Lyme Disease and the heart

Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
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Yvonne
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:29

Z Kardiol. 2000 Nov;89(11):1046-52. Links

Acute myocarditis and cardiomyopathy in Lyme borreliosis

[Article in German]


Scheffold N, Sucker C, Bergler-Klein J, Kaag N, Cyran J.
Medizinische Klinik I Schwerpunkt Kardiologie Klinikum Heilbronn Akademisches Lehrkrankenhaus der Universität Heidelberg Am Gesundbrunnen 20-24 D-74078 Heilbronn. Norbert-Scheffold@t-online.de

Heart involvement of Lyme disease occurs in about 4-10% of patients with Lyme borreliosis. The most common manifestation is acute, self-limiting Lyme carditis, which manifests mostly as transient conduction disorders of the heart, pericarditis and myocarditis. Laboratory tests (ELISA, immunoblotting and PCR) usually have limited sensitivity and specificity, and criteria of performance and interpretation have not yet been fully evaluated. Therefore the laboratory evidence should only be interpreted in conjunction with other clinical and diagnostic features. Recently there has been convincing evidence published that long standing dilated cardiomyopathy in many cases is associated with a chronic Borrelia burgdorferi (BB) infection. Several studies showed a higher prevalence of BB antibodies in patients with severe heart failure in endemic areas (e.g., 26% versus 8% in healthy individuals). The isolation of spirochetes from the myocardium gave further evidence that BB may cause chronic heart muscle disease. In several studies antimicrobial treatment showed an improvement of the left ventricular function in patients with dilated cardiomyopathy associated with BB. However the duration of dilated cardiomyopathy before treatment plays an important part in the clinical outcome of BB-associated chronic myocarditis.

PMID: 11149272
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:31

Int J Cardiol. 1998 May 15;64(3):309-10. Links

First description of recurrent pericardial effusion associated with borrelia burgdorferi infection.

Gasser R, Horn S, Reisinger E, Fischer L, Pokan R, Wendelin I, Klein W.
The Borreliosis Study Group, Department of Medicine, University of Graz, Austria.

Lyme disease is well known for affecting the myocardium in the form of carditis and dilated cardiomyopathy. Pericardial effusion associated with Lyme disease has not been described as yet. This article demonstrates a case of a female patient, 54 years of age, with Borrelia burgdorferi infection and associated pericardial effusion. Recurrent pericardiocenteses as well as conventional treatment of the condition were without success. Diagnosis of Borrelia infection and subsequent treatment with ceftriaxone led to permanent restitution of the pericardial effusion.

PMID: 9672415

Pericardial effusion = http://en.wikipedia.org/wiki/Pericardial_effusion
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:32

Am J Emerg Med. 1998 May;16(3):265-9. Links

Lyme carditis: a rare presentation in an unexpected setting.

Robinson TT, Herman L, Birrer RB, Wallis KJ, Sama A.
Department of Emergency Medicine, Catholic Medical Center of Brooklyn and Queens, Jamaica, NY 11432, USA.

A case is reported of a 27-year-old man who presented to an inner city trauma center after he had experienced several seizure-like episodes. He was diagnosed with Lyme carditis and required 6 weeks of treatment with intravenous ceftriaxone for complete resolution of his symptoms. The case is discussed along with a review of the literature.

PMID: 9596429
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:32

Cardiol. 2001 Apr;24(4):307-12. Links

Possible causes of symptoms in suspected coronary heart disease but normal angiograms.

Mölzer G, Finsterer J, Krugluger W, Stanek G, Stöllberger C.
Second Medical Department of Rudolfstiftung Hospital, Vienna, Austria.

BACKGROUND: In patients with suspected coronary heart disease and normal angiography, the causes of cardiac symptoms frequently remain undetermined. A correct diagnosis is desirable, however, since some of the underlying disorders may be curable, treatable, influence prognosis, or induce screening of the relatives.

HYPOTHESIS: In such patients, the prevalence of arterial hypertension, hemochromatosis, hypothyroidism, hypoparathyroidism, tachycardiomyopathy, amyloidosis, and neuromuscular disorders as a possible cause for their symptoms and the seroprevalence of micro-organisms, known to cause myocardial damage, were assessed. METHODS: Consecutive patients with normal coronary angiograms were invited for two visits comprising clinical history and investigation, electrocardiograms, blood tests, and echocardiography. Patients were investigated neurologically if unexplained anginal chest pain or creatine kinase elevation persisted or if echocardiography showed isolated left ventricular abnormal trabeculations.

RESULTS: In 71 patients (31 women, 40 men, mean age 60 years), the most common cause for cardiac symptoms was hypertension (66%), followed by neuromuscular disorders (13%), tachycardiomyopathy (9%), hypothyroidism (4%), and hemochromatosis (3%). The seroprevalence for Chlamydia species was 90%, Helicobacter pylori 70%, Chlamydia pneumoniae 63%, Borrelia burgdorferi sensu lato 15%, and Rickettsia conorii 10%. No possible cause was found in 24% of the patients.

CONCLUSIONS: In patients with suspected coronary heart disease and normal angiograms, hypertension, neuromuscular disorders, tachycardiomyopathy,
hypothyroidism, and hemochromatosis should be considered as possible causes.

PMID: 11303699
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:34

Ultraschall Med. 1995 Aug;16(4):200-2. Links

Coronary aneurysm in a 69-year-old patient. Transthoracic echocardiography

[Article in German]


Watzinger N, Fruhwald FM, Schafhalter I, Hermann J, Luha O, Zweiker R, Gasser R, Eber B, Klein W.
Abteilung für Kardiologie, Medizinische Universitätsklinik Graz.

This case report is on a 69-year old male patient treated with cephalosporins because of suspected myocarditis due to borreliosis. Using transthoracic echocardiography a big aneurysm of the proximal part of the left coronary artery was detected. Coronary angiography revealed an aneurysm 1.2 cm in diameter at the origin of the left anterior descending branch and confirmed the initial diagnosis. In addition, coronary three-vessel disease with reduced left ventricular function was found. Coronaritis due to Lyme borreliosis could not be ruled out with certainty. The patient was relatively asymptomatic, and hence conservative therapy was recommended. The case described here serves as a basis for a discussion on the aetiology, clinical manifestation, diagnosis and therapeutic management of coronary aneurysms.

PMID: 7569863
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:37

http://chestjournal.chestpubs.org/conte ... ayifla.Com

Transient complete AV block in Lyme disease.Electrophysiologic observations.
CASE REPORT
A 40-year-old athlete was admitted to our hospital because of
complete AV block ofunknown origin, with recurrent dizziness and
near collapse, which had been occurring for two days. For three
weeks, he had had arthritis-like symptoms in the toes of his right
foot. No erythema migrans had been noticed. On physical examination
the temperature was normal, the pulse rate was regular at
40 beats per minute, and the blood pressure was 12&70 mm Hg.
There were cannon-wave pulsations in the jugular veins and a first
heart sound of variable intensity. No pulmonary rales were heard.
Four toes of the pafientıs right foot were warm, red, and painful,
but not swollen. There were no dermatologic abnormalities. The
surface ECG showed complete AV block with an escape rhythm of
37/miii; the QRS configuration suggested a focus in the left bundle
branch. The configuration of the P wave was abnormal, and its
duration was prolonged. In spite of administration of atropine and
isoproterenol (isoprenaline), there were recurrent periods of yentricular
asystole, sometimes lasting as long as 10 seconds. The
erythrocyte sedimentation rate was 22 mm/in. Other routine laboratory
tests yielded normal results. The chest roentgenograms and
echocardiogram also proved to be normal.

A gallium scan showed diffuse uptake in the myocardium (Fig 1).
Serologic tests for B burgdorfrri were positive for 1gM (1:128) and
wealdy positive for IgG (1:64). Tests for chlamydia and cytomegalo-
virus were weakly positive, but an increase in titer did not occur.
Serologic markers for other microorganisms and diseases were all
negative, including the Treponema pallidum hemagglutination assay,
streptococcal antibody tests, several viruses (Coxsackie virus; echovirus;
adenovirus; influenza A; hepatitis B), rheumatoid factor, and
antinuclear antibodies. In agreement with the gallium scan, signs
of endomyocarditis were found in an endomyocardial biopsy. In
combination with the serologic results, this indicated Lyme carditis.
In order to study the characteristics of the AV block, the patient
underwent serial EP investigations. During the phase of complete
AV block, no sign of His bundle activity could be found, despite
extensive mapping ofthe His bundle region, using several types of
catheters (Fig 2A). A temporary pacemaker was inserted, and the
patient was treated with tetracycline (500 mg four times per day
orally), the latter being changed to penicillin (4 million IU intravenously
four times daily) after five days. Between the sixth and tenth
day after admission, the AV conduction disturbances on the surface
ECG regressed to a second-degree and later on to a first-degree AV
block. The EP study was repeated after a week; this time, His
bundle activity could easily by found, using a bipolar His bundle
catheter (Cordis) (Fig 2B).
After three weeks of antibiotic therapy, the patient was discharged
with a normal surface ECG and minor residual complaints of arthtitis.
DISCUSSION

In principle, all types of AV block may occur in Lyme
disease, even in one patient. The degree of AV block can
vary within periods of minutes.” Lyme carditis-related
tachyarrhythmias, whether or not induced by bradycardia,
are not reported. Our patient presented with complete AV
block. Despite extensive mapping of the His bundle region,
no His bundle activity could be found during the acute
phase of Lyme carditis. There was no His bundle spike
following the atrial electrogram nor preceding or following
the fascicular escape complexes, although His bundle activity
buried in the QRS complex cannot be ruled out. The
QRS configuration and the QRS duration of 130 ms were
compatible with an escape focus in the left bundle branch.
The configuration ofthe P wave and its duration of 120 msec
suggested a prolonged intra-atrial conduction time (Fig 2A).
During right ventricular stimulation with progressively
increased rate, also no retrograde His bundle activity could
be found. Programmed EP stimulation in the right ventricular
apex, using one extrastimulus, revealed a ventricular
effective refractory period of250 msec. No tachyarrhythmias
were induced. Overdrive suppression of the escape focus
was always interrupted by backup pacing after three seconds.
When the EP study was repeated, His bundle activity was
easily found. The AH interval was slightly prolonged (155
ms), the HV interval was normal (45 ms), and the QRS
duration had decreased to 100 ms. The Pıwave duration had
decreased to 100 ms, and the P-wave configuration had
normalized (Fig 2B). The length of time between the serial
EP studies was about one week.

In general, in case of complete AV block with principal
location in the AV node, one would expect a stable escape
focus in the common His bundle, at least in young and
otherwise healthy patients. In our patient, there was no such
stable focus. The initial complete absence of His bundle
activity and the prolonged AH interval in the recovery phase
point to a predominant affection of the AV node with
concomitant affection of the His bundle. In addition, the
instability ofthe left bundle-branch focus and its disproportionate
prolonged QRS duration of 130 ms suggest attendant
affliction of the His-Purkinje system. The initial configuration
of the P wave and its duration suggest accompanying
intra-atrial conduction disturbances. However, at EP studies
in Lyme disease reported in the literature, usually more
localized supra-Hisian and sometimes infra-Hisian blocks
were found, mostly with unstable ventricular or fascicular
escape fıj3.4.6.8 Only one study reported attendant intraatrial
conduction disturbances.ı

The reversibility ofthe conduction disturbances, as shown
in this patient and as described in the literature, suggests
caution with respect to implantation of a permanent pacemaker
pacemaker
in case of sudden appearance of AV conduction
disturbances of unknown origin. In recent literature, there
have been, to our knowledge, no cases of Lyme carditisrelated
serious AV conduction disturbances (all treated with
antibiotics) without regression within two to six weeks.ııı
In conclusion, the electrocardiographic and EP findings
in this patient demonstrate, in our opinion, that complete
AV block in the course of Lyme disease may signify a more
extensive affection of the AV conduction system than described
before. Besides affection ofthe AV node, there may
be involvement ofthe common His bundle, the His-Purkinje
system, and the intra-atrial conduction system. The serial
EP recordings in this patient show an almost complete
resolution of the extensive conduction disturbances within two weeks.

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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:38

http://www.uptodateonline.com/patients/ ... v/OI8oEMqh
INTRODUCTION — Lyme disease is a multisystem disease caused by infection with Borrelia burgdorferi. Cardiac involvement occurs during the early disseminated phase of the disease, usually within weeks to a few months after infection [1]. The clinical features of Lyme carditis can occur due to heart block related to dysfunction of the conduction system and decreased cardiac contractility due to myopericarditis.

The epidemiology, clinical manifestations, diagnosis, and prognosis of Lyme carditis will be reviewed here. The other clinical manifestations of Lyme disease and the treatment of Lyme carditis are discussed separately. (See "Clinical manifestations of Lyme disease in adults" and see "Treatment of Lyme disease", section on Carditis).
EPIDEMIOLOGY — The incidence of carditis varies with geography and the clinical setting:

Carditis occurs in approximately 4 to 10 percent of untreated adults (and a much lower proportion of children) in the United States.
Carditis is less frequent in Europe, affecting approximately 0.3 to 4.0 percent of untreated adults [2]. This difference may be related to infection by different organisms. B. burgdorferi sensu stricto is responsible for all cases in the United States, whereas B. afzelii and B. garinii are responsible for many cases in Europe, although B. burgdorferi sensu stricto occurs there as well. (See "Microbiology and epidemiology of Lyme disease").
Appropriate antibiotic therapy for erythema migrans or other features of early localized Lyme disease prevents subsequent Lyme disease, including cardiac manifestations of the disorder

There is a male predominance of approximately 3:1 in cardiac Lyme disease [4], which is in contrast to the slight female predominance or equal sex distribution in Lyme disease overall
CLINICAL MANIFESTATIONS — The cardiac features of early disseminated Lyme disease typically occur one to two months (range <1 to 28 weeks after the onset of infection) [6,7]. Cardiac disease can be the only feature of infection, or can occur coincident with other features of early Lyme disease, such as erythema migrans or early neurologic symptoms. Patients with cardiac involvement may be asymptomatic or complain of lightheadedness, syncope, shortness of breath, palpitations, and/or chest pain. In a review of 84 patients with Lyme carditis, the United States Centers for Disease Control and Prevention (CDC) reported the following frequency of signs or symptoms [8]:

Palpitations — 69 percent.
Conduction abnormalities — 19 percent
Myocarditis —10 percent
Left ventricular failure — 5 percent
Twenty percent of these patients required hospitalization
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:43

http://pediatrics.aappublications.org/c ... 123/5/e835

Pediatrics. 2009 May;123(5):e835-41. Links
Comment in:
Pediatrics. 2009 May;123(5):1408.

Lyme carditis in children: presentation, predictive factors, and clinical course.

Costello JM, Alexander ME, Greco KM, Perez-Atayde AR, Laussen PC.
Harvard Medical School, Division of Cardiac Intensive Care, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Bader 600, Boston, MA 02115, USA. john.costello@cardio.chboston.org

OBJECTIVES: We sought to identify predictive factors for Lyme carditis in children and to characterize the clinical course of these patients. METHODS: We reviewed all cases of early disseminated Lyme disease presenting to our institution from January 1994 through July 2008, and summarized the presentation and course of those patients with carditis. A case-control study was used to identify predictive factors for carditis. Controls were patients with early disseminated Lyme disease without carditis. 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. The median time to recovery of sinus rhythm in these 14 patients was 3 days (range: 1-7 days), and none required a permanent pacemaker. Four (12%) of 33 patients with carditis had depressed ventricular systolic function, 3 (9%) of whom required mechanical ventilation, temporary pacing, and inotropic support. Complete resolution of rhythm disturbances and myocardial dysfunction occurred in 24 (89%) of 27 patients for whom follow-up data were available. Most patients with carditis also had other systemic Lyme involvement. By using multivariate logistic regression analysis, we found that children >10 years of age, those with arthralgias, and those with cardiopulmonary symptoms were more likely to have carditis. CONCLUSIONS: The spectrum of presentation for children with Lyme carditis is broad, ranging from asymptomatic, first-degree heart block to fulminant myocarditis. Variable degrees of heart block are the most common manifestation and occasionally require temporary pacing. Transient myocardial dysfunction, although less common, can be life-threatening. Advanced heart block resolves within 1 week in most cases. In children with early disseminated Lyme disease, older age, arthralgias, and cardiopulmonary symptoms independently predict the presence of carditis.

PMID: 19403477
RESULTS

From January 1994 through July 2008, 296 patients presented to the emergency department and/or were admitted to our institution with Lyme disease. Of these, we excluded 19 patients with early localized Lyme disease, 66 with late disseminated Lyme disease, 2 who were admitted for antibiotic desensitization during the course of treatment initiated elsewhere, and 2 who were >21 years of age. Thus, 207 children who presented at our institution for acute evaluation and management of early disseminated Lyme disease were included in the study. Laboratory testing for Lyme disease in these patients is summarized in Table 2. All of the 33 patients with carditis had at least 1 electrocardiogram and 25 (76%) of 33 had at least 1 echocardiogram. Of the 174 patients without carditis, 104 (60%) had an electrocardiogram and 3 (2%) had an echocardiogram


Of the 207 study patients, 33 (16%) had carditis. Patients with carditis had a wide range of systemic involvement, including flu-like symptoms (fever, malaise, headache, arthralgias, and/or myalgias) in 94%, meningitis in 48%, multiple erythema migrans in 48%, and erythema migrans in 24% (Table 3). Of the 33 patients with carditis, only 1 (3%) presented with isolated carditis and had no erythema migrans or noncardiac systemic manifestations of Lyme disease



Associations were sought between 24 variables and the presence of carditis in children with early disseminated Lyme disease (Table 3). Predictive factors for carditis by univariate analysis included age (>10 years), arthralgias, and cardiopulmonary symptoms, whereas patients with a cranial nerve palsy were less likely to have carditis. By multivariate analysis, children >10 years of age (adjusted odds ratio [aOR]: 8.30 [95% confidence interval (CI): 2.41–28.62]) and those with arthralgias (aOR: 5.81 [95% CI: 2.02–16.75]) or cardiopulmonary symptoms (aOR: 76.77 [95% CI: 13.50–436.49]) were more likely to have carditis. The presence of cardiopulmonary symptoms had a 42% sensitivity for identifying patients with Lyme carditis, whereas the absence of any cardiopulmonary symptom had a 99% specificity for identifying those patients without carditis.
Resource consumption and early outcomes for children with early disseminated Lyme disease with carditis were compared with those without carditis (Table 4). The former were more likely to be hospitalized, to remain in the hospital longer, and to require intensive care. There was no mortality in either group (Table 4).
Of the 33 patients with carditis, 14 presented to our institution with first-degree AVB, including 1 patient who also had ST-T wave changes and another who had a prolonged QTc interval. Two of 3 patients who initially had first-degree AVB with a PR interval of 300 milliseconds developed second-degree AVB within 48 hours of admission. In contrast, none of the 11 patients with first-degree AVB whose initial PR interval was <300 milliseconds had documented advanced heart block.
Of the 33 patients with carditis, 14 (42%) had advanced heart block documented either at presentation (n = 12) or during their hospitalization (n = 2), including 9 (27%) with periods of high-grade or complete heart block (Fig 1 and Table 5). Other electrocardiographic abnormalities are summarized in Table 5. The 14 patients with advanced heart block had recovery to sustained sinus rhythm with first-degree AVB in a median of 3 days (range: 1–7 days) after initiation of antibiotic therapy, and none required a permanent pacemaker.


Of the 33 patients with carditis, 4 (12%) had depressed ventricular systolic function on echocardiogram including 3 (9%) who presented in cardiogenic shock. Of the 4 patients with depressed ventricular function, 3 had complete heart block and 1 had a prolonged QTc interval. On admission to our cardiac ICU, 1 of these 3 patients required cardiopulmonary resuscitation and extracorporeal membrane oxygenation (ECMO) for 5 days before experiencing a complete recovery. As viral myocarditis was initially being considered, the 3 patients presenting in shock had endomyocardial biopsies, all of which showed florid myocarditis characterized by an extensive, predominantly lymphocytic infiltrate associated with myocyte damage and necrosis (Fig 2A). In 2 cases in which immunohistochemical lymphocyte markers were used, a slight predominance of B lymphocytes (Fig 2B) over T lymphocytes (Fig 2C) was present, and there were scattered plasma cells (Fig 2A). In 1 case, a Steiner stain revealed rare spirochetal organisms, consistent with B burgdorferi (Fig 2D). One of these 3 patients had significantly elevated plasma adenovirus IgM titers, raising the possibility of concurrent infection. Fresh tissue from the endomyocardial biopsy of this child was tested by polymerase chain reaction using probes for a viral panel that included adenovirus, cytomegalovirus, Epstein-Barr virus, enterovirus, influenza A, mumps, parvovirus, respiratory syncytial virus, and rubella, and all were negative. These 3 patients received inotropic support and mechanical ventilation for 2 to 7 days.

Temporary transvenous pacing was used for 1 to 7 days to treat complete heart block in 4 (12%) children including the 3 patients who presented in shock. Two patients were paced by using temporary transvenous ventricular demand systems. On the premise that achieving atrioventricular synchrony would augment cardiac output in the setting of severe left ventricular dysfunction, the other 2 patients were managed with temporary dual chamber systems using standard permanent leads, which permitted more effective atrial sensing.
Six of the 33 children had prolongation of the corrected QT interval in the setting of early disseminated disease. Two of these patients have been previously reported.11 Four of these 6 patients had concurrent meningitis. None developed torsades de pointes or other ventricular arrhythmias. The corrected QT interval normalized within 1 week to 3 months in all 5 patients who had follow-up electrocardiograms at our institution.

Antibiotic therapy consisted of 21 to 28 days of ceftriaxone for all 9 patients with complete heart block and 3 of the 5 patients with second-degree heart block. The other 2 patients with second-degree heart block received ceftriaxone while hospitalized and then were prescribed enteral antibiotics to complete a 21- to 28-day course. Antibiotic route and duration of therapy for patients with carditis without advanced heart block was largely determined by the presence or absence of meningitis.

Follow-up was available for 27 (81%) of 33 children with carditis at a median of 0.1 year (range: 0.01–2.7 years). Of these 27 patients, 24 had complete resolution of their cardiac symptoms, rhythm disturbances, and myocardial dysfunction. One patient had ongoing second-degree AVB at 2.7 years after the initial presentation, and 2 patients had improved, but still mildly prolonged, PR intervals at short-term follow-up (200 milliseconds at 2.5 months and 188 milliseconds at 2 weeks).
DISCUSSION


This report includes the largest series of children with Lyme-associated carditis published to date. Carditis was found in 16% of children who had early disseminated Lyme disease and presented for acute management to our hospital. Noncardiac manifestations, including erythema migrans and meningitis, were coincident in the majority of patients with carditis. Age of >10 years, arthralgia, and cardiopulmonary symptoms remained significantly associated with a diagnosis of carditis after multivariate analysis. Not surprisingly, cardiopulmonary symptoms were rarely present in patients without carditis. Although 41% of the patients with carditis had advanced heart block, and 11% presented with cardiogenic shock, a full recovery should be expected with supportive care and antibiotic therapy.

The incidence of carditis in children with Lyme disease encountered in the community is likely lower than the 4% to 10% rate commonly cited in adults. A total of 291 children were reported in 2 prospective cohort studies of patients with Lyme disease identified by community pediatricians, of which only 1 had evidence of carditis.17,18 Neither report included the number of patients who had electrocardiograms, and thus patients with mild carditis may not have been recognized. Woolf and colleagues10 found that 7 of 45 children with definite or probable Lyme disease seen at a Lyme referral center had abnormal electrocardiograms, including 2 with first-degree AVB, 1 with ST-T wave abnormalities, 1 with a single premature ventricular beat, 1 with sinus arrhythmia, 1 with ectopic atrial bradycardia, and 1 with left axis deviation. The latter 4 electrocardiographic findings have not been generally associated with Lyme carditis, and thus the conservative incidence of Lyme carditis in this series is 3 (7%) of 45.10 The higher incidence of carditis found in our study (16%) is likely a result of referral and selection biases, because we only included patients with early disseminated Lyme disease. Although most children with early disseminated Lyme disease do not require emergency care or hospitalization, a 16% incidence of carditis may be representative of patients seeking care for early disseminated Lyme disease at large children's hospitals located in endemic regions

The first detailed description of Lyme-associated carditis in adults was reported in 1980 by Steere et al.3 The etiology of myocardial and atrioventricular conduction tissue injury is likely related to direct invasion of cardiac tissue by spirochetes and the resultant inflammatory response.2,4,19 The most common clinical feature of Lyme carditis is variable degrees of AVB. Atrioventricular conduction disturbances can fluctuate rapidly, and serial reassessment is warranted until the trajectory of illness is fully appreciated. Our data suggest that in the evaluation of children with possible early disseminated Lyme disease, the threshold for obtaining an electrocardiogram should be particularly low in older children, those with arthralgias, and especially those with cardiopulmonary symptoms. After initiating antibiotic therapy, those whose initial PR intervals are prolonged but <300 milliseconds should have a repeat electrocardiogram within 1 to 2 days. Those children with initial PR intervals of 300 milliseconds are more likely to develop high-grade AV block and warrant telemetry monitoring in a hospital capable of providing temporary transvenous pacing.

The myocardial inflammatory infiltrate found in the endomyocardial biopsies in 3 of our patients
was a mixed population of B and T lymphocytes (predominantly the former) and scattered plasma cells, similar to that reported in adult Lyme carditis.19,20 These findings are unlike those seen in acute viral myocarditis, in which the infiltrate consists almost exclusively of T lymphocytes and is devoid of plasma cells. These findings also contrast with the pathologic findings in murine models of Lyme carditis, in which there is a predominant myocardial infiltrate of macrophages; the reason for this discrepancy is unknown.21

Several authors have stated that the severity of myocardial dysfunction associated with Lyme carditis, when present, is almost always mild.2,14,22 In our highly selected cohort, 3 (9%) of 33 patients had severely depressed ventricular systolic function documented by echocardiography. Clinicians should consider obtaining an echocardiogram for any child with suspected Lyme carditis, particularly for those patients with signs or symptoms of acute heart failure or advanced heart block. Given the potential for rapid deterioration and the excellent response to treatment, we suggest that children with Lyme carditis and myocardial dysfunction be hospitalized in an institution capable of providing rapid-deployment ECMO for mechanical cardiac support.23 In this report, we described for the first time the use of temporary dual-chamber pacing for 2 children with severe Lyme carditis with complete heart block and severely depressed biventricular function (1 of whom was on ECMO). This pacing strategy seems prudent in selected patients given the improvement in cardiac output observed when atrioventricular sequential pacing is employed in children with complete heart block after cardiac surgery.24,25

Adequate studies have not been conducted to determine if antibiotics hasten the recovery of atrioventricular conduction or other features of Lyme carditis.2 However, because myocardial invasion by spirochetes has been demonstrated by endomyocardial biopsy (Fig 2D), and given that noncardiac Lyme sequelae are largely prevented by antibiotics, antibiotics are recommended for patients with Lyme carditis.2,19,26,27 Although corticosteroids are sometimes advocated, there is no evidence that they are beneficial in patients with Lyme carditis and advanced heart block.3,7,22,28 No patient in this series received corticosteroids.

The timing of resolution of advanced heart block in our patients is consistent with that reported in previous case series in adults3,28,29 and case reports in children.6,7 This knowledge is useful when counseling patients about the expected time course for improvement and reinforces the adult experience that permanent pacemaker implantation is rarely required.4,19,28 Isolated case reports suggest that disturbances in atrioventricular conduction can rarely be permanent after Lyme carditis, as we saw with 1 patient who had persistent second-degree AVB.28,30,31

Transient prolongation of the corrected QT interval may be an underappreciated marker of Lyme carditis.11 Although 4 of our 6 patients had concurrent meningitis, their neurologic symptoms improved well before normalization of the corrected QT interval. It seems prudent to avoid drugs that prolong the QT interval in these patients until the electrocardiogram has normalized.

This study is limited by its retrospective design. In addition, case finding was limited to patients who presented to our tertiary care institution who likely had a greater severity of illness. Younger patients may be less likely to report certain predictive symptoms examined in this study (eg, arthralgias). Not every patient with early disseminated Lyme disease received an electrocardiogram or echocardiogram, and thus cases of mild carditis may have gone undetected
CONCLUSIONS

The spectrum of presentation for children with Lyme carditis ranges from asymptomatic first-degree heart block to fulminant myocarditis. Variable degrees of heart block are the most common manifestation and occasionally require temporary pacing. Transient myocardial dysfunction, although less common, can be life-threatening. Advanced heart block resolves within a week in most cases. In children with early disseminated Lyme disease, multivariate analysis identified older patients and those reporting arthralgias and cardiopulmonary symptoms as more likely to have carditis
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 24 Nov 2009 9:44

Kardiol Pol. 2009 May;67(5):516-20. Links

May Lyme borreliosis lead to heart transplantation? - a case report.

[Article in Polish]


Maroszyńska-Dmoch E, Wozakowska-Kapłon B.
I Oddział Kardiologii, Swietokrzyskie Centrum Kardiologii, ul. Grunwaldzka 45, 25-736 Kielce, tel.: +48 41 367 13 01, e-mail: bw.kaplon@poczta.onet.pl.

A case of a 65-year-old man, who used to work as a forester for many years, with end-stage dilated cardiomyopathy and subsequent heart transplantation is described. Eight years later the diagnosis of Lyme borreliosis was established, which was the likely cause of cardiac disease in this patient.

PMID: 19521937 [PubMed - in process]
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Yvonne
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Re: Lyme Disease and the heart

Post by Yvonne » Tue 29 Dec 2009 9:29

http://cpj.sagepub.com/cgi/content/abst ... 1/82?rss=1

Asymptomatic, Transient Complete Heart Block in a Pediatric Patient with Lyme Disease
Alan K. Heckler, DO
National Capitol Military Children's Center, Walter Reed Army Medical Center, Washington, DC, alan.heckler@nccpeds.com

Daniel Shmorhun, MD

National Capitol Military Children's Center, Walter Reed Army Medical Center, Washington, DC

Lyme Disease, caused by the spirochete Borrellia burgdorferi, is the most common vector-borne disease in the United States. Clinically, it primarily affects the skin, joints, nervous system, and heart. Lyme carditis occurs in 4%-10% of adults with Lyme disease. Transient variable-level atrioventricular blocks, occurring in 77% of adults with Lyme carditis, are the most common cardiac manifestation. Up to 50% of Lyme carditis patients may develop complete heart block. The incidence of Lyme carditis in the pediatric population is not well established. We present a pediatric patient with a transient asymptomatic complete heart block resulting from Lyme carditis, an under-recognized complication of Lyme disease in the pediatric population.
Listen to all,
plucking a feather from every passing goose,
but follow no one absolutely

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