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Lyme Carditis Abstracts

The following abstracts are offered for more information. An abstract is helpful; however, to learn the full meaning of a study, the entire paper should be reviewed.

Lyme Carditis in children

Lyme Carditis: cardiac abnormalities of Lyme disease

Complete heart block due to Lyme Carditis.

Borrelia burgdorferi myocarditis

Molecular diagnosis of culture negative infective endocarditis

Borrelia infection as a cause of Carditis (a long-term study).

Update on Lyme Carditis.

Cardiac manifestations of Lyme disease. 

Fatal Pancarditis in a patient with coexistent Lyme disease and Babesiosis.

Carditis in Lyme disease susceptible and resistant strains of laboratory mice infected with Borrelia burgdorferi

Cardiac symptoms from other tick-borne diseases:

When to Suspect and How to Monitor Babesiosis

Prosthetic Valve Endocarditis Caused by Bartonella quintana

Bartonella Infections in Sweden 

Bartonella quintana endocarditis

Lyme Carditis in children: presentation, predictive factors, and clinical course.

Pediatrics. 2009 May;123(5):e835-41.

Costello JM, Alexander ME, Greco KM, Perez-Atayde AR, Laussen PC.

Harvard Medical School, Division of Cardiac Intensive Care, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Bader 600, Boston, MA 02115, USA. john.costello@cardio.chboston.org

OBJECTIVES: We sought to identify predictive factors for Lyme carditis in children and to characterize the clinical course of these patients. METHODS: We reviewed all cases of early disseminated Lyme disease presenting to our institution from January 1994 through July 2008, and summarized the presentation and course of those patients with carditis. A case-control study was used to identify predictive factors for carditis. Controls were patients with early disseminated Lyme disease without carditis. RESULTS: Of 207 children with early disseminated Lyme disease, 33 (16%) had carditis, 14 (42%) of whom had advanced heart block, including 9 (27%) with complete heart block. The median time to recovery of sinus rhythm in these 14 patients was 3 days (range: 1-7 days), and none required a permanent pacemaker. Four (12%) of 33 patients with carditis had depressed ventricular systolic function, 3 (9%) of whom required mechanical ventilation, temporary pacing, and inotropic support. Complete resolution of rhythm disturbances and myocardial dysfunction occurred in 24 (89%) of 27 patients for whom follow-up data were available. Most patients with carditis also had other systemic Lyme involvement. By using multivariate logistic regression analysis, we found that children >10 years of age, those with arthralgias, and those with cardiopulmonary symptoms were more likely to have carditis. CONCLUSIONS: The spectrum of presentation for children with Lyme carditis is broad, ranging from asymptomatic, first-degree heart block to fulminant myocarditis. Variable degrees of heart block are the most common manifestation and occasionally require temporary pacing. Transient myocardial dysfunction, although less common, can be life-threatening. Advanced heart block resolves within 1 week in most cases. In children with early disseminated Lyme disease, older age, arthralgias, and cardiopulmonary symptoms independently predict the presence of carditis.

PMID: 19403477 [PubMed - indexed for MEDLINE]

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Lyme Carditis: cardiac abnormalities of Lyme disease.

Ann Intern Med. 1980 Jul;93(1):8-16.

Steere AC, Batsford WP, Weinberg M, Alexander J, Berger HJ, Wolfson S, Malawista SE.

We studied 20 patients, mostly young adult men, with cardiac involvement of Lyme disease. The commonest abnormality (18 patients) was fluctuating degrees of atrioventricular block; eight of them developed complete heart block. Thirteen patients had evidence of more diffuse cardiac involvement: electrocardiographic changes compatible with acute myopericarditis (11 patients), radionuclide evidence of mild left ventricular dysfunction (five of 12 patients tested), or frank cardiomegaly (one patient). Heart involvement was usually preceded by erythema chronicum migrans and sometimes accompanied by meningoencephalitis, facial palsy, arthritis, elevated serum IgM levels, or cryoglobulins containing IgM. The duration of cardiac involvement was usually brief (3 days to 6 weeks). The clinical picture in these patients has similarities to acute rheumatic fever; but in Lyme disease, complete heart block may be commoner, myopericardial involvement tends to be milder, and valves seem not to be affected.

PMID: 6967274 [PubMed - indexed for MEDLINE]

Complete heart block due to Lyme Carditis.

J Invasive Cardiol. 2003 Jun;15(6):367-9. 
Lo R, Menzies DJ, Archer H, Cohen TJ. 
Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA. 

Lyme carditis is becoming a more frequent complication of Lyme disease, primarily due to the increasing incidence of this disease in the United States. Cardiovascular manifestations of Lyme disease often occur within 21 days of exposure and include fluctuating degrees of atrioventricular (AV) block, acute myopericarditis or mild left ventricular dysfunction and rarely cardiomegaly or fatal pericarditis. AV block can vary from first-, second-, third-degree heart block, to junctional rhythm and asystolic pauses. Patients with suspected or known Lyme disease presenting with cardiac symptoms, or patients in an endemic area presenting with cardiac symptoms with no other cardiac risk factors should have a screening electrocardiogram along with Lyme titers. We present a case of third-degree AV block due to Lyme carditis, illustrating one of the cardiac complications of Lyme disease. This disease is usually self-limiting when treated appropriately with antibiotics, and does not require permanent cardiac pacing. 
PMID: 12777681 [PubMed - in process] http://www.canlyme.com/heart.html

Fatal Pancarditis in a patient with coexistent Lyme disease and Babesiosis.

Demonstration of spirochetes in the myocardium. 

Marcus, L. C., A. C. Steere, P. H. Duray, A. E. Anderson, and E. B. Mahoney. 

1985. Fatal pancarditis in a patient with coexistent Lyme disease and babesiosis. 

Demonstration of spirochetes in the myocardium. Ann. Intern. Med. 103:374-376

[Abstract/Free Full Text] 120

[ Borrelia burgdorferi myocarditis] 
Ugeskr Laeger. 2003 Apr 7;165(15):1570. Related Articles, Links 
[Article in Danish] 
Hendricks O, Kjaeldgaard P, Koldbaek I. 
Klinisk Mikrobiologisk Afdeling, Sonderborg Sygehus, DK-6400 Sonderborg. 
We describe a case of progressive arrhythmia and heart failure combined with neurological symptoms that was resistant to conventional cardiological treatment. The outcome of a serological analysis was Borrelia IgG on a level consistent with chronic Lyme Disease. Antibiotic treatment with doxycycline resulted in complete remission of all cardiological symptoms. This case demonstrated Lyme Disease to be a potential factor in the pathogenesis of myocarditis as suggested by international publications. 
PMID: 12715663 [PubMed - indexed for MEDLINE]

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Molecular diagnosis of culture negative infective endocarditis: clinical validation in a group of surgically treated patients. 
Grijalva M, Horvath R, Dendis M, Erny J, Benedik J. 
Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic. 
OBJECTIVE: To assess the clinical validity of polymerase chain reaction (PCR) based molecular methods in the microbiological diagnosis of culture negative infective endocarditis in a group of surgically treated patients. DESIGN: Retrospective case-control study. SETTING: Reference cardiovascular surgical centre. PATIENTS AND SAMPLES: 15 culture negative patients with infective endocarditis classified according to Duke criteria, with 17 heart valve samples; 13 age and sex matched control patients without infective endocarditis, with 13 valve samples. 
INTERVENTIONS: Medical records were reviewed and clinical, demographic, and microbiological data collected, including results of molecular detection of bacteria and fungi from valve samples. The clinical validity of molecular diagnosis was assessed, along with the sensitivity and speed of the systems. RESULTS: In the study group, 14 patients were PCR positive (93%). Organisms detected were streptococci (3), staphylococci (2), enterobacter (1), Tropheryma whippelii (1), Borrelia burgdorferi (1), Candida albicans (1), and Aspergillus species (2). Three cases were positive on universal bacterial detection but the pathogen could not be identified because of contaminating background. One case was negative. All but two positive cases showed clinical correlations. These two cases had no symptoms of infective endocarditis but there was agreement with the surgical findings. All control cases were PCR negative. Results were available within eight hours, and if sequencing was necessary, within 48 hours. 

CONCLUSIONS: PCR based molecular detection of pathogens in valve samples from surgically treated culture negative infective endocarditis patients is fast, sensitive, and reliable. The technology, combined with thorough validation and clinical interpretation, may be a promising tool for routine testing of infective endocarditis. Publication Types: Validation Studies PMID: 12591825 [PubMed - indexed for MEDLINE] 

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Borrelia infection as a cause of carditis (a long-term study). 

Wien Klin Wochenschr. 2001 Jan 15;113(1-2):38-44. 
Bartunek P, Mrazek V, Gorican K, Bina R, Listvanova S, Zapletalova J. 
Department of Internal Medicine IV, Charles University School of Medicine I, Prague, Czech Republic. 
BACKGROUND: Although the frequency of Lyme carditis is not high, it is one of the most challenging conditions in terms of diagnosis. No long-term studies that would help expand our body of knowledge concerning the circumstances of its development and the natural course of this form of Lyme borreliosis (LB), the most widespread anthropozoonosis in Central Europe, have been reported to date. AIM: The authors sought to describe and assess the consequences of a less common form of Lyme carditis (LC). An assessment of the following aspects was made: a) the forms, natural history and sequelae of the less common clinical appearances of LC, b) the role of antibiotic therapy with reference to the late manifestations of LB. 

METHODS: Three patients were selected from a group of 60 consecutive patients with demonstrated LC during a follow-up period from 1987 to 2000. Patient no. 1 was being followed for myocarditis with frequent ventricular extrasystoles, patient no. 2 for pericarditis, and patient no. 3 for dilated cardiomyopathy as a late manifestation of LB. In addition to routine examination at entry, the patients were subjected to a standard 12-lead ECG, continuous 24-hour Holter ECG monitoring, exercise testing (bicycle ergometry), investigations of antibodies using ELISA and Western blot, investigation of thyroid (T3, T4, TSH tests) and mineral levels. 

RESULTS: The study showed no significant correlation between the clinical course and levels of specific antibodies. It confirmed the concept that inadequate or no therapy with antibiotics in the initial stage of the disease has a significant effect on the development of late sequelae. CONCLUSION: Based on the long-term treatment of three patients with less common, yet clinically urgent findings, the authors conclude that even a relatively serious clinical course is associated with no major limitations for affected individuals after an interval of several years. PMID: 11233466 [PubMed - indexed for MEDLINE] 

Update on Lyme Carditis
Bateman H, Sigal L. Division of Rheumatology and Connective Tissue Research, MEB-484, University of Medicine and Dentistry-Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ 08903, USA. E-mail: Batemanhe@umdnj.edu; Sigallh@umdnj.edu 
Lyme carditis is an uncommon manifestation of infection with Borrelia bugdorferi. It is easily treated with standard antibiotic regimens and prognosis is excellent, especially if treatment is prompt. For symptomatic or higher degrees of block, patients may require hospitalization for monitoring and occasionally temporary external pacing. Intravenous antibiotics are warranted for such patients. For less severe conduction disturbances, oral therapy suffices. 
PMID: 11095868 [PubMed] back to top

Cardiac manifestations of Lyme disease. 
Pinto DS. 
Harvard Medical School, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. Dpinto@caregroup.harvard.edu 
Lyme disease is a vector-borne illness that can affect numerous organ systems during the early disseminated phase, including the heart. The clinical course of Lyme carditis is usually benign with most patients recovering completely. In rare instances, death from Lyme carditis has been reported. The cardinal manifestation of Lyme carditis is conduction system disease, which generally is self-limited. Heart block occurs usually at the level of the atrioventricular node but often is unresponsive to atropine sulfate. Temporary pacing may be necessary in more than 30% of patients, but permanent heart block rarely develops. Myocardial and pericardial involvement can occur but generally is mild and self-limited. Diagnosis is made by associating the clinical and historical features of borreliosis, such as previous tick bite, EM, or neurologic involvement, with electrocardiographic abnormalities and symptoms such as chest pain, palpitations, syncope, and dyspnea.

Serologic studies and endomyocardial biopsy can only support the clinical diagnosis in the correct setting, and MR imaging, echocardiography, and gallium scanning have utility in selected circumstances. No treatment has been shown clearly to attenuate or prevent the development of Lyme carditis, but mild carditis generally is treated with oral antibiotics and severe carditis with intravenous antibiotics in an effort to eradicate the infection and prevent late complications of Lyme disease. There is conflicting evidence regarding the role that B. burgdorferi plays in the development and progression of chronic congestive heart failure. Because of the significant false-positive ELISA rate in this population and the unclear benefit of antibiotic therapy, confirmatory Western blot analysis is recommended. Routine therapy and screening of patients with idiopathic dilated cardiomyopathy is of limited utility and should be reserved for patients with clear history of antecedent Lyme disease or tick bite. 
Publication Types: Review Review, Tutorial 
PMID: 11982302 [PubMed - indexed for MEDLINE]

Carditis in Lyme disease susceptible and resistant strains of laboratory mice infected with Borrelia burgdorferi.Armstrong, A. L., S. W. Barthold, D. H. Persing, and D. S. Beck. 1992.  Am. J. Trop. Med. Hyg. 47:249-258. [Abstract/Free Full Text] 2


When to Suspect and How to Monitor Babesiosis
Eleftherios Mylonakis, MD., Massachusetts General Hospital, Boston, Massachusetts
Congestive heart failure, disseminated intravascular coagulation and acute respiratory distress syndrome (that can occur even a few days after the onset of effective antimicrobial treatment) are the most common complications of human babesiosis (Table 2). Renal failure and myocardial infarction also have been associated with severe babesiosismore http://www.aafp.org/afp/20010515/1969.html

Prosthetic Valve Endocarditis Caused by Bartonella quintana
John L. Klein,* Sukumaran K. Nair,* Tim G. Harrison,† Ian Hunt,* Norman K. Fry,† and Jon S. Friedland*‡
*Hammersmith Hospital, London, United Kingdom; †PHLS Central Public Health Laboratory, London, United Kingdom; and ‡Imperial College, London, United Kingdom 

Bartonella quintana endocarditis

Transient monoclonal gammopathy in a patient with Bartonella quintana endocarditis.

Sève P, Turner R, Stankovic K, Perard L, Broussolle C.

Am J Hematol. 2006 Feb;81(2):115-7.
PMID: 16432867 [PubMed - indexed for MEDLINE]
Related citations

2.Monoclonal and biclonal gammopathy in two patients infected with Bartonella henselae.

Krause R, Auner HW, Daxböck F, Mulabecirovic A, Krejs GJ, Wenisch C, Reisinger EC.

Ann Hematol. 2003 Jul;82(7):455-7. Epub 2003 May 23.
PMID: 12764550 [PubMed - indexed for MEDLINE]
Related citations

Bartonella Infections in Sweden 

Quite a few Swedes died of Bartonella infections after bitten by ticks while orienteering.  

Christian Ehrenborg wrote a dissertation on Baronella infections in Sweden. 

Bartonella Infections in Sweden: Clinical Investigations and Molecular Epidemiology Författare:   Ehrenborg, Christian   Förlag:   Uppsala universitet/Institutionen för medicinska vetenskaper   Datum:   2007-04-26   År:   2007   SAB-kod:   Veba   ISBN:   978-91-554-6886-6 

Abstract:   Characteristically, in infections that are caused by the zoonotic pathogen Bartonella naturally infected reservoir hosts are asymptomatic, where infected incidental, non-natural, hosts develop symptomatic disease. Cat-scratch disease (CSD) is a well known example. Bartonella infections in humans may be self-limiting or fulminant and affect different organ systems. The objectives of the present thesis were to (1) identify and characterise Bartonella infection cases in Sweden, (2) to investigate certain human populations regarding Bartonella infections, and (3) compare natural populations of different Bartonella species. Cases with typical and atypical CSD were recognised by using a combination of PCR and serology. Gene sequence comparisons of different genes in B. henselae isolates from the United States and Europe showed that ftsZ gene variation is a useful tool for Bartonella genotyping. Myocarditis was a common finding among Swedish elite orienteers succumbing to sudden unexpected cardiac death (SUCD). The natural cycle of Bartonella spp., the life style of orienteers, elevated antibody titres to Bartonella antigens, Bartonella DNA amplified from myocardium and the lack of another feasible explanation make Bartonella a plausible aetiological factor. The first reported case of Bartonella endocarditis (B. quintana) was identified in an immunocompromised patient who underwent heart valve replacement. The patient had been body louse-infested during his childhood. It is hypothesised that a chronic B. quintana infection was activated by the immunosuppression. There was no evidence of an ongoing trench fever (TF) epidemic in a Swedish homeless population, although an increased risk for exposure to Bartonella antigens was demonstrated. The lack of louse infestation might explain the absence of B. quintana bacteremia and low B. quintana antibody titres. Comparisons of genetic loci and the whole genomes of environmental B. grahamii isolates from the Uppsala region, Sweden displayed variants that were not related to specific host species but to geographic locality. Natural boundaries seemed to restrict gene flow.



Class III AV block expected to resolve and/or unlikely to recur (McAlister et al., 1989) (e.g., drug toxicity, Lyme disease, or during hypoxia in sleep apnea syndrome in absence of symptoms). (Level of evidence: B) http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3439&string=de+AND+lyme

Fatal Pancarditis in a patient with coexistent Lyme disease and Babesiosis.

Demonstration of spirochetes in the myocardium.

Marcus, L. C., A. C. Steere, P. H. Duray, A. E. Anderson, and E. B. Mahoney.

1985. Fatal pancarditis in a patient with coexistent Lyme disease and babesiosis.

Demonstration of spirochetes in the myocardium. Ann. Intern. Med. 103:374-376

[Abstract/Free Full Text] 120