Lyme myocarditis in patient with no other signs of Lyme disease

In their case report, “Fulminant Lyme myocarditis without any other signs of Lyme disease in a 37-year-old male patient with microscopic polyangiitis,” Schroeter and colleagues describe a patient with microscopic polyangiitis (MPA), a rare type of vasculitis who was admitted to the hospital with acute heart failure.

The 37-year-old man developed Lyme myocarditis without displaying any clinical symptoms of Lyme disease. He did not recall a tick bite or rash.

He resided in Germany and had been receiving immunosuppressive treatment for MPA.

The man initially presented to the emergency department with fatigue, palpitations and shortness of breath, which had been ongoing for one week.

The patient was “severely dyspnoeic (New York Heart Association IV), afebrile, and tachycardic (heart rate of 123/min) with blood pressure of 95/55 mmHg (without inotropic support),” the authors wrote.¹

An echocardiography and cardiac magnetic resonance imaging indicated a severely reduced left ventricular ejection fraction (LVEF) with global hypokinesia.

Biopsies of the left ventricular revealed a sudden onset of Lyme carditis with evidence of typical lymphocytic myocarditis.

“Nested PCR revealed the presence of Borrelia DNA in the endomyocardial biopsy,” the authors wrote. “Direct sequencing of the Borrelia product revealed the presence of Borrelia afzelii.”

The man displayed no clinical signs of Lyme disease, nor did he recall a tick bite or rash.

He was treated with intravenous ceftriaxone, followed by oral doxycycline.

“Repeat EMB [endomyocardial biopsies] a few months later revealed a dramatic regression of the cardiac inflammation and absence of Borrelia DNA in the myocardium.”

The authors suggest, “This case explicitly underlines the importance and value of left ventricular endomyocardial biopsy, providing (immuno-)histological evidence of typical lymphocytic myocarditis and detection of spirochaete by PCR.”

Furthermore, “Cardiac magnetic resonance imaging and blood ELISA were neither informative nor specific enough (especially in relation to cardiac involvement).”

Authors Conclusion: “A severely reduced LVEF [left ventricular ejection fraction] can be the primary manifestation of Lyme disease even without typical systemic findings and can have a favourable prognosis with antibiotic treatment.”