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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Flulike illness, or confirmed Lyme disease, followed by evidence of atrioventricular block

  • Diagnosis is confirmed by the association of typical clinical features with serologic testing

GENERAL CONSIDERATIONS

  • Infectious disease caused by Borrelia burgdorferi, a tick-borne spirochete

  • Male predominance 3:1 for cardiac Lyme disease

  • Initial manifestations include:

    • – Myalgias

    • – Arthralgia

    • – Fever

    • – Headache

    • – Erythema migrans

  • Four to 10% of infected patients develop symptoms from transient cardiac involvement weeks to months after initial presentation

  • The most common manifestation is conduction abnormality in the form of varying degrees of atrioventricular block

  • Syncope due to complete heart block is common

  • Diffuse ST-segment and T-wave changes and asymptomatic left ventricular dysfunction may be found, but congestive heart failure is rare

  • Occasional patients develop symptomatic myocarditis or pericarditis

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Cardiac features can be coincident with other early features of Lyme disease, including erythema migrans and neurologic abnormalities, or may be the only manifestation of infection

  • Palpitations (common)

  • Lightheadedness

  • Syncope (common)

  • Dyspnea

  • Chest pain

  • Some patients are asymptomatic

PHYSICAL EXAM FINDINGS

  • Bradycardia

  • Cannon a waves in the jugular venous pressure in patients with complete heart block

  • Congestive heart failure is uncommon

  • Erythema migrans

  • Monoarthritis

  • Cranial nerve palsy or other findings of meningoencephalitis

DIFFERENTIAL DIAGNOSIS

  • Myocarditis due to other infectious agents

  • Intrinsic conduction system disease

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Lyme serology with enzyme-linked immunosorbent assay (ELISA) and/or Western blot analysis

ELECTROCARDIOGRAPHY

  • Varying degrees of atrioventricular block, which can progress to complete heart block in a short period of time

  • Bundle branch block, fascicular block

  • Nonspecific ST- and T-wave changes

IMAGING STUDIES

  • Chest x-ray:

    • – Cardiomegaly may be present and is usually transient

  • Echocardiography:

    • – Mild cardiomegaly and/or mild left ventricular dysfunction

    • – Pericardial effusion may be present

    • – These changes are usually transient

DIAGNOSTIC PROCEDURES

  • Electrophysiologic testing is rarely required; typical findings include:

    • – Heart block within the atrioventricular node, although heart block may occur at other levels within the conduction systems

    • – Sinus node dysfunction may also be present

  • Endomyocardial biopsy (rarely indicated) shows the following:

    • – Lymphoid and plasmacytic infiltrates

    • – Variable amounts of necrosis, fibrosis, and edema that are indicative of active myocarditis

    • – Spirochetes have been isolated in some

TREATMENT

CARDIOLOGY REFERRAL

  • Atrioventricular block of any type

  • Evidence of myocarditis or left ventricular dysfunction

HOSPITALIZATION CRITERIA

  • Symptomatic patients, including syncope

  • High-grade or progressive atrioventricular block, symptomatic or asymptomatic

MEDICATIONS

  • Antibiotic therapy ...

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