Can Lyme Disease Cause Myocarditis in Teenagers? A Case of Chest Pain and Lyme Disease

Lyme myocarditis is a rare cardiac complication of Lyme disease
Teenagers may present with chest pain or gastrointestinal symptoms
Early ECG evaluation and antibiotic treatment can lead to recovery

Can Lyme disease cause myocarditis in teenagers? Yes. Lyme disease myocarditis is uncommon, but it can occur in adolescents and may present with chest pain, shortness of breath, fatigue, palpitations, dizziness, or gastrointestinal symptoms. Lyme carditis most commonly affects the heart’s electrical conduction system, causing varying degrees of atrioventricular (AV) block. Less commonly, Lyme disease can also inflame the heart muscle itself, resulting in myocarditis. Because these symptoms can resemble viral illness, gallbladder disease, or other cardiac conditions, diagnosis may be delayed.

A recent review found that atrioventricular block remains the most common manifestation of Lyme carditis, while structural cardiac complications—including myocarditis and pericarditis—occur much less frequently. Although most patients recover with prompt antimicrobial therapy, persistent cardiac dysfunction has been reported in a minority of patients, highlighting the importance of early recognition and treatment.

In 2013, the Centers for Disease Control and Prevention (CDC) highlighted the potential seriousness of Lyme carditis after describing three sudden cardiac deaths associated with Lyme carditis. During November 2012 through July 2013, one woman and two men between 26 and 38 years of age from Lyme-endemic states died suddenly and were found at autopsy to have evidence of Lyme carditis.

Although these fatal cases involved adults, Lyme myocarditis and Lyme carditis can also occur in children and adolescents. Fortunately, early recognition, appropriate cardiac evaluation, and prompt antibiotic treatment usually result in an excellent prognosis. In pediatric patients with Lyme myocarditis, respiratory and gastrointestinal symptoms, with or without chest pain, are among the most common presenting features.

In Pediatric Emergency Care, Fishe and colleagues described a previously healthy adolescent girl whose severe chest pain ultimately proved to be Lyme myocarditis rather than gallbladder disease or another more common condition. The patient lived in a Lyme-endemic region but did not recall a tick bite, illustrating that the absence of a known tick exposure does not exclude Lyme disease.

The case also highlights an important clinical teaching point. In children and adolescents, Lyme myocarditis may present with respiratory or gastrointestinal complaints, with or without chest pain. Recognizing these atypical presentations may lead to earlier electrocardiogram (ECG) testing, Lyme disease evaluation, and treatment.

A previously healthy 15-year-old African-American girl was hospitalized after a three-day history of intermittent retrosternal and epigastric pain. She described the pain as “gnawing” and “twisting” without radiation to the sternal or right upper quadrant area. She rated the pain as 9 out of 10 in severity. Physical examination found no evidence of costochondritis.

Because of her symptoms and laboratory abnormalities, physicians initially considered gallbladder disease. She had mildly elevated liver function tests, focal dilation of the common bile duct, gallbladder wall thickening on ultrasound, and a positive Murphy sign. The pediatric surgeon concluded that the findings were consistent with cholelithiasis but not acute cholecystitis.

This portion of the case illustrates how Lyme myocarditis can occasionally mimic hepatobiliary disease. Upper abdominal pain, abnormal liver enzymes, and right upper quadrant tenderness may initially suggest gallbladder pathology rather than cardiac inflammation, potentially delaying the diagnosis unless clinicians maintain a broad differential diagnosis. In patients from Lyme-endemic regions, persistent chest pain accompanied by abnormal ECG findings or elevated cardiac biomarkers should prompt consideration of Lyme disease despite an alternative abdominal diagnosis.

The patient was admitted with a presumptive diagnosis of myocarditis. Her initial electrocardiogram (ECG) demonstrated normal sinus rhythm but revealed low voltage throughout all leads, a widened QRS complex, right axis deviation, and a nonspecific intraventricular conduction block.

Laboratory testing also supported significant myocardial injury. According to Fishe and colleagues, her troponin-I level was markedly elevated at 15.81 ng/mL (hospital laboratory criterion for acute myocardial infarction >0.3 ng/mL). A bedside echocardiogram demonstrated moderately reduced left ventricular systolic function with an ejection fraction of 37% to 40% and a trivial pericardial effusion.

Because myocarditis has many potential causes, she initially received empiric treatment with intravenous immune globulin (IVIG) at 1 g/kg. However, during hospitalization she developed second-degree atrioventricular block (Mobitz type II) together with hypotension, findings that raised concern for Lyme carditis.

Recognizing that Lyme disease can involve both the cardiac conduction system and, less commonly, the heart muscle itself, the medical team ordered Lyme disease serologic testing and empirically started doxycycline while awaiting the laboratory results.

She also received a milrinone infusion for afterload reduction and intravenous furosemide for pulmonary edema. Her clinical course improved rapidly. By hospital day 2, her ECG had improved from second-degree heart block to first-degree atrioventricular block, and by hospital day 3 the conduction abnormalities had completely resolved.

Her Lyme disease was subsequently confirmed by positive serologic testing. The Lyme enzyme-linked immunosorbent assay (ELISA) was positive, and Lyme immunoglobulin M (IgM) measured 0.87 (reference range, 0.00-0.79), supporting the diagnosis of acute Lyme disease.

The patient recovered steadily and was discharged home on hospital day 7 with oral furosemide, enalapril, and doxycycline.

The authors noted that a Cochrane review found insufficient evidence to support the routine use of IVIG in acute myocarditis. More recent reviews likewise emphasize that prompt antimicrobial therapy remains the cornerstone of treatment for Lyme carditis and Lyme myocarditis. Although most patients recover completely, persistent conduction abnormalities, myocardial dysfunction, and other long-term cardiac sequelae have been reported in a minority of patients, underscoring the importance of early diagnosis and appropriate follow-up when clinically indicated.

This case demonstrates how Lyme myocarditis can evolve rapidly from severe chest pain to significant cardiac dysfunction and heart block. Fortunately, early recognition, supportive cardiac care, and prompt antibiotic therapy resulted in an excellent outcome.

Fishe and colleagues emphasize that clinicians should explain all diagnostic findings obtained during the evaluation and maintain a low threshold for obtaining an electrocardiogram (ECG) in patients with suspected Lyme disease who develop cardiopulmonary symptoms. They also remind clinicians that children and adolescents commonly present with respiratory or gastrointestinal complaints, with or without chest pain, making early recognition particularly challenging.

Clinicians should also remember that many patients with Lyme carditis or Lyme myocarditis do not recall a tick bite. In endemic regions, unexplained chest pain, elevated troponin levels, new conduction abnormalities, or myocarditis should prompt consideration of Lyme disease even when a classic erythema migrans rash is absent.

Frequently Asked Questions

Can Lyme disease cause myocarditis?

Yes. Although Lyme carditis most commonly affects the heart’s electrical conduction system, Lyme disease can occasionally cause myocarditis, an inflammation of the heart muscle. Patients may develop chest pain, elevated cardiac enzymes, reduced heart function, heart block, or heart failure symptoms. Prompt recognition and antibiotic treatment are essential, and most patients recover completely with appropriate therapy.

Can Lyme disease cause myocarditis in teenagers?

Yes. Although uncommon, Lyme myocarditis can occur in children and adolescents. This case illustrates that teenagers may present with severe chest pain, respiratory symptoms, or gastrointestinal complaints rather than the classic features of Lyme disease. A history of a tick bite or erythema migrans rash may be absent.

Can Lyme myocarditis be mistaken for gallbladder disease?

Yes. Upper abdominal pain, abnormal liver function tests, gallbladder wall thickening, and right upper quadrant tenderness may initially suggest gallbladder disease. This case demonstrates why Lyme disease should remain part of the differential diagnosis in patients from endemic regions who later develop cardiac abnormalities.

How is Lyme myocarditis diagnosed?

Diagnosis is based on the clinical presentation together with electrocardiogram (ECG) findings, cardiac biomarkers such as troponin, echocardiography when appropriate, and Lyme disease serologic testing. In patients from Lyme-endemic areas, clinicians should have a low threshold for obtaining an ECG when unexplained chest pain, palpitations, syncope, or other cardiopulmonary symptoms develop.

Clinical Takeaway

Lyme myocarditis is a rare but potentially serious manifestation of Lyme disease that may mimic viral myocarditis, gallbladder disease, or other causes of chest and upper abdominal pain. In adolescents, respiratory and gastrointestinal complaints may occur with or without chest pain, making diagnosis particularly challenging.

Most patients with Lyme myocarditis recover with prompt antibiotic therapy. However, recent evidence suggests that a small subset may experience persistent conduction abnormalities or myocardial dysfunction, emphasizing the importance of early diagnosis, appropriate treatment, and follow-up when clinically indicated.

Related Articles

Learn more about the cardiac manifestations and diagnosis of Lyme disease:

Lyme Carditis: Symptoms, Heart Block, and Treatment
Can Lyme Disease Be Fatal? A 17-Year-Old’s Fatal Lyme Carditis Case
Lyme Disease Symptoms Guide
Why Lyme Disease Is Often Misdiagnosed

References

1. Centers for Disease Control and Prevention. Three sudden cardiac deaths associated with Lyme carditis — United States, November 2012–July 2013. MMWR Morb Mortal Wkly Rep. 2013;62(49):993-996.
2. Fishe JN, Marchese RF, Callahan JM. Lyme Myocarditis Presenting as Chest Pain in an Adolescent Girl. Pediatr Emerg Care. 2016;32(7):460-462.
3. Badheeb M, Ahmed A, Stolear A, et al. Long-term Cardiac Sequelae in Lyme Carditis: A Review. Curr Cardiol Rev. 2026;22(4):e1573403X395575.

---

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