Persistent atrioventricular block in Lyme borreliosis

Associations of Atrioventricular Blocks and Other Arrhythmias in Patients with Lyme Carditis: A Systematic Review and Meta-Analysis

Lyme disease often leads to cardiac injury and electrophysiological abnormalities. This study aimed to explore links between atrioventricular blocks and additional arrhythmias in Lyme carditis patients. This systematic review and meta-analysis of existing literature was performed from 1990 to 2023, and aimed to identify cases of Lyme carditis through serology or clinical diagnosis with concomitant arrhythmias. Pubmed and Web of Science were searched using appropriate MESH terms. Patients were divided into groups with atrioventricular blocks and other arrhythmias for cardiovascular (CV) outcome assessment. A total of 110 cases were analyzed. The majority (77.3%) were male, with mean age = 39.65 ± 14.80 years. Most patients presented within one week of symptom onset (30.9%). Men were more likely to have first-degree atrioventricular blocks (OR = 1.36 [95% CI 1.12-3.96], p = 0.01); these blocks tended to be reversible in nature (OR = 1.51 [95% CI 1.39-3.92], p = 0.01). Men exhibited a higher likelihood of experiencing variable arrhythmias (OR = 1.31 [95% CI 1.08-2.16], p < 0.001). Ventricular and supraventricular arrhythmias were more likely to exhibit instability (OR = 0.96 [95% CI 0.81-1.16] p = 0.01) and variability (OR = 1.99 [95% CI 0.47-8.31], p < 0.001). Men with Lyme carditis are likely to present with various atrioventricular blocks. These atrioventricular blocks are benign, and follow a predictable and stable clinical course. Further large-scale studies are warranted to confirm these associations.

Incidence of Lyme Carditis and Lyme Carditis as a Cause of Pacemaker Implantation: A Nationwide Registry-Based Case-Control Study

Background

Lyme borreliosis (LB) of the heart is called Lyme carditis (LC), which often manifests with high-grade atrioventricular block (AVB) requiring pacemaker implantation. LC is treated with antibiotics, and most patients recover fully after treatment. The overall incidence of LC, and of LC as a cause of pacemaker implantation, has not previously been systematically studied.

Methods

This was a case-control study based on data from Swedish national registers. The study was divided into two parts; part 1 including all patients diagnosed with AVB between 2001 and 2018, and part 2 including all patients who had received a pacemaker due to AVB between 2010 and 2018. Patients diagnosed with LB 90 days before and 180 days after the AVB diagnosis were identified among the patients and compared to matched control groups generated from the general population.

Results

Of 81 063 patients with AVB, 102 were diagnosed with LB. In the control group, 27 were diagnosed with LB. The yearly incidence of LC was 0.056 per 100 000 adults and year. Of 25 241 patients who had received a pacemaker for AVB, 31 were diagnosed with LB. In the control group, 8 were diagnosed with LB. The yearly incidence of LC as a cause of pacemaker implantation was 0.033 per 100 000 adults and year. The estimated risk for patients with LC to receive a permanent pacemaker was 59%.

Conclusions

LC is a rare cause of AVB. Nevertheless, more than half of patients with LC receive a permanent pacemaker for a condition that is easily cured with antibiotics.

Lyme Carditis: From Pathophysiology to Clinical Management

Cardiac involvement is a rare but relevant manifestation of Lyme disease that frequently presents as atrioventricular block (AVB). Immune-mediated injury has been implicated in the pathogenesis of Lyme carditis due to possible cross-reaction between Borrelia burgdorferi antigens and cardiac epitopes. The degree of the AVB can fluctuate rapidly, with two-thirds of patients progressing to complete AVB. Thus, continuous heart rhythm monitoring is essential, and a temporary pacemaker may be necessary. Routinely permanent pacemaker implantation, however, is contraindicated because of the frequent transient nature of the condition. Antibiotic therapy should be initiated as soon as the clinical suspicion of Lyme carditis arises to reduce the duration of the disease and minimize the risk of complications. Diagnosis is challenging and is based on geographical epidemiology, clinical history, signs and symptoms, serological testing, ECG and echocardiographic findings, and exclusion of other pathologies. This paper aims to explain the pathophysiological basis of Lyme carditis, describe its clinical features, and delineate the treatment principles.

Incidence of carditis and predictors of pacemaker implantation in patients hospitalized with Lyme disease

BACKGROUND

Lyme carditis, defined as direct infection of cardiac tissue by Borrelia bacteria, affects up to 10% of patients with Lyme disease. The most frequently reported clinical manifestation of Lyme carditis is cardiac conduction system disease. The goal of this study was to identify the incidence and predictors of permanent pacemaker implantation in patients hospitalized with Lyme disease.

METHODS

A retrospective cohort analysis of the Nationwide Inpatient sample was performed to identify patients hospitalized with Lyme disease in the US between 2003 and 2014. Patients with Lyme carditis were defined as those hospitalized with Lyme disease who also had cardiac conduction disease, acute myocarditis, or acute pericarditis. Patients who already had pacemaker implants at the time of hospitalization (N = 310) were excluded from the Lyme carditis subgroup. The primary study outcome was permanent pacemaker implantation. Secondary outcomes included temporary cardiac pacing, permanent pacemaker implant, and in-hospital mortality.

RESULTS

Of the 96,140 patients hospitalized with Lyme disease during the study period, 10,465 (11%) presented with Lyme carditis. Cardiac conduction system disease was present in 9,729 (93%) of patients with Lyme carditis. Permanent pacemaker implantation was performed in 1,033 patients (1% of all Lyme hospitalizations and 11% of patients with Lyme carditis-associated conduction system disease). Predictors of permanent pacemaker implantation included older age (OR: 1.06 per 1 year; 95% CI:1.05-1.07; P<0.001), complete heart block (OR: 21.5; 95% CI: 12.9-35.7; P<0.001), and sinoatrial node dysfunction (OR: 16.8; 95% CI: 8.7-32.6; P<0.001). In-hospital mortality rate was higher in patients with Lyme carditis (1.5%) than in patients without Lyme carditis (0.5%).

CONCLUSIONS

Approximately 11% of patients hospitalized with Lyme disease present with carditis, primarily in the form of cardiac conduction system disease. In this 12-year study, 1% of all hospitalized patients and 11% of those with Lyme-associated cardiac conduction system disease underwent permanent pacemaker implantation.

Lyme disease and heart transplantation: presentation of a clinical case and a literature review

BACKGROUND

Lyme disease, the most common anthropozoonosis, is a transmissible natural focal infection affecting various organs and systems. Also known as Lyme borreliosis, it is caused by Borrelia spirochetes, which are distributed by ticks of the genus Ixodes. Early diagnosis is difficult due to frequent occurrence of atypical symptoms, unnoticed tick bites, the absence of migratory erythematous lesions, and symptoms occurring during the non-tick season. If not diagnosed and treated in time, dissemination of the infection occurs and various complications develop since borrelias damage not only the skin but also the nervous system, joints, and, in rare cases, the heart and eyes.

MATERIALS AND METHODS

This article presents a clinical case of Lyme borreliosis-induced myocarditis, which led to the development of dilated cardiomyopathy and, consequently, urgent cardiac transplantation. According to our data, this is one of the first described cases of this complication in the world.

RESULTS AND CONCLUSIONS

When diagnosed in time and treated properly, the prognosis of Lyme myocarditis is usually good. In most cases, the atrioventricular block disappears within 1-2 weeks of antibiotic treatment and the implantation of a temporary pacemaker is rarely needed. In those rare cases of a chronic Borrelia burgdorferi infection, dilated cardiomyopathy may develop; thus if a sudden atrioventricular block occurs, the physician should be vigilant and perform the necessary tests to exclude the diagnosis of Lyme disease.

RESULTS AND CONCLUSIONS

When diagnosed in time and treated properly, the prognosis of Lyme myocarditis is usually good. In most cases, the atrioventricular block disappears within 1-2 weeks of antibiotic treatment and the implantation of a temporary pacemaker is rarely needed. In those rare cases of a chronic Borrelia burgdorferi infection, dilated cardiomyopathy may develop; thus if a sudden atrioventricular block occurs, the physician should be vigilant and perform the necessary tests to exclude the diagnosis of Lyme disease.

A tick beat in the electrocardiogram: Persistent third degree block as only manifestation of Lyme disease

Lyme disease is the most common tick-borne illness in North America. A 23-year-old female presented to our emergency department with a chief complaint of sudden dyspnea and chest pain. An electrocardiogram revealed a third degree heart block. She was a resident of the Northeast region of Mexico and referred a recent travel to an endemic area for Borrelia burgdorferi in the center of Mexico in the past weeks. Lyme carditis was diagnosed after enzyme linked immunosorbent assay for IgM antibodies against B. burgdorferi was reported positive and corroborated by a confirmatory immunoblot analysis. Persistent AV block was the only manifestation in our patient, a presentation scarcely reported in literature.

Suspicious index in Lyme carditis: Systematic review and proposed new risk score

BACKGROUND

Lyme carditis (LC), an early manifestation of Lyme disease that most commonly presents as high-degree atrioventricular block (AVB), usually resolves with antibiotic treatment. When LC is not identified as the cause of AVB, a permanent pacemaker may be inappropriately implanted in a reversible cardiac conduction disorder.

HYPOTHESIS

The likelihood that a patient's high-degree AVB is caused by LC can be evaluated by clinical characteristics incorporated into a risk stratification tool.

METHODS

A systematic review of all published cases of LC with high-degree AVB, and five cases from the authors' experience, was conducted. The results informed the development of a new risk stratification tool, the Suspicious Index in LC (SILC) score. The SILC score was then applied to each case included in the review.

RESULTS

Of the 88 cases included, 51 (58%) were high-risk, 31 (35.2%) intermediate-risk, and 6 (6.8%) low-risk for LC according to the SILC score (sensitivity 93.2%). For the subset of 32 cases that reported on all SILC variables, 24 (75%) cases were classified as high-risk, 8 (25%) intermediate-risk, and 0 low-risk (sensitivity 100%). Specificity could not be assessed (no control group). Notably, 6 of the 11 patients who received permanent pacemakers had reversal of AVB with antibiotic treatment.

CONCLUSION

The SILC risk score and COSTAR mnemonic (constitutional symptoms; outdoor activity; sex = male; tick bite; age < 50; rash = erythema migrans) may help to identify LC in patients presenting with high-degree AVB, and ultimately, minimize the implantation of unnecessary permanent pacemakers.

Putting Heart Block Back in the "Lyme Light"

We report a case of syncope in a young patient who presented with high-degree, variable atrioventricular heart block. Despite having no other classic manifestations of Lyme disease, she was treated with intravenous ceftriaxone for Lyme carditis on high clinical suspicion due to geographic location. The heart block resolved within 24 h of treatment. Although rare, we demonstrate the importance of considering Lyme carditis in patients who present with new-onset heart block and a history of living in an endemic area. Initiation of empiric antibiotic therapy can lead to rapid resolution of this condition. .

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

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.

Lyme carditis

Cardiovascular manifestations of Lyme disease were first reported nearly 30 years ago. This article describes Lyme carditis, its epidemiology, pathophysiology, methods of diagnosis, and treatment options.

Complete heart block due to Lyme carditis in two pediatric patients and a review of the literature

Carditis is a common manifestation of adult patients with Lyme disease affecting 4-10% of Lyme patients in the United States. However, children with Lyme disease rarely present with acute carditis. The management of pediatric patients with complete heart block (CHB) secondary to Lyme carditis has not been well described. We report the acute management of 2 pediatric patients that presented in CHB secondary to Lyme disease.

[Lyme arthritis, Lyme carditis and other presentations potentially associated to Lyme disease]

Lyme disease or Lyme borreliosis is the most common tick-transmitted disease in the Northern hemisphere and is caused by Borrelia burgdorferi spirochetes. Lyme disease commonly begins with a characteristic skin lesion, erythema migrans. Weeks or months later, the patients may have neurologic, joint, or cardiac abnormalities. Some patients may still present persistent deep fatigue and various unspecific symptoms after standard courses of antibiotic treatment for Lyme disease. This constellation of symptoms has been variously referred to as "chronic Lyme disease", or "post-Lyme disease syndrome". The first French National Consensus Conference on Lyme Disease was the reason to review all aspects of articular and cardiac manifestations of Lyme disease after a synthesis of recent literature. The involvement of Borrelia species in chronic Lyme disease and other pathologies is discussed.

Cardiac manifestations of Lyme disease

Lyme disease is a vector-borne illness that can affect numerous organ systems during the early disseminated phase, including the heart. The clinical course of Lyme carditis is usually benign with most patients recovering completely. In rare instances, death from Lyme carditis has been reported. The cardinal manifestation of Lyme carditis is conduction system disease, which generally is self-limited. Heart block occurs usually at the level of the atrioventricular node but often is unresponsive to atropine sulfate. Temporary pacing may be necessary in more than 30% of patients, but permanent heart block rarely develops. Myocardial and pericardial involvement can occur but generally is mild and self-limited. Diagnosis is made by associating the clinical and historical features of borreliosis, such as previous tick bite, EM, or neurologic involvement, with electrocardiographic abnormalities and symptoms such as chest pain, palpitations, syncope, and dyspnea. Serologic studies and endomyocardial biopsy can support the diagnosis in the correct clinical setting, and MR imaging, echocardiography, and gallium scanning have utility in selected circumstances. No treatment has been shown clearly to attenuate or prevent the development of Lyme carditis, but mild carditis generally is treated with oral antibiotics and severe carditis with intravenous antibiotics in an effort to eradicate the infection and prevent late complications of Lyme disease. There is conflicting evidence regarding the role that B. burgdorferi plays in the development and progression of chronic congestive heart failure. Because of the significant false-positive ELISA rate in this population and the unclear benefit of antibiotic therapy, confirmatory Western blot analysis is recommended. Routine therapy and screening of patients with idiopathic dilated cardiomyopathy is of limited utility and should be reserved for patients with clear history of antecedent Lyme disease or tick bite.

Tick-borne pulmonary disease: update on diagnosis and management

Ticks are capable of transmitting viruses, bacteria, protozoa, and rickettsiae to man. Several of these tick-borne pathogens can lead to pulmonary disease. Characteristic clinical features, such as erythema migrans in Lyme disease, or spotted rash in a spotted fever group disease, may serve as important diagnostic clues. Successful management of tick-borne diseases depends on a high index of suspicion and recognition of their clinical features. Patients at risk for tick bites may be coinfected with two or more tick-borne pathogens. A Lyme vaccine has recently become available for use in the United States. Disease prevention depends on the avoidance of tick bites. When patients present with respiratory symptoms and a history of a recent tick bite or a characteristic skin rash, a differential diagnosis of a tick-borne pulmonary disease should be considered. Early diagnosis and appropriate antibiotic therapy for these disorders lead to greatly improved outcomes.

Early disseminated Lyme disease: cardiac manifestations

The cardiac features of Lyme disease usually occur within weeks to months of the infecting tick bite; the result may be disruption of the conduction system, leading to heart block and muscle dysfunction, causing a mild myopericarditis. Lyme carditis is usually mild, although permanent heart block and a few fatalities claimed to be due to Lyme carditis have been reported, the latter usually with poor documentation. In general, Lyme carditis is treatable and curable with antibiotic regimens in current use. Recent reports have suggested that Lyme disease may be a cause of chronic congestive cardiomyopathy. Lyme carditis should be considered in the proper clinical setting with appropriate use of diagnostic tests, recalling that patients with carditis early in Lyme disease may be seronegative and that all patients who are seropositive do not necessarily have Lyme disease.

Complete heart block in a 9 year old girl caused by borreliosis

A complete atrioventricular block was seen in a nine year old girl in whom an infection with Borrelia burgdorferi was confirmed by serological testing. There were no other symptoms or cutaneous manifestations of the disease. Though a rash on the right ear was later recalled by her parents. The patient was treated with high dose penicillin and orciprenaline was given intermittently. The complete heart block disappeared within four days.

Epidemiology and clinical manifestations of Lyme borreliosis in childhood. A prospective multicentre study with special regard to neuroborreliosis

Lyme borreliosis is a tick-borne infection caused by the spirochete Borrelia burgdorferi, whose discovery in 1982 solved an aetiological mystery involving a variety of dermatological and neurological disorders and explained their association with Lyme disease. Lyme borreliosis occurs frequently and is readily treatable with antibiotics. Along with its discovery, however, came the realization that it is difficult to diagnose accurately, especially antibody diagnosis. False-positive antibody results in particular led to gradual widening of the clinical spectrum, and differential diagnosis became increasingly difficult. This prospective, multicentre study presents a systematic description of Lyme borreliosis in childhood, emphasizing epidemiological and clinical issues. Because, predominantly, inpatients were examined, Lyme neuroborreliosis was the focus of the study, with the chief concern being to minimize false-positive results. To this end, we chose to narrow the diagnostic criteria, using the presence of specific antibodies in the cerebrospinal fluid as the determining factor. The epidemiological investigation was focused on the incidence of Lyme neuroborreliosis in childhood in southern Lower Saxony as well as on the prevalence of Lyme neuroborreliosis among acute-inflammatory neurological illnesses in children. The clinical part of the study aimed at establishing criteria for differential diagnosis in addition to the detection of specific antibodies. The detection of specific IgM antibodies using an IgM capture ELISA confirmed the presence of acute Lyme borreliosis. The study examined 208 children with Lyme borreliosis, of whom 169 had Lyme neuroborreliosis, from mid-1986 until the end of 1989. The yearly incidence of Lyme neuroborreliosis in Lower Saxony was 5.8 cases/100,000 children aged 1 to 13. The manifestation index was 0.16, or one case of Lyme neuroborreliosis per 620 infected children, compared with the presence of specific antibodies against B. burgdorferi for children in the same age group and region. Both the seasonal distribution of Lyme borreliosis, which peaked in summer and autumn, as well as the information about when the tick bites took place point to an incubation period of a few weeks. The most frequent manifestation of Lyme neuroborreliosis in childhood was acute peripheral facial palsy, found in 55% of all cases (n = 93). Lyme borreliosis proved to be the most frequently verifiable cause of acute peripheral facial palsy in children, causing every second case of this disorder in summer and autumn.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiovascular manifestations of Lyme disease

Although the cardiac manifestations of Lyme disease may be diverse, in general they are treatable with currently available therapies. A high index of suspicion is required to make a diagnosis, especially for patients who may lack a suggestive history of tick exposure or residence in an endemic region. Lyme disease-related heart block may require pacemaker insertion and supportive care. The efficacy of antibiotics in the therapy of acute and chronic cardiac Lyme disease will require further study. Serologic testing and cardiac histopathology are the most precise methods of diagnosis. There is a need to develop more sensitive and specific diagnostic tests for Lyme disease and for Lyme carditis in particular.