Temporary Pacemaker in Lyme Carditis: Reversible Heart Block Case
Temporary pacemaker use in Lyme carditis demonstrates that even severe heart block can be fully reversible. This case — the first to capture day-by-day electrocardiographic progression — shows high-degree AV block evolving to complete heart block and then resolving to normal sinus rhythm within two weeks.
This raises an important question: do young patients with Lyme carditis need permanent pacemakers? In many cases, temporary pacing combined with antibiotic treatment may be sufficient.
Sudden Syncope Without Warning
The patient presented with a syncopal episode with no prodrome, shortness of breath and weakness, according to the case study, entitled Electrocardiographic progression of acute Lyme disease.
“Syncope with no prodrome” means he fainted without warning. No lightheadedness beforehand. One moment conscious, next moment unconscious. This pattern indicates severe cardiac pathology, where heart rate drops abruptly and cerebral perfusion is compromised.
Three weeks prior, he had experienced an insect bite on his calf after outdoor exposure. One week later, he developed chills, sweats, myalgia, back pain, headache and fatigue. By week three, cardiac involvement had progressed to complete heart block.
Diagnosis and Immediate Intervention
Lyme carditis was diagnosed based on clinical presentation, bradycardia (38 bpm), high-degree AV block, and absence of ischemia. A temporary transvenous pacemaker was placed, and intravenous ceftriaxone was initiated.
The diagnosis relied on clinical judgment: young patient, outdoor exposure, systemic symptoms, and severe conduction abnormality without coronary disease.
The temporary pacemaker provided immediate stabilization while antibiotic therapy addressed the underlying infection.
First Case to Capture Daily EKG Evolution
The Lyme carditis resolved without the need for a permanent pacemaker. The EKG evolved from high-degree AV block to complete heart block, then improved progressively to normal sinus rhythm.
EKG Progression Timeline:
- Day 1: High-degree AV block, pulse 38 bpm
- Days 2-3: Progression to complete heart block
- Day 5: Improvement to 2:1 AV block
- Day 6: Temporary pacemaker removed
- Week 2: Normal sinus rhythm restored
This pattern shows initial worsening followed by recovery once antibiotic treatment takes effect.
Temporary Pacemaker Removed Day 6
The pacemaker was removed on Day 6 after recovery of intrinsic conduction. By the second week, the patient had returned to normal sinus rhythm and completed antibiotic therapy without requiring a permanent device.
Most Patients Don’t Remember Tick Bite
Most patients with Lyme carditis do not recall a tick bite. The absence of a clear exposure history should not exclude Lyme disease when the clinical presentation is suggestive.
Similarly, only about 40% of Lyme carditis patients report erythema migrans rash, compared with higher rates in general Lyme disease.
Who Needs Hospitalization?
Hospitalization is recommended for patients with second- or third-degree AV block, or first-degree AV block with significant PR prolongation. Continuous monitoring is essential, as conduction abnormalities can progress rapidly.
Heart block can progress within hours, requiring close observation and timely intervention.
CDC Observations on Lyme Carditis
Several clinical observations are important:
- Males are disproportionately affected
- Patients aged 15-45 are at higher risk
- Many cases occur without rash
- Cardiac symptoms require prompt evaluation
- ECG is essential when Lyme carditis is suspected
- Exposure history should always be assessed
Why This Case Matters
This case illustrates a reversible cardiac complication of Lyme disease. Recognition of Lyme carditis can prevent unnecessary permanent pacemaker placement.
Acute heart block may resolve with appropriate antibiotic therapy, particularly when diagnosed early.
- Young patient without prior cardiac disease
- Rapid progression to complete block
- Temporary pacing used effectively
- Complete recovery without permanent device
- Objective documentation of reversibility
Clinical Perspective
This case illustrates a broader principle: early recognition of Lyme carditis can significantly alter outcomes. Prompt treatment may allow recovery of cardiac conduction and avoidance of long-term device placement.
Patients with cardiac symptoms may benefit from review of Lyme disease symptoms, evaluation of testing accuracy, and awareness of Lyme carditis.
Frequently Asked Questions
Why did the heart block worsen initially?
Initial worsening may reflect disease progression or inflammatory response before improvement with antibiotics.
How long are temporary pacemakers needed?
Typically less than 2 weeks, depending on recovery of conduction.
What if I don’t remember a tick bite?
Most Lyme carditis patients do not recall tick exposure.
Should I get an EKG?
Yes, if cardiac symptoms are present.
How common is Lyme carditis without rash?
Approximately 60% of cases occur without erythema migrans.
Related Reading:
Lyme Carditis: When Heart Symptoms Can’t Wait
Temporary vs Permanent Pacemaker in Lyme Carditis
Who Is Most at Risk for Lyme Carditis?
Heart Block Progression in Lyme Disease
Avoiding Permanent Pacemakers in Lyme Carditis
Lyme Carditis Without Typical Symptoms
References:
- Fuster LS, Gul EE, Baranchuk A. Electrocardiographic progression of acute Lyme disease. Am J Emerg Med 2017.
- CDC Lyme disease surveillance data. :contentReference[oaicite:0]{index=0}
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
Hooray for a proper diagnosis, right here in Ontario! I’d like to suggest that the treating doctors have this published in a journal read by Infectious Disease Doctors.
I agree with Denise. My following concerns are how many other lives can be saved if doctors learn and understand what lyme can really do and.. sadly, how many lives could have been spared had more doctors been educated sooner? So many lymies will become a statistic and a part of history one day when this modern day epidemic finally gets the exposure it so desperately needs.
Glad to see this. Lyme nearly killed my husband last June, after contracting Lyme carditis. He went into cardiac arrest after a 3-week ‘flu.’ The only reason he lived was that he was already in the cardiac ICU; the entire team jumped on him immediately and brought him back. (Thank God.) He was put on powerful IV antibiotics (ceftriaxone) for 4 weeks via a PIC line.
He’d had no rash. We never saw the tick that bit him, nor knew where on his body he’d been bitten. It was in May, tick nymph season. Four weeks earlier he had been on a camping trip in Maryland woods. A week after the trip ended, he fell ill with what seemed like the flu, but wasn’t contagious.
I grew suspicious as he grew weaker and weaker, until finally in the 3rd week of illness, I insisted he go to the ER because he simply couldn’t get out of bed and was grey as death.
He was immediately admitted with 3rd degree heart block and sent to cardiac ICU where staff began IV antibiotics.
They did not place a pacemaker, however, until after the code blue. Once he was defibrillated and revived, they immediately placed one.
It was a lesson learned. The military (this occurred at Walter Reed in Bethesda, MD) has since changed its Lyme carditis protocol to place a pacemaker at the outset of treatment with severe heart block, so that a similar scenario doesn’t happen again.
Thanks for this article and efforts to raise awareness of Lyme.
I recently had someone copy from the CDC’s site to find out the “terms” ….
Needless to say I’m wondering?
Does this only happen immediately after a tick bite, or can it happen down the road years later when as shown in studies Lyme can suddenly come awake after little or no signs or symptoms?
This can happen years later. I was bit by a tick in November 2020. It was embedded in my side and there was a redness around it when I saw it. I did not go to the doctor because the redness cleared and there was no bulls eye rash.
In early August 2022 I tested positive for Covid. Ten days later I was negative. Two weeks after Covid I became I’ll with a fever, headache, and cough. Thinking it was still Covid, I tested myself for Covid 3 days in a row and they were negative . August 21, I went to the ER and was diagnosed with long haul Covid. I never felt better as I was a bit feverish, headaches came and went and very fatigued in the days to come. On Sept9 I drove to the ER with heart palpitations high bp and a red warm rash on my leg and neck. After blood work and an EKG found nothing troubling, They sent me home and told me to follow up with a cardiologist. Two days later I return to the ER with slow heart rate (40-50bpm) I was admitted to the hospital with EKG showing 3rd degree heart block. Doctors started me on ceftriaxon right away and was rushed to surgery and needed a temporary pace maker. Lyme tests came back positive.
I am glad the doctors looked past COVID and Long COVID
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395762/
I thought this article may help shed some additional light on this issue, although it could be put into layman’s terms.
Thanks for sharing the Pubmed link titles “Lyme Carditis—Diagnosis, Treatment and Prognosis”. It is encouraging to hear others address this all important issue.