Diplopia (double vision) and heart block in early-disseminated Lyme disease

In the latest issue of Mayo Clinical Proceedings, a physician from Mayo Clinic describes a 49-year-old man from Minnesota with acute-onset diplopia (double vision) and heart block in early-disseminated Lyme disease. [1] “This patient met criteria for early-disseminated Lyme disease with multiple erythema migrans lesions and evidence of cardiac and neurologic involvement,” according to Blackwell from the Department of General Internal Medicine, Mayo Clinic. Over the course of a month, the patient’s rash grew to cover most of his chest.

by Daniel J. Cameron, MD MPH

One month prior to being evaluated, the man had removed a tick from his outdoor cat. His laboratory tests were positive on both a Lyme enzyme-linked immunosorbent assay screening and confirmatory Western blot with 3 IgM bands: p41, p39, and p23.

His electrocardiography revealed new second-degree Mobitz type I heart block. He was admitted for additional workup and monitoring.

Source: Mayo Clinic, Whitney Blackwell, MD https://www.mayoclinicproceedings.org

A magnetic resonance imaging was arranged within 24 hours of admission. The image “revealed abnormal enhancement of the bilateral oculomotor nerves, left trigeminal nerve, and probable left abducens nerve, consistent with disseminated Lyme disease,” explains Blackwell.

The man’s rash, heart block, fatigue and myalgias improved quickly on initiation of a four-week course of intravenous ceftriaxone.

It is not clear if the heart block, diplopia, hospitalization, and 4 weeks of intravenous ceftriaxone could have been prevented if the 49-year-old man had been treated a month earlier at the onset of the rash. The case report did not discuss whether the antibiotics resolved the diplopia.

References:

1. Blackwell WA. Early Disseminated Lyme Disease. Mayo Clin Proc. 2017;92(4):687-688.