Case Presentation: While erythema migrans (EM) is the most common feature of Lyme disease occurring in about 60% to 90% of cases in North America, Lyme Carditis is very rare and generally accounts for less than 1% in most series.We hereby present a rare case of complete heart block in a 34-year-old healthy male in the absence of any dermatological manifestations.
Discussion: A healthy, 34-year-old avid hiker with a recent hiking expedition in New York was brought in to the hospital by family due to recurrent episodes of syncope associated with lethargy and intermittent fevers in absence of any dermatological manifestations. On arrival to the hospital, patient was found to be in cardiogenic shock secondary to complete heart block requiring transvenous pacing and dopamine infusion. In the setting of history of recent hiking expedition, he was empirically started on Ceftriaxone 2g daily. Labs were remarkable for positive IgM and IgG by western blot and ELISA against B.Burgdorferi. Imaging findings were remarkable for normal coronary computed tomography (CT) and echocardiogram showed diastolic MR and TR, consistent with high-degree AV block. Patient completed one-week course of 2g of Ceftriaxone and was discharged on a 4-week course of Doxycycline 100 mg BID due to insurance shortcomings. At the time of discharge, patient was back to normal sinus rhythm and maintained normal sinus rhythm at follow up in the infectious diseases clinic without any further syncopal events.
Conclusions: In our case, patient had a syncopal event one month following the tick bite. Interestingly, he did not have typical dermatological manifestations, such as Erythema Migrans. He continues to remain symptom-free during his further follow-ups with infectious disease clinic. He is currently pending Holter monitoring with electrophysiology service. With this case, our goal is to bring forth awareness regarding peculiar manifestations of Lyme disease, especially in the Northeast United States. Complete Heart Block in an otherwise healthy adult should raise suspicion for Lyme disease even in the absence of classic rash associated with this entity. It is important to understand that 49% of the atrioventricular block (AV) in Lyme patients is third degree.Early detection and empiric antibiotic initiation leads to a favorable course with resolution of AV block. While these patients may require a further evaluation with Holter monitor, permanent cardiac pacemaker should not always be first line therapy.