A unique infective etiology for cardiomyopathy in a South Asian patient

Left ventricular (LV) dysfunction can occur due to various causes. In order to provide appropriate treatment, it is essential to establish the correct etiology of LV dysfunction. A 52-year-old male, resident of South India, presented with dyspnea on exertion for two months. Echocardiography showed global LV hypokinesia with ejection fraction of 45% and global longitudinal strain (GLS) of -12.5%. Coronary angiogram (CAG) showed single-vessel disease of right coronary artery. The CAG findings were inconsistent with distribution of LV dysfunction. There was also history of fever and migratory polyarthritis involving large joints of upper and lower limbs 2-3 months previously. Hemogram revealed mild anemia with iron deficiency. Erythrocyte sedimentation rate was elevated (100 mm/h). Lyme serology (IgM) results were positive. Fundus examination showed cotton wool spots bilaterally. Upper gastrointestinal endoscopy and biopsy indicated duodenitis. Diagnosis of Lyme cardiomyopathy was made. All the findings in our patient are explained by Lyme disease including cardiomyopathy, history of fever with polyarthritis, duodenitis, and cotton wool spots on fundus. The patient received doxycycline for 3 weeks. Subsequent follow ups for LV function showed improvement in LV ejection fraction from 45% to 52%. GLS improved from -12.5% to -15%.

All cases of left ventricular dysfunction should be thoroughly evaluated. Infectious diseases can also underlie left ventricular dysfunction. It is essential to confirm a history of fever and joint symptoms. In cases with migratory polyarthritis, Lyme disease should be suspected, and fundus examination together with Lyme serology testing can lead to diagnosis and appropriate treatment.