Lyme disease chest pain can perfectly mimic myocardial infarction with elevated cardiac biomarkers and EKG changes indistinguishable from acute coronary syndrome. A 45-year-old woman presenting with chest pain radiating to her neck had all the hallmarks of heart attack until cardiac catheterization revealed normal coronary arteries. Only when facial palsy developed two days later was Lyme disease recognized as the true cause.
Presentation Mimicking Myocardial Infarction
According to the authors, Lyme disease mimicked a myocardial infarction (heart attack) in a 45-year-old woman who presented with a sudden onset of chest pain, radiating to her neck.
Chest pain radiating to the neck is a classic presentation of myocardial infarction. The location, quality, and radiation pattern all suggested cardiac ischemia — inadequate blood flow to the heart muscle from blocked coronary arteries.
Strong Evidence for Heart Attack
The evidence supporting a diagnosis of myocardial infarction was strong. A medical workup showed the woman had EKG changes, high admission levels of Troponin and CK-MB, and rising Troponin and CK-MB at 6 hours.
Let’s break down why this evidence was so convincing:
- EKG changes: Electrical pattern on the electrocardiogram consistent with cardiac ischemia or injury
- Elevated Troponin: Troponin is a protein released when heart muscle cells die. Elevated levels are the gold standard for diagnosing heart attack
- Elevated CK-MB: Another cardiac biomarker that rises when heart muscle is damaged
- Rising levels at 6 hours: Serial measurements showing increasing biomarkers support ongoing cardiac damage, not a false positive
By all conventional criteria, this woman was having a heart attack. The diagnosis seemed certain.
Cardiac Catheterization Rules Out Blockage
Fortunately, the woman’s cardiac catheterization did not show any significant obstructive coronary artery disease.
This finding changed everything. Cardiac catheterization involves threading a catheter through blood vessels to the heart and injecting dye to visualize the coronary arteries. If the woman was having a traditional heart attack from blocked arteries, the catheterization would have shown the blockage.
The absence of coronary artery disease meant her chest pain, EKG changes, and elevated cardiac biomarkers had a different cause. Her heart muscle was being damaged, but not from blocked arteries.
Diagnosis Revealed by Facial Palsy
She was diagnosed with Lyme disease 2 days later after she had developed a right-sided facial palsy. The diagnosis was confirmed by ELISA and positive IgM and IgG antibodies.
The facial palsy (Bell’s palsy) was the diagnostic key. Sudden onset of one-sided facial weakness in a patient with unexplained cardiac symptoms should immediately raise suspicion for Lyme disease.
The positive IgM and IgG antibodies indicated active or recent Lyme infection. The combination of facial nerve palsy and cardiac involvement confirmed disseminated Lyme disease affecting multiple organ systems.
Treatment and Recovery
Treatment was successful with a combination of intravenous ceftriaxone and oral steroids.
The IV ceftriaxone targeted the Borrelia burgdorferi spirochetes causing the infection. The oral steroids likely addressed the facial nerve inflammation causing the palsy, though steroid use in Lyme disease remains somewhat controversial.
The successful treatment response confirmed the diagnosis and demonstrated that her cardiac symptoms were indeed from Lyme myocarditis, not coronary artery disease.
Why This Case Is Unusual
“This is a rare case of Lyme myocarditis associated with markedly elevated Troponin I, normal left ventricle function, and an absence of conduction abnormalities,” writes Gilson.
Three features make this case atypical for Lyme carditis:
1. Markedly elevated Troponin without conduction abnormalities: Most Lyme carditis cases present with heart block (conduction abnormalities) rather than elevated cardiac biomarkers. This patient had significant myocardial damage (evidenced by troponin) but preserved electrical conduction.
2. Normal left ventricle function: Despite elevated biomarkers indicating heart muscle damage, her heart’s pumping function remained normal. The damage was present but hadn’t impaired mechanical function.
3. Presentation mimicking acute MI: The chest pain, radiation pattern, EKG changes, and rising biomarkers created a perfect mimic of coronary artery blockage. Most Lyme carditis cases don’t look this much like traditional heart attack.
Diagnostic Challenges in Endemic Areas
The authors point out the difficulties diagnosing atypical manifestations of Lyme disease, stating, “Lyme myocarditis may be a challenging diagnosis in endemic areas especially in patients with coronary artery disease risk factors, presenting with typical chest pain, EKG changes and positive cardiac biomarkers.”
This statement highlights a critical problem: in endemic areas, middle-aged patients with cardiac risk factors who present with chest pain will almost always be assumed to have coronary disease. The clinical presentation drives clinicians toward that diagnosis.
But some percentage of these patients — we don’t know exactly how many — have Lyme myocarditis instead. Without maintaining Lyme disease in the differential diagnosis, they’ll be misdiagnosed.
Including Lyme in the Differential
The authors reminded doctors of the need to include Lyme disease in the differential diagnosis even in patients presenting with clinical symptoms suggestive of acute coronary syndrome.
This recommendation challenges standard practice. When a 45-year-old presents with chest pain, EKG changes, and elevated troponin, the emergency response protocol assumes heart attack. Treatment protocols activate, cardiac catheterization is arranged, antiplatelet agents and anticoagulants are administered.
But in endemic areas, Lyme myocarditis should be on the differential diagnosis list alongside acute coronary syndrome. The key differentiating feature: normal coronary arteries on catheterization despite elevated biomarkers and EKG changes.
When to Suspect Lyme Disease
Several clinical clues should raise suspicion for Lyme disease in patients presenting with chest pain:
- Geographic context: Patient lives in or recently visited endemic area
- Demographics: Younger patients (20-50 years old) with few traditional cardiac risk factors
- Normal coronary arteries: Catheterization shows no significant disease despite elevated biomarkers
- Systemic symptoms: Fever, headache, fatigue, body aches accompanying chest pain
- Multi-system involvement: Neurologic symptoms (facial palsy, meningitis) or joint symptoms
- Recent tick exposure: Known tick bite or outdoor activities in previous weeks to months
- Seasonal timing: Presentation in late spring, summer, or early fall
The Diagnostic Trap
This case illustrates a diagnostic trap: when clinical presentation perfectly fits a common diagnosis (heart attack), clinicians stop looking for alternatives. The chest pain, EKG changes, and elevated troponin created such a compelling picture of acute coronary syndrome that Lyme disease wouldn’t have been considered without the facial palsy.
But what if the facial palsy had developed a week later, or not at all? The diagnosis might have been missed entirely. The patient would have been labeled as having had a heart attack with “spontaneous resolution” or “coronary vasospasm” — diagnoses that don’t quite fit but seem better than admitting diagnostic uncertainty.
Clinical Perspective
In my 37 years treating Lyme disease, I’ve seen several patients with Lyme carditis initially diagnosed as heart attack. The pattern is similar: chest pain, elevated biomarkers, normal coronary arteries on catheterization, eventual recognition of Lyme disease when other symptoms develop.
The challenge is that Lyme myocarditis without conduction abnormalities is genuinely rare. Most cardiac Lyme presents with heart block, not with MI-like chest pain and biomarker elevation. So the diagnosis isn’t obvious even to clinicians familiar with Lyme disease.
This is where clinical judgment becomes critical. When coronary arteries are normal despite clear evidence of myocardial damage, the differential diagnosis must expand beyond coronary disease. In endemic areas during tick season, Lyme myocarditis should be high on that list.
The combination of oral steroids and IV ceftriaxone is interesting. Some physicians avoid steroids in Lyme disease, concerned they might suppress the immune response needed to clear the infection. Others use them selectively for severe inflammatory manifestations like facial palsy. This case suggests the combination was safe and effective, though the ceftriaxone likely did the heavy lifting.
The broader lesson: Lyme disease can affect the heart in diverse ways. While heart block is most common, myocarditis mimicking MI is documented. Maintaining diagnostic flexibility, especially in endemic areas, prevents misdiagnosis and ensures appropriate treatment.
Frequently Asked Questions
Can Lyme disease cause chest pain like a heart attack?
Yes. This patient had chest pain radiating to her neck with elevated troponin and EKG changes mimicking myocardial infarction. Lyme myocarditis can damage heart muscle causing symptoms identical to heart attack despite normal coronary arteries.
Can Lyme disease elevate troponin levels?
Yes. This case documented markedly elevated Troponin I from Lyme myocarditis. When spirochetes inflame and damage heart muscle, troponin is released just as it would be from blocked coronary arteries causing traditional heart attack.
How do you tell the difference between Lyme myocarditis and heart attack?
Cardiac catheterization is key. Heart attack shows blocked coronary arteries; Lyme myocarditis shows normal coronary arteries despite elevated biomarkers and EKG changes. Additional clues include systemic Lyme symptoms, facial palsy, and endemic area residence.
Can Lyme disease cause EKG changes?
Yes. Lyme carditis causes various EKG abnormalities including changes that mimic heart attack. This patient’s EKG changes suggested cardiac ischemia but were actually from inflammatory myocarditis.
Why is Lyme myocarditis without heart block unusual?
Most Lyme carditis cases present with conduction abnormalities (heart block) because spirochetes preferentially infiltrate the AV node. Myocarditis with elevated biomarkers but preserved conduction is documented but less common.
Should all chest pain patients in endemic areas be tested for Lyme disease?
Not all, but Lyme disease should be in the differential for younger patients with chest pain, elevated biomarkers, and normal coronary arteries on catheterization. Additional factors include systemic symptoms, recent tick exposure, and multi-system involvement.
Can Lyme myocarditis be treated successfully?
Yes. This patient recovered with IV ceftriaxone. Lyme carditis responds well to antibiotics when diagnosed and treated appropriately, with cardiac symptoms typically resolving within days to weeks.
Related Reading:
Lyme Carditis: When Heart Symptoms Can’t Wait
Lyme Carditis Diagnosis: 18 Cases Show Broader ECG Findings
Lyme Disease Cardiac Problems: 19 Documented Complications
Lyme Carditis Symptoms: 5 Critical Warning Signs
Young Adults and Lyme Carditis: Why Males Are at Highest Risk
Lyme Carditis Without Typical Symptoms
References:
- Gilson J, Khalighi K, Elmi F, Krishnamurthy M, Talebian A, Toor RS. Lyme disease presenting with facial palsy and myocarditis mimicking myocardial infarction. J Community Hosp Intern Med Perspect. 2017;7(6):363-365.
PTLDS is a medical term implying that all medical treatment has failed, and that one’s only hope is to seek alternatives outside the medical system. Chronic Lyme Disease, on the other hand, is acknowledgment of a disease process that proceeds Borrelia infection and by nature of tick biology, may include multiple co-infections. Whether by ongoing infection, immune response, unknown factors or a combination of these, people are still sick and treatments still need to be explored. Please stop calling it post treatment.
I am not happy with the term either. The 2006 IDSA guideline advised using the PTLDS label for patients still ill with functional limitations after 3 weeks of doxycycline. The term implies that the infection has cleared.
My husband was 59 when he died from Lymes Carditis. All Lymes tests for the month prior were negative. The CDC and Minnesota Department of Public Health confirmed the results after his autopsy.
Just wanted to tell you how sorry I am for the loss of your husband. Everything about this disease is horrible, including the lack of support from doctors and insurance companies, dismissal by the media and consequent ridicule from the public. So grateful to the medical professionals, researchers and patients who work tirelessly to change things for the better. Hoping you have some of those people in your life, and that those relationships provide the love and support you deserve.
Thats makes me so sad and scared My condolences. Im 21 and was actually positive for it. I’m being treated with doxy but im still scared I can die from this. I have anxiety 🙁
How are you doing now? I am currently on Doxycycline It’s been interesting feeling the medication work in various body parts. I had Herxheimer reaction, which went away and am now with chest pain behind the left breast, but all other symptoms are disappearing, as I believe the cheat pain will too. Have you recovered?
This is how my Lyme story started 3+ years ago. I had symptoms of a heart attack, raised troponin levels. All other cardio test came back that as a 50 year old, I had the cardiovascular system of a 35 year old.
I still have some palpitations, but my chest pain and back pain have cleared for the most part. My worst symptom is daily horrendous anxiety, major depression, crying jags. Still very scary for me EVERY DAY. Still in treatment.
Hello, I have had Lyme for over over 10 years it is believed. I did a short course of abx when I found out, now am
On herbal treatment. I had a oil set embolism before beginning the herbal treatment last year. A huge history o unexplained chest pains and tachycardia with a near normal cardiac workup other than some what my doc describes as insignificant ekg changes. They won’t even refer me to cardiology again although my symptoms are much the same and unimproved.
Doctors differ in how they look at Lyme disease. You should seek a Lyme disease second opinion in addition to followup by a cardiologist.
I Was finally diagnosed with lymes disease after going to the er for chills ,fever neck pain in 2016 by my primary care after the erythema rash developed on my knee several days later. I was placed on doxy for 10 days and all was good. Aug 2 2018 I woke with pain in my left shoulder pain , thought I slept wrong I took some aleeve in the morning went to work and still felt the discomfort. I develvedoped chills and thought am I getting lymes again. I had aches and pain in my upper body., pain when taking deep breath also. I went home thinking should I have gone to the er again. I took aleeve again and later had chills took my temp was 100.2 . I had no appetite. I tried to lie down for a while and rest and could not get comfortable at all. The pain in my shoulder and chest when I breathed was getting worse. So at 2 am I drove myself to my local er thinking I was having a heart attack or pulmonary embolism. I was taken quickly ekg no changes my bp was 211/90 hr 90. Labs drawn . All neg except for bnp was 298. Ct for pe was neg but did show Cardiomegaly. Lyme test was neg no rashes.
The er physician discussed I was not in any life threatening state. I stated to him it must be lymes again , my symptoms were very similar to 2016 except I had no chest pain or shoulder pain.i started on doxy that morning and chest pain and shoulder pain decreased . The pain would flare up and I would take ibproben 600mg every 12 hours and that seem to help a lot. I was able to sleep . I have access to my medical records and reviewed them from my visit in 2016 my chest X-ray showed Cardiomegaly also my crp was 3.9. . I made an appointment to see my primary care in 2 weeks . I am courious what labs should be drawn , should I see a cardiologist? I am also thinking of going to the Lyme research in Valhalla. Any suggestions.
You should definitely see a cardiologist. You also should pursue the tick borne infection question. Doctors are divided on their approach to tick borne illnesses. You should weigh the different treatment approaches.
I had a tick bite 8 months ago with a cascading rash. I started having a host of symptoms (swollen lymph nodes, left side facial insensitivity including the tongue, tingling in the arms, legs, and back of the head. I have a low body temp 97.5 and had terrible flu like symptoms. I was tested (Quest labs) using Western blot and was negative. I am an avid runner but started having minor chest pains (left side) that have progressively gotten more constant. They do not worsen with exercise. I received an MRI on brain which was negative. I have had 2 EKGs and have also had a stress test with contrast. All negative. All blood work negative. I am taking lisinopril for blood pressure and am on daay 30 of a 42 day doxy regiment. The symptoms have improved significantly with the exception of the chest pain. Any ideas?
Thanks for sharing your story. It is very common to end up with a wide range of tests in addition to tick borne illness. It sounds as if your doctor treated you based on clinical judgemnt with modest gains. Antibiotics can lead to chest pain. You should make sure you take probiotics. It is it doxycycline, you may need to take it with food. You will need followup to check to see if you are well. Don’t forget coinfections e.g. Babesia. My comments are meant for discussion and should not be a substitute for your doctor. You will need to work with your doctor.
This post caught my eye after a month of disconcerting chest pain directly over my heart and right side arm pressure and pain, especially while taking minocycline. Was diagnosed with Lyme 13 years ago and bartonella just two months ago. Went to ER, heart and lungs are fine, blood work is good, thyroid is fine but Hashimoto’s is flaring.
Dr. Cameron mentioned that antibiotics lead to chest pain–why is that? Is this a sign of a problem or just one more thing to get used to? So greatful for these forums, thank you!
I have seen chest pain related to gastritis or costochondritis due to Lyme disease. I have also seen chest pain relate to heart disease. I always include a cardiologist in the mix.
Hi Robert, I was wondering if your symptoms went away? Everything sounds very similar to what I have and I am a runner too. It started as a minor chest pain (left side) and slowly spread to a pretty bad shoulder and neck pain that gets worse at nights. I feel like my muscles on the upper left side got heavy or swollen and push on my nerves and that’s causing pain. It comes along with fatigue and low body temperature. There are good days and bad days. It’s been for 6 months. Quest lab tests for lyme came negative. I did 3 MRIs and chest CT scan – all negative. Not sure what’s going on and what should be my next step. Doctors tell me it’s not lyme, but nothing really helps and everything does sound awfully similar to what other people say on this page. If all your are symptoms has gone away, I will ask my doctors to prescribe doxy too. Thanks a million for any info.
Chest pain is so scary. I’ve been to 3 cardiologists and one electrophysiologist and they’ve all cleared me for heart problems. I just hate feeling like they’re missing something. I guess I just have to trust their judgement and the evidence the tests and multiple labs presents. Not sure why I have sharp bursts of chest pain other than lyme disease and co-infections. I absolutley never had palpitations, chest pain or shortness of breath before. Got sick last July and these symptoms began. I am glad I got checked out, both for cardiac and pulmonary issues. I just wish the pain would go away for good.
I am glad you do not have cardiac or pulmonary problems. You will likely have to see other doctors including doctors experienced in Lyme disease to try and find a solution.
Pretty scary stuff 🙁
Hope the women is now ok though!
I’ve had Lyme, Rocky Mountain Spotted Fever, Babesia, and Bartonella for 4 years now and I still get intermittent chest pains like a heart attack. Had a full cardiology work up when I was first sick but not yet diagnosed, everything looked wonderful. A couple years in I started getting race heart rates, low bp, and fainting episodes. A few EKGs came back abnormal, but would then resolve once at the hospital. My LLMD and PCP suspect POTs, I do have significant neurological disruption (left side of body feels slightly disconnected compared to the right, my pulse has also been noted as weaker in my left side, numbness, tingling, burning, shooting, occasional tremors with stress) to add on top of that. There’s also the issue of mold exposure, so trying to narrow it all down before jumping to carditis. Terrifying though, to have all the symptoms of a heart attack and physically feel like you’re dying while the people around you have no clue how to stop it or ease it.
You should also consider speaking with your Physician the Alpha-Gal Mammalian Meat Allergy allergy as possibly being a contributor to your chest pain. After treatment for Lyme Disease, it took 8 years for me to determine that most of my inflammation, respiratory issues and chest pain were directly related to the Alpha Gal Allergy and avoidance of key triggers, including meat, dairy, toothpaste and any products containing carrageenan.
It’s interesting how other diseases/illnesses can mimic a heart attack and cause the same symptoms. Some of these aren’t even necessarily dangerous. With mitral valve prolapse, for example, chest pain/angina is common, as are symptoms such as shortness of breath, fatigue, dizziness, etc. Thing is, one never knows, so it’s important to not brush off new/scary symptoms or wait it out.
@SuMay and @DocCameron – Came across this post as I’ve been diagnosed with Lyme via Igenix (Western blot came back neg of course). Biggest issue by far was I couldn’t seem to take a deep breath for months all of a sudden and had major breathing issues (enhanced when lying down). Added now are chest pains that typically are on the left side near and around my heart in various places. At first I thought it was some sort of heart attack (both jabbing sharp pains and then at times dull ache). Some days now the pain reverberates to the right side as well. @Su – Have your problems with chest pain resolved at all? Were you able to discover anything specific as it relates to the antibiotics and getting rid of the chest pain? @Doc – The part about costochondritis caught my eye as my PT specialist from years past kept saying I had exactly that (costo). Are there any known solutions or ideas on treatment for the chest pain while taking antibiotics for people with costo? Thx
I have patients with similar issues despite exhaustive evaluations by cardiologists. I have had some patients who have benefited from treatment for Lyme disease. I have also had patients who have air hunger from Babesia.
I realize I’m posting on an old feed, but didn’t see any comments asking if a loop recorder might help in these cases when palpitations, bradycardia and tachycardia are apparent but dismissed as not being dangerous. It seems they only look for afib?
I’m reading the devices can cause heart and or vessel issues, so is it worth the risk? Or should we be asking for some other type of tests?
I have not heard of the loop recorder have been a problem.
I was diagnosed with ALS in November and I am devastated as you can imagine. I found an engorged deer tick on my back in 2020. I was given 2 doses of doxycycline. I have had about 3 Lyme tests, all negative. Symptoms are very similar to Als. Weakness, slurred speech, twitching. Any comments? What do you think?
I have not been convinced a single 200 mg dose of doxycycline prevents more than a rash. I have also been concerned that a single dose of doxycycline may interfere with the testing. I advise my patients to look at Lyme disease a second time in addition to working with their neurologist even if the tests are negative.
Could you please pay attention in one of your much respected blogs to lyme induced costochondritis?
Thanks. There is not much written in the literature to discuss in a blog. I approach costochondritis in my Lyme patients by ruling out a cardiac cause. I approach costochondritis in my Lyme disease patients as I would for synovitis and bursitis.
This is a helpful information for us. Thanks for sharing it.