History and Presentation:
A 36-year-old man comes to the emergency department after briefly losing consciousness while watching television half an hour ago. The patient had no preceding chest pain or shortness of breath, but he has been having recurrent palpitations over the past several days.
Two weeks ago, he noticed a non-itchy rash on his thigh that he treated with an over-the-counter steroid cream.
Medical history and Surgical History:
Unremarkable.
Family History:
There is no family history of heart disease or sudden cardiac death.
Social History:
The patient recently began working as a forest ranger in Pennsylvania. He does not use tobacco, alcohol, or illicit drugs.
Physical Examination:
On physical examination, he is found to have
Diagnosis:
Based on history and recent work history in forest and clinical manifestation of bullseye lesion on thigh and complete heart block makes Disseminated Lyme Disease leading to Lyme Carditis is the most likely diagnosis.
Pathophysiology:
This patient most likely has early disseminated Lyme disease. Lyme disease is caused by the bacterial spirochete Borrelia burgdorferi, which is transmitted by the Ixodes tick Most cases initially present with a non-itchy, bull's-eye-shaped rash, known as erythema migrans, at the site of infection. Left untreated for several weeks or more, a small percentage of those infected will develop cardiac involvement (Lyme carditis).
Lyme carditis most commonly manifests with varying degrees of atrioventricular (AV) conduction block. Patients who develop complete AV block are likely to have symptoms of dyspnea, lightheadedness, or syncope.
Treatment:
Treatment for symptomatic AV block due to Lyme carditis typically requires hospitalization with temporary pacing and the administration of intravenous antibiotics (ceftriaxone is the drug of choice). Some patients might need a temporary pacemaker. Patients generally recover within 1-6 weeks.
Inj. Ceftriaxone 2gm IVxOD for 14 to 21 days.
A 36-year-old man comes to the emergency department after briefly losing consciousness while watching television half an hour ago. The patient had no preceding chest pain or shortness of breath, but he has been having recurrent palpitations over the past several days.
Two weeks ago, he noticed a non-itchy rash on his thigh that he treated with an over-the-counter steroid cream.
Medical history and Surgical History:
Unremarkable.
Family History:
There is no family history of heart disease or sudden cardiac death.
Social History:
The patient recently began working as a forest ranger in Pennsylvania. He does not use tobacco, alcohol, or illicit drugs.
Physical Examination:
On physical examination, he is found to have
- BP: 112/68mmHg
- Pulse 45bpms
- Temp: 98F
- Respiration 20/min
- CNS: GCS 15/15 with normal motor and sensory responses
- Respiration: NVB+0
- GIT: abdomen is soft and non-tender and bowel sounds are audible (3/min)
- CVS: Rapid heart rate, taping apical pulse, S1 and S2 audible and no apparent murmurs.
- ECG:
Reveals complete atrioventricular block. - Echocardiography (ECHO): shows normal ventricular function with no major valvular disease.
- Non-itchy rash on his thigh that he treated with an over-the-counter steroid cream.
Diagnosis:
Based on history and recent work history in forest and clinical manifestation of bullseye lesion on thigh and complete heart block makes Disseminated Lyme Disease leading to Lyme Carditis is the most likely diagnosis.
Pathophysiology:
This patient most likely has early disseminated Lyme disease. Lyme disease is caused by the bacterial spirochete Borrelia burgdorferi, which is transmitted by the Ixodes tick Most cases initially present with a non-itchy, bull's-eye-shaped rash, known as erythema migrans, at the site of infection. Left untreated for several weeks or more, a small percentage of those infected will develop cardiac involvement (Lyme carditis).
Lyme carditis most commonly manifests with varying degrees of atrioventricular (AV) conduction block. Patients who develop complete AV block are likely to have symptoms of dyspnea, lightheadedness, or syncope.
Treatment:
Treatment for symptomatic AV block due to Lyme carditis typically requires hospitalization with temporary pacing and the administration of intravenous antibiotics (ceftriaxone is the drug of choice). Some patients might need a temporary pacemaker. Patients generally recover within 1-6 weeks.
Inj. Ceftriaxone 2gm IVxOD for 14 to 21 days.
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