Cardiac involvement in Lyme disease

Cardiac manifestations of Lyme Borreliosis are relatively infrequent, occurring within weeks after the infectious tick bite (median of 21 days), and resulting at this stage from a direct borrelial infection of the myocardium, as indicated by reports of spirochete isolation from pericardium and myocardium. They may persist or appear in the late, tertiary phase of the illness, being then more likely due to infection-triggered autoimmunity. Lyme carditis typically presents with a fluctuating degree of atrioventricular block that spontaneously resolves in several days. Rarely, myocarditis may occur with or without pericardial involvement, in patients presenting with chest pain, ST depression or T wave inversion, mimicking an acute myocardial infarction, and various arrhythmias are reported, as well as pericardial effusion or heart failure. A complete recovery is usually observed, spontaneous or after antibiotherapy. Severe myocarditis or Pericarditis leading to death is exceptional. The diagnosis of Lyme carditis is based on the same association of clinical and laboratory features as in Lyme disease without cardiac involvement. But the occurrence of conduction disturbances in healthy young people suggests screening for other criteria of Lyme disease. The management of Lyme carditis does not differ from the treatment of Lyme disease without carditis and is mainly based upon the use of doxycycline or ceftriaxone.     

Lyme arthritis, Lyme carditis and other presentations potentially associated to Lyme disease

Lyme disease or Lyme borreliosis is the most common tick-transmitted disease in the Northern hemisphere and is caused by Borrelia burgdorferi spirochetes. Lyme disease commonly begins with a characteristic skin lesion, erythema migrans. Weeks or months later, the patients may have neurologic, joint, or cardiac abnormalities. Some patients may still present persistent deep fatigue and various unspecific symptoms after standard courses of antibiotic treatment for Lyme disease. This constellation of symptoms has been variously referred to as "chronic Lyme disease", or "post-Lyme disease syndrome". The first French National Consensus Conference on Lyme Disease was the reason to review all aspects of articular and cardiac manifestations of Lyme disease after a synthesis of recent literature. The involvement of Borrelia species in chronic Lyme disease and other pathologies is discussed.     

Lyme borreliosis

Lyme borreliosis is a complex infectious process that primarily involves the skin, heart, joints, and nervous systems. The infectious agent is the spirochete B burgdorferi, which is transmitted by the Ixodes genus of ticks. The clinical presentations of Lyme disease are protean because of the overlap of stages and varied organ system involvement. Furthermore, as previously mentioned, approximately one-third of Lyme patients are unable to recall a tick bite. Lyme borreliosis should be suspected in anyone with a tick bite. The findings of an EM lesion and flu-like symptoms strongly favor the diagnosis of stage 1 disease. Stage 2 evolves weeks to months after a tick bite, with cardiac and neurological findings as well as musculoskeletal pain. Stage 3 primarily manifests itself as arthritis associated with continuing or additional neurologic complications. Serologic studies are currently the most practical laboratory aid in diagnosis, because almost all infected individuals have a positive antibody response to the spirochete. Treatment with antibiotics usually proves successful, although longer courses of therapy may be needed in later stages of the disease, and some patients may not respond.     

远程心电监测高危心律失常在社区心脏病猝死预警中的应用

目的探讨远程心电图检测对高危心律失常的临床应用。方法对2010年1月至2011年3月上海市长宁区虹桥街道社区卫生服务中心就诊的937例心脏病患者应用远程心电监测进行12导联心电图检查。结果937例患者中709例伴有心律失常（75．8％）,心律失常以房性早搏最多（154例）,其次为室性早搏（150例）、房扑房颤（149例）、束支传导阻滞（183例）、房室传导阻滞（55例）、房性心动过速（18例）。结论在社区应用远程心电监护,利于提高心律失常诊断符合率,降低心律失常发生心脏性猝死的危险。     

急性下壁心肌梗死并发房室传导阻滞的临床研究

目的探讨急性下壁心肌梗死并发不同程度房室传导阻滞的诊断、临床特点、治疗措施及其预后。方法探讨急性下壁心肌梗死并发不同程度房室传导阻滞的诊断、临床特点、治疗措施及其预后。方法该院在2008年1月—2012年6月期间共接诊急性下壁心肌梗死患者120例,其中并发房室传导阻滞患者40例,回顾分析其临床资料。结果 80例急性心肌梗死患者死亡6例,74例好转出院,治疗有效率为92.5%;40例急性下壁心肌梗死并发房室传导阻滞患者经过治疗死亡2例,38例均好转出院并且房室传导阻滞均得到有效地恢复,治疗有效率为95.0%,其中临床中Ⅰ度房室传导阻滞(23例、75%),Ⅱ度Ⅰ型房室传导阻滞(5例,12.5%),Ⅱ度Ⅱ型房室传导阻滞(9例,22.5%)、Ⅲ度房室传导阻滞(3例,7.5%)。结论在急性下壁心肌梗死并发房室传导阻滞的治疗中要严格注意其临床特征及其变化,对原发病心肌梗死要积极地治疗,对并发症房室传导阻滞要慎重的对待,可有效的提高其预后效果。     

Cardiac rehabilitation in patients with a congenital heart disease, an implantable cardioverter defibrillator or chronic heart failure

Cardiac rehabilitation is no longer just used to treat patients after the manifestation of a coronary artery disease such as a myocardial infarct, after a PTCA or after a coronary bypass operation. Patients with a congenital heart disease, patients who have received an implantable cardioverter defibrillator (ICD) and patients with stable chronic heart failure are also suitable candidates for a multidisciplinary cardiac rehabilitation programme. The new Dutch guidelines for cardiac rehabilitation, published in 2004, can be helpful in identifying potential candidates for a programme. Physical training is often a component of the treatment, but psycho-social counselling and education targeted at reducing anxiety and uncertainty, accepting the heart disease and learning to cope with it, can be just as important as those aspects targeted at improving the physical condition. Cardiac rehabilitation that includes physical training is safe for patients with congenital heart disease, for patients who have undergone an ICD implantation and for patients with stable chronic heart failure, as long as the pretraining exercise test is given a guiding role in selecting the appropriate physical work load. Patients with stable chronic heart failure should continue their physical training in order to maintain its beneficial physical and psychological effects.     

Ocular manifestations of Lyme disease

Despite the wide spectrum of clinical entities, eye involvement remains a rare event in patients with Lyme borreliosis. Most of ocular manifestations occur during the late phase of the disease. The infection needs to be considered along with more conventional causes of ocular inflammation, particularly in regions where Lyme disease is common. The pathogenesis of this condition remains controversial. Direct ocular infection and a delayed hypersensitivity mechanism may be involved at different disease stages. Uveitis and optic neuritis are the most common ocular complications. Serological testing lacks sensitivity and specificity. In atypical cases, ocular fluids sampling and analysis may be proposed. PCR seems to be an interesting diagnostic tool, allowing genotypic analysis. In the majority of cases, therapeutic strategy should be based on the association of antibiotics and corticosteroids. A new course of antibiotics may be prescribed to patients with chronic or relapsing inflammation due to bacterial persistence in ocular tissues.     

Guideline 'Lyme borreliosis'

Borrelia burgdorferi is the causative bacterial agent of Lyme borreliosis, a tick-transmitted infectious disease. The Dutch Institute for Health Care Improvement (CBO) has now issued a guideline on 'Lyme borreliosis'. Lyme borreliosis is classified as 'early', 'early disseminated', 'late' or as 'post-infectious complaints and symptoms'. Erythema migrans is the most common manifestation of early Lyme borreliosis. Frequent neurological manifestations of 'early disseminated Lyme borreliosis' include meningoradiculitis, meningitis and peripheral facial palsy, but Lyme carditis and arthritis also occur. Late Lyme borreliosis is characterised by skin abnormalities (acrodermatitis chronica atrophicans), chronic neuroborreliosis or chronic arthritis. Confirmation serology with respect to Borrelia is the most commonly used laboratory technique, but in early Lyme borreliosis the immune response may be absent. In addition, the mere presence of antibodies in the serum is no proof of an active infection with Borrelia and serology may yield false-positive reactions. Doxycycline and ceftriaxone are the most commonly used antibiotics in the various stages of Lyme borreliosis. Lyme borreliosis may be prevented by avoiding high-risk areas, keeping the skin covered as much as possible, and inspection of the skin after possible exposure to remove ticks within 24 hours. Laboratory tests after a tick bite are not recommended, nor is prophylactic treatment with antibiotics.     

老年退行性心脏瓣膜病对心功能及心律失常情况的影响

目的探讨老年退行性心脏瓣膜病（SDHVD）对心功能及心律失常情况的影响。方法选择2008年1月至2009年8月在我院住院,年龄≥60岁的老年患者做为研究对象,根据超声心动图有无心脏瓣膜钙化分为钙化组356名,平均年龄（69.36±6.923）岁;对照组364例,平均年龄（67.57±6.032）岁;所有入选对象均除外风湿性心脏病、先天性心脏病、胶原病、梅毒、感染性心内膜炎等对瓣膜钙化有影响的疾病,除外中、重度的瓣膜狭窄或（和）关闭不全。观察两组患者心功能及心律失常情况。结果瓣膜钙化组中单纯左房扩大和E/A值小于1的患者明显高于对照组,P〈0.05;瓣膜钙化组患者房颤、房室（室内）传导阻滞的发生率明显高于对照组P〈0.05。结论 SDHVD易出现舒张性心功能不全,容易合并心律失常,以房颤和传导阻滞多见。     

Cardiac involvement in leptospirosis

Leptospirosis is a neglected global disease with significant morbidity and mortality. Cardiac complications such as chest pain, arrhythmias, pulmonary oedema and refractory shock have been reported in patients with severe disease. However, the frequency and extent of cardiac involvement in leptospirosis, are under-reported and poorly understood. Multiple factors may contribute to clinical manifestations that suggest cardiac involvement, causing diagnostic confusion. A variety of electrocardiographic changes occur in leptospirosis, with atrial fibrillation, atrioventricular conduction blocks and non-specific ventricular repolarization abnormalities being the most common. Electrolyte abnormalities are likely to contribute to electrocardiographic changes; direct effects on Na(+)-K(+)-Cl(-) transporters in the renal tubules have been postulated. Echocardiographic evidence of myocardial dysfunction has not been adequately demonstrated. The diagnostic value of cardiac biomarkers is unknown. Histopathological changes in the myocardium have been clearly shown, with myocardial inflammation and vasculitis present in postmortem studies. Nonetheless, the pathophysiology of cardiac involvement in leptospirosis is poorly understood. Cardiac involvement, demonstrated electrocardiographically or clinically, tends to predict poor outcome. No specific therapies are available to prevent or treat cardiac involvement in leptospirosis; current management is based on correction of deranged homeostasis and supportive therapy. Evidence suggests that direct myocardial damage occurs in patients with severe leptospirosis, and further studies are recommended to elucidate its pathophysiology, clinical features and contribution to overall prognosis, and to identify appropriate diagnostic investigations and specific therapies.     

The Lyme vaccine: a cautionary tale

People living in endemic areas acquire Lyme disease from the bite of an infected tick. This infection, when diagnosed and treated early in its course, usually responds well to antibiotic therapy. A minority of patients develops more serious disease, particularly after a delay in diagnosis or therapy, and sometimes chronic neurological, cardiac, or rheumatological manifestations. In 1998, the FDA approved a new recombinant Lyme vaccine, LYMErix, which reduced new infections in vaccinated adults by nearly 80%. Just 3 years later, the manufacturer voluntarily withdrew its product from the market amidst media coverage, fears of vaccine side-effects, and declining sales. This paper reviews these events in detail and focuses on the public communication of risks and benefits of the Lyme vaccine and important lessons learned.     

Dispelling the chronic Lyme disease myth

Lyme disease is a tick-borne illness endemic to Minnesota that can have potentially severe complications. As the incidence of Lyme disease continues to increase, it is important for physicians in Minnesota to become familiar with its clinical aspects, including the concept of "chronic Lyme disease." Chronic Lyme disease is a misnomer that is often applied to patients with nonspecific presentations who may or may not have a history of infection with Borrelia burgdorferi, the agent that causes Lyme disease. When a patient does present with persistent nonspecific symptoms attributed to chronic Lyme disease, clinicians should ascertain the presence of objective manifestations, obtain laboratory results, and get a history of tick exposure. If active infection with B. burgdorferi is unlikely, they should avoid prescribing empiric antibiotic therapy and instead thoroughly evaluate the patient for other possible causes of the complaints and recommend appropriate care.     

肺炎支原体肺炎患儿心血管损害的临床分析

目的:探讨肺炎支原体(MP)肺炎患儿并发的心肌损害的发生率、损害的类型及治疗方法。方法:观察79例2001~2004年在我院确诊为肺炎支原体肺炎患儿。男44例,女35例。年龄4个月~15岁。MP肺炎诊断均符合《实用儿科学》(胡亚美,江载芳主编)(第7版)的临床诊断标准〔1〕,均进行Holter、心肌酶、肌钙蛋白、超声心动图及X-ray检查,合并有下述表现之一为有心血管损害:①CK—MB升高或心肌肌钙蛋白I阳性;②24 h动态心电图(Holter)为窦性心动过速、窦性心动过缓、多源、多发或成对室性期前收缩、房性期前收缩,QRS波群低电压,房室传导阻滞及ST—T、改变;③超声心动图或胸片显示:心脏扩大;④心源性休克、心功能不全或心脑综合征。结果:MP肺炎患儿中合并心血管损害者15例,占19.0%。15例合并心肌损害:肌钙蛋白阳性15例,12例心肌酶升高,其中CK—MB升高8例,CK-MB、HDBH、LDH均升高2例,CK—MB、CK、HDBH、LDH、AST均升高2例;10例心律失常,其中窦性心动过速1例,窦性心动过缓l例,室性期前收缩1例,房性期前收缩1例,QRS波群低电压1例,一度房室传导阻滞2例,二度Ⅱ型房室传导阻滞1例,三度房室传导阻滞1例,ST—T改变1例:5例超声心动图及X-ray检查心脏扩大。给予阿奇霉素(10 mg.kg-1.d-1)、维生素C(200 mg.kg-1.d-1)及博迈(5~10 m l/d)治疗,并口服玉丹荣心丸及复合B族维生素14~21天后,11例治愈,4例好转,随访3个月基本痊愈。结论:部分肺炎支原体肺炎患儿可合并心血管损害,其中婴幼儿山于表达能力差,症状、体征不典型,容易漏诊,应注意入院时的症状及心脏体征,及早诊断并提出防治措施,以免贻误病情。     

福建省莱姆病的发现

血清学调查证实福建省8个县(市)林区人群存在莱姆病感染。根据流行病学、临床学和血清学确诊莱姆病典型病例6例,疑似病例9例。从蜱类中肠涂片见到典型的莱姆病螺旋体。     

Cardiac involvement in spondylarthropathies

Cardiac involvement is a real manifestation of spondylarthropathies and include specially aortic regurgitation and conduction troubles. We present a prospective open study of fifty patients with spondylarthropathy (responded to Amor criteria) in order to evaluate the frequency of cardiac involvement, to see its type and if we can evaluate a group of patients able to this complication. We have included forty-four men and six women with a mean age of 38 years. The disease evolve for 8.8 years in mean. Ag HLA B27 was present in 70% of the cases. Thirty patients have ankylosing spondylitis, although twenty have a secondary spondylarthropathy: psoriasic rheumatism (12 cases), inflammatory bowel disease: Crohn's disease (4 cases), RCH (three cases) and Fiessenger le Roy-Reiter syndrome in one case. All the patients have had a cardiac check up with research of clinical cardiac manifestation, thoracic chest, trans-thoracic echographi, Halter rhythmic done in five cases only. Cardiac involvement is found in five cases (10%): aortic regurgitation in 3 cases (6%) and mitral regurgitation in 2 cases (4%). These valvular disease are well tolerated.     

Antibiotic therapy for Lyme disease in Maryland.

The recommended treatment of Lyme disease is evolving and important questions remain unanswered, such as (a) Are inexpensive oral regimens effective in curing acute illness and preventing arthritic, neurologic, and cardiac manifestations or are much more costly, and potentially toxic, intravenous antibiotics required? (b) Are relatively short 2- to 3-week courses of antibiotics sufficient or are prolonged regimens of a month, or more, better? This study reviews antibiotic therapy prescribed by Maryland physicians for the 283 cases reported in 1991 that meet the Centers for Disease Control and Prevention''s case definition for Lyme disease. The purpose of the review was to obtain baseline information on the antibiotics being used by physicians in practice to treat patients that they believe have Lyme disease. The most frequently prescribed antibiotics for either the 60 percent of patients presenting with erythema migrans or the 40 percent with arthritic, neurologic, or cardiac manifestations were oral doxycycline (47 percent), tetracycline (11 percent), and amoxicillin (13 percent). Seventy-one percent of therapeutic courses were for 2 to 3 weeks. Amoxicillin was used in two-thirds of children younger than 8 years. Sixty (21 percent) received intravenous therapy, of which ceftriaxone, with or without other antibiotics, was almost always (95 percent) used. Intravenous therapy was more frequently given to those with arthritic, neurologic, and cardiac manifestations than to those with erythema migrans (odds ratio = 3.7) and to those with these systemic symptoms along with erythema migrans than to those with erythema migrans alone (odds ratio = 3.8).(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of patients presenting with generalized musculoskeletal pain and a suspicion of Lyme disease

Lyme disease is caused by bacteria of the B. burgdorferi sensu lato complex, and can give polymorphic clinical manifestations that can affect several organs such as the skin, the central nervous system, or the joints. In recent years, patients’ associations and physicians have been supporting the hypothesis that this infection would manifest as chronic generalized musculoskeletal pain symptoms, named “chronic Lyme disease”. Fibromyalgia is a clinical presentation characterized by chronic generalized musculoskeletal pain with a major impact on quality of life and social and psychological functioning. We analyzed existing literature data on pain syndromes associated with Lyme disease (post-treatment Lyme disease syndrome) or tick bites (polymorphic symptoms after a tick bite). We also analyzed existing data on the diagnosis, pathophysiology, and treatment of fibromyalgia. Our review shows that post-treatment Lyme disease syndrome has characteristics very close to post-infectious fibromyalgia. On the other hand, patients presenting for Lyme disease screening because of chronic generalized musculoskeletal pain symptoms after a tick bite should also be screened for fibromyalgia to allow appropriate management. Antibiotics are not recommended here.     

Activity of lysosomal exoglycosidases in serum of patients with chronic borrelia arthritis

To estimate activities of lisosomal exoglycosidases in serum of patients with chronic borrelia arthritis. Study group consisted of 18 patients aged 18-72 years (x=46) hospitalized in Department of Infectious Diseases and Neuroinfections of Medical Academy in Bia?ystok with diagnosis of chronic arthritis in course of borreliosis. Control consisted of 20 healthy volunteers (health services employees) aged 25-65 years (x=45), with no detectable anti-Borrelia burgdorferi antibodies in serum. In all borreliosis patients serum activity of: N-acetyl-beta-D-glucosaminidase (HEX), beta-galactosidase and alpha-mannosidase was measured before and after 4 weeks of doxycycline treatment. Results were analyzed with Statistica 6.0 software. P < 0.05 was considered statistically significant. HEX activity was significantly increased in serum of Lyme arthritis patients before treatment compared to controls. It decreased after 4-week treatment, remaining insignificantly higher than in controls. b-galactosidase and a-mannosidase activities in serum of Lyme arthritis patients were insignificantly higher than in controls and fell after treatment to the levels observed in control group. N-acetyl-beta-D-glucosaminidase (HEX) is sensitive enzymatic marker of Lyme arthritis. It may be used to monitor course of the disease and its efficiency of treatment.     

Electrophysiologic effects of magnesium sulfate infusion in patients with cardiac conduction defects.

We report the electrocardiographic and electrophysiologic effects of magnesium (Mg) sulfate infusion in 25 normomagnesemic patients (16 men and 9 women, aged 22-74 years; mean +/? SD, 60.4 +/? 11.9) with different cardiac conduction impairments. Ten patients had chronic ischemic heart disease, two had idiopathic dilated cardiomyopathy, two had hypertensive heart disease, three had valvular heart disease, five had sclerodegenerative heart disease and three had no clinical evidence of cardiac disease. Five patients had trifascicular block [first degree atrioventricular (A-V) block+right bundle branch block (RBBB)+left anterior hemiblock (LAH)], eight had bifascicular block (6 RBBB+LAH, 2 first degree A-V block+RBBB), four had isolated first degree A-V block and eight had bundle branch block [5 RBBB, 3 left bundle branch block (LBBB)]. Before and during Mg infusion (50 mg/min/60 min) we evaluated the A-V (P-R), intraatrial (P-A), suprahisian (A-H), infrahisian (H-V) conduction times, electrical ventricular systole (Q-T), Q-T index (Q-Tc) intraventricular conduction time (QRS) and heart rate. At the end of infusion the P-R, P-A, A-H, H-V increased from 215.4 +/? 36.6, 33.6 +/? 9.1, 112.8 +/? 37.3, 69.0 +/? 12.8 ms to 217.6 +/? 37.1 (p less than 0.002), 33.8 +/? 9.4 (NS), 114.2 +/? 38.1 (p less than 0.005), 69.6 +/? 13.3 (NS) ms. QRS complex did not change (125 +/? 16.9 ms).(ABSTRACT TRUNCATED AT 250 WORDS)     

Electrophysiologic effects of magnesium sulfate infusion in patients with cardiac conduction defects.

We report the electrocardiographic and electrophysiologic effects of magnesium (Mg) sulfate infusion in 25 normomagnesemic patients (16 men and 9 women, aged 22-74 years; mean +/- SD, 60.4 +/- 11.9) with different cardiac conduction impairments. Ten patients had chronic ischemic heart disease, two had idiopathic dilated cardiomyopathy, two had hypertensive heart disease, three had valvular heart disease, five had sclerodegenerative heart disease and three had no clinical evidence of cardiac disease. Five patients had trifascicular block [first degree atrioventricular (A-V) block+right bundle branch block (RBBB)+left anterior hemiblock (LAH)], eight had bifascicular block (6 RBBB+LAH, 2 first degree A-V block+RBBB), four had isolated first degree A-V block and eight had bundle branch block [5 RBBB, 3 left bundle branch block (LBBB)]. Before and during Mg infusion (50 mg/min/60 min) we evaluated the A-V (P-R), intraatrial (P-A), suprahisian (A-H), infrahisian (H-V) conduction times, electrical ventricular systole (Q-T), Q-T index (Q-Tc) intraventricular conduction time (QRS) and heart rate. At the end of infusion the P-R, P-A, A-H, H-V increased from 215.4 +/- 36.6, 33.6 +/- 9.1, 112.8 +/- 37.3, 69.0 +/- 12.8 ms to 217.6 +/- 37.1 (p less than 0.002), 33.8 +/- 9.4 (NS), 114.2 +/- 38.1 (p less than 0.005), 69.6 +/- 13.3 (NS) ms. QRS complex did not change (125 +/- 16.9 ms).(ABSTRACT TRUNCATED AT 250 WORDS)