Lyme Carditis: A Rare Presentation of Sinus Bradycardia Without Any Conduction Defects

Abstract

Lyme carditis is a rare cardiac manifestation of Lyme disease that occurs when bacterial spirochetes infect the pericardium or myocardium triggering an inflammatory response. The most common electrocardiogram (EKG) findings in these patients include atrioventricular (AV) conduction abnormalities (first, second, and third degree heart block).A 56-year-old male with a history of hypothyroidism, from the Northeastern region of the United States, presented to the emergency department with lightheadedness and chest pain. His EKG revealed sinus bradycardia with a heart rate of 49 beats per minute, without ST segment elevation, T wave inversions, or signs of heart block. An enzyme-linked immunosorbent assay (ELISA) Lyme titer was elevated, and confirmatory Western blot was positive for IgG and negative for IgM. He was treated with intravenous (IV) ceftriaxone; however, he continued to have persistent bradycardia with his heart rate dropping to 20 to 30 beats per minute throughout the night. Additionally, he had several sinus pauses while sleeping, with the longest lasting for 6.1 seconds. A pacemaker and an additional three-week course of IV ceftriaxone was determined to be the best treatment for his resistant bradycardia secondary to Lyme carditis. No symptoms were present at his one month follow-up appointment, as an outpatient, after completing ceftriaxone therapy. The patient follows up with cardiology regularly to have his pacemaker checked.Here we present a unique case of Lyme carditis, without the classical findings of Lyme disease or common EKG findings of AV conduction abnormalities. A high clinical suspicion of Lyme carditis is required when someone from a Lyme endemic region presents with unexplained cardiac symptoms and electrocardiogram abnormalities. This case report aims to add to the knowledge gap between suspicion of Lyme carditis and sinus bradycardia as the only presenting symptom.

Sinus Bradycardia as an Early Marker of Heart Damage in a Girl With Lyme Disease (Case Report and Mini Review)

“…A-V block in the presence of mild left ventricular dilata3tion can be due to various causes , but it may also be suggestive of Lyme disease, cardiac sarcoidosis, or giant cell myocarditis. In another recent publication [18], autor said that conduction system involvement is diverse, possibly including but not limited to bundle branch block, intraventricular conduction delay, prolonged QT interval, ventricular and fascicular tachycardias, and complete heart block.The most common LC electrocardiogram (ECG) findings in patients include atrioventricular (AV) conduction abnormalities (first, second, and third degree heart block) [19], atrial fibrillation and a full atrio-ventricular block [20] of a first-second grade type I . In our study echocardiography of the heart (at the time of admission to the hospital).…”

“…Acute rheumatic cardiitis should also be excluded in diagnostic search in patients with violation of AB conduction due to acquired heart disease, especially in pediatric practice. Most cases are reversible AV-blocks of the first or second degree [19]. The mechanisms of development of infectious genesis carditis, are actively studied today, including a completely new infection SARSCoV-2 [16, 23,26].…”

Jaw Pain and Profound Bradycardia – An Atypical Presentation of Lyme Carditis

“…The Centers for Disease Control and Prevention (CDC) recommends a two-tiered strategy for serological identification, whereby a negative ELISA is followed up a month later with another ELISA or confirmatory Western Blot if two of three IgM (21-24, 39, and 41 kDa) or five of 10 IgG bands (18, 21-24, 28, 30, 39, 41, 45, 58, 66, and 93 kDa) are positive on initial ELISA testing [ 11 ]. In order to test for serology, Lyme disease must be included in the list of suspected causes of high degree AV block in patients presenting similar to the aforementioned case.…”

“…However, early recognition and treatment is generally accepted as beneficial, with additional reduction in mortality from temporary implantation of a cardiac pacemaker to prevent progression from high degree AVblock to asystole during initial treatment. Adapted from Grella et al [11].…”

Lyme carditis in an adolescent (сlinical case)

“…На ЕКГ у цього пацієнта зареєстрована синусова брадикардія з ЧСС 49 уд./хв, без підйому сегмента ST, інверсії зубця Т та ознак блокади серця. За результатами ІФА, титр антитіл підвищений, а підтверджувальний Вестерн-блот позитивний на IgG і негативний на IgM [9]. Це узгоджується з нашим клінічним випадком, у пацієнта за даними ЕКГ також виявлена синусова брадикардія з ЧСС 49-60 уд./хв.…”