Lyme Myocarditis in Adolescents: Atypical Symptoms Can Be Misleading
Lyme myocarditis in adolescents often presents with gastrointestinal or respiratory symptoms rather than classic cardiac complaints. A 15-year-old girl with severe epigastric pain was initially evaluated for gallbladder disease before Lyme myocarditis was identified. Her troponin was 50 times the threshold for heart attack, yet chest pain was not her primary complaint. :contentReference[oaicite:0]{index=0}
Why Lyme Myocarditis in Adolescents Is Often Missed
In 2013, the CDC reported sudden cardiac deaths in young adults due to unrecognized Lyme carditis. These cases highlight the risk of missed diagnosis in younger patients without classic cardiac symptoms.
Recognizing atypical Lyme myocarditis in adolescents can be life-saving.
Case Report: Adolescent With Atypical Presentation
A previously healthy 15-year-old girl presented with severe retrosternal and epigastric pain, described as “gnawing” and “twisting,” rated 9/10 in severity.
The symptom pattern suggested gastrointestinal disease rather than cardiac involvement, contributing to delayed recognition.
Initial Workup Suggested Gallbladder Disease
Findings included abnormal liver tests, bile duct dilation, gallbladder thickening, and a positive Murphy sign.
The evaluation was appropriate but did not identify the underlying cardiac condition.
Severe Cardiac Involvement Identified
Electrocardiography revealed conduction abnormalities. Troponin-I was 15.81 ng/mL—more than 50 times the threshold for myocardial infarction.
Echocardiography showed reduced ejection fraction (37–40%), indicating significant myocardial dysfunction.
Early Recognition Changed the Outcome
Lyme disease was considered early due to the patient’s residence in an endemic area and unexplained myocarditis.
She developed second-degree atrioventricular block and hypotension, confirming cardiac involvement.
Rapid Recovery With Treatment
Empiric doxycycline was started promptly. Her conduction abnormalities resolved within days, demonstrating the reversibility of Lyme myocarditis.
Key Clinical Lessons
- Lyme myocarditis in adolescents often presents without chest pain
- Gastrointestinal symptoms may dominate
- EKG is essential in unexplained presentations
- Early treatment can reverse severe cardiac dysfunction
When Lyme Testing Is Negative
Negative serology does not exclude Lyme myocarditis early in infection.
Clinical judgment should guide evaluation and treatment decisions.
Clinical Perspective
This case highlights a key diagnostic challenge: Lyme myocarditis in adolescents may not resemble typical cardiac disease.
Unexplained abdominal pain, respiratory symptoms, or cardiac complaints in patients from endemic areas should prompt evaluation for Lyme carditis, including an immediate EKG.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
Hello Dr Cameron: my son has similar Lyme carditis symptoms now: 1st degree AV block and shortness of breath (since May), new intermittent pain in sternum (esp. upon sneezing) and abdominal pain within the last two days. He has a WB from May; pos IGm for 2 bands and IGg pos for three bands specific to Lyme per Horowitz criteria. Negative ELISA. Neg. Babesia PCR via Sonoma.
Based upon migrating muscle and joint pain, heart block, he was treated with oral doxy six weeks, June- July and then added 3 weeks of azithromycin and atovaquone for presumptive babesia when the dyspnea got worse. Muscle and joint pain resolved after 5 weeks; dyspnea improved much, as of mid July, but still remains now and is getting worse along with new onset chest and stomach pain.
His Aug 8 EKG follow-up shows 1st degree AV block still.
What imaging and testing do you recommend for him now? It seems IV ceftriaxone is far superior to oral doxy in cases like this?
Lyme disease can lead to autonomic changes that affect the stomach. C. difficile can also affect the stomach. It is hard to know if the heart block will change. I like IV. I also like doxycycline.
Hello Dr. Cameron. I an a Registered Nurse for nearly 25 years. I have a friend whose son (@35 y/o male) who is suffering from unsuccessful treatment of Lymes Disease. He, today is c/o sub- sternal pain, headaches, extreme fatigue. He lives in Maryland where he believes he was bitten by a tick. To date, he has been unable to locate a Physician who can/will treat him. He has been dealing with this for @ 2 1/2 years and I, in my Nursingexperience, believe his medicalstatus is worsening. Is there anything you can direct him towards in terms of “next steps.” I, as an RN am concerned about possible endocarditis. My email is
di**************@***il.com
My name is Diane Lee Bloodworth
I reside in Pennsylvania.
Thank you very much for any information or suggestions you may provide.
Hello Dr Cameron I’m a 43 year women I was just diagnosed with a positive western blog test for lyme disease I was given doxycycline took for 15 days only because I developed a right abdominal pain and dark urine also left side pain after this I was given 300 mg of cefdinir for a urinary tract infection ( proteus mirabilis) finish the treatment .ultrasound showed I now have one kidney inflamated and acalcoulous cholecystitis I’m having mild pain I do feel ill but nothing I cannot handle what should I do thier sending me for a HIDA scan .I’m getting intravenous ceftriaxone I believe in two days for lyme and I also have a bladder cyst and a prolapse that needs intervention any advice would be very much appreciated?
I am glad you have a doctor who is working through each of your issues. I would be concerned using IV ceftriaxone as it can leave sludge in your gall bladder and you have a history of cholecystitis. Call my office at 914 666 4665 if you have any questions.