Lyme carditis, more than blocked beats

1.0 CME. Lyme carditis is a serious and sometimes fatal manifestation of the infection.


Elizabeth Maloney, MD
Education Co-Director, Invisible International


Lyme carditis is a serious and sometimes fatal manifestation of the infection.

Learning objectives

  1. Recognize all manifestations of Lyme carditis
  2. Make a diagnosis of Lyme Carditis on clinical grounds as serologic testing may be negative
  3. Begin antibiotic treatment early, as soon as the diagnosis is suspected, and properly select inpatient versus outpatient therapy
  4. Consider age, gender, personal beliefs, and co-morbidities when managing patients with Lyme carditis

This session, Lyme carditis, more than blocked beats, is approved for 1.0 enduring AAFP Prescribed credit.

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

The AAFP has reviewed One Health Medical Education for a Changing Climate and deemed it acceptable for AAFP credit. Term of approval is from 01/02/2024 to 01/01/2025. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure information

In an effort to be transparent in our attempts to provide independent, unbiased educational content, we have received disclosure information from everyone who controlled content. None of the below planners, reviewers, and/or faculty have any financial relationships with commercial interests to disclose:


Christine Green, MD
Elizabeth Maloney, MD
Charlotte Mao, MD
Nev Zubcevik, DO
Judy Hyle, CHCP


William Choctaw, MD, JD
Michael Marchiano, MD
Lester Holstein, MD
Harold Damuth, MD

Evidence-based bibliography for further study

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• Centers for Disease Control and Prevention (CDC). Three sudden cardiac deaths associated with Lyme carditis – United States, November 2012-July 2013. MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62(49):993-996 

• Costello JM, Alexander ME, Greco KM, Perez-Atayde AR, Laussen PC. Lyme carditis in children: presentation, predictive factors, and clinical course. Pediatrics. 2009 May;123(5):e835-841. 

• Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ. Treatment of late Lyme borreliosis–randomised comparison of ceftriaxone and penicillin. Lancet. 1988 May 28;1(8596):1191-1194. 

• Duray PH. Clinical pathologic correlations of Lyme disease. Rev Infect Dis. 1989 Sep-Oct;11 Suppl 6:S1487-1493. 

• Feng J, Shi W, Zhang S, Sullivan D, Auwaerter PG, Zhang Y. A Drug Combination Screen Identifies Drugs Active against Amoxicillin-Induced Round Bodies of In Vitro Borrelia burgdorferi Persisters from an FDA Drug Library. Front Microbiol. 2016 May 23;7:743. 

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• Fishe JN, Marchese RF, Callahan JM. Lyme Myocarditis Presenting as Chest Pain in an Adolescent Girl. Pediatr Emerg Care. 2016 Jul;32(7):459-461. 

• Forrester JD, Meiman J, Mullins J, Nelson R, Ertel SH, Cartter M, et al. Notes from the field: update on Lyme carditis, groups at high risk, and frequency of associated sudden cardiac death– United States. MMWR Morb Mortal Wkly Rep. 2014 Oct 31;63(43):982-3. 

• Forrester JD, Mead P. Third-degree heart block associated with lyme carditis: review of published cases. Clin Infect Dis. 2014 Oct;59(7):996-1000. 

• Frank DB, Patel AR, Sanchez GR, Shah MJ, Bonney WJ. Junctional tachycardia in a child with Lyme carditis. Pediatr Cardiol. 2011 Jun;32(5):689-691. 

• Gasser R, Horn S, Reisinger E, Fischer L, Pokan R, Wendelin I, Klein W. First description of recurrent pericardial effusion associated with borrelia burgdorferi infection. Int J Cardiol. 1998 May 15;64(3):309-310. 

• Greenberg YJ, Brennan JJ, Rosenfeld LE. Lyme myocarditis presenting as fascicular tachycardia with underlying complete heart block. J Cardiovasc Electrophysiol. 1997 Mar;8(3):323-324. 

• Hegerova LT, Olson TC. The ticking heart: a case and review of acute lyme cardiac complications. Minn Med. 2014 May;97(5):42. 

• Jahangir A, Kolbert C, Edwards W, Mitchell P, Dumler JS, Persing DH. Fatal pancarditis associated with human granulocytic Ehrlichiosis in a 44-year-old man. Clin Infect Dis. 1998 Dec;27(6):1424- 1427. 

• Kameda G Vieker S, Hartmann J, Niehues T, Längler A. Diastolic heart murmur, nocturnal back pain, and lumbar rigidity in a 7-year girl: an unusual manifestation of lyme disease in childhood. Case Rep Pediatr. 2012;2012:976961. doi: 10.1155/2012/976961. 

• Karadag B, Spieker LE, Schwitter J, Ruschitzka F, Lüscher TF, Noll G, Corti R. Lyme carditis: restitutio ad integrum documented by cardiac magnetic resonance imaging. Cardiol Rev. 2004 Jul-Aug;12(4):185-187. 

• Karatolios K, Maisch B, Pankuweit S. Suspected inflammatory cardiomyopathy. Prevalence of Borrelia burgdorferi in endomyocardial biopsies with positive serological evidence. Herz. 2015 Mar;40 Suppl 1:91-95. 

• Khalil S, Padala SK, Hui CM, Steckman DA, Sidhu MS, Torosoff MT. Lyme Carditis in the Fast Lane: From Alternating Bundle Branch Block to Asystole in 12 Hours. Conn Med. 2015 Oct;79(9):517- 520. 

• Guex-Crosier Y, Herbort CP. Recurrent uveitis, cystoid macular edema and pericarditis in Lyme disease. Ocul Immunol Inflamm. 1994;2(2):111-113. 

• Hidri N, Barraud O, de Martino S, Garnier F, Paraf F, Martin C, et al. Lyme endocarditis. Clin Microbiol Infect. 2012 Dec;18(12):E531-2. 

• Koene R, Boulware DR, Kemperman M, Konety SH, Groth M, Jessurun J, Eckman PM. Acute heart failure from lyme carditis. Circ Heart Fail. 2012 Mar 1;5(2):e24-6. 

• Kuchynka P, Palecek T, Havranek S, Vitkova I, Nemecek E, Trckova R, et al. Recent-onset dilated cardiomyopathy associated with Borrelia burgdorferi infection. Herz. 2015 Sep;40(6):892-897. 

• Lelovas P, Dontas I, Bassiakou E, Xanthos T. Cardiac implications of Lyme disease, diagnosis and therapeutic approach. Int J Cardiol. 2008 Sep16;129(1):15-21. 

• Manek M, Kulkarni A, Viera A. Hint of Lyme, an uncommon cause of syncope. BMJ Case Rep. 2014 Mar 6;2014: bcr2013201547. doi: 10.1136/bcr-2013-201547. 

• Marcus LC, Steere AC, Duray PH, Anderson AE, Mahoney EB. Fatal pancarditis in a patient with coexistent Lyme disease and babesiosis. Demonstration of spirochetes in the myocardium. Ann Intern Med. 1985 Sep;103(3):374-376. 

• McAlister HF, Klementowicz PT, Andrews C, Fisher JD, Feld M, Furman S. Lyme carditis: an important cause of reversible heart block. Ann Intern Med. 1989 Mar 1;110(5):339-345. 

• Muehlenbachs A, Bollweg BC, Schulz TJ, Forrester JD, DeLeon Carnes M, Molins C et al. Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis. Am J Pathol. 2016 May;186(5):1195-1205. 

• Munk PS, Ørn S, Larsen AI. Lyme carditis: persistent local delayed enhancement by cardiac magnetic resonance imaging. Int J Cardiol. 2007 Feb 14;115(3):e108-110. 

• Oktay AA, Dibs SR, Friedman H. Sinus pause in association with Lyme carditis. Tex Heart Inst J. 2015 Jun 1;42(3):248-250. 

• Pachner AR, Amemiya K, Bartlett M, Schaefer H, Reddy K, Zhang WF. Lyme borreliosis in rhesus macaques: effects of corticosteroids on spirochetal load and isotype switching of anti-borrelia burgdorferi antibody. Clin Diagn Lab Immunol. 2001 Mar;8(2):225-232. 

• Pound MW, May DB. Proposed mechanisms and preventative options of Jarisch-Herxheimer reactions. J Clin Pharm Ther. 2005 Jun;30(3):291-295. 

• Robinson ML, Kobayashi T, Higgins Y, Calkins H, Melia MT. Lyme carditis. Infect Dis Clin North Am. 2015 Jun;29(2):255-268. 

• Rojas-Marte G, Chadha S, Topi B, Hollander G, Shani J. Heart block and Lyme carditis. QJM. 2014 Sep;107(9):771-772. 

• Rosenfeld ME, Beckerman B, Ward MF, Sama A. Lyme carditis: complete AV dissociation with episodic asystole presenting as syncope in the emergency department. J Emerg Med. 1999 Jul- Aug;17(4):661-664. 

• Rostoff P, Gajos G, Konduracka E, Gackowski A, Nessler J, Piwowarska W. Lyme carditis: epidemiology, pathophysiology, and clinical features in endemic areas. Int J Cardiol. 2010 Oct 8;144(2):328-333. 

• Rudenko N, Golovchenko M, Mokrácek A, Piskunová N, Ruzek D, Mallatová N, Grubhoffer L.Detection of Borrelia bissettii in cardiac valve tissue of a patient with endocarditis and aortic valve stenosis in the Czech Republic. J Clin Microbiol. 2008 Oct;46(10):3540-3543. 

• Sapi E, Kaur N, Anyanwu S, Luecke DF, Datar A, Patel S, et al. Evaluation of in-vitro antibiotic susceptibility of different morphological forms of Borrelia burgdorferi. Infect Drug Resist. 2011;4:97-113. 

• Scheffold N, Herkommer B, Kandolf R, May AE. Lyme carditis–diagnosis, treatment and prognosis. Dtsch Arztebl Int. 2015 Mar 20;112(12):202-208. 

• Sharma B, Brown AV, Matluck NE, Hu LT, Lewis K. Borrelia burgdorferi, the Causative Agent of Lyme Disease, Forms Drug-Tolerant Persister Cells. Antimicrob Agents Chemother. 2015 Aug;59(8):4616-4624. 

• van Hattem JM, Keijer JT, Nijveldt R. A man with cardiac Lyme borreliosis. CMAJ. 2015 Oct 6;187(14):1071-1073. 

• Steere AC, Batsford WP, Weinberg M, Alexander J, Berger HJ, Wolfson S, Malawista SE. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med. 1980 Jul;93(1):8-16. 

• Welsh EJ, Cohn KA, Nigrovic LE, Thompson AD, Hines EM, Lyons TW, Glatz AC, Shah SS. Electrocardiograph Abnormalities in Children With Lyme Meningitis. J Pediatric Infect Dis Soc. 2012 Dec;1(4):293-298. 

• Wenger N, Pellaton C, Bruchez P, Schläpfer J. Atrial fibrillation, complete atrioventricular block and escape rhythm with bundle-branch block morphologies:an exceptional presentation of Lyme carditis. Int J Cardiol. 2012 Sep 20;160(1):e12-4. 

• Yoon EC, Vail E, Kleinman G, Lento PA, Li S, Wang G, Limberger R, Fallon JT. Lyme disease: a case report of a 17-year-old male with fatal Lyme carditis. Cardiovasc Pathol. 2015 Sep- Oct;24(5):317-321. 

• Besant G, Wan D, Yeung C, Blakely C, Branscombe P, Suarez-Fuster L, et al. Suspicious index in Lyme carditis: Systematic review and proposed new risk score. Clin Cardiol. 2018 Dec;41(12):1611-1616.

About Instructor

Elizabeth L. Maloney, MD

Dr. Elizabeth Maloney is a Minnesota family physician. She received her medical degree from the University of Minnesota in 1986 and completed her residency in family medicine at the University in 1989. Early in her career, she practiced in Guam, where lab and other testing modalities were often unavailable. It was here that she honed her clinical skills and learned to translate history and exam findings into clinical diagnoses and treatment plans. Dr. Maloney began reviewing the scientific literature on tick-borne diseases in earnest in 2006. Her initial review was an attempt to understand why some patients did not present or respond as described in review articles and conference lectures. When she discovered that Borrelia burgdorferi, the agent of Lyme disease, is a complex organism, the immune response to it is nuanced and there are gaps in the clinical understanding of Lyme disease, Dr. Maloney changed her focus towards educating medical professionals about tick-borne illnesses. Dr. Maloney began providing accredited continuing medical education courses on Lyme disease for physicians in 2007 and continues to do so. She has also developed similar education for nurses and mental health providers. She has published several papers in peer-reviewed medical journals and is frequently invited to speak to medical professionals across the US. She has served as a consultant to private organizations and government agencies in the US and Canada. In February 2018 she was selected to serve on the Pathogenesis, Transmission and Treatment subcommittee of the federally mandated Tick-borne Disease Working Group. Additionally, she recently accepted an invitation to serve on a peer review committee for the Canadian Institutes of Health Research.

12 Courses

Not Enrolled

Course Includes

  • 1 Lesson
  • 2 Quizzes
  • Course Certificate