HEART Abstracts and Quotes
Lyme and Coinfections
May 2019- Lyme Carditis
QUOTE- "Exercise and stress testing should be avoided in suspected cases of LC [Lyme Carditis] 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.”
https://www.ncbi.nlm.nih.gov/pubmed/31096922
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BMJ Case Rep. 2019 Apr 29;12(4). pii: e228975. doi: 10.1136/bcr-2018-228975.
Lyme carditis presenting as atrial fibrillation.
Zainal A1, Hanafi A1, Nadkarni N1, Mubasher M1, Lingutla D1, Hoefen R2.
Abstract
The incidence of Lyme disease in the USA is 8 per 100 000 cases and 95% of those occur in the Northeastern region. Cardiac involvement occurs in only 1% of untreated patients. We describe the case of a 46-year-old man who presented with chest pressure, dyspnoea, palpitations and syncope. He presented initially with atrial fibrillation with rapid ventricular response, a rare manifestation of Lyme carditis. In another hospital presentation, he had varying degrees of atrioventricular block including Mobitz I second-degree heart block. After appropriate antibiotic treatment, he made a full recovery and his ECG normalised. The authors aim to urge physicians treating patients in endemic areas to consider Lyme carditis in the workup for patients with atrial fibrillation and unexplained heart block, as the associated atrioventricular nodal complications may be fatal.
© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/31036741
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http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3439&string=de+AND+lyme
Class III AV block expected to resolve and/or unlikely to recur (McAlister et al., 1989) (e.g., drug toxicity, Lyme disease, or during hypoxia in sleep apnea syndrome in absence of symptoms). (Level of evidence: B)
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http://www.canlyme.com/heart.html
J Invasive Cardiol. 2003 Jun;15(6):367-9.
Complete heart block due to lyme carditis.
Lo R, Menzies DJ, Archer H, Cohen TJ.
Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA.
Lyme carditis is becoming a more frequent complication of Lyme disease, primarily due to the increasing incidence of this disease in the United States. Cardiovascular manifestations of Lyme disease often occur within 21 days of exposure and include fluctuating degrees of atrioventricular (AV) block, acute myopericarditis or mild left ventricular dysfunction and rarely cardiomegaly or fatal pericarditis. AV block can vary from first-, second-, third-degree heart block, to junctional rhythm and asystolic pauses. Patients with suspected or known Lyme disease presenting with cardiac symptoms, or patients in an endemic area presenting with cardiac symptoms with no other cardiac risk factors should have a screening electrocardiogram along with Lyme titers. We present a case of third-degree AV block due to Lyme carditis, illustrating one of the cardiac complications of Lyme disease. This disease is usually self-limiting when treated appropriately with antibiotics, and does not require permanent cardiac pacing.
PMID: 12777681 [PubMed - in process]
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Ugeskr Laeger. 2003 Apr 7;165(15):1570. Related Articles, Links
[ Borrelia burgdorferi myocarditis]
[Article in Danish]
Hendricks O, Kjaeldgaard P, Koldbaek I.
Klinisk Mikrobiologisk Afdeling, Sonderborg Sygehus, DK-6400 Sonderborg.
We describe a case of progressive arrhythmia and heart failure combined with neurological symptoms that was resistant to conventional cardiological treatment. The outcome of a serological analysis was Borrelia IgG on a level consistent with chronic Lyme Disease. Antibiotic treatment with doxycycline resulted in complete remission of all cardiological symptoms. This case demonstrated Lyme Disease to be a potential factor in the pathogenesis of myocarditis as suggested by international publications.
PMID: 12715663 [PubMed - indexed for MEDLINE]
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Molecular diagnosis of culture negative infective endocarditis: clinical validation in a group of surgically treated patients.
Grijalva M, Horvath R, Dendis M, Erny J, Benedik J.
Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic.
OBJECTIVE: To assess the clinical validity of polymerase chain reaction (PCR) based molecular methods in the microbiological diagnosis of culture negative infective endocarditis in a group of surgically treated patients. DESIGN: Retrospective case-control study. SETTING: Reference cardiovascular surgical centre. PATIENTS AND SAMPLES: 15 culture negative patients with infective endocarditis classified according to Duke criteria, with 17 heart valve samples; 13 age and sex matched control patients without infective endocarditis, with 13 valve samples.
INTERVENTIONS: Medical records were reviewed and clinical, demographic, and microbiological data collected, including results of molecular detection of bacteria and fungi from valve samples. The clinical validity of molecular diagnosis was assessed, along with the sensitivity and speed of the systems. RESULTS: In the study group, 14 patients were PCR positive (93%). Organisms detected were streptococci (3), staphylococci (2), enterobacter (1), Tropheryma whippelii (1), Borrelia burgdorferi (1), Candida albicans (1), and Aspergillus species (2). Three cases were positive on universal bacterial detection but the pathogen could not be identified because of contaminating background. One case was negative. All but two positive cases showed clinical correlations. These two cases had no symptoms of infective endocarditis but there was agreement with the surgical findings. All control cases were PCR negative. Results were available within eight hours, and if sequencing was necessary, within 48 hours.
CONCLUSIONS: PCR based molecular detection of pathogens in valve samples from surgically treated culture negative infective endocarditis patients is fast, sensitive, and reliable. The technology, combined with thorough validation and clinical interpretation, may be a promising tool for routine testing of infective endocarditis. Publication Types: Validation Studies PMID: 12591825 [PubMed - indexed for MEDLINE]
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Wien Klin Wochenschr. 2001 Jan 15;113(1-2):38-44.
Borrelia infection as a cause of carditis (a long-term study).
Bartunek P, Mrazek V, Gorican K, Bina R, Listvanova S, Zapletalova J.
Department of Internal Medicine IV, Charles University School of Medicine I, Prague, Czech Republic.
BACKGROUND: Although the frequency of Lyme carditis is not high, it is one of the most challenging conditions in terms of diagnosis. No long-term studies that would help expand our body of knowledge concerning the circumstances of its development and the natural course of this form of Lyme borreliosis (LB), the most widespread anthropozoonosis in Central Europe, have been reported to date. AIM: The authors sought to describe and assess the consequences of a less common form of Lyme carditis (LC). An assessment of the following aspects was made: a) the forms, natural history and sequelae of the less common clinical appearances of LC, b) the role of antibiotic therapy with reference to the late manifestations of LB.
METHODS: Three patients were selected from a group of 60 consecutive patients with demonstrated LC during a follow-up period from 1987 to 2000. Patient no. 1 was being followed for myocarditis with frequent ventricular extrasystoles, patient no. 2 for pericarditis, and patient no. 3 for dilated cardiomyopathy as a late manifestation of LB. In addition to routine examination at entry, the patients were subjected to a standard 12-lead ECG, continuous 24-hour Holter ECG monitoring, exercise testing (bicycle ergometry), investigations of antibodies using ELISA and Western blot, investigation of thyroid (T3, T4, TSH tests) and mineral levels.
RESULTS: The study showed no significant correlation between the clinical course and levels of specific antibodies. It confirmed the concept that inadequate or no therapy with antibiotics in the initial stage of the disease has a significant effect on the development of late sequelae. CONCLUSION: Based on the long-term treatment of three patients with less common, yet clinically urgent findings, the authors conclude that even a relatively serious clinical course is associated with no major limitations for affected individuals after an interval of several years. PMID: 11233466 [PubMed - indexed for MEDLINE]
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Update on Lyme Carditis.
Bateman H, Sigal L. Division of Rheumatology and Connective Tissue Research, MEB-484, University of Medicine and Dentistry-Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ 08903, USA. E-mail: Batemanhe@umdnj.edu; Sigallh@umdnj.edu
Lyme carditis is an uncommon manifestation of infection with Borrelia bugdorferi. It is easily treated with standard antibiotic regimens and prognosis is excellent, especially if treatment is prompt. For symptomatic or higher degrees of block, patients may require hospitalization for monitoring and occasionally temporary external pacing. Intravenous antibiotics are warranted for such patients. For less severe conduction disturbances, oral therapy suffices.
PMID: 11095868 [PubMed]
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Cardiac manifestations of Lyme disease.
Pinto DS.
Harvard Medical School, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. Dpinto@caregroup.harvard.edu
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 only support the clinical diagnosis in the correct 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.
Publication Types: Review Review, Tutorial
PMID: 11982302 [PubMed - indexed for MEDLINE]
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Prosthetic Valve Endocarditis Caused by Bartonella quintana
John L. Klein,* Sukumaran K. Nair,* Tim G. Harrison,† Ian Hunt,* Norman K. Fry,† and Jon S. Friedland*‡
*Hammersmith Hospital, London, United Kingdom; †PHLS Central Public Health Laboratory, London, United Kingdom; and ‡Imperial College, London, United Kingdom
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http://www.aafp.org/afp/20010515/1969.html
When to Suspect and How to Monitor Babesiosis
ELEFTHERIOS MYLONAKIS, M.D., Massachusetts General Hospital, Boston, Massachusetts
Congestive heart failure, disseminated intravascular coagulation and acute respiratory distress syndrome (that can occur even a few days after the onset of effective antimicrobial treatment) are the most common complications of human babesiosis (Table 2). Renal failure and myocardial infarction also have been associated with severe babesiosis.