A 42-year-old New York City man quarantining upstate during COVID-19 developed Lyme carditis that progressed to cardiac arrest within two weeks of tick bite. The case demonstrates how rapidly Lyme carditis can deteriorate when diagnosis is delayed – and how completely patients recover when treatment finally begins.

Geographic Dislocation During Pandemic

A 42-year-old man from New York City received a Lyme carditis diagnosis after quarantining in upstate New York during the COVID-19 pandemic. The case is discussed in the article “A curious case of Lyme carditis in an urban hospital,” by Brissett et al.

“Lyme carditis was a surprise diagnosis in our hospital due to the patient’s geographical dislocation during the COVID-19 pandemic,” writes Brissett.

This geographic dislocation created a diagnostic blind spot. NYC hospitals rarely see Lyme carditis – it’s not on their standard differential diagnosis for cardiac presentations. When this patient arrived at an urban ER with severe cardiac symptoms, the medical team had no reason to suspect a tick-borne disease contracted during upstate quarantine.

The Timeline: Tick Bite to Cardiac Arrest

In an effort to remain safe during the COVID-19 pandemic, the man sheltered at an upstate New York residence. During this time, he noticed a tick bite.

Two weeks later, he was admitted to the emergency room of an NYC hospital with “progressively worsening generalized weakness, presyncope and dyspnea on exertion.”

This two-week interval from tick bite to emergency presentation is characteristic of Lyme carditis, which typically develops 1 week to 2 months after infection. But the rapidity of progression is alarming – within 14 days, he went from tick bite to life-threatening cardiac emergency.

Emergency Room Presentation

In addition, the patient was diaphoretic (excessive sweating) and appeared anxious when admitted to the ER. “Asystole was also noted on telemetry leading to a transient loss of consciousness,” the authors explain.

The man “had marked bradycardia at 30 beats per minute and hypotension.”

These findings paint a picture of profound cardiac compromise. Heart rate of 30 beats per minute is dangerously low (normal is 60-100). Asystole – complete absence of electrical activity – led to loss of consciousness. The excessive sweating and anxiety reflected his body’s stress response to inadequate cardiac output.

Two days prior to presenting to the ER, the patient had developed a Bull’s-eye rash, which extended from his back to his thigh.

The presence of erythema migrans rash should have been a major diagnostic clue. But in the chaos of managing severe bradycardia and asystole in a patient from NYC, the connection between tick bite two weeks ago, current rash, and cardiac emergency wasn’t immediately made.

Cardiac Findings

An EKG revealed third-degree heart block with ventricular escape rhythm.

Third-degree (complete) heart block means no electrical signals travel from the atria to the ventricles. The heart’s upper and lower chambers beat independently. The ventricles maintain some activity through an “escape rhythm” – a backup pacemaker that fires slowly, explaining the 30 beats per minute heart rate.

This represents the most severe form of Lyme carditis-induced conduction abnormality. Without treatment, complete heart block can progress to cardiac arrest.

Delayed Lyme Carditis Diagnosis Worsens Outcome

The patient’s condition quickly worsened, and he went into cardiac arrest.

He was resuscitated and a temporary transvenous pacemaker was implanted.

This progression from ER arrival to cardiac arrest demonstrates the narrow window for diagnosis in severe Lyme carditis. The patient presented critically ill, but there was still time for intervention. Once cardiac arrest occurred, the situation became immediately life-threatening.

“Cardiac arrest is rare, and mortality extremely uncommon,” the authors explain. “Of the rare case fatalities reported, delay in recognition was the main factor leading to a poor outcome.”

This statement deserves emphasis: deaths from Lyme carditis are preventable. When patients die, it’s because the diagnosis wasn’t made in time. The infection itself is treatable; the danger is failing to recognize it.

Young and colleagues agree. “Patients with Lyme carditis often have missed or late diagnoses, which can result in unnecessary pacemaker implantations, complications, and even fatalities.”

Diagnostic Confirmation

The patient’s test results were positive for Lyme disease on the ELISA, IgG Western blot, and IgM Western blot. Troponin and COVID-19 tests were negative.

Multiple positive tests provided strong serologic confirmation. Both IgM and IgG positivity suggests early disseminated disease with robust immune response. The negative troponin indicated the heart block wasn’t due to myocardial infarction. The negative COVID-19 test was particularly relevant given the pandemic timing.

Treatment and Recovery

After 3 days of treatment with IV antibiotics (ceftriaxone), EKG results were normal. He was later prescribed oral doxycycline and had a complete recovery.

The speed of recovery is remarkable. Within 72 hours of starting antibiotics, his heart block completely resolved. The temporary pacemaker could be removed. He didn’t need permanent pacing.

This rapid improvement demonstrates that the conduction abnormality was caused by active infection and inflammation, not permanent structural damage. Once antibiotics killed the spirochetes and inflammation resolved, normal electrical conduction returned.

What Makes This Case Unique

The authors note several important points:

“This case is unique due to its occurrence in an urban hospital where such cases are uncommon.”

Urban hospitals in NYC don’t expect Lyme carditis. The disease isn’t on their diagnostic radar for cardiac emergencies. This geographic unfamiliarity contributed to delayed recognition even though the patient had classic findings: tick bite, EM rash, and third-degree heart block.

“Our case highlights the rapidly progressive nature of the illness [Lyme carditis] and the rapid rate of recovery when timely intervention is instituted.”

Two weeks from tick bite to cardiac arrest. Three days from antibiotic initiation to normal EKG. Both timelines are dramatic – demonstrating both the danger of missing the diagnosis and the effectiveness of treatment once given.

“With appropriate use of antibiotic and temporary pacemaker placement, our patient had resolution of his symptoms and had a remarkable recovery.”

The COVID-19 Context

The pandemic created perfect conditions for this near-tragedy. A city dweller quarantined in an endemic area he wouldn’t normally visit. Hospitals focused on COVID-19, not tick-borne diseases. A patient presenting with severe illness during peak pandemic stress on the healthcare system.

But the pandemic also created the exposure. Without COVID-19, this NYC resident might never have spent extended time in upstate New York during tick season. His geographic dislocation was entirely pandemic-driven.

Clinical Perspective

This case represents a pattern I see far too often: patients experiencing multiple healthcare encounters before Lyme carditis is finally diagnosed. This man didn’t just show up in cardiac arrest – he had two days of progressive symptoms before seeking ER care. He had a Bull’s-eye rash. He had a documented tick bite two weeks prior.

All the diagnostic clues were present. What was missing was the clinical index of suspicion in an urban hospital unfamiliar with Lyme disease.

The consequence of that diagnostic gap was cardiac arrest. The patient required resuscitation and emergency pacemaker placement. He came perilously close to becoming a Lyme carditis fatality statistic.

Yet with appropriate treatment, he made a complete recovery. This is the tragedy of Lyme carditis deaths – they’re preventable. The infection responds dramatically to antibiotics. The conduction abnormalities resolve. Patients recover completely.

But only if we make the diagnosis before it’s too late.

Lessons for Clinicians

Several teaching points emerge from this case:

• Geographic history matters. Ask about recent travel, not just current residence. This patient’s upstate quarantine was the key to diagnosis.
• Tick bite + cardiac symptoms = urgent Lyme evaluation. Don’t wait for perfect serologic confirmation when the clinical picture suggests Lyme carditis.
• EM rash is diagnostic. When present, it confirms Lyme disease regardless of testing. This patient had classic erythema migrans.
• Time is critical. Lyme carditis can progress from symptoms to cardiac arrest in hours to days. Early recognition prevents catastrophic outcomes.
• Treatment works. Even severe heart block resolves rapidly with antibiotics. Don’t assume patients with third-degree block need permanent pacemakers until after infection is treated.

Frequently Asked Questions

How quickly can Lyme carditis progress?

This case demonstrates rapid progression – from tick bite to cardiac arrest in just two weeks. Lyme carditis typically develops 1 week to 2 months after infection, and can deteriorate from mild symptoms to life-threatening heart block within days.

Can Lyme carditis cause cardiac arrest?

Yes, though it’s rare. Complete (third-degree) heart block can progress to asystole and cardiac arrest. Most Lyme carditis deaths occur because the diagnosis was delayed, not because the infection itself is untreatable.

How fast does Lyme carditis respond to treatment?

Remarkably fast. This patient had normal EKG results within 3 days of starting IV antibiotics. Heart block typically resolves within days to weeks of antibiotic initiation, often allowing temporary pacemakers to be removed.

Do patients with third-degree heart block from Lyme need permanent pacemakers?

Usually not. When heart block is caused by Lyme carditis rather than structural heart disease, it resolves with antibiotic treatment. Temporary pacing bridges patients until antibiotics work; permanent pacemakers are rarely needed.

Can you get Lyme disease while quarantining for COVID-19?

Yes. Many people quarantined in rural or suburban areas during COVID-19, often in regions with endemic tick populations. This geographic dislocation created Lyme disease exposures in people who don’t normally spend time in endemic areas, leading to diagnostic confusion when they presented to urban hospitals.