Jump to comment:
- Page navigation anchor for RE: Lyme carditis and neuroborreliosisRE: Lyme carditis and neuroborreliosis
The three cases presented in the "Practice "section of the May 25, 2020 CMAJ provide an informative discussion of the diagnosis and treatment of Lyme carditis and neuroborreliosis in a tertiary care centre. I am a retired Ontario pediatrician and coroner, having practiced for over 50 years. In the last 15 years I was a member of the Pediatric Death Review Committee of the Ontario Office of the Chief Corner.
Certain factors were common to each of these cases: known endemic area; clusters of symptoms; and, a presence of a rash. Each of the three cases occurred in areas known to be endemic for ticks infected with Borrelia. In each case, the patient or caregiver described clusters of symptoms supporting multi-system involvement. All cases reported the presence of a rash.
Lyme disease has best outcomes when diagnosed and treated early. In these three cases, an earlier consideration of Lyme Disease and a clinical diagnosis, could have changed the eventual course of this disease in these three individuals.
Physicians need to recognize symptom clusters and maintain a high index of suspicion for Lyme disease. Dr. Elizabeth Maloney 4 is one of the leading US MDs training physicians and sits on a peer review committee for the Canadian Institutes of Health Research. She speaks to the need for clinical judgment in the diagnosis and treatment of Lyme disease, stating: “Clinically, in keeping with the its multisystem nature, Lyme disease has been describe...
Show MoreCompeting Interests: None declared.References
- Milena Semproni, Richard Rusk, Terence Wuerz. Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block. CMAJ 2020;192:E574-E577.
- Robert L. Myette, Jenna Webber, Hannah Mikhail and Kirk Leifso CMAJ May 25, 2020 192 (21) E578-E582; DOI: https://doi.org/10.1503/cmaj.191279
- Dennys Franco-Avecilla, Cynthia Yeung and Adrian Baranchuk CMAJ May 25, 2020 192 (21) E584; DOI: https://doi.org/10.1503/cmaj.191660
- Maloney, E.L. The need for clinical judgment in the diagnosis and treatment of Lyme Disease. (2009) Jnl American Physicians and Surgeons
- Smith RP, Schoen RT, Rahn DW, et al. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med. 2002;136(6):421-428. doi:10.7326/0003-4819-136-6-200203190-00005
- Page navigation anchor for RE: The Epidemiology of Lyme Disease in British ColumbiaRE: The Epidemiology of Lyme Disease in British Columbia
The recent publication on Lyme Disease (LD) raises a number of issues regarding epidemiology in Canada and rekindles the experiences of past from British Columbia.
Show More
In the late 1980s, when LD activity flourished in the USA, interest was pioneered in British Columbia and Canada by then Dr. Satyendra Banerjee, his wife Maya, and myself. By 1989 and shortly thereafter, anecdotes of bonafide (screening IFA and confirmatory Western blotting) disease were evident albeit infrequent in this province. Some illnesses included erythema chronicum migrans, carditis, and fever of unknown origin.(1) A considerable proportion were known to have been acquired outside of Canada. In short order, we created in-house immunoblotting and conducted a large serosurvey of asymptomatic blood donors which showed a 5-10% IFA seroreactivity with titers >1/256. Much of the latter was deemed non-specific, but immunoblot reactivity to various Borrelia burgdorferi antigens was observed for some. Given then societal pressures and beliefs that rheumatological diseases in this province might be commonly ascribed to LD, we collaborated with pediatric rheumatologist Dr. Peter Malleson to conduct a serodiagnostic analysis of childhood arthritis. LD could not be confirmed among a diversity of such patients including those with pauciarticular and polyarticular disease.(2) Over three decades since, LD continues to be found endemically in our province but yet infrequent.(3) Infections have been documented...Competing Interests: None declared.References
- 1. Cimolai N, Banerjee S, Wong L, Banerjee M, Smith J. Lyme disease presenting as prolonged pyrexia of unknown origin. Clin Microbiol Infect 1997;3(2):267-268.
- 2. Banerjee S, Banerjee M, Cimolai N, Malleson P, Proctor E. Seroprevalence survey of borreliosis in children with chronic arthritis in British Columbia, Canada. J Rheumatol 1992;19(10):1620-1624.
- 3. Cimolai N, Cimolai T. Infections in the natural environment of British Columbia, Canada. J Infect Public Health 2008;1(1):11-26.
- 4. Morshed MG, Lee M-K, Man S, et al. Surveillance for Borrelia burgdorferi in Ixodes ticks and small rodents in British Columbia. Vector Borne Zoonotic Dis 2015;15(11):701-705.
- 5. Scott JD, Clark KL, Foley JE, et al. Detection of Borrelia genomospecies 2 in Ixodes spinipalpis ticks collected from a rabbit in Canada. J Parasitol 2017;103(1):38-46.
- Page navigation anchor for RE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular blockRE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block
I am glad to see that this case was reported.
Lyme disease is a very serious disease, hard to diagnose, and difficult to treat unless caught very early. That almost never occurs in Canada as confirmed by this published paper. https://tinyurl.com/ybhgtlnb
The requirement for the person to have been in a known endemic area as part of the diagnostic criteria is negligence. Ticks are found anywhere that birds fly as they transport these ticks everywhere, randomly. Likewise, the rash should not be part of the criteria unless it is present. Only a small subset of borrelia bacteria will cause any rash. https://tinyurl.com/ycz96es9 Only 18% of children studied in Nova Scotia with confirmed cases had any rash at all. The rash occurs much less that 50% of the time https://tinyurl.com/ybbfaxtk and of the rashes that do occur, only 9% take the over-imprinted 'bull's eye' form. https://tinyurl.com/y7nu9ac5
Canadian protocol and physician education for diagnosis and treatment is terrible and misleading. Patients and their experts have been trying to tell those who control all aspects of Lyme disease in Canada, the Public Health Agency of Canada (PHAC), and the Association of Medical Microbiology and Infectious Disease of Canada, for over a decade that we need to be at the decisi...
Show MoreCompeting Interests: President, Canadian Lyme Disease FoundationReferences
- Milena Semproni, Richard Rusk, Terence Wuerz. Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block. CMAJ 2020;192:E574-E577.
- https://tinyurl.com/ybhgtlnb
- https://tinyurl.com/ycz96es9
- https://tinyurl.com/ybbfaxtk
- https://tinyurl.com/y7nu9ac5
- Page navigation anchor for RE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular blockRE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block
The case study presented by Semproni et al. suggests a stronger conclusion. In 2013, after weeks of increasing fatigue and exertion intolerance, I presented at an ER following a brief loss of consciousness. At triage, I was bradycardic at 29bpm and ECG showed third-degree atrioventricular block. I was 39 years old and healthy with no history of cardiac complications.
The treatment team discussed the possibility of Lyme carditis, given the lack of other explanations for third-degree AV block. The decision was made to immediately implant a permanent pacemaker, on the theory that regardless of cause, the need to reestablish reliable pacing was the first priority. I was discharged the following day with doxycycline before serologic confirmation of Lyme.
The Semproni et al. case study is vague as to why transcutaneous, transvenous, or permanent pacing was not established immediately and why the team relied on cardiac monitoring instead. It is true that other authors (Wormser GP, Dattwyler RJ, Shapiro ED, et al.) also suggest that admission to a unit with cardiac telemetry is the first step.
Three months after discharge, I had my permanent pacemaker extracted after repeated ECG confirmation that the AV block was permanently resolved.
Given the potential for rapid and unpredictable progression of Lyme carditis, the Semproni et al. case study suggests that perhaps the standard of care for cases of suspected Lyme carditis should include immediately re...
Show MoreCompeting Interests: None declared.References
- . RE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block. 2020;:-.
- Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2
- Page navigation anchor for RE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular blockRE: Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block
The CDC recognized that Lyme could kill outright but gambled that these events would be rare enough that they would not hold the public’s attention for long enough for sustained reaction. Physicians are taught that this is a minor nuisance disease not much different than you would expect to find with any other insect bite [ticks are arachnids] defined by a much over-emphasized rash and flue–like symptoms that was easy to recognize and treat at any stage with a single bacteriostatic agent and that patients would get better on their own even if they received no treatment. Medical authorities continue to focus on only the earliest acute symptoms [the rash] and ignore that left untreated or under-treated, the disease can metamorphose into a multi-staged, multi-systemic disease that are in the same health threat category as Zika, West Nile, Ebola and cancer.
This is a medical system divided against itself. Adherents to the dominant
medical opinion on Lyme and tick-borne diseases [TBD’s] are willing for various ideological reasons to let people perish. The defining characteristic of corruption in modern medicine is the abandonment of the patient’s interest. Patients are often road-kill on the highway to profit for the insurance industry.The fact is that denying, downplaying and trivializing Lyme has happened from the earliest days when we first became aware of its presence in Canada and when it became endemic in the 1980’s and evidence is being spun to fit a...
Show MoreCompeting Interests: Board member Canadian Lyme Disease Foundation [www.CanLyme.org]References
- Milena Semproni, Richard Rusk, Terence Wuerz. Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block. CMAJ 2020;192:E574-E577.
- Page navigation anchor for RE: Fatal Lyme carditis .....RE: Fatal Lyme carditis .....
Living in south western Nova Scotia, a known tick hot spot, I read this article with interest. The local community has been aware for years that Lyme disease is often misdiagnosed causing a lot of strange symptoms from Bell's palsy to knee arthritis in children to fatal carditis. With its confusing array of possible symptoms, a lack of early definitive lab tests and differing opinions about treatment options, there are many who state that Lyme disease has become Canada's 'orphan' disease. Currently, there is a strong fear in this area, that research into Lyme Disease prevention, diagnosis and treatment will be further put on the back burner during the Covid-19 pandemic.
Dr Nancy Covington, Mahone BayCompeting Interests: None declared.References
- Milena Semproni, Richard Rusk, Terence Wuerz. Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block. CMAJ 2020;192:E574-E577.