Archive for the ‘Heart Issues’ Category

Lyme Carditis 2021 Update

https://lymediseaseassociation.org/blogs/lda-guest-blogs/adrian-baranchuk-md-guest-blog/

Adrian Baranchuk, MD, Guest Blog – Lyme Carditis 2021 Update

LDA Guest Blogger

Adrian_Baranchuk_Photo_2020

Adrian Baranchuk MD, FACC, FRCPC, FCCS, FSIAC is Professor of Medicine at Queen’s University, Kingston, Ontario, Canada. He is Editor-in-chief, Journal of Electrocardiology; Vice President, International Society of Holter and Non-Invasive Electrocardiology (ISHNE); Secretary, Interamerican Society of Cardiology (SIAC); Co-Director, ECG University; Past President, International Society of Electrocardiology (ISE); and Director, NET-Heart Project (Neglected Tropical Diseases and other Infectious Diseases affecting the Heart).

Lyme Carditis: Update 2021. An Evasive Diagnosis in the Time of COVID-19

Adrian Baranchuk MD, FACC, FRCPC, FCCS, FSIAC; Chang (Nancy) Wang MSc (c), MD
Department of Medicine, Kingston Health Science Center, Kingston, Ontario, Canada

Lyme disease (LD) is a tick-borne bacterial infection caused by Borrelia burgdorferi. Lyme carditis (LC) is an early-disseminated manifestation of LD, most commonly manifesting as a complete “shut-down” of the electrical system (high-degree atrioventricular block (AVB)) that can evolve rapidly over minutes, hours, or days producing severe symptoms like fainting, palpitations, shortness of breath, extreme dizziness, or sudden death (1-2).

Other cardiovascular manifestations include alterations of the “motor” of the heart (sinus node disease) (3), a disorganization of the cardiac rhythm that increases the risk of stroke (atrial fibrillation) (2), lesion in the distal cables of the heart (bundle branch blocks) (4), and different degrees of inflammation of the layers of the cardiac walls (myocarditis, pericarditis, and endocarditis) (2). Some of these manifestations could be so severe that a total dysfunction of the cardiac function occurs in a matter of hours, and the patient may die even if admitted to the best ICU in the world.

The initial symptoms of LD can be mistaken by other common infections or allergic reactions. Delayed diagnosis is one of the most important risk factors to serious LD presentations including LC in all its forms. The good news is that prompt diagnosis and appropriate antibiotic therapy links to a much better prognosis. In addition, we now know that when appropriately treated with antibiotics according to guidelines (2); there is no evidence of residual disease in the heart (5).

Most conduction abnormalities caused by LC resolve with appropriate antibiotic therapy (2).

The current COVID-19 pandemic is posing a new challenge in the diagnosis of LD. There are lots of overlapping symptoms such as: fever, malaise, generalized pain, lack of energy, etc. During these times, one would advise on ruling out COVID-19 first before embarking on any other test. However, what could we recommend in terms of confirming or ruling out LD, specifically during these challenging times?

Learning how to recognize the many presentations of LD from a clinical point of view has been published several times. It is especially important to ask about outdoor activities, history of tick bites, tick removal and dermatological rashes (remember that the classic “bull eye” is only present in about 40% of cases). Extensive dermatologic examination may be necessary. Residence in an endemic region for LD is essential for risk stratification, as these recommendations should be encouraged in all ED and family doctor offices in areas of high prevalence.

Once the diagnosis is suspected, specific interrogation should be directed to cardiovascular symptoms such as: dizziness, palpitations, fainting or near fainting, chest pain and shortness of breath. If the patient recognizes any of these symptoms, along with any other factors suggesting LD, a 12-lead ECG (the simple and unexpensive electrocardiogram) should be performed (2). Any evidence of electrical disturbance should prompt admission in hospital for a course of IV antibiotics while waiting the results of serological tests.

On the other hand, in patients presenting with unexpected high-degree AV block, clinical suspicion for LC can be assessed using the validated risk score called SILC (Suspicious Index in Lyme carditis) (6) where the acronym COSTAR(Constitutional symptoms, Outdoor activities/endemic region, Sex male, Tick bite, Age > 50, Rash) may help in determining the risk of presenting early disseminated LC.

In summary, use your clinical tools to suspect LD in the context of COVID-19 pandemic, order serological tests when appropriate, and remember to check for cardiovascular complications with a history, physical, and ECG. If evidence of LC, admit the patient to hospital with continuous cardiac monitoring and appropriate IV antibiotics. Decision for permanent pacemaker implantation should wait until completion of antibiotics as heart block in LC is often reversible. Most patients maintain normal rhythm on long-term follow-up. Avoiding unnecessary implants is crucial as most of these patients are young and active individuals.

References
1. Wan D, Blakely C, Branscombe P, Suarez-Fuster L, Glover B, Baranchuk A. Lyme Carditis and High-degree Atrioventricular Block. Am J Cardiol 2018; 26(5): 233-239
2. Yeung C, Baranchuk A. Diagnosis and Treatment of Lyme Carditis. J Am Coll Cardiol 2019; 73(6): 717-726
3. Gazendam N, Yeung C, Baranchuk A. Lyme carditis presenting as sick sinus syndrome. J Electrocardiol 2020; 59: 65-67
4. Maxwell N, Dryer M, Baranchuk A, Vinocur M. Phase 4 Block of the Right Bundle Branch Suggesting His-Purkinje System Involvement in Lyme Carditis. HeartRhythm Case Reports. 2020; 7(2): 112-116
5. Wang C, Baranchuk A. Long-term evolution of patients treated for early disseminated Lyme carditis. Third prize at the ICE 2021 (International Congress on Electrocardiology)
6. Besant G, Wan D, Yeung C, Blakely C, Branscombe P, Suarez-Fuster L, Redfearn D, Simpson C, Abdollah H, Glover B, Baranchuk A. Suspicious Index in Lyme Carditis (SILC): Systematic Review and Proposed New Risk Score. Clin Cardiol 2018; 41(12):1611-1616

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For more:

Vector Biology: Connecting Human Health, Animal Health & the Environment

Vector Biology: Connecting human health, animal

health and the environment

Mount Allison University

Lyme Research Network

Vett Lloyd, Chris Zinck, Samantha Bishop

Vector-Biology-Connecting-human-health-animal-health-and-the-environment-Vett-Lloyd(1)   Slides Here 

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Important Findings:

Donor 1
Borrelia was detected by nPCR, FISH and protein was detected by immunohistology in biopsied thoracic artery tissue. It was not detected in the other cardiac tissues.
▪ Borrelia burgdorferi DNA present only at low abundance in connective tissue
▪ These results validate the clinical diagnosis of Lyme disease in this individual, US serology and tick exposure
▪ Limited detection is consistent with aggressive treatment, although Borrelia DNA was detected. Viability cannot be assessed by these methods.
Round body more common than long/spriocheatal forms
▪ The individual is still well, active and healthy

Donor 2
▪ Abundant Borrelia was detected by FISH in the pericardium
▪ Other tissues still to be tested
▪ These results are consistent with tick exposure and US WB but not Canadian serology
Round body more common than long/spriocheatal forms
▪ Involvement of Borrelia infection in donor 2’s heart failure is an important question for the family and for all individuals living in endemic areas

Significance

➢ This study demonstrates that Borrelia DNA can be detected in human tissues using molecular methods

Chronic Bartonella Infections in Animals and Humans: Crypto-Infections Conference

Chronic Bartonella Infections in Animals and Humans

2nd European Crypto-Infections Conference

Catherine McAuley Center, Dublin, Ireland

September 26-27, 2020

Presentation by Bruno B. Chomel, Distinguished Professor of Zoonoses

Department of Population Health and Reproduction,

School of Veterinary Medicine,

University of California, Davis, CA, USA

Bartonella-endocarditis-Dublin-2020-Bruno-Chomel(3)  Slides Here

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For more:

How To Diagnose If Lyme Disease is Affecting the Heart and How to Best Treat it

https://www.bayarealyme.org/blog/how-to-diagnose-if-lyme-disease-is-affecting-the-heart-and-how-to-best-treat-it/  Video Here:  Approx. 35 Min

HOW TO DIAGNOSE IF LYME DISEASE IS AFFECTING THE HEART AND HOW TO BEST TREAT IT

Dr. Baranchuk, Professor of Medicine at Queen’s University in the Division of Cardiology in Ontario Canada

Dr. Baranchuk, Professor of Medicine at Queen’s University in the Division of Cardiology in Ontario Canada, Editor-in-Chief of the Journal of Electrocardiology, Vice-President of the International Society of Holter and Noninvasive Electrocardiology and Secretary of the Inter-American Society of Cardiology, discusses his screening process for identifying Lyme infections in the heart and how to treat these patients without unnecessary pacemakers.

For more:  

Classification of Patients Referred Under Suspicion of Tick-borne Diseases, Copenhagen, Denmark

https://pubmed.ncbi.nlm.nih.gov/33126203/

Classification of patients referred under suspicion of tick-borne diseases, Copenhagen, Denmark

Affiliations expand

Free article

Abstract

To provide better care for patients suspected of having a tick-transmitted infection, the Clinic for Tick-borne Diseases at Rigshospitalet, Copenhagen, Denmark was established. The aim of this prospective cohort study was to evaluate diagnostic outcome and to characterize demographics and clinical presentations of patients referred between the 1st of September 2017 to 31st of August 2019. A diagnosis of Lyme borreliosis was based on medical history, symptoms, serology and cerebrospinal fluid analysis. The patients were classified as:

  • definite Lyme borreliosis
  • possible Lyme borreliosis
  • post-treatment Lyme disease syndrome

Antibiotic treatment of Lyme borreliosis manifestations was initiated in accordance with the national guidelines. Patients not fulfilling the criteria of Lyme borreliosis were further investigated and discussed with an interdisciplinary team consisting of specialists from relevant specialties, according to individual clinical presentation and symptoms. Clinical information and demographics were registered and managed in a database. A total of 215 patients were included in the study period. Median age was 51 years (range 17-83 years), and 56 % were female.

Definite Lyme borreliosis was diagnosed in 45 patients, of which:

  • 20 patients had erythema migrans
  • 14 patients had definite Lyme neuroborreliosis
  • six had acrodermatitis chronica atrophicans
  • four had multiple erythema migrans
  • one had Lyme carditis
  • 12 patients were classified as possible Lyme borreliosis
  • 12 patients as post-treatment Lyme disease syndrome
A total of 146 patients (68 %) did not fulfil the diagnostic criteria of Lyme borreliosis.
  • Half of these patients (73 patients, 34 %) were diagnosed with an alternative diagnosis including inflammatory diseases, cancer diseases and two patients with a tick-associated disease other than Lyme borreliosis.

A total of 73 patients (34 %) were discharged without sign of somatic disease.

Lyme borreliosis patients had a shorter duration of symptoms prior to the first hospital encounter compared to patients discharged without a specific diagnosis (p<0.001). When comparing symptoms at presentation, patients discharged without a specific diagnosis suffered more often from general fatigue and cognitive dysfunction.

In conclusion, 66 % of all referred patients were given a specific diagnosis after ended outpatient course. A total of 32 % was diagnosed with either definite Lyme borreliosis, possible Lyme borreliosis or post-treatment Lyme disease syndrome; 34 % was diagnosed with a non-tick-associated diagnosis. Our findings underscore the complexity in diagnosing Lyme borreliosis and the importance of ruling out other diseases through careful examination.

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**Comment**

While Lyme isn’t everything, it CAN BE anything.  This paper shows once again that half are turned away due to strict diagnostic criteria utilizing faulty serology testing where few are positively diagnosed. They are slapped with a label that will keep them from proper treatment and are doomed to a life of misery.

Nothing new here.  Same song, different day.