Lyme Carditis Guidelines: Which Lyme Disease Guidelines Should Clinicians Follow?
In their article Lyme Carditis: A Rare Presentation of Sinus Bradycardia Without Any Conduction Defects, Grella and colleagues present “a unique case of Lyme carditis, without the classical findings of Lyme disease [such as a rash] or common EKG findings of AV conduction abnormalities.”1 The case highlights how different Lyme disease guidelines can lead to different treatment decisions.
Management of Lyme carditis may vary depending on which Lyme disease guidelines clinicians follow and how patients respond to initial therapy.
A 56-year-old man was admitted to the emergency department with lightheadedness and chest pain. An EKG revealed sinus bradycardia — an abnormally slow heart rhythm that can occur when Lyme disease affects the electrical conduction system of the heart.
Western blot test results for Lyme disease were positive and included IgG bands 18, 28, 39, 41, 45, 58, 66, and 93. His IgM was reported as negative, although band 23 was positive.
The patient was initially treated with a 7-day course of intravenous ceftriaxone.
However, “he continued to have persistent bradycardia with his heart rate dropping to 20 to 30 beats per minute throughout the night,” writes Grella. “Additionally, he had several sinus pauses while sleeping, with the longest lasting for 6.1 seconds.”
The patient required further treatment with a pacemaker and an additional 3-week course of intravenous ceftriaxone.
At his one-month follow-up visit, he was symptom-free.
Lyme Carditis Does Not Always Present Classically
The authors note that Lyme disease patients may present in different ways.
“A gray zone exists in regards to the treatment of Lyme disease because every patient does not present with the characteristic rash and symptoms of Lyme disease.”
This case highlights that Lyme carditis may occur even without the classic erythema migrans rash or the more common AV conduction abnormalities typically associated with Lyme disease.
Different Lyme Disease Guidelines
As Grella points out, there are different treatment guidelines for Lyme disease.
The Infectious Diseases Society of America (IDSA) recommends that patients receive a short course of antibiotics because persistent infection is considered infrequent or non-existent.
By contrast, the International Lyme and Associated Diseases Society (ILADS) recommends using the GRADE system. This approach allows clinicians to consider longer antibiotic treatment when symptoms persist or when patients fail to respond to initial therapy.
These differences in recommendations reflect ongoing debates about treatment duration and how clinicians should respond when symptoms continue after initial therapy.
Lyme Carditis Treatment May Depend on Severity
Lyme carditis treatment may also vary depending on the severity of cardiac involvement.
Patients with Lyme carditis who do not have high-grade heart block may be managed with oral antibiotics.
Patients with high-grade heart block should be hospitalized, closely monitored, and treated with intravenous ceftriaxone (2 g daily) or intravenous penicillin for second- or third-degree AV block or PR interval greater than 300 ms.
Other organizations recommend different approaches. For example, the European Federation of Neurological Societies (EFNS) recommends ceftriaxone or cefotaxime for approximately two weeks as standard treatment for acute Lyme carditis.
What This Case Teaches
This case illustrates several important points:
- Lyme carditis can present without the classic rash.
- Lyme carditis may occur without typical AV conduction abnormalities.
- A short initial course of treatment may not always be sufficient.
- Different Lyme disease guidelines can lead to different treatment decisions.
The Authors Conclude
“A high clinical suspicion of Lyme carditis is required when someone from a Lyme endemic region presents with unexplained cardiac symptoms and has EKG findings suggestive of carditis.”
Editor’s note: The eventual treatment duration in this case was consistent with ILADS guidelines, as the patient did not respond to the initial short course of therapy.
Editor’s disclosure: I am a co-author of the ILADS Lyme disease treatment guidelines.
Frequently Asked Questions
How is Lyme carditis treated?
Lyme carditis treatment depends on the severity of heart involvement. Mild cases may be treated with oral antibiotics, while patients with significant conduction abnormalities may require hospitalization and intravenous antibiotics.
Can Lyme carditis occur without a rash?
Yes. Lyme carditis may occur even when the classic erythema migrans rash is absent. This can make diagnosis more challenging and requires clinicians to consider Lyme disease in patients with unexplained cardiac symptoms in endemic regions.
Related Articles:
17-year-old young man dies from Lyme carditis
Broad range of presentations for Lyme carditis
Lyme carditis causes complete heart block in 26-year-old man
References:
- Grella BA, Patel M, Tadepalli S, Bader CW, Kronhaus K. Lyme Carditis: A Rare Presentation of Sinus Bradycardia Without Any Conduction Defects. Cureus. 2019 Sep 2;11(9):e5554.
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
How does one get their PCP to understand Lyme disease and the treatment? My PCP is not on board with it.
There are doctors who have given other doctors if they treat Lyme disease. That opposition is preventing some of our brightest doctors from treating more than early Lyme disease. Until times change, you will likely need to seek a second opinion. Call my office in New York at 914 666 4665 if any further questions.
Theres a hearing next week here in Richmond VA for a doctor who dared to treat Chronic Lyme and now they’re trying to suspend her license!!! My friend told me that she was asked if she had Lyme when trying to obtain new Health Insurance. It’s so disheartening.
Thanks for sharing your frustration.
You commented that multi system disease presentations like Lyme disease get a psychiatric Diagnosis many times. This is SO true with Lyme Disease. In 1986, Jeff Boyle presented with one of the first cases of Lyme disease in Illinois. He lived on the Fox River in Algonquin, IL. The Fox River comes to IL from Wisconsin. WI is endemic for Lyme and having ticks. They migrated on birds traveling to Illinois down the Fox River. He went to Mayo Clinic to get information about this unknown disease. They said then that it was a psychological problem and gave him an anti psychotic drug. He was referred to the local mental health center, where I met him. He even got psychotherapy where he talked about the symptoms of his disease. I’m an Occupational Therapist and his symptoms were new to me. But now I have Lyme disease, I remember his symptoms. I got bit in the same area. The birds have been carrying The ticks down from Wisconsin and NO ONE reported to the public that this was a problem and they need to take precautions. Back then people would say to him to look further for a diagnosis and treatment for his illness. He said “I’ve been to Mayo Clinic. Where else do I go?” I’m sure that Jeff has taken his life by now. My other friend Jim Cemenski lived on the Fox River in Algonquin also. He also had Lyme Disease for quite a number of years. He passed it on to his wife who was diagnosed with fibromyalgia. Another nightmare story of Lyme Disease.