b s t r a c t Lyme carditis poses a challenge to physicians given dramatic clinical presentations like the one presented in this case. Quite frequently, these young patients are implanted with permanent pacemakers; given lack of knowledge on the transient nature of the cardiac conduction system inflammation. This is the first case in the literature that has captured the electrocardiographic evolution of Lyme carditis, day by day until complete resolution. © 2017 Elsevier Inc. All rights reserved.
1. Case description A 30-year-old man presented to the emergency department (ED) due to a syncopal episode with no prodrome, shortness of breath and weakness. He reported no medical conditions and no use of recreational drugs. Three weeks prior to the presentation, he had experienced an “insect bite” on his calf after being outside. A week later, he developed chills, sweats, myalgia, back pain, headache and fatigue. Blood pressure at the ED was within normal limits; and a pulse rate of 38 bpm was detected. No murmurs, rubs, or gallops in supine, sitting, or standing positions. The rest of the physical examination was within normal limits. The electrocardiographic progression during the first 12 days is shown in Fig. 1.
was decreased to 35 bpm to allow intrinsic conduction. On the fifth day of admission, ECG showed 2:1 AV block with a narrow conducted QRS (Day 5). Temporary PM was removed on day 6. The electrocardiographic progression shows some improvement depicting 2nd degree type-1 AV block (Wenckebach 4:3 and 3:2) (Day 7). On the 10th day of admission, the ECG was consistent with 1st degree AV block (PR interval of 280 ms) (Day 10). An exercise stress test was performed, depicting 1:1 conduction up to 167 bpm (Day 12). Subsequently the patient developed 2nd degree type-1 AV block which resolved 1 min later during the resting phase. The patient remained asymptomatic during the test. The patient was discharged home to complete 4 weeks of antibiotic treatment and to use an event monitor for the first 2 weeks. Follow-up ECG at 2 weeks revealed normal sinus rhythm with normal PR interval.
1.1. Question 3. Discussion What could likely be the cause of this conduction problem? Does this patient need a permanent pacemaker (PM) implantation? 2. Clinical course The ECG on presentation depicted high degree AV block that rapidly evolved into 3rd degree AV block with a junctional escape rhythm at 38 bpm (Day 1, first and second panels). Due to hemodynamic instability, a temporary transvenous pacemaker was placed through the jugular vein (Day 1, third panel). The patient was admitted to the cardiac unit for monitoring and further management. Causes of conduction disturbance in the young were ruled out (normal biological markers). Because of the recent history of ‘insect bite’ and symptoms compatible with Lyme disease, after obtaining samples for serological testing, empiric antibiotic (ceftriaxone) was administered intravenously. His pacer rate ⁎ Corresponding author at: Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada. E-mail address: [email protected] (A. Baranchuk).
http://dx.doi.org/10.1016/j.ajem.2017.02.052 0735-6757/© 2017 Elsevier Inc. All rights reserved.
When called to evaluate this previously healthy 30-year-old patient with history of syncope and a recent insect bite while working outside and symptomatic by myalgia, fatigue, chills, shortness of breath and electrocardiographic evidence of complete AV block, the clinical team considered (after ruling out ischemia) Lyme disease (Lyme carditis) as the most likely diagnosis. Lyme disease is a multisystem illness caused by Borrelia burgdorferi, a spirochete transmitted by certain species of Ixodes ticks [1]. Typical symptoms include palpitations, syncope, chest pain, and dyspnea. Carditis is a rare complication of Lyme disease that occurs when Lyme spirochetes invades the heart at different levels. The most aggressive form is the pancarditis that involves the endo-, myo-, epi-, and pericardium simultaneously. The most commonly recognized clinical manifestation of Lyme carditis is AV block, which can fluctuate between first-, second-, and third-degree block. Among reported Lyme disease cases, second- or third-degree heart block occurs in approximately 1% of patients [2]. Most patients presenting with Lyme carditis and new onset arrhythmia do not remember when they have been bitten or they do
1040.e6
L.S. Fuster et al. / American Journal of Emergency Medicine 35 (2017) 1040.e5–1040.e6
• Patients with suspected Lyme disease should be interrogated for cardiac symptoms, including palpitations, chest pain, lightheadedness, fainting, and shortness of breath. • ECG is mandatory if Lyme carditis is suspected. • Ask patients with unexplained heart block about possible exposure to infected ticks. • Encourage taking personal prevention measures, specifically using tick repellent, conducting daily tick checks, and showering soon after potential tick exposure. Take-home points
Fig. 1. Electrocardiographic progression of a patient with acute Lyme disease.
not have a clear history of tick bite, therefore it is a reasonable decision to investigate those patients for suspicious Lyme disease especially in high-risk areas or in patients with pathognomonic symptoms like erithema migrans (characteristic migrating rash). Males account for a little N50% of all patients with Lyme disease, and previous reports have shown a male to female ratio of 3:1 among Lyme carditis patients [1]. Young males are far more frequently affected by 3rd degree AV block probably because of patient-related deferral of medical consultation [1,2]. Additionally, whereas the age distribution of patients with Lyme disease is typically bimodal, with the highest incidence in children aged 5–9 years and adults aged 45–59 years, patients with 3rd degree AV block from Lyme carditis are predominantly aged 10–45 years [3]. The prognosis is generally excellent with appropriate antimicrobial therapy [4]. Because a temporary pacemaker may be required, hospitalization is recommended for patients with 2nd or 3rd degree AV block, and for patients with 1st degree AV block and a PR interval N 300 ms. Signs of cardiac involvement, including conduction disorders, usually resolve within 1–6 weeks after initiation of antibiotics [5-7]. Some general aspects and recommendations from the “Centers for Disease Control and Prevention” are worth to remember [1]: • Males are disproportionately affected by Lyme carditis. • Individuals aged 15–45 years develop Lyme carditis more frequently among patients with Lyme disease. • Most cases occur in the summer or early autumn in high-incidence Lyme disease areas. • Only 40% of patients with Lyme carditis report having erythema migrans rash, as compared with 70%–80% of patients overall.
✓ Lyme carditis is an uncommon manifestation of Lyme disease, but also one of the most serious. ✓ Progression to 3rd degree AV block can be rapid, and potentially fatal if untreated. ✓ Although one-third of patients may need supportive transvenous pacing, after appropriate antibiotic therapy is initiated, 3rd degree AV block (or high degree AV block) from Lyme carditis typically resolves within the first 10 days. Conflict of interest and disclosure of funding All authors declare that, the manuscript, as submitted or its essence in another version, is not under consideration for publication elsewhere, and it will not be submitted elsewhere until a final decision is made by the editors of American Journal of Emergency Medicine. The authors have no commercial associations or sources of support that might pose a conflict of interest. All authors have made substantive contributions to the study, and all authors endorse the data and conclusions. Nevertheless, confirmation of informed patient consent for publication was obtained. References [1] Centers for Disease Control and Prevention. Notice to readers: final 2012 reports of nationally notifiable infectious diseases. MMWR Morb Mortal Wkly Rep 2013;62: 669–82. [2] Forrester JD, Mead P. Third-degree heart block associated with Lyme carditis: review of published cases. Clin Infect Dis 2014;59:996–1000. [3] Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet 2012;379:461–73. [4] Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43:1089–134. [5] McAlister HF, Klementowicz PT, Andrews C, Fisher JD, Feld M, Furman S. Lyme carditis: an important cause of reversible heart block. Ann Intern Med 1989;1110: 339–45. [6] Mannava K, Grabinski ZG, Mousa O. Putting heart block back in the “Lyme Light”. J Cardiol Cases 2015;11:105–8. [7] Timmer SA, Boswijk DJ, Kimman GP, Germans T. A case of reversible third-degree AV block due to Lyme carditis. J Electrocardiol 2016;49:519–21.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Electrocardiographic progression of acute Lyme disease Laiden Suarez Fuster, Enes Elvin Gul, Adrian Baranchuk ⁎ Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
a r t i c l e
i n f o
Article history: Received 2 January 2017 Received in revised form 26 February 2017 Accepted 28 February 2017
a b s t r a c t Lyme carditis poses a challenge to physicians given dramatic clinical presentations like the one presented in this case. Quite frequently, these young patients are implanted with permanent pacemakers; given lack of knowledge on the transient nature of the cardiac conduction system inflammation. This is the first case in the literature that has captured the electrocardiographic evolution of Lyme carditis, day by day until complete resolution. © 2017 Elsevier Inc. All rights reserved.
1. Case description A 30-year-old man presented to the emergency department (ED) due to a syncopal episode with no prodrome, shortness of breath and weakness. He reported no medical conditions and no use of recreational drugs. Three weeks prior to the presentation, he had experienced an “insect bite” on his calf after being outside. A week later, he developed chills, sweats, myalgia, back pain, headache and fatigue. Blood pressure at the ED was within normal limits; and a pulse rate of 38 bpm was detected. No murmurs, rubs, or gallops in supine, sitting, or standing positions. The rest of the physical examination was within normal limits. The electrocardiographic progression during the first 12 days is shown in Fig. 1.
was decreased to 35 bpm to allow intrinsic conduction. On the fifth day of admission, ECG showed 2:1 AV block with a narrow conducted QRS (Day 5). Temporary PM was removed on day 6. The electrocardiographic progression shows some improvement depicting 2nd degree type-1 AV block (Wenckebach 4:3 and 3:2) (Day 7). On the 10th day of admission, the ECG was consistent with 1st degree AV block (PR interval of 280 ms) (Day 10). An exercise stress test was performed, depicting 1:1 conduction up to 167 bpm (Day 12). Subsequently the patient developed 2nd degree type-1 AV block which resolved 1 min later during the resting phase. The patient remained asymptomatic during the test. The patient was discharged home to complete 4 weeks of antibiotic treatment and to use an event monitor for the first 2 weeks. Follow-up ECG at 2 weeks revealed normal sinus rhythm with normal PR interval.
1.1. Question 3. Discussion What could likely be the cause of this conduction problem? Does this patient need a permanent pacemaker (PM) implantation? 2. Clinical course The ECG on presentation depicted high degree AV block that rapidly evolved into 3rd degree AV block with a junctional escape rhythm at 38 bpm (Day 1, first and second panels). Due to hemodynamic instability, a temporary transvenous pacemaker was placed through the jugular vein (Day 1, third panel). The patient was admitted to the cardiac unit for monitoring and further management. Causes of conduction disturbance in the young were ruled out (normal biological markers). Because of the recent history of ‘insect bite’ and symptoms compatible with Lyme disease, after obtaining samples for serological testing, empiric antibiotic (ceftriaxone) was administered intravenously. His pacer rate ⁎ Corresponding author at: Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada. E-mail address: [email protected] (A. Baranchuk).
http://dx.doi.org/10.1016/j.ajem.2017.02.052 0735-6757/© 2017 Elsevier Inc. All rights reserved.
When called to evaluate this previously healthy 30-year-old patient with history of syncope and a recent insect bite while working outside and symptomatic by myalgia, fatigue, chills, shortness of breath and electrocardiographic evidence of complete AV block, the clinical team considered (after ruling out ischemia) Lyme disease (Lyme carditis) as the most likely diagnosis. Lyme disease is a multisystem illness caused by Borrelia burgdorferi, a spirochete transmitted by certain species of Ixodes ticks [1]. Typical symptoms include palpitations, syncope, chest pain, and dyspnea. Carditis is a rare complication of Lyme disease that occurs when Lyme spirochetes invades the heart at different levels. The most aggressive form is the pancarditis that involves the endo-, myo-, epi-, and pericardium simultaneously. The most commonly recognized clinical manifestation of Lyme carditis is AV block, which can fluctuate between first-, second-, and third-degree block. Among reported Lyme disease cases, second- or third-degree heart block occurs in approximately 1% of patients [2]. Most patients presenting with Lyme carditis and new onset arrhythmia do not remember when they have been bitten or they do
1040.e6
L.S. Fuster et al. / American Journal of Emergency Medicine 35 (2017) 1040.e5–1040.e6
• Patients with suspected Lyme disease should be interrogated for cardiac symptoms, including palpitations, chest pain, lightheadedness, fainting, and shortness of breath. • ECG is mandatory if Lyme carditis is suspected. • Ask patients with unexplained heart block about possible exposure to infected ticks. • Encourage taking personal prevention measures, specifically using tick repellent, conducting daily tick checks, and showering soon after potential tick exposure. Take-home points
Fig. 1. Electrocardiographic progression of a patient with acute Lyme disease.
not have a clear history of tick bite, therefore it is a reasonable decision to investigate those patients for suspicious Lyme disease especially in high-risk areas or in patients with pathognomonic symptoms like erithema migrans (characteristic migrating rash). Males account for a little N50% of all patients with Lyme disease, and previous reports have shown a male to female ratio of 3:1 among Lyme carditis patients [1]. Young males are far more frequently affected by 3rd degree AV block probably because of patient-related deferral of medical consultation [1,2]. Additionally, whereas the age distribution of patients with Lyme disease is typically bimodal, with the highest incidence in children aged 5–9 years and adults aged 45–59 years, patients with 3rd degree AV block from Lyme carditis are predominantly aged 10–45 years [3]. The prognosis is generally excellent with appropriate antimicrobial therapy [4]. Because a temporary pacemaker may be required, hospitalization is recommended for patients with 2nd or 3rd degree AV block, and for patients with 1st degree AV block and a PR interval N 300 ms. Signs of cardiac involvement, including conduction disorders, usually resolve within 1–6 weeks after initiation of antibiotics [5-7]. Some general aspects and recommendations from the “Centers for Disease Control and Prevention” are worth to remember [1]: • Males are disproportionately affected by Lyme carditis. • Individuals aged 15–45 years develop Lyme carditis more frequently among patients with Lyme disease. • Most cases occur in the summer or early autumn in high-incidence Lyme disease areas. • Only 40% of patients with Lyme carditis report having erythema migrans rash, as compared with 70%–80% of patients overall.
✓ Lyme carditis is an uncommon manifestation of Lyme disease, but also one of the most serious. ✓ Progression to 3rd degree AV block can be rapid, and potentially fatal if untreated. ✓ Although one-third of patients may need supportive transvenous pacing, after appropriate antibiotic therapy is initiated, 3rd degree AV block (or high degree AV block) from Lyme carditis typically resolves within the first 10 days. Conflict of interest and disclosure of funding All authors declare that, the manuscript, as submitted or its essence in another version, is not under consideration for publication elsewhere, and it will not be submitted elsewhere until a final decision is made by the editors of American Journal of Emergency Medicine. The authors have no commercial associations or sources of support that might pose a conflict of interest. All authors have made substantive contributions to the study, and all authors endorse the data and conclusions. Nevertheless, confirmation of informed patient consent for publication was obtained. References [1] Centers for Disease Control and Prevention. Notice to readers: final 2012 reports of nationally notifiable infectious diseases. MMWR Morb Mortal Wkly Rep 2013;62: 669–82. [2] Forrester JD, Mead P. Third-degree heart block associated with Lyme carditis: review of published cases. Clin Infect Dis 2014;59:996–1000. [3] Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet 2012;379:461–73. [4] Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43:1089–134. [5] McAlister HF, Klementowicz PT, Andrews C, Fisher JD, Feld M, Furman S. Lyme carditis: an important cause of reversible heart block. Ann Intern Med 1989;1110: 339–45. [6] Mannava K, Grabinski ZG, Mousa O. Putting heart block back in the “Lyme Light”. J Cardiol Cases 2015;11:105–8. [7] Timmer SA, Boswijk DJ, Kimman GP, Germans T. A case of reversible third-degree AV block due to Lyme carditis. J Electrocardiol 2016;49:519–21.