RE: Lyme carditis and neuroborreliosis
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
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 described as being symptom rich, and exam poor (p. 83).” Dr. Maloney elaborates: “What gives the individual symptoms of Lyme disease value is their occurrence in clusters; a single symptom means little, but four or five may, for all practical purposes, make the case (p.84).” To restrict the medical exam to objective findings will result in missed or delayed diagnosis.
Smith et. al.5 reviewed 118 patients with microbiologically confirmed erythema migrans. Fifty nine percent were homogeneous, 32% had dense central erythema and only 9% had classical central clearing. The authors list the signs and symptoms associated with these various morphological patterns in Table 1 (p.424). They noted that patients with early Lyme disease who lacked an EM rash presented with an average of four or more symptoms. Fever, chills, malaise, and myalgia (all nonspecific), were present in 46-71 % of the patients with definite Lyme disease alone. Given this diverse morphology of presenting rashes and the continued emphasis on a bulls-eye rash, any rash occurring in an endemic area (or on returning from travel in these areas) could be associated with Lyme disease and should be put at the top of the differential diagnosis, especially when patients present with clusters of symptoms.
Until such a time when there is a reliable definitive test, we need to hone our clinical skills and add Lyme to our differential diagnosis to prevent escalation of the disease.