Herz. 2015 May 5. [Epub ahead of print]
Recent-onset dilated cardiomyopathy associated with Borrelia burgdorferi infection.
Kuchynka P1, Palecek T, Havranek S, Vitkova I, Nemecek E, Trckova R, Berenová D, Krsek D, Podzimkova J, Fikrle M, Danek BA, Linhart A.
1 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
Several recent small studies have suggested a causal link between Lyme disease and dilated cardiomyopathy (DCM) by demonstrating the presence of the Borrelia burgdorferi (Bb) genome in the myocardium of patients with recent-onset DCM. The aim of this study was to further investigate the effect of targeted antibiotic treatment of Bb-related recent-onset DCM in a larger cohort of patients.
PATIENTS AND METHODS:
We performed endomyocardial biopsy (EMB) in 110 individuals (53 ± 11 years, 34 women) with recent-onset unexplained DCM, and detected the Bb genome in 22 (20 %) subjects. Bb-positive patients were subsequently treated with intravenous ceftriaxone for 21 days in addition to conventional heart failure medication.
At the 1-year follow-up, a significant improvement in left ventricular (LV) ejection fraction (26 ± 6 vs. 44 ± 12 %; p < 0.01) and a decrease in LV end-diastolic (69 ± 7 vs. 63 ± 11 mm; p < 0.01) and end-systolic (61 ± 9 vs. 52 ± 4 mm; p < 0.01) diameters were documented. Moreover, a significant improvement in heart failure symptoms (NYHA class 3.4 ± 0.6 vs. 1.5 ± 0.7; p < 0.01) was also observed.
Targeted antibiotic treatment of Bb-related recent-onset DCM in addition to conventional heart failure therapy is associated with favorable cardiac remodeling and improvement of heart failure symptoms.
[PubMed - as supplied by publisher]
Here are some related articles (mostly in reverse date order):
Eur J Heart Fail. 2012 Jun;14(6):588-96. doi: 10.1093/eurjhf/hfs027. Epub 2012 Feb 29.
Detection of Borrelia burgdorferi sensu lato in endomyocardial biopsy specimens in individuals with recent-onset dilated cardiomyopathy.
Kubánek M1, Šramko M, Berenová D, Hulínská D, Hrbáčková H, Malušková J, Lodererová A, Málek I, Kautzner J.
1 Department of Cardiology, Institute for Clinical and Experimental Medicine, Videňská 1958/9, Prague, Czech Republic.
Recent studies in patients with dilated cardiomyopathy (DCM) have detected the genome of Borrelia burgdorferi sensu lato (BBSL) in endomyocardial biopsy (EMB) specimens using a qualitative polymerase chain reaction (PCR), suggesting a causal link between Lyme disease and DCM in areas in which Lyme disease is endemic. We aimed to study this relationship using a comprehensive molecular analysis detecting BBSL in EMB samples.
METHODS AND RESULTS:
We performed a comprehensive histopathological, immunohistochemical, ultrastructural, and molecular analysis targeting cardiotropic viruses and BBSL in EMB specimens of 41 individuals with recent-onset DCM and 15 controls with end-stage coronary artery disease. Specifically, quantitative PCR and electron microscopy of EMB specimens were employed. In addition, autoantibodies and manifestation of autoimmune diseases were evaluated in both groups. Individuals with recent-onset DCM presented more frequently with myocardial BBSL persistence as compared with the control group (24% vs. 0%, P = 0.035). In contrast, the prevalence of parvovirus B19 and cytomegalovirus was similar in both groups. Sequence analysis of borrelial DNA revealed the following genospecies: Borrelia burgdorferi sensu stricto in three patients (30%), Borrelia afzelii in two patients (20%), and Borrelia garinii in four patients (40%), the results being inconclusive in one case. BBSL-positive DCM patients had a higher prevalence of organ-specific autoimmune diseases in comparison with the remaining DCM patients (50% vs. 16%, P = 0.030).
Myocardial persistence of BBSL may be involved in the pathophysiology of DCM in individuals living in areas in which Lyme disease is endemic.
Reading between the Lyme: is Borrelia burgdorferi a cause of dilated cardiomyopathy? The debate continues. [Eur J Heart Fail. 2012]
[PubMed - indexed for MEDLINE]
http://onlinelibrary.wiley.com/doi/10.1 ... fs047/full
European Journal of Heart Failure
Volume 14, Issue 6, pages 567–568, June 2012
Reading between the Lyme: is Borrelia burgdorferi a cause of dilated cardiomyopathy? The debate continues
Piccirillo Bryan J.1 andPride Yuri B.2,*
Article first published online: 18 FEB 2014
This editorial refers to ‘Detection of Borrelia burgdorferi sensu lato in endomyocardial biopsy specimens in individuals with recent-onset dilated cardiomyopathy’, by M. Kubánek et al. doi:10.1093/eurjhf/hfs027
Lyme disease, caused by a group of spirochetes classified as Borrelia burgdorferi sensu lato (BBSL), is the most prevalent tick-borne illness in the northern hemisphere. Infection can lead to cardiac complications in 0.5–10% of cases, with conduction disturbances, myocarditis, and pericarditis being the most described. It has been hypothesized that Lyme disease may also be a cause of dilated cardiomyopathy in endemic areas. A variety of mechanisms cause dilated cardiomyopathy, including myocardial infarction and myocarditis., However, in the majority of cases, the aetiology remains idiopathic. Thus, diagnosis of Lyme disease in cases of idiopathic dilated cardiomyopathy could potentially improve the clinical outcome of patients with otherwise unknown causes of left ventricular dysfunction.
The study also provides interesting insights into the pathophysiology of dilated cardiomyopathy and Lyme disease. Quantification of Borrelia DNA in myocardial samples from this study was significantly lower than what had previously been reported in primate studies. In combination with the histopathology results of Borrelia-positive myocardium, this may indicate a more chronic inflammatory state possibly associated with a later stage of disease in this study population. The authors postulate that this may be why there was only a modest improvement in left ventricular function after antibiotic administration. In addition, the data indicate that a history of autoimmune disease may be linked to a greater susceptibility for developing a dilated cardiomyopathy when infected with Borrelia. Similar findings were shown in a recent report in rat and mice models indicating that there was longer myocardial persistence of B. burgdorferi in autoimmunity-susceptible animals. Future investigations may be aimed at identification of inflammatory factors and receptors in the myocardium to explore an autoimmune connection further.
The authors report a very thorough analysis that shows a significantly higher prevalence of the B. burgdorferi genome in patients with new-onset dilated cardiomyopathy when compared with controls in an endemic region of the Czeck Republic. While this was a small study, it provides a foundation for larger epidemiological analyses, biomolecular investigation of inflammatory and infectious mechanisms, and larger control trials for antibiotic treatment. These results solidify the concept of an association between Lyme disease and idiopathic dilated cardiomyopathy.
Med Microbiol Immunol. 2010 May;199(2):139-43. doi: 10.1007/s00430-009-0141-6. Epub 2010 Jan 6.
Presence of Borrelia burgdorferi in endomyocardial biopsies in patients with new-onset unexplained dilated cardiomyopathy.
Palecek T1, Kuchynka P, Hulinska D, Schramlova J, Hrbackova H, Vitkova I, Simek S, Horak J, Louch WE, Linhart A.
1 1st Medical Faculty, 2nd Medical Department - Clinical Department of Cardiology and Angiology, Charles University of Prague, Prague, Czech Republic.
Dilated cardiomyopathy (DCM) represents the third most common cause of heart failure and the most frequent cause of heart transplantation. Infectious, mostly viral, and autoimmune mechanisms, together with genetic abnormalities, have been reported as three major causes of DCM. We hypothesized that Lyme disease (LD), caused by spirochete Borrelia burgdorferi (Bb), might be an important cause of new-onset unexplained DCM in patients living in a highly endemic area for LD such as the Czech Republic. We performed endomyocardial biopsy (EMB) in 39 consecutive patients presenting with symptomatic unexplained left ventricular (LV) systolic dysfunction lasting no more than 12 months. In eight subjects (21%), Bb was detected in the EMB sample by polymerase chain reaction or by electron microscopy. None of these patients exhibited any form of atrioventricular block or other extracardiac manifestation of Bb infection. Serological testing identified IgG antibodies against Bb in only two cases and IgM antibodies in none. All affected patients were treated with intravenous ceftriaxone for 3 weeks. At 6 months follow-up, LV morphology and function as well as functional status of these patients significantly improved. In conclusion, Bb infection may represent an important cause of new-onset unexplained DCM in patients living in endemic regions such as the Czech Republic. Because the antibiotic treatment appears to be markedly effective and serological examination does not provide a tool for diagnosing the disease, EMB focused on the detection of Bb should be performed in all patients from endemic areas with new-onset unexplained DCM not responding to conventional therapy.
[PubMed - indexed for MEDLINE]
Prague Med Rep. 2006;107(2):213-26.
Lyme borreliosis infection as a cause of dilated cardiomyopathy.
Bartůnek P1, Gorican K, Mrázek V, Varejka P, Veiser T, Hercogová J, Hulínská D, Janovská D.
1 Fourth Department of Medicine of the First Faculty of Medicine, Charles University in Prague, Czech Republic.
The relatively low percent of patients affected with the cardiac form of Lyme borreliosis is difficult to diagnose, especially if the disease manifests itself in ways other than atrio-ventricular blockade. The advanced stage of Lyme carditis manifesting as dilated cardiomyopathy is a special case of this affliction. The authors of this report present clinical experience with an attempt to support the working hypothesis about involvement of Lyme borreliosis infection in the development of dilated cardiomyopathy. The patients were clinically examined thoroughly with special attention to the cardiovascular system. In addition to the basic clinical methods, the following procedures have been employed: dynamic Holter's electrocardiography, exercise ECG test, coronarography, and myocardial biopsy. From laboratory methods pertaining to the detection of Borrelia, ELISA method, Western blot, PCR, electron microscopy and histopathological analysis were used. In all three cases, clinical and laboratory findings provided the evidence of the borreliosis infection involvement in the development of dilated cardiomyopathy.
PMID: 17066741 [PubMed - indexed for MEDLINE]
Z Kardiol. 2000 Nov;89(11):1046-52.
[Acute myocarditis and cardiomyopathy in Lyme borreliosis].
[Article in German]
Scheffold N1, Sucker C, Bergler-Klein J, Kaag N, Cyran J.
1Medizinische Klinik I Schwerpunkt Kardiologie Klinikum Heilbronn Akademisches Lehrkrankenhaus der Universität Heidelberg Am Gesundbrunnen 20-24 D-74078 Heilbronn.
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 [PubMed - indexed for MEDLINE]
Acta Med Austriaca. 1998;25(2):44-50.
[Cardiac manifestations of Lyme borreliosis with special reference to contractile dysfunction].
[Article in German]
Seinost G1, Gasser R, Reisinger E, Rigler MY, Fischer L, Keplinger A, Dattwyler RJ, Dunn JJ, Klein W.
1Klinischen Abteilung für Kardiologie, Medizinischen Universitätsklinik Graz, Osterreich.
Borrelia burgdorferi infection (BBI) is suggested to be associated with dilated cardiomyopathy (IDC). Stanek et al. were able to cultivate Borrelia burgdorferi (BB) from myocardial biopsy tissue of a patient with longstanding dilated cardiomyopathy. Here we present a study in which we examined the effect of standard antibiotic treatment on the left ventricular ejection fraction (LV-EF) in patients with dilated cardiomyopathy associated with BBI. In this study we assessed the serum (IgG, IgM ELISA; Western Blot) and the history of 46 IDC-patients with specific respect spect to BBI (mean LV-EF: 30.4 +/- 1.3%; measured by cardiac catheterisation and echocardiography--length-area-volume method). All 46 patients received standard treatment for dilated cardiomyopathy: ACE-inhibitors, digitalis and diuretics. 11 (24%) patients showed positive serology and a history of BBI; 9 of these also had a typical history of tick bite and erythema chronicum migrans (ECM) and/or other organ involvement, 2 had no recollection of tick bite or EMC, but showed other BB-associated disorders (neuropathy, oligoarthritis). These 11 patients with BBI received standard antibiotic treatment with intravenous ceftriaxone 2 g bid for 14 days. 6 (55%) recovered completely and showed a normal LV-EF after 6 months, 3 (27%) improved their LV-EF and 2 (18%) did not improve at all. This amounts to 9 (82%) recovery/improvement in the BB-group. The 35 patients who did not show positive serology or a history of BBI did not receive antibiotic treatment. In this group without BBI 12 (26%) showed recovery/improvement following the standard treatment of dilated cardiomyopathy (see above). Our results indicate that BBI could play a decisive role in the development of dilated cardiomyopathy, especially in a geographical region as Graz, where BB is endemic. While aware of the small number of BB-patients in this study, we nevertheless conclude that, in a remarkable number of patients with signs of BBI, dilated cardiomyopathy could be reversed and LV-EF improved upon standard antibiotic treatment.
[PubMed - indexed for MEDLINE]
Cardiovasc Drugs Ther. 1996 Jul;10(3):351-60.
Reversal of Borrelia burgdorferi associated dilated cardiomyopathy by antibiotic treatment?
Gasser R1, Fruhwald F, Schumacher M, Seinost G, Reisinger E, Eber B, Keplinger A, Horvath R, Sedaj B, Klein W, Pierer K.
1 Department of Medicine, University of Graz, Austria.
It is suggested that Borrelia burgdorferi infection could be associated with dilated cardiomyopathy (IDC). Stanek et al. were able to cultivate Borrelia burgdorferi from myocardial biopsy tissue of a patient with longstanding dilated cardiomyopathy. Here we present a study in which we examined the effect of standard antibiotic treatment on the left ventricular ejection fraction (LVEF) in patients with dilated cardiomyopathy associated with Borrelia burgdorferi infection. In this study we assessed the serum (IgG, IgM Elisa) and history of 46 IDC patients with specific regard to Borrelia burgdorferi infection (mean LVEF 30.4 +/- 1.3%, measured by cardiac catheterization and echocardiography with the length-area-volume method). All 46 patients received standard treatment for dilated cardiomyopathy: ACE inhibitors, digitalis, and diuretics. Eleven (24%) patients showed positive serology and a history of Borrelia burgdorferi infection; nine of these also had a typical history of tick bite and erythema chronicum migrans (ECM) and/or other organ involvement, and two had no recollection of tick bite or ECM but showed other Borrelia burgdorferi-associated disorders (neuropathy, oligoarthritis). These 11 patients with Borrelia burgdorferi infection received standard antibiotic treatment with intravenous ceftriaxone 2 g bid for 14 days. Six (55%) recovered completely and showed a normal LVEF after 6 months, three (27%) improved their LVEF, and two (18%) did not improve at all. This amounts to nine (82%) patients with recovery/improvement in the Borrelia burgdorferi group. The 35 patients who did not show positive serology or a history of Borrelia burgdorferi infection did not receive antibiotic treatment. In this group without Borrelia burgdorferi infection 12 (26%), showed recovery/improvement following the standard treatment of dilated cardiomyopathy (see earlier). Our results indicate that Borrelia burgdorferi infection could play a decisive role in the development of dilated cardiomyopathy, especially in a geographical region such as Graz, where Borrelia burgdorferi is endemic. While we are aware of the small number of Borrelia burgdorferi patients in this study, we nevertheless conclude that in a remarkable number of patients with signs of Borrelia burgdorferi infection, dilated cardiomyopathy could be reversed and LVEF improved.
[PubMed - indexed for MEDLINE]
Wien Med Wochenschr. 1995;145(7-8):196-8.
[Lyme borreliosis and cardiomyopathy].
[Article in German]
Bergler-Klein J1, Ullrich R, Glogar D, Stanek G.
1 Abteilung für Kardiologie, Klinik für Innere Medizin, Wien.
According to current opinion there is acute, self-limiting Lyme carditis, and chronic Lyme carditis. Acute Lyme carditis manifests mostly as transient conduction disorders of the heart (e.g. AV-blocking I to III), and as supraventricular and ventricular rhythm disturbances, pericarditis, myocarditis, and pancarditis in single cases. Chronic Lyme carditis is defined as a case of chronic heart failure confirmed by positive serology and endomyocardial biopsy. Anamnestic aid is rare. Neither tick-bites nor preceding or accompanying erythema chronicum migrans are constantly reported. Seropositivity and control of its specificity by western blot are indicative but no etiological proof. Even histological detection of spirochetes in endomyocardial tissue or cultivation of borrelia from endomyocardial biopsy are no final etiological proof of the respective cardial disorder. Those findings, however, are an indication for antibiotic treatment. According to the severity of the disorder, antibiotics are administered orally (penicillin or derivatives) or parenterally with penicillin or cephalosporins of the 3rd generation over 4 and 2 weeks, respectively.
PMID: 7610674 [PubMed - indexed for MEDLINE]
Eur Heart J. 1991 Aug;12 Suppl D:73-5.
Lyme borreliosis as a cause of myocarditis and heart muscle disease.
Klein J1, Stanek G, Bittner R, Horvat R, Holzinger C, Glogar D.
1 Dept. of Cardiology, University of Vienna, Austria.
Lyme borreliosis (LB) is a multisystem disorder that may cause self-limiting or chronic diseases of the skin, the nervous system, the joints, heart and other organs. The aetiological agent is the recently discovered Borrelia burgdorferi. In 1980, cardiac manifestations of LB were first described, including acute conduction disorders, atrioventricular block, transient left ventricular dysfunction and even cardiomegaly. Pathohistological examination showed spirochaetes in cases of acute perimyocarditis. Recently, we were able to cultivate Borrelia burgdorferi from the myocardium of a patient with long-standing dilated cardiomyopathy. In this study, we have examined 54 consecutive patients suffering from chronic heart failure for antibodies to Borrelia burgdorferi. On ELISA, 32.7% were clearly seropositive. The endomyocardial biopsy of another patient also revealed spirochaetes in the myocardium by a modified Steiner's silver stain technique. These findings give further evidence that LB is associated with chronic heart muscle disease.
PMID: 1915460 [PubMed - indexed for MEDLINE]
N Engl J Med. 1990 Jan 25;322(4):249-52.
Isolation of Borrelia burgdorferi from the myocardium of a patient with longstanding cardiomyopathy.
Stanek G1, Klein J, Bittner R, Glogar D.
1Hygiene Institute, University of Vienna, Austria.
PMID: 2294450 [PubMed - indexed for MEDLINE]
It seems to me that Lyme carditis involving problems with heart rhythm or heart block are mentioned much more often than dilated cardiomyopathy (involving the heart muscle) in the U.S. and Canada. I wonder if this is due to borrelia species/strain differences or because North American doctors are underestimating the possibility of dilated cardiomyopathy being caused (or at least triggered) by Lyme disease in some cases.