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Neville DN, Alexander ME, Bennett JE, Balamuth F, Garro A, Levas MN, Thompson AD, Kharbanda AB, Lewander DP, Dart AH, Nigrovic LE. Electrocardiogram as a Lyme Disease Screening Test. J Pediatr 2021; 238:228-232.e1. [PMID: 34265339 DOI: 10.1016/j.jpeds.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine the association between electrocardiographic (ECG) evidence of carditis at the time of Lyme disease evaluation and a diagnosis of Lyme disease. STUDY DESIGN We performed an 8-center prospective cohort study of children undergoing emergency department evaluation for Lyme disease limited to those who had an ECG obtained by their treating clinicians. The study cardiologist reviewed all ECGs flagged as abnormal by the study sites to assess for ECG evidence of carditis. We defined Lyme disease as the presence of an erythema migrans lesion or a positive 2-tier Lyme disease serology. We used logistic regression to measure the association between Lyme disease and atrioventricular (AV) block or any ECG evidence of carditis. RESULTS Of the 546 children who had an ECG obtained, 214 (39%) had Lyme disease. Overall, 42 children had ECG evidence of carditis, of whom 24 had AV block (20 first-degree). Of the patients with ECG evidence of carditis, only 21 (50%) had any cardiac symptoms. The presence of AV block (OR 4.7, 95% CI 1.8-12.1) and any ECG evidence of carditis (OR 2.3, 95% CI 1.2-4.3) were both associated with diagnosis of Lyme disease. CONCLUSIONS ECG evidence of carditis, especially AV block, was associated with a diagnosis of Lyme disease. ECG evidence of carditis can be used as a diagnostic biomarker for Lyme disease to guide initial management while awaiting Lyme disease test results.
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Affiliation(s)
- Desiree N Neville
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Mark E Alexander
- Arrhythmia Service, Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Michael N Levas
- Division of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Amy D Thompson
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - David P Lewander
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1-e48. [PMID: 33417672 DOI: 10.1093/cid/ciaa1215] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
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Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
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Kannangara DW, Sidra S, Pritiben P. First case report of inducible heart block in Lyme disease and an update of Lyme carditis. BMC Infect Dis 2019; 19:428. [PMID: 31096922 PMCID: PMC6524294 DOI: 10.1186/s12879-019-4025-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background Lyme disease (LD), is the most common vector-borne illness in the US and Europe, with predominantly cutaneous, articular, cardiac and neuro-psychiatric manifestations. LD affects all layers of the heart and every part of the conducting system. Carditis is a less common manifestation of LD. Heart block (HB) as the initial and sole manifestation of LD is rare. Inducible HB has never been reported in LD. We report a case of heart block (HB) inducible with exercise and reversible with rest. Case presentation A 37-year-old male presented to the emergency department after experiencing two episodes of syncope while at work. He presented, with a heart rate of 57 bpm, and the ECG showed sinus bradycardia with first degree AV block. The PR interval was 480 ms (NL 120–200 ms). Physical exam was unremarkable. The cardiologist’s initial impression was vaso-vagal attack. He developed high degree AV block during a stress test for the initial work up, which resolved on cessation of exercise. A similar episode while walking in the hallway, resolved at rest. The high degree AV block appeared inducible with exercise and reversible with rest. His Lyme serology was strongly positive. He was treated with ceftriaxone and doxycycline. After completing treatment, the patient had a normal ECG and returned to work without limitations, doing manual labor. Conclusions Manifestations of Lyme carditis (LC) vary from asymptomatic and symptomatic electrocardiographic changes and heart block (HB) reversible with treatment, to sudden death. HB as the sole and initial presentation of LC is rare. There have been no reports of inducible HB in LD. Here we present a case of inducible and reversible high degree HB in a case of LC and an update of literature. Exercise and stress testing should be avoided in suspected cases of LC until resolution of carditis. Lyme carditis should be suspected in individuals with cardiac manifestations in an endemic area, particularly in the younger patients with no other etiology evident.
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Affiliation(s)
- Don Walter Kannangara
- St Luke's University Health Network, Warren Campus, 185 Roseberry Street, Phillipsburg, NJ, 08865, USA.
| | - Sindhu Sidra
- St Luke's University Health Network, Warren Campus, 185 Roseberry Street, Phillipsburg, NJ, 08865, USA
| | - Patel Pritiben
- St Luke's University Health Network, Warren Campus, 185 Roseberry Street, Phillipsburg, NJ, 08865, USA
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Nawrocki PS, Poremba M. A 15-Year-Old Male With Wide Complex Tachyarrhythmia. Air Med J 2018; 37:383-387. [PMID: 30424858 DOI: 10.1016/j.amj.2018.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/19/2018] [Accepted: 07/22/2018] [Indexed: 06/09/2023]
Abstract
A 15-year-old male presented with exertional syncope and was found to be in an unstable regular wide complex tachyarrhythmia (WCT). After a trial of antiarrhythmic medication, his clinical condition declined, necessitating synchronized cardioversion. Although he noted symptomatic improvement after cardioversion, he was found to be in third-degree heart block. The patient was transported by rotor wing aircraft to a pediatric cardiac intensive care unit where he was ultimately diagnosed with Lyme disease. He was treated with a course of intravenous antibiotics, his heart block resolved, and he was discharged home with a good neurologic outcome.
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Affiliation(s)
- Philip S Nawrocki
- Department of Emergency Medicine, Allegheny General Hospital, Pittsburgh, PA.
| | - Matthew Poremba
- Department of Emergency Medicine, Allegheny General Hospital, Pittsburgh, PA
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Nelson CA, Farina MA, Olson D, Dominguez SR, McFarland EJ. Visual Diagnosis: 19-year-old Boy with Syncope and Bradycardia. Pediatr Rev 2016; 37:e25-8. [PMID: 27368365 DOI: 10.1542/pir.2015-0121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Christina A Nelson
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, CO
| | - Mark A Farina
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO
| | - Daniel Olson
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Samuel R Dominguez
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth J McFarland
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
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