Article, Infectious Diseases

Seeks, finds, threats: Lyme disease!

Lyme disease!”>Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 33 (2015) 307.e5-307.e6

Seeks, finds, threats: Lyme disease!?

Abstract

Lyme borreliosis is a disease commonly found in humans. Here we report the case of a young, healthy girl presenting with symptomatic first- and second-degree atrioventricular blocks secondary to cardiac myocarditis. The disappearance of the conduction anomaly after antibiotic treatment confirmed Lyme disease before the results from the serology. Therefore, when a healthy, young person suddenly presents with an atrioventricular conduction block, physicians should consider a diagnosis of Lyme disease.

Lyme borreliosis is a disease caused by a spirochete from the Borrelia species that is transmitted by ticks. The disease occurs worldwide but is more prevalent in the wooded areas of Europe and North America. Around 86 000 people are diagnosed as having Lyme disease every year [1,2].

A healthy 13-year-old girl presented at our emergency department with malaise and palpitations. After a careful anamnesis, she also complained of dyspnea when going up stairs, abnormal asthenia, and chest pain over the past weeks. There was no history of family cardiac Rhythm disturbances. The physical examination was normal. The electrocardiogram (ECG) showed a sinus rhythm with a first-degree atrioventricular (AV) block and an AV Wenckebach block (second- degree Mobitz 1 block) (Figure). The exercise ECG test (maximum of 80 W) revealed asthenia and persistence of the first- and second- degree blocks. Results from the echocardiography and complete blood sample were normal (no cardiac enzymes). The patient was hospitalized for monitoring and electrophysiologic study. The moni- toring showed rhythm variability and several blocked P waves. The electrophysiologic study detected no other anomalies. Cardiac mag- netic resonance imaging demonstrated an inferobasal and poster- obasal spot compatible with a specific carditis. After obtaining these results, we further questioned the mother about the daughter’s history. She remembered having removed several ticks from her daughter’s skin about 3 months before the onset of symptoms. Complementary laboratory work was obtained, specifically blood antibody titers for Borrelia burgdorferi.

The young girl remained hospitalized for treatment of the

abnormal heart rhythm with antibiotics. Ceftriaxone was intrave- nously provided (IV, 2 g). At day 5 after initiating the ceftriaxone treatment, the symptoms and ECG of the patient were normalized, and the patient was released from the hospital. We continued ceftriaxone treatment for 10 days after discharge. Blood antibody results (IgM and IgG) for B burgdorferi using an enzyme-linked immunosorbent assay (ELISA) came back positive. The follow-up was

normal: there were no symptoms and the ECG, and exercise ECG was normalized.

Seek: Lyme disease. A bit of tick is usually more predominant in woodland areas. A variable percentage of ticks are carriers of B species, the bacteria responsible for Lyme disease. The species of Borrelia indicate the type of land where the tick is found. There are different phases of Lyme disease. The first phase consists of a dermatologic involvement, such as erythema migrans rash. Indeed, this is the most identifiable early symptom and may appear days to weeks after the initial tick bite. The next phase involves neurologic (meningoradicu- litis, facial palsy, etc), cardiac (myopericarditis, AV conduction blocks, and cardiomyopathy), and rheumatologic (arthritis) signs [1,3-5]. These symptoms can occur weeks to a few months after the onset of infection [6]. Lyme carditis is a rare manifestation (0.5%-4% of cases in Europe) [7]. In this case, a healthy and young girl with AV conduction blocks, we must seek Lyme disease, although it was also necessary to exclude other possible causes (Table) [5].

Find and confirm: Lyme disease. After determining that Lyme disease is possible, physicians should first confirm the diagnosis based on the correlation of the symptoms. The next step is to use an immunofluorescence technique, such as ELISA or Western blot, more specific to confirm the diagnosis [5,6]. The only definitive test for diagnosing Lyme cardiac disease is based on histopathology (endo- myocardial biopsy); however, it is very invasive. In this case, we used ELISA to confirm our diagnosis of Lyme disease with B burgdorferi. There was no indication for an endomyocardial biopsy.

Threat: Lyme disease. The only definitive way to reduce the risk of tick-borne infections is to avoid tick bites. When a tick is found attached to the skin, it is advisable to remove it as soon as possible to reduce the risk of potential Borrelia spirochete transmission. However, if infection does occur, both local and disseminated Lyme disease can be treated with antibiotics. In cardiac Lyme disease, carditis and AV block can occur. In Europe, 0.3% to 4% of patients infected with B burgdorferi are reported to have Cardiac manifestations. There are various ways in which conduction blockage can occur: AV block type 1 (98%), type 2 (40%), and type 3 (50%) [5,8,9]. Histopathologic and immunologic studies suggest that the disease effects on the conductive tissue are associated with a major inflammatory response [10]. The recommendations for treatment of cardiac Lyme disease depend on the type of AV block. For a type 1 AV block, amoxicillin or doxycycline per os is suggested for 14 or 21 days. Other AV blocks or a prolonged P-R interval on the ECG (>=300 ms) require penicillin (IV, 28 days) or ceftriaxone (IV, 14 days) [11,12]. In our case, the AV block type 1 and type 2 with carditis were treated with IV antibiotic alone (ceftriaxone), without any indication for a pacemaker.

? No conflict of interest.

0735-6757/(C) 2014

307.e6 X. Muschart, D. Blommaert / American Journal of Emergency Medicine 33 (2015) 307.e5-307.e6

Figure. Electrocardiogram 12-lead derivation showing the atrioventricular Wenckebach block.

Xavier Muschart, MD?

Dominique Blommaert, MD Department of Emergency and Cardiology, Mont-Godinne University Hospital, Universite Catholique de Louvain, Yvoir, Belgium

?Corresponding author.

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.07.019

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Table

Differential diagnosis for atrioventricular block

Infections: Lyme disease, Treponema pallidum infection, diphtheria, Yersinia enterocolitica infection, viral infections (coxsackie, influenza, mumps, etc), toxoplasmosis, Chagas disease, Rickettsial infections, etc.

Cardiac disease: coronary artery disease, myopathy, congenital heart disease, etc.

Autoimmune or inflammatory disease: (neonatal) lupus, endocarditis, Acute rheumatic fever, thyroid disease, amyloidosis, sarcoidosis, dermatomyositis, Paget disease, etc.

Cardiac tumor: rhabdomyoma, etc.

Other iatrogenic: medication, drug toxicity, cardiac surgery, Catheter ablation, trauma, hyperkalemia, etc.