Patel Kinjan P, Farjo Peter D, Juskowich Joy J, Hama Amin Ali, Mills James D
Department of Internal Medicine, West Virginia UniversityMorgantown, WV, USA.
West Virginia University Heart and Vascular InstituteMorgantown, WV, USA.
Am J Cardiovasc Dis. 2017 Apr 15;7(2):53-56. eCollection 2017.
Lyme disease is an infection that is estimated to affect over 300,000 people in the United States annually. Typically, it presents with erythema migrans (EM), an annular rash at the site of tick attachment, within 3 to 30 days of inoculation. Untreated patients may progress to early disseminated disease. A further complication, Lyme carditis is rare but may occur several weeks later. It commonly manifests as a variable atrioventricular (AV) conduction block, with a high-grade AV block occurring in only 1% of untreated patients. This case demonstrates an unusually early presentation of Lyme carditis with complete heart block.
A 21-year-old male was transferred from an outside emergency department (ED) for possible pacemaker placement due to symptomatic third-degree AV block. Four days earlier the patient presented to the outside ED with fever, chills, and unrecognized EM on his right neck. He was discharged with antipyretics, but no antibiotic therapy. On the day of transfer, he returned with persistent fevers, EM now on his trunk and upper extremities, lightheadedness, and substernal chest pressure. An electrocardiogram revealed the third-degree AV block leading to transfer. Upon arrival, the patient was promptly diagnosed with Lyme carditis. Pacemaker implantation was deferred, and intravenous (IV) ceftriaxone was initiated. Within 48 hours his third-degree AV block improved to a first-degree block. By this time, his EM had also resolved. He was discharged with oral doxycycline and a 30-day event monitor, which ultimately showed persistent first-degree AV block.
This case reinforces a unique presentation of Lyme carditis. Disseminated EM and Lyme carditis may present concurrently within 2 weeks of tick attachment. Early recognition and treatment is important for preventing progression to disseminated infection. Lyme-associated AV block will reverse within 48 to 72 hours of initiating IV antibiotic therapy and will not require pacemaker implantation. Lyme carditis should be considered in patients without heart disease who present with any degree of AV block.
莱姆病是一种感染性疾病，据估计在美国每年影响超过30万人。通常，在接种后3至30天内，会出现游走性红斑（EM），即蜱虫叮咬部位出现的环形皮疹。未经治疗的患者可能会发展为早期播散性疾病。另一种并发症莱姆心肌炎虽罕见，但可能在数周后发生。它通常表现为可变的房室（AV）传导阻滞，仅1%的未经治疗患者会出现高度房室传导阻滞。本病例展示了莱姆心肌炎伴完全性心脏传导阻滞的异常早期表现。
一名21岁男性因症状性三度房室传导阻滞从外部急诊科（ED）转入，可能需要植入起搏器。四天前，患者因发热、寒战以及右颈部未被识别的游走性红斑就诊于外部急诊科。他服用退烧药后出院，但未接受抗生素治疗。在转院当天，他因持续发热、躯干和上肢出现游走性红斑、头晕以及胸骨后胸痛再次就诊。心电图显示三度房室传导阻滞，导致其转院。到达后，患者迅速被诊断为莱姆心肌炎。起搏器植入被推迟，并开始静脉注射头孢曲松。48小时内，他的三度房室传导阻滞改善为一度阻滞。此时，他的游走性红斑也已消退。他出院时口服强力霉素并佩戴30天事件监测仪，最终显示为持续性一度房室传导阻滞。
本病例强化了莱姆心肌炎的独特表现。播散性游走性红斑和莱姆心肌炎可能在蜱虫叮咬后2周内同时出现。早期识别和治疗对于预防进展为播散性感染很重要。莱姆相关的房室传导阻滞在开始静脉抗生素治疗后48至72小时内会逆转，无需植入起搏器。对于无心脏病但出现任何程度房室传导阻滞的患者，应考虑莱姆心肌炎。
