Doctors should be alert to atypical symptoms of Lyme disease

If the deconfinement and the beginning of summer mean the return of walks in the forest, it is nevertheless necessary to pay attention to an upsurge in diseases which could occur. Indeed, in Canada, the expansion of areas where the blacklegged tick is found is raising concerns about Lyme disease. What makes matters even more complicated is that Lyme disease can present itself in unpredictable ways and lead to death.

Three articles from Canadian Medical Association Journal describe cases of atypical skin lesions in a 37-year-old man who died, cardiac abnormalities in a 56-year-old woman, and severe neurological symptoms in a four-year-old boy. This shows the diversity of clinical presentations of Lyme disease.

Danger to the heart

When the heart is affected by Lyme disease, serious heart rhythm abnormalities can ensue in a small group of people, this is called Lyme carditis. In areas where the tick is endemic, it is possible that Lyme carditis occurs in people with atrioventricular block, a disease that causes a transmission defect in the electrical impulses of the heart. Likewise, it is possible for these people to have rashes. In these cases, antibiotics are recommended at an early stage, even before the diagnosis is confirmed.

One of the case studies highlights the difficulties encountered in diagnosing Lyme disease. In the first, a 37-year-old man had previously maintained good health. The classic symptoms of the disease were absent in this case. He had reported flu-like symptoms to his family doctor, including fever, sore throat, nasal congestion and migrating joint pain. He said he came into contact with ticks a few weeks ago. The doctor treated him for a viral infection and the patient’s symptoms resolved.

After a few weeks, the patient developed heart palpitations, shortness of breath, and chest discomfort. He was sent to the emergency room and the electrocardiography (ECG) revealed complete heart block. Although treatment for Lyme carditis was started, his condition worsened in a short time and he died. Serology results confirmed Lyme disease, which was confirmed by an autopsy.

Act without waiting for confirmation

For Dr. Milena Semproni, an infectious disease fellow at the University of Manitoba and the Winnipeg Regional Health Authority (Winnipeg, Manitoba) and co-author of the study, “the diagnosis of Lyme carditis is based on clinical suspicion and serology consistent with acute Lyme disease. Unfortunately, diagnosis can be delayed during serological treatment and clinical suspicion should guide empiric treatment. Because early diagnosis is clinical, cases can be overlooked by clinicians, especially when Lyme disease spreads to new geographic areas.”

If Lyme carditis is suspected, an ECG should be performed urgently and the patient should be given antibiotics without waiting for serological confirmation. The authors warn of serious heart rhythm abnormalities and sudden cardiac death in a small group of patients, although this is rare. Ten other North American cases of death from sudden heart disease attributed to Lyme carditis have been described in the literature. Among them, eight patients were male and the cases occurred between June and November, when the ticks are active.

A related article describes the case of a patient who reported a large red rash, pain and chills. After seeking medical help a second time for heart palpitations, doctors discovered he was suffering from Lyme carditis. In this case, treatment with antibiotics was successful.

Time is of the essence

As Dr Ardian Baranchuk, from the Department of Medicine at Queen’s University in Kingston, also a co-author of the study, writes, “Since most conduction abnormalities caused by Lyme carditis resolve with appropriate antibiotic treatment, recognition of atypical dermatologic presentations in the setting of Lyme carditis prevents unnecessary permanent pacemaker implantation in these otherwise healthy young people.”

In the third case, a four-year-old boy was brought to hospital with fever, vomiting, malaise, ataxia (loss of control over physical movement) and aphasia (inability or reduced ability to understand and speak). The child fully recovered after antibiotic treatment.

In his review, the Canadian Medical Association Journal also reports how medical organizations are developing tools to help Canadian doctors talk to patients about Lyme disease. She says many frontline doctors feel ill-prepared to counter misinformation about the disease and are pressured to perform Lyme tests and prescribe antibiotics unnecessarily.

He cites an informal survey conducted by Dr. Lynora Saxinger, an infectious disease specialist and associate professor at the University of Alberta’s medical school. According to the survey of primary care physicians, 30% said they did not feel they had appropriate educational resources to offer patients.