Loading...

Follow Daniel Cameron on Feedspot

Continue with Google
Continue with Facebook
or

Valid

by Daniel J. Cameron, MD, MPH

This is the first case report of an inducible heart block in Lyme disease. The young man initially presented to the emergency department with syncope. “ECG showed sinus bradycardia with first degree AV block, with a PR interval of 480 ms (NL 120–200 ms),” writes Kannangara.

An exercise stress test done by the cardiologist was terminated early. The patient developed dyspnea, and his ECG demonstrated a progression of first-degree AV block to high degree AV block.

The majority of AV blocks in Lyme carditis are reversible with antibiotic treatment, the authors write.

Once back at rest, the patient’s high degree AV block reverted to first degree AV block. “He had a similar episode while walking in the hallway wearing a Holter monitor, on day 5, also reversible with rest,” the authors explain.

The first case of inducible heart block in Lyme disease is reported in a 37-year-old man.
Click To Tweet

The patient was diagnosed with Lyme disease based on exposure, history of tick bites, a positive IgG Western blot test, the absence of another cause and his recovery following a combination of intravenous ceftriaxone and oral doxycycline.

He has since returned to work and has been symptom-free for 2 years.

Kannangara and colleagues summarized the growing list of cardiac problems in Lyme disease, as described in the medical literature:

  • First-degree heart block
  • Wenckebach phenomenon (Mobitz type I)
  • Mobitz type II
  • Complete Heart block / High degree AV block
  • Bundle branch block
  • Sinus arrest / Sinus pauses
  • Supraventricular tachycardia
  • Atrial fibrillation
  • Junctional tachycardia
  • Fascicular tachycardia
  • Ventricular tachycardia
  • Ventricular flutter
  • Bradycardia
  • Narrow QRS escape rhythm
  • Prolonged QT
  • ST depression / T inversion
  • ST elevation
  • Asystole
  • History of Wolf Parkinson White Syndrome. In a case of sudden death due to LC (Lyme Carditis).

The authors concluded their article with several pearls:

  • Lyme carditis may present with heart block as the sole or initial presentation with or without other manifestations of Lyme disease.
  • First degree heart block is the most common manifestation, which could rapidly progress to complete heart block.
  • As illustrated in this case, exercise and stress testing should not be carried out in Lyme disease patients until complete recovery from heart block.
  • Lyme carditis should be suspected in patients with cardiac symptoms living in an endemic region, particularly in younger patients with no other etiology evident.

 

Related Articles:

Can we avoid using a pacemaker for Lyme carditis with high-degree AV block?

First case of reversible complete heart block due to Lyme disease reported in Canada

Lyme carditis causes complete heart block in 26-year-old man 

 

References:

  1. Kannangara DW, Sidra S, Pritiben P. First case report of inducible heart block in Lyme disease and an update of Lyme carditis. BMC Infect Dis. 2019;19(1):428.

 

The post Growing list of cardiac problems in Lyme disease appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

There has been an “unprecedented increase in locally acquired cases in New York City,” writes VanAcker in the journal Emerging Infectious Diseases. [2] In response, VanAcker and colleagues launched a study to determine tick densities and B. burgdorferi infection prevalence in nymphal deer ticks (I. scapularis) in New York City’s public parks.

They also examined the effect of landscape composition and configuration on tick populations and infection rates.

Investigators collected 560 ticks from 24 parks throughout all 5 boroughs, which included Staten Island (13), Manhattan (2), Brooklyn (2), Bronx (3) and Queens (4).

“At least 1 I. scapularis nymph [tick] was found at 17 of 24 parks surveyed throughout NYC,” the authors explain.

Meanwhile, 10 of the 17 parks had more than 6 nymphs and were considered to have established deer tick populations. All of these parks were on Staten Island (with the exception of Pelham Bay Park in the Bronx).

At each park, between 8% – 40% of the ticks tested positive for B. burgdorferi. The average nymphal infection prevalence was 26.6%.

Interestingly, the parks which did not have established tick populations also did not have many deer. This “indicates a strong link between deer and presence of I. scapularis ticks in NYC parks,” the authors write.

“We found forested parks with vegetated buffers and increased connectivity had higher nymph densities,” VanAcker writes, “and the degree of park connectivity strongly determined B. burgdorferi nymphal infection prevalence.”

According to the authors, this study challenges the belief that tick-borne diseases are merely a risk to those living in suburban regions and natural settings.

So, why are ticks migrating into New York City? VanAcker and colleagues suggest:

  • “Green space design affects vector and host communities in areas of emerging urban tick-borne disease.”
  • “Locally dispersing or migrating passerine birds play a role in moving immature ticks longer distances.”

Related Articles:

B. burgdorferi, the pathogen that causes Lyme disease, is widespread in New York City metro area

Infected ticks prevalent in urban areas in the United Kingdom (UK)

Urban ticks carry B. burgdorferi and B. Miyamotoi

References:

  1. Daskalakis DC. Department of Health and Mental Health. Advisory #14: tick-borne disease advisory. New York City, NY, 2017. [cited 2019 Jan 15].
  2. VanAcker MC, Little EAH, Molaei G, Bajwa WI, Diuk-Wasser MA. Enhancement of Risk for Lyme Disease by Landscape Connectivity, New York, New York, USA. Emerg Infect Dis. 2019;25(6):1136-1143.

The post Infected deer ticks moving into New York City appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

Conversely, anchor bias might also occur if a doctor considers only the initial information and incorrectly diagnoses Lyme disease and misses the true diagnosis. Aguirre and colleagues describe this scenario in their paper Anchoring Bias, Lyme Disease, and the Diagnosis Conundrum. [1]

A 29-year-old man living in Florida presented with severe headaches, fever, myalgia, and diarrhea. “He developed facial paresis with nonfocal paresthesia, bilateral scotomas, and a self-resolved erythematous patch along his inner thigh weeks prior,” the authors state.

“Initial suspicion for early disseminated Lyme with aseptic meningitis was fueled by tick exposure, cutaneous exanthem, and facial palsy,” writes Aguirre.

The patient also had a Western blot positive IgM and a negative IgG for Borrelia burgdorferi. Doctors initially presumed he had early disseminated Lyme meningitis and prescribed doxycycline.

However, after further testing, the final diagnosis was changed to Echovirus 30 and Coxsackie B5.

The authors concluded that the diagnosis of Lyme disease was an anchor bias.

“His headache and vision improved gradually,” writes Aguirre. “However, the patient experienced distress from misdiagnosis with a life-threatening and contagious illness affecting family contact and financial burden from prolonged work leave.”

Editor’s note: I am not convinced that this is a good example of an anchor bias. Lyme disease does occur in Florida. “Of 216 regional cases reported in 2016, 132 were confirmed positive by the CDC,” writes Aguirre.

Furthermore, I do not agree with the authors’ conclusion that anchor bias could have been avoided if the CDC’s two-tier testing process was used. Only 25% of patients with early Lyme disease tested positive with it, according to a 2017 study published in Clinical Infectious Diseases. And, only 55% of the early Lyme disease study participants had positive results on convalescence.

It is also common practice for a doctor to treat an illness empirically until test results are received. It is also common practice to change the diagnosis as additional testing becomes available.

Related Articles

Relying on a negative Lyme disease test can prove deadly

Study finds misdiagnosis and delayed diagnosis common for Lyme disease patients

References

  1. Aguirre LE, Chueng T, Lorio M, Mueller M. Anchoring Bias, Lyme Disease, and the Diagnosis Conundrum. Cureus. 2019;11(3):e4300.

The post Getting the diagnosis correct and avoiding ‘anchor bias’ appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

According to Kumar and colleagues, the woman was an avid gardener, who had a history of COPD (chronic obstructive pulmonary disease) and high blood pressure. She was admitted to the hospital with dyspnea, fatigue, and a cough productive of yellowish mucoid sputum.

The patient also had significant altered mental status, pallor, and peripheral edema. A lung examination revealed bibasilar crackles, Kumar explains. [1]

The woman, who had no history of a rash or tick bite, was treated empirically for community-acquired pneumonia. And was prescribed ceftriaxone and azithromycin.

Tick bites can transmit more than Lyme disease. This patient was infected with 3 different diseases.
Click To Tweet

However, lab tests later revealed the presence of 3 tick-borne pathogens. “We present a case of triple infection with babesiosis, Lyme disease, and anaplasmosis treated with antibiotics and red blood cell (RBC) exchange (erythrocytapheresis),” explains Kumar.

1) Babesia − A tiny parasite that infects the red blood cells.

“A peripheral blood smear revealed the presence of intracytoplasmic parasites consistent with Babesia,” writes Kumar. Consequently, the woman was started on azithromycin and atovaquone.

Further testing revealed that she had severe babesiosis. Her parasitic load was so high (9.04%) that she required a red blood cell (RBC) exchange (erythrocytapheresis).

Repeat testing, however, found the parasitic load remained high (6.54%), which required a second round of RBC exchange.

“Antimicrobials were changed to clindamycin, quinine, and doxycycline for a total of 14 days,” writes Kumar.

2) Borrelia burgdorferi − The bacteria that causes Lyme disease. Serologic tests were positive. The patient was prescribed doxycycline.

3) Anaplasma − The bacteria that causes anaplasmosis, formerly known as human granulocytic ehrlichiosis (HGE). Anaplasma titers were positive.

Authors suggest: “Patients presenting with an atypical clinical picture of a single pathogen or a lack of improvement with antibiotics after 48 hours require further testing for the presence of other infections.”

“A delay in the diagnosis can lead to an increased risk of complications and disease duration,” writes Kumar and colleagues.

Related Articles:

One bite, six diseases: all from the same tick 

First-line combination therapy for tick-borne illnesses

Video: Co-infections of Lyme disease

References:

  1. Kumar M, Sharma A, Grover P. Triple Tick Attack. Cureus. 2019;11(2):e4064.

The post Tick bite causes 3 diseases in elderly woman appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

The New York Times article, written by Apoorva Mandavilli, the mother of a 9-year-old boy who developed Lyme disease, portrays it as a relatively insignificant disease. It is, as she states, “An easily treated infection with no long-term consequences for children, or even the vast majority of adults.”

However, she goes on to cite several stories which depict the devastation the disease can actually cause:

  • “A parent at the school bus stop told me about a family friend in her 20’s who has never recovered from her infection.”
  • “A co-worker at the neighborhood co-op told me that his father-in-law has had seizures ever since his diagnosis.”
  • “Even a fellow science journalist told me she knows some people never recover.”

Doctors on the “frontline” who treat Lyme disease and other tick-borne illnesses on a daily basis and manage complex cases have seen many of these chronically ill patients. Other doctors do not treat these difficult cases and may, therefore, dismiss the seriousness of the disease.

“It’s baloney that you can’t cure Lyme disease, it’s eminently curable,” states Dr. Eugene Shapiro, professor of pediatrics and of epidemiology at Yale.

Mandavilli cites Dr. Shapiro as saying “most people who report chronic problems were most likely wrongly diagnosed with Lyme disease when they had something else to begin with.”

Watch Video: Dr. Eugene Shapiro on Lyme disease in children.

“Some people who have unexplained pain or fatigue may latch on to Lyme disease,” Shapiro says, “as a possible explanation after getting an inaccurate diagnosis from a doctor who misinterprets the test.”

But as so many patients have discovered, Lyme disease is not a simple illness. It is as complex as the bacterial spirochete that causes it. And getting an accurate and timely diagnosis is challenging, as even Mandavilli discovered.

Her child had complained about an ache in his legs, which she attributed to growing pains, his gait or regular squash lessons. Neither she nor the boy’s doctor suspected Lyme disease.

“We saw a couple of doctors, who ordered various X-rays and scans. When an M.R.I. showed inflammation in Akash’s knee and ankle, the orthopedist we saw called to say it could be juvenile arthritis or any of a long list of autoimmune or inflammatory disorders,” states Mandavilli.

The parents, fortunately, stumbled upon the diagnosis of Lyme disease after a family friend suggested it. Lyme disease tests confirmed the diagnosis, and the child was treated successfully.

It is important for physicians to recognize that, in some people, Lyme disease can cause long-term, chronic symptoms. And it is imperative that it be included in their differential diagnosis.

Related Articles:

Case report: persistent pain and fatigue after treatment for Lyme disease

Lyme disease induces severe cardiac problems in 15-year-old boy

Reference:

https://www.nytimes.com/2019/06/27/well/live/lyme-disease-children-treatment-diagnosis.html

The post Article outrage: Lyme disease easily treated? appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

So, what does it take to be “Lyme literate”?

Baker argues that “Lyme disease conforms to the same fundamental rules and principles applicable to other infectious diseases.”

But he fails to define what it would take for a board certified infectious disease specialist to be “Lyme literate.”

I would assume a “Lyme literate” doctor would be able to diagnose and treat the following types of cases:

  1. Lyme encephalopathy [2]
  2. Lyme neuropathy [2]
  3. Neuropsychiatric Lyme disease [3]
  4. Pediatric neuropsychiatric disorders – PANS [4]
  5. Lyme carditis [5]
  6. Autonomic dysfunction – POTS [6]
  7. Post-treatment Lyme fatigue – Post Lyme disease [7]
  8. Neuropathic pain [8]
  9. Persistent symptoms after Lyme disease [9]
  10. Concurrent Co-infections [10]

References:

  1. Baker PJ. Is It Possible to Make a Correct Diagnosis of Lyme Disease on Symptoms Alone? Review of Key Issues and Public Health Implications. Am J Med. 2019.
  2. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990;323(21):1438-1444.
  3. Fallon BA, Nields JA. Lyme disease: a neuropsychiatric illness. Am J Psychiatry. 1994;151(11):1571-1583.
  4. Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev. 2018;86:51-65.
  5. Muehlenbachs A, Bollweg BC, Schulz TJ, et al. Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis. Am J Pathol. 2016.
  6. Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Postural orthostatic tachycardia syndrome following Lyme disease. Cardiol J. 2011;18(1):63-66.
  7. Krupp LB, Hyman LG, Grimson R, et al. Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial. Neurology. 2003;60(12):1923-1930.
  8. Simons LE. Fear of pain in children and adolescents with neuropathic pain and complex regional pain syndrome. Pain. 2016;157 Suppl 1:S90-97.
  9. Klempner MS, Hu LT, Evans J, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med. 2001;345(2):85-92.
  10. Krause PJ, Telford SR, 3rd, Spielman A, et al. Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness. Jama. 1996;275(21):1657-1660.

The post What does it take to be a “Lyme literate” doctor? appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

In 2017, a 58-year-old woman from Missouri, who initially presented with generalized weakness, myalgia, nausea, and a rash, was diagnosed with the virus. She had been exposed to ticks one week earlier. She died after 23 days in the hospital.

The virus is so new that relatively little is known about it. Symptoms typically include fever, fatigue, rash, headache, body aches, nausea and vomiting.

Flu drug protects mice from fatal Bourbon virus infection.

There are no tests to diagnose the disease and no approved treatments or vaccines.

But now, for the first time,  researchers at Washington University School of Medicine in St. Louis believe they may have identified a potential treatment for the Bourbon virus.

Using a mouse model, Boon and colleagues discovered that the experimental antiviral drug favipiravir, used to treat influenza in some countries, cured mice infected with the virus. [1]

The authors “treated the mice daily with 150 mg/kg of favipiravir in 0.5% methylcellulose via oral gavage for 8 days beginning immediately after infection.”

“Without the flu drug, 100% of the infected mice died, and with the treatment, 100% survived,” states Boon, senior author of the study.

“Favipiravir may be a candidate drug for the treatment of BRBV [Bourbon virus] in humans,” the authors write. They also suggest that other RNA polymerase inhibitors could be used.

Findings from mouse study suggest that antiviral flu drug may effectively treat the Bourbon virus in humans.
Click To Tweet

Then, to determine the effectiveness of favipiravir in mice after the onset of symptoms, the authors began treatment with 3 dpi with BRBV-STL. “At this time point, the animals were starting to lose weight and replicating BRBV-STL was detected throughout the body.”

One day after treatment began with favipiravir, the mice stopped losing weight and gradually recovered from infection, the authors write.

“Remarkably, all of the animals survived the infection, whereas the mock-treated animals all succumbed.” The study demonstrated that the broad-spectrum antiviral drug stops replication of the Bourbon virus.

“Up until now, doctors have not had any way to treat Bourbon virus. We’ve found something that works, at least in mice, and it suggests that antivirals for flu are a good place to start looking for a treatment for Bourbon,” states Boon.

“Prophylactic and therapeutic treatment with favipiravir resulted in complete protection from a lethal BRBV [Bourbon virus] infection.”

Favipiravir is approved in Japan for the treatment of influenza but not in the United States.

Related Articles:

10 cases of Heartland virus reviewed

Chikungunya virus can mimic Lyme disease

References:

  1. Bricker TL, Shafiuddin M, Gounder AP, Janowski AB, Zhao G, Williams GD, Jagger BW, Diamond MS, Bailey T, Kwon JH, Wang D, Boon ACM. Therapeutic efficacy of Favipiravir against Bourbon virus in mice. PLOS Pathogens. June 13, 2019. DOI: 10.1371/journal.ppat.1007790

The post Bourbon virus: flu drug to treat the deadly disease? appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

In 2017, a 58-year-old woman from Missouri, who initially presented with generalized weakness, myalgia, nausea, and a rash, was diagnosed with the virus. She had been exposed to ticks one week earlier. She died after 23 days in the hospital.

The virus is so new that relatively little is known about it. Symptoms typically include fever, fatigue, rash, headache, body aches, nausea and vomiting.

Flu drug protects mice from fatal Bourbon virus infection.

There are no tests to diagnose the disease and no approved treatments or vaccines.

But now, for the first time,  researchers at Washington University School of Medicine in St. Louis believe they may have identified a potential treatment for the Bourbon virus.

Using a mouse model, Boon and colleagues discovered that the experimental antiviral drug favipiravir, used to treat influenza in some countries, cured mice infected with the virus. [1]

The authors “treated the mice daily with 150 mg/kg of favipiravir in 0.5% methylcellulose via oral gavage for 8 days beginning immediately after infection.”

“Without the flu drug, 100% of the infected mice died, and with the treatment, 100% survived,” states Boon, senior author of the study.

“Favipiravir may be a candidate drug for the treatment of BRBV [Bourbon virus] in humans,” the authors write. They also suggest that other RNA polymerase inhibitors could be used.

Findings from mouse study suggest that antiviral flu drug may effectively treat the Bourbon virus in humans.
Click To Tweet

Then, to determine the effectiveness of favipiravir in mice after the onset of symptoms, the authors began treatment with 3 dpi with BRBV-STL. “At this time point, the animals were starting to lose weight and replicating BRBV-STL was detected throughout the body.”

One day after treatment began with favipiravir, the mice stopped losing weight and gradually recovered from infection, the authors write.

“Remarkably, all of the animals survived the infection, whereas the mock-treated animals all succumbed.” The study demonstrated that the broad-spectrum antiviral drug stops replication of the Bourbon virus.

“Up until now, doctors have not had any way to treat Bourbon virus. We’ve found something that works, at least in mice, and it suggests that antivirals for flu are a good place to start looking for a treatment for Bourbon,” states Boon.

“Prophylactic and therapeutic treatment with favipiravir resulted in complete protection from a lethal BRBV [Bourbon virus] infection.”

Favipiravir is approved in Japan for the treatment of influenza but not in the United States.

Related Articles:

10 cases of Heartland virus reviewed

Chikungunya virus can mimic Lyme disease

References:

  1. Bricker TL, Shafiuddin M, Gounder AP, Janowski AB, Zhao G, Williams GD, Jagger BW, Diamond MS, Bailey T, Kwon JH, Wang D, Boon ACM. Therapeutic efficacy of Favipiravir against Bourbon virus in mice. PLOS Pathogens. June 13, 2019. DOI: 10.1371/journal.ppat.1007790

The post Bourbon virus: flu drug to treat the deadly disease? appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

by Daniel J. Cameron, MD, MPH

While the Powassan virus is considered rare, it can be dangerous and is fatal in 10% of the cases. In 2013, a Maine woman died from the disease and as of 2017, 10 residents have been infected.

An increase in cases of Powassan is particularly alarming, given that there is no medication to treat this infection, yet it can cause long-term neurologic problems. The virus can also be transmitted in as little as 15 minutes.

Survey finds B. miyamotoi under-diagnosed in Maine, while Powassan virus causes concern.

Now, a survey by Smith and colleagues examines the prevalence of B. burgdorferi (the causative agent of Lyme disease), B. miyamotoi, and the Powassan virus (POWV) among residents living in Maine. [1]

Using a tick identification database, the authors surveyed 230 individuals who had been bitten by Ixodes scapularis (deer ticks) or Ixodes cookei (woodchuck or groundhog) ticks between 2009 – 20013. Nearly all of the residents (99%) had been bitten by I. scapularis ticks.

Testing revealed:

  • 13.9% of the people were positive for B. burgdorferi;
  • 2.6% were positive for B. miyamotoi;
  • 0.9% of the subjects were positive for B. burgdorferi and B. miyamotoi;
  • 0.4% were positive for the Powassan encephalitis virus.

“Among residents of southern Maine with a history of I. scapularis tick bites,” the authors write, “the percentage who were seropositive for B. burgdorferi was 5 times greater than that for B. miyamotoi (13.9% vs. 2.6%) and 35 times greater than the percentage of deer ticks infected with POWV (0.4%).”

Although the number of I. scapularis ticks in Maine infected with the Powassan virus is low, frequent exposure to tick bites and the speed of transmission of the virus raises concerns, the authors write.

Borrelia miyamotoi under-diagnosed in Maine, survey concludes.
Click To Tweet

Out of all the Borrelia spp. infections (n=1,854) reported in Maine in 2017, only 6 cases were attributed to B. miyamotoi. The majority were diagnosed as Lyme disease.

“On the basis of a seroprevalence of ≈2% in this study and that B. miyamotoi might be transmitted by all tick stages, we believe that this disease [B. miyamotoi] is underdiagnosed in Maine.”

Author’s Note: It is encouraging that researchers are learning more about emerging infections, including the Powassan virus. But it is also important for clinicians to not overlook treatable tick-borne diseases when assessing a patient.

(An adolescent from Poughkeepsie, NY, who had been diagnosed with Powassan virus and later died, was discovered post-mortem to have had Lyme carditis, a treatable tick-borne illness.)

Related Articles:

The best antibiotics to treat Borrelia miyamotoi?

Study finds tiny larval ticks can transmit Borrelia miyamotoi

Powassan virus infection causes polio-like illness

References:

  1. Smith RP Jr, Elias SP, Cavanaugh CE, et al. Seroprevalence of Borrelia burgdorferi, B. miyamotoi, and Powassan Virus in Residents Bitten by Ixodes Ticks, Maine, USA. Emerg Infect Dis. 2019;25(4):804–807. doi:10.3201/eid2504.180202

The post Prevalence of Borrelia infections and Powassan virus in Maine appeared first on Daniel Cameron, MD, MPH.

  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

In the summer of 2013, a young man from Poughkeepsie, NY, died suddenly after suffering from flu-like symptoms for nearly 3 weeks. Initial reports suggested he had died from complications due to the Powassan virus, a rare illness, transmitted by ticks that can be fatal.

However, a paper published in the March issue of Cardiovascular Pathologist, reports the adolescent, in fact, had died from Lyme carditis.

Negative Lyme disease tests overshadowed the patient’s clinical symptoms. A diagnosis of Powassan virus was changed to Lyme carditis after the young man’s death.

According to the report, the ELISA and Western blot IgM tests, conducted as part of the autopsy, were positive for Borrelia burgdorferi, the agent that causes Lyme disease. Additional tests, including PCR (polymerase chain reaction) and immonohistochemistry (ICH) staining found Borrelia spirochete present in the patient’s liver, heart, lung, and brain tissues.

“The findings support B. burgdorferi as the causative agent for his fulminant carditis and that the patient suffered fatal Lyme carditis,” the authors write.

The high school honor roll student had aspired to be an environmental engineer and loved the outdoors. He had just returned home from a two-week stay at a camp in Rhode Island, a state that is endemic for Lyme disease, when he fell ill.

According to his parents, he initially developed a mild cough, occasional fevers, a sore throat, malaise, headaches and body aches. Serology tests for Lyme disease and anaplasmosis were negative.

The young man’s symptoms progressed. He complained of gastrointestinal problems, light-headedness and photophobia (light sensitivity). According to the Poughkeepsie Journal, he was instructed to rest and stay hydrated.

A few days later, he collapsed suddenly in his backyard. The young man had gone into cardiac arrest. “Doctors in Westchester tried to diagnose his condition but were stumped,” states the Poughkeepsie Journal. The teenager died several hours later. He was just 17-years-old.

When an individual manifests symptoms consistent with Lyme disease and has been exposed to a tick endemic region, clinicians should consider a Lyme disease diagnosis, even with a negative test result.

Because Lyme disease symptoms are often compared to those of the flu, people may tend to equate the two illnesses, and mistakenly assume that Lyme disease is harmless. That is not necessarily the case. If the infection is not treated appropriately in its initial stage, the disease can progress, causing debilitating symptoms, chronic illness and, in rare cases, fatalities.

What is Lyme carditis?

Lyme carditis occurs when the Lyme spirochete (Borrelia burgdorferi) enters the heart tissue. It is considered rare with only a handful of fatalities reported. The condition can be extremely challenging to diagnose, since patients typically describe classic flu-like symptoms. In fact, one study found 94% of patients with Lyme carditis exhibited nonspecific symptoms, including fever, malaise, headache, arthralgia, and/or myalgias. 1

Children and adolescents can also be affected. A 2009 study in Pediatrics, Lyme carditis in children: presentation, predictive factors and clinical course, evaluated 207 pediatric patients with early disseminated Lyme disease and found that 16% had Lyme carditis, 42% of those patients had advanced heart block, with 27% exhibiting complete heart block and 4 patients with severely depressed systolic ventricular function. 1

While Lyme carditis may be rare, this young man’s tragic death illustrates the potential dangers of relying on serology tests to diagnose and treat Lyme disease.  It also underscores the ongoing confusion among clinicians over the accuracy and reliability of such tests, specifically the ELISA and Western blot.

The young man appeared to fit the requirements for a Lyme disease diagnosis. He had the typical symptoms associated with Lyme – fatigue, headaches, body aches, GI disruptions, fevers, light sensitivity – and he had visited a tick endemic region with a high probability for exposure to ticks.

Furthermore, he lived in Dutchess County, New York, an area that’s endemic for Lyme disease with an estimated 50% of deer ticks infected with the Lyme organism.

Yet, the young man was not diagnosed, nor treated for Lyme disease. It is unfortunate that his negative test results overshadowed his clinical symptoms and history.

The Centers for Disease Control and Prevention (CDC) point out that patients tested during the first few weeks of illness often test negative, because there’s not enough antibodies in the bloodstream to be detected. The ELISA and Western blot can miss up to 60% of well-defined Lyme disease cases. 2

Physicians who treat Lyme disease according to guidelines put forth by the International Lyme and Associated Diseases Society (ILADS) are encouraged to treat patients based on clinical judgment even when tests are negative.

Last updated: June 10, 2019

Related Articles:

5 things to know about Lyme carditis

Lyme carditis causes complete heart block in 26-year-old man

How Lyme myocarditis might present in an adolescent patient

References

  1. Costello JM, Alexander ME, Greco KM, Perez-Atayde AR, Laussen PC. Lyme carditis in children: presentation, predictive factors and clinical course. Pediatrics 2009;123:835–41.
  2. Molins CR, Ashton LV, Wormser GP, Hess AM, Delorey MJ, Mahapatra S, Schriefer ME, Belisle JT. Development of a Metabolic Biosignature for Detection of Early Lyme Disease. Clin Infect Dis. 2015 Mar 11.

The post Relying on a negative Lyme disease test can prove deadly appeared first on Daniel Cameron, MD, MPH.

Read for later

Articles marked as Favorite are saved for later viewing.
close
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

Separate tags by commas
To access this feature, please upgrade your account.
Start your free month
Free Preview