Lyme carditis--diagnosis, treatment and prognosis

Abstract

Background: There are 60,000 to 100,000 new cases of borreliosis in Germany each year. This infectious disease most commonly affects the skin, joints, and nervous system. Lyme carditis is a rare manifestation with potentially lethal complications.

Methods: This review is based on selected publications on the clinical manifestations, diagnosis, and treatment of Lyme carditis, and on the authors' scientific and clinical experience.

Results: Lyme carditis is seen in 4% to 10% of all patients with Lyme borreliosis. Whenever the clinical suspicion of Lyme carditis arises, an ECG is mandatory for the detection or exclusion of an atrioventricular conduction block. Patients with a PQ interval longer than 300 ms need continuous ECG monitoring. 90% of patients with Lyme carditis develop cardiac conduction abnormalities, and 60% develop signs of perimyocarditis. Borrelia serology (ELISA) may still be negative in the early phase of the condition, but is always positive in later phases. Cardiac MRI can be used to confirm the diagnosis and to monitor the patient's subsequent course. The treatment of choice is with antibiotics, preferably ceftriaxone. The cardiac conduction disturbances are usually reversible, and the implantation of a permanent pacemaker is only exceptionally necessary. There is no clear evidence at present for an association between borreliosis and the later development of a dilated cardiomyopathy. When Lyme carditis is treated according to the current guidelines, its prognosis is highly favorable.

Conclusion: Lyme carditis is among the rarer manifestations of Lyme borreliosis but must nevertheless be considered prominently in differential diagnosis because of the potentially severe cardiac arrhythmias that it can cause.

Figure 1

Erythema chronicum migrans on lower arm as an early manifestation of Lyme disease— erythematous ring expanding peripherally

Figure 2

First step: Two-tiered antibody testing for Lyme disease

Figure 3

Histology of endomyocardial biopsy from a patient with Lyme carditis: Polymerase chain reaction (PCR) band pattern (top insert in the image) with patient specimen (P) on the left. Identification of Borrelia burgdorferi DNA (ospA gene region, PCR amplificate of 190 bp as a bright band), control (K) on the right with corresponding band on the same height, and size standard (M) on the far right. Histopathological appearance of lymphocytic myocarditis (red arrows) with significant subendocardial fibrosis (stained blue) and pathogen persistence correspond to stage II of Lyme disease (Masson’s trichrome stain, x 400)

Figure 4

Cardiac magnetic resonance imaging with 4-chamber view a) of a patient with Lyme carditis along with first-degree AV block and complete left bundle-branch block: after gadolinium administration, multilocular late-enhancement (LE), situated subepicardially, mid-myocardially and subendocardially. b) In the short-axis view, LE is primarily situated in the mid-myocardium; however, the septum is also affected, possibly the substrate of the affected conduction system (yellow arrow). In addition, slight enhancement of the pericardium (red arrow)