Unresolved Heart Block in Lyme Carditis: A Case Report

A man in his thirties presented to the emergency department with a one-day history of syncopal episodes. He was found to have complete heart block and had multiple long and symptomatic pauses in telemetry while in the hospital. The longest pause was measured at 30 seconds. He had frequent occupational exposure to ticks and was found to have positive immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies for Lyme disease. He was immediately started on IV (intravenous) ceftriaxone and isoproterenol infusion for inotropy in anticipation of recovery of atrioventricular (AV) conduction with IV antibiotics. Rapid response was called for multiple symptomatic pauses overnight, the longest one lasting 30 seconds. The patient was taken for urgent temporary transvenous pacemaker placement in the morning. AV conduction failed to improve with IV antibiotics. A permanent pacemaker was placed on day four of hospitalization as his complete heart block failed to resolve with IV antibiotics and the patient could not be weaned from temporary pacemaker support. A complete heart block is a rare manifestation of Lyme disease and warrants a high index of suspicion when a patient in an endemic area presents with this condition. A majority of patients recover with IV antibiotics, although some patients may need to be put on temporary pacemaker support in the interim. On rare occasions, a permanent pacemaker is necessary. Atrioventricular conduction may fail to improve with IV antibiotics, and these patients may need early pacemaker support with a transvenous pacemaker in addition to IV ceftriaxone followed by permanent pacemaker placement. Our patient presented with recurrent Lyme disease and had a complete heart block on presentation, which failed to improve with IV antibiotics and required temporary transvenous pacemaker support followed by permanent pacemaker placement.