First case report of inducible heart block in Lyme disease and an update of Lyme carditis
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.
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.
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.
KeywordsLyme disease Lyme Carditis Heart block Tick(s) Borrelia burgdorferi
Beats per minute
Center for disease control
Complete heart block
Magnetic resonance imaging
ECG changes reported in Lyme carditis
Steere et al. (1980,1984), Naik et al. 2008, van der Linde (1991), Afari (2016), Tumminello (2017)
Steere et al. (1984), Shah and Kanzaria (2012), Dobbs and Mugmon (2013), Lee and Sigla (2016), Bennett et al. (2016), Muhammad and Simmonelli (2018)
Shah and Kanzaria (2012), Muhammad and Simonelli (2018), Kashou et al. (2018)
Steere et al. (1980,1984), van der Linde (1990), Greenberg et al. (1997), Kline (2007) Bacino et al. (2011), Shah and Kanzaria 2012, Wenger et al. (2012), Dobbs and Mugman (2013), Jensen et al. (2014), Shah et al. (2015), Afari (2016), Timmer (2016), Afari (2016), Lee and Singla (2016), Chaudhry et al. (2017), Patel (2017)
Khalil et al. (2015), Wenger et al. (2012), Cunha et al. (2017)
Franck and Wollschläger (2003), Koene et al. (2012), Oktay et al. (2015)
Supraventricular tachycardia 
Konopka et al. (2013)
Naik et al. 2008, Wenger et al. (2012)
Tanksley and Playe (2005), Frank et al. (2011), Cunningham et al. (2016)
Greenberg et al. (1997), Khalil et al. (2015)
Vlay et al. (1991), Koene et al. (2012), Jensen et al. (2014)
Ventricular flutter 
Koene et al. (2012)
Steere et al. 1980, Kline (2007), Naik et al. 2008, Abraham et al. (2010), Bennett et al. (2016) Muhammad and Simonelli (2018)
Narrow QRS escape rhythm 
Shah and Kanzaria (2012)
Seslar et al., (2006), Welsh et al. (2012)
Steere et al. (1980), Welsh et al. (2012)
ST elevation 
Michalski et al. (2017)
Khalil et al. (2015)
History of Wolf Parkinson White Syndrome
In a case of sudden death due to LC 
PR interval decrease with treatment
Lyme serology results
Lyme AB IGG
Lyme AB IGM
Lyme 18 kD IgG
Lyme 23 kD IgG
Lyme 30 kD IgG
Lyme 39 kD IgG
Lyme 41 kG IgG
Lyme 45 kG IgG
Lyme 58 kG igG
Lyme 23 kD IgM
Lyme 39 kD IgM
Lyme 41 kD IgM
Discussion and conclusions
Cardiac involvement has been reported with B.burgdorferi ss (US cases), B garinii, B afzelli  and B bissettii . Patients with CHB (Complete heart block) due to LC may have erythema migrans [32, 36, 37, 47, 48, 58] or other manifestations such as joint involvement . Basic investigations include the history of possible tick exposure, laboratory testing, a 12-channel electrocardiogram, 24-h Holter monitor, chest x-ray, and echocardiography . The two-tier antibody-based test recommended by the CDC is highly specific but has poor sensitivity . Supplementary studies that have been used in the diagnosis include echocardiography [7, 57, 60], gadolinium enhanced cardiac MRI [16, 27], endo-myocardial biopsy [6, 7, 22, 61, 62] with special staining [3, 4, 8, 40], culture  or electron microscopy [7, 61, 62, 63], Ga67 Scan [64, 65, 66], and Indium 111 labelled anti-myosin antibody scintigraphy . Histology of affected cardiac tissue shows infiltration predominantly with lymphocytes and plasma cells [15, 22, 29, 40].
Progression of first-degree heart block to second degree and then to complete heart block without treatment has been reported. Regression of complete heart block to second degree, then first degree followed by complete resolution with treatment is also known . Inducible heart block in Lyme disease has not been reported. We present the first report of inducible heart block in a patient whose initial and sole manifestation of LD was HB. First-degree heart block worsened to high degree AV block on exercise, which was reversible with rest and reproducible during the hospitalization.
As illustrated in this case, exercise and stress testing should not be carried out in LD patients until complete recovery from heart block. HB secondary to Lyme disease rarely requires a permanent pacemaker. However, patients with a PR interval greater than 300 ms should be monitored in an intensive care setting, as they may rapidly progress to complete HB . A temporary pacer is sometimes required; however, most patients respond to treatment within two to three weeks. The antibiotics used in LC include amoxicillin , ceftriaxone [8, 9, 32, 36, 38, 41, 53], doxycycline  and ceftriaxone and doxycycline [13, 37]. Duration of treatment varied from 2 weeks to one month.
LC may present with HB as the sole  or initial presentation [45, 66] with or without other manifestations of LD [30, 32, 36, 37, 48] or with multiple electrocardiographic (Table 1) and clinical presentations. First degree HB is the most common manifestation, which could rapidly progress to CHB . It is important to keep a high degree of suspicion for Lyme disease in endemic areas in patients with cardiac symptoms with or without other manifestations of LD, particularly younger individuals with no other etiology evident. Some patients with complete heart block may need a temporary pacemaker [26, 39, 47, 55, 66, 67]. The majority of AV blocks in LC are reversible with antibiotic treatment. Exercise is contraindicated until resolution of LC.
We acknowledge the assistance of Dr. Amit Prasad, MD and Dr. Renu Toshniwal, MD for involvement in patient care.
No funding was received for the study.
Availability of data and materials
All data generated or analysed during this study are included in this published article. Additional data analysed during the current study are available from the corresponding author on reasonable request.
Patient management (DWK), preparing case report (SS, DWK, PP), tables (DWK), figures (DWK, SS, PP) literature review (DWK), and preparing manuscript and references (DWK, SS, PP). All authors have read and approved the manuscript.
Ethics approval and consent to participate
Approved by St Luke’s University Health Network (SLUHN) Institutional Review Board Exempt study 2018–113.
Consent for publication
Written Informed consent was given by patient and wife for publication of this case report with Lyme test results and ECG findings.
All authors have no financial disclosures or competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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