Skip to main content

Main menu

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Letters

Lyme carditis and neuroborreliosis

Edward J. Cormode
CMAJ September 14, 2020 192 (37) E1076; DOI: https://doi.org/10.1503/cmaj.76511
Edward J. Cormode
Retired pediatrician, Victoria, BC
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site

The 3 cases presented in the Practice section of the May 25, 2020, issue of CMAJ provide an informative discussion of the diagnosis and treatment of Lyme carditis and neuroborreliosis in a tertiary care centre.1–3 I am a retired Ontario pediatrician and coroner, having practised for more than 50 years. In the last 15 years I was a member of the Paediatric 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 presence of a rash. Each of the 3 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 multisystem involvement. All of the cases reported the presence of a rash.

Outcomes are best when Lyme disease is diagnosed and treated early. In these 3 cases, an earlier diagnosis of Lyme disease could have changed the eventual course of this disease.

Physicians need to recognize symptom clusters and maintain a high index of suspicion for Lyme disease. Dr. Elizabeth Maloney4 trains physicians about Lyme disease and sits on a peer review committee for the Canadian Institutes of Health Research. She has spoken to the need for clinical judgment in the diagnosis and treatment of Lyme disease, stating: “Clinically, in keeping with its multisystem nature, Lyme disease has been described as being symptom rich, and exam poor.”4 Dr. Maloney elaborated: “What gives the individual symptoms of Lyme disease value is their occurrence in clusters; a single symptom means little, but 4 or 5 may, for all practical purposes, make the case.”4 To restrict the medical examination to objective findings will result in missed or delayed diagnosis.

Smith and colleagues5 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 listed the signs and symptoms associated with these various morphological patterns within the article. They noted that patients with early Lyme disease who did not have an erythema migrans rash presented with an average of 4 or more symptoms. Fever, chills, malaise and myalgia (all nonspecific) were present in 46%–71% of the patients with definite Lyme disease. Given this diverse morphology of presenting rashes, 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 there is a reliable, definitive test, we need to hone our clinical skills and add Lyme disease to our differential diagnosis.

Footnotes

  • Competing interests: None declared.

References

    1. Semproni M,
    2. Rusk R,
    3. Wuerz T
    . Fatal Lyme carditis presenting as fluctuating high-grade atrioventricular block. CMAJ 2020;192:E574–7.
    1. Myette RL,
    2. Webber J,
    3. Mikhail H,
    4. et al
    . A 4-year-old boy with ataxia and aphasia. CMAJ 2020; 192:E578–82.
    1. Franco-Avecilla D,
    2. Yeung C,
    3. Baranchuk A
    . Lyme carditis presenting with an atypical rash. CMAJ 2020;192:E584.
    1. Maloney EL
    . The need for clinical judgment in the diagnosis and treatment of Lyme Disease. Journal of American Physicians and Surgeons 2009;14:82–9.
    1. Smith RP,
    2. Schoen RT,
    3. Rahn DW,
    4. et al
    . Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med 2002;136:421–8.

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • CPD credits
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Advisory Panels
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions
  • Accessibiity
  • CMA Civility Standards
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: cmajgroup@cmaj.ca

Powered by HighWire