Atypical case of Lyme carditis in Florida woman

In this case report, “A Rare Presentation of Lyme Disease in an Immunocompromised Patient,” Basile and colleagues highlight atypical cardiac manifestations due to Lyme disease and the challenges in diagnosing Lyme carditis in immunocompromised patients. [1]

According to the authors, this patient presented with myocarditis-predominant Lyme carditis without cardiac conduction abnormalities – an unusual presentation given that 90% of Lyme carditis cases involve conduction abnormalities.

A 57-year-old woman, who was immunocompromised and living in Florida, was admitted to the hospital for acute heart failure with reduced ejection fraction.

Her symptoms included “subacute arthralgias, shortness of breath, bilateral lower extremity swelling, exertional chest pain, dyspnea on exertion, a productive cough, subjective fevers, and unilateral vision loss,” the authors state.

The woman had removed an engorged tick one month prior to the onset of symptoms and had reportedly had an erythematous (EM) rash at the site of the tick bite.

“The signs and symptoms subsequently developed within one to three weeks after removal of the tick.”

The woman had an extensive medical history which included human immunodeficiency virus (HIV), tuberculosis, prior injection drug use, bipolar disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, and atrial fibrillation/flutter with previous cardioversion.

According to the authors, chest X-rays showed pulmonary vascular congestion, cephalization of vasculature, and bilateral infiltrates – consistent with pulmonary edema.

Testing for Lyme disease was positive by Western blot with positivity on 3 Borrelia-specific bands (41 kDa, 23 kDa, and 39 kDa).

“The 39 kDa band has the highest correlation with early-stage Lyme disease and is therefore the most specific of the panel for B. burgdorferi infection,” the authors point out.

Furthermore, an EKG revealed acute isolated systolic heart failure without any cardiac conduction system abnormalities.

“Given the constellation of symptoms – panuveitis, joint pain, unspecified rashes, new heart failure, and positive Lyme serologies – the diagnosis of Lyme carditis was made.”

The woman was treated successfully with doxycycline.

“On the first day of treatment,” the authors state, “the patient experienced increased erythema of her extremities with generalized pruritus, subjective fever, and fatigue consistent with a Jarisch-Herxheimer reaction.” But her symptoms improved after 48 hours.

“One rare and reversible etiology of acute-onset congestive heart failure is Borrelia burgdorferi infection.”

This case is unique:

• “There are only a few reported cases of Lyme carditis-associated heart failure without conduction abnormalities.” The majority of cases present with conduction abnormalities.
• The patient presented with multiple nonspecific findings in the setting of uncontrolled HIV.
• The woman was a resident of Florida and had not recently travelled out-of-state. Lyme disease is typically associated with regions in the northeastern United States.