with the serologic results, this indicated. Lyme carditis. In order to study the characteristics of the AV block, the patient underwent serial. EP investigations. During.
confirmed a diagnosis ofH capsulatum on the basis of immunofluorescent stainingofthe yeastforms. The brmthingbacteria, although members of the order Actinomycetales, could not be identified immunologically as Actinomyces Israeli or Nocardia asteroides. Culture studies were not helpful.
T’ansient
Complete
AV Block
In
Lyme DIsease* Electrophysiologic R. van der Linde,
Marcel
Observations
M.D.;
HarryjG.M.
Crijns
M.D.;
and
DISCUSSION It is widely
result losis
from
that
accepted
calcification
or Histoplasma
most
oflymph infection.
cases
nodes However,
Kong I. lie,
of broncholithiasis following
tubercu-
few studies have ofetiology by use of special The inability to demonstrate in fact does not exclude
the question or culture. organisms by these techniques infection either, as the broncholith in reality represents the burned out and inactive stage ofthe disease. In an attempt to define the etiology of broncholithiasis, Weed and Anderson from the Mayo Clinic applied special staining and culture techniques to 12 broncholiths of nine patients with broncholithiasis Although the culture results were thought to be unhelpful, the special stain findings were of interest. Five stones from five patients contained struclures with the morphologic features of H capsulatum, while eight stones from five patients contained acid-fast branching filaments consistent with N astemides. In two stones from two patients, structures resembling both Histoplasma and directly
addressed
staining
techniques
Nocardia
were
present
in generous
numbers.
The
branching
identified had morphologic features similar to those illustrated by Weed and Anderson, but the acid-fast stain performed by our technique was negative. In addition, we were able to exclude an Actinomyces or Nocardia species on the basis of immunologic techniques applied to tissue sections. Actinomyces and related organisms have a tendency to colonize devitalized tissue, and they have been identified in association with the calcified lymph nodes of tuberculosis. The presence of these Actinomyceslike organisms in both our case and the Mayo Clinic study probably represents a phenomenon ofsecondary invasion of tissue previously devitalized by earlier Histoplasma infection. The secondary infection may have resulted from bloodborne seeding or aspiration. Only the Actinomyces-like organisms were identified on our initial sections, resulting in the false impression that the organisms
broncholiths tions,
were
however,
became
we
that
unmasked.
ofinappropriate
caused
revealed
by
these
buddingyeasts
Negative collection
cultures
bacteria.
Further
see-
and the true etiology probably were a result
of specimens.
The authors would like to thank the Diseases Mycology Department ofthe Center for Disease Control, Atlanta, for their help in identifying the microorganisms. We are most grateful to Bill Oxberry for photographic assistance and Francine Valerio for preparation of this ACKNOWLEDGMENTS: Center oflnfectious
manuscript.
REFERENCES 1 Schmidt
HW, Clagett OT, McDonald JR. Broncholithiasis. J Thorac Cardiovasc Surg 1950; 19:226-45 2 Kelley WA. Broncholithiasis. Pbstgrad Med 1979; 66:81-90 3 Weed LA, Andersen HA. Etiology of broncholithiasis. Chest 1960; 37:270-77 4 Lee BY. Actinomycosis of the lung coexisting with pulmonary tuberculosis. Chest 1966; 50:211-13
M.D.
The findings in a patient with complete AV block and intraatrial conduction disturbances due to Lyme disease are presented. The electrocardiographic foHow-up and serial
EP findings
suggest
that
may
a more
extensive
signify
system (with disturbances)
eventually than described
complete
resolution
conduction
system
AV block
complete
in Lyme
in earlier
of the occurred
reports.
considerable within
two
disease
AV conduction
affection ofthe attendant intra-atrial
conduction An almost
damage
to the
weeks.
(Chest
1989;
96:219-21)
yme disease is nowadays known as an infectious disease caused by the bite of a tick or a flea, by which the spirochete, Borrelia burgdorferi, can affect skin, joints, nervous system, and heart. Although the clinical expression of Lyme disease is highly variable,” the most common and clinically most troublesome cardiac manifestation is AV block.” The electrophysiology ofAV block in Lyme disease has not received much attention, and serial EP investigations have not, to our knowledge, been performed before. This report describes a patient with Lyme disease in whom complete AV block was the presenting and main clinical problem and in whom the course of the AV (and intra-atrial) conduction disturbances was pursued with surface
electrocardiographic
follow-up
and
serial
EP
investi-
gations. CASE
REPORT
A 40-year-old athlete was admitted to our hospital because of complete AV block ofunknown origin, with recurrent dizziness and near collapse, which had been occurring for two days. For three weeks, he had had arthritis-like symptoms in the toes of his right foot. No erythema migrans had been noticed. On physical examination the temperature was normal, the pulse rate was regular at 40 beats per minute, and the blood pressure was 12&70 mm Hg. There were cannon-wave pulsations in the jugular veins and a first heart sound of variable intensity. No pulmonary rales were heard. Four toes of the pafients right foot were warm, red, and painful, but not swollen. There were no dermatologic abnormalities. The surface ECG showed complete AV block with an escape rhythm of 37/miii; the QRS configuration suggested a focus in the left bundle branch. The configuration of the P wave was abnormal, and its duration was prolonged. In spite of administration of atropine and isoproterenol (isoprenaline), there were recurrent periods of yentricular asystole, sometimes lasting as long as 10 seconds. The erythrocyte sedimentation rate was 22 mm/in. Other routine laboratory tests yielded normal results. The chest roentgenograms and echocardiogram also proved to be normal. A gallium scan showed diffuse uptake in the myocardium (Fig 1). Serologic tests for B burgdorfrri were positive for 1gM (1:128) and wealdy positive for IgG (1:64). Tests for chlamydia and cytomegalo-
#{149}m the Department
of Cardiology Thoraxcentre, University Hospital Groningen, Groningen, the Netherlands. Reprint raqueSts: Dr. van der Linde, Department of Cardiology. Thoraxcentre, University Hospital, 97l3EZGroningen, Netherlands CHEST/96/1/JULY,1909
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21596/ on 03/28/2017
219
AV block,
..
1. Gallium
FIGURE
lateral
A (left), Anterior view. B (right), show diffuse uptake in myocardium.
scans.
view. Both views
Left
no sign of His
bundle
activity
bundle
could
be
found,
despite
of catheters (Fig 2A). A temporary pacemaker was inserted, and the patient was treated with tetracycline (500 mg four times per day orally), the latter being changed to penicillin (4 million IU intravenously four times daily) after five days. Between the sixth and tenth day after admission, the AV conduction disturbances on the surface ECG regressed to a second-degree and later on to a first-degree AV block. The EP study was repeated after a week; this time, His bundle activity could easily by found, using a bipolar His bundle catheter (Cordis) (Fig 2B). After three weeks ofantibiotic therapy, the patient was discharged with a normal surface ECG and minor residual complaints of extensive
mapping
ofthe
His
region,
using
several
types
arthritis.
virus
did not occur. Serologic markers for other microorganisms and diseases were all negative, including the Treponema pallidum hemagglutination assay, streptococcal antibody tests, several viruses (Coxsackie virus; echwere
ovirus;
weakly
adenovirus;
antinuclear
positive,
influenza
antibodies.
of endomyocarditis combination
the
to study
underwent
serial
A; hepatitis found
serologic
the EP
an increase
In agreement were
with
In order
but
B), rheumatoid
with
in an results,
factor,
the gallium
scan,
endomyocardial of the
During
Lyme
AV block, the
and
signs
biopsy.
indicated
this
characteristics investigations.
in titer
phase
the
carditis. patient
of complete
In
DIsCUsSIoN
In principle, disease, vary
all types of AV block may occur in Lyme in one patient. The degree of AV block can
even within
periods
tachyarrhythmias, are
not reported.
Despite no His bundle
block.
of minutes.” Lyme whether or not induced Our
extensive activity
patient
presented
carditis-related by bradycardia, with
complete
AV
mapping ofthe His bundle region, could be found during the acute
“U
III
vi
lIRE
RVA
II ‘‘I
2.
FIGURE
(top),
Electrophysiologic
Complete
AV block.
recordings.
No His bundle
A
activ-
ity is present.
Duration of P wave is 120 ms and is 130 ms. B (bottom), Firstdegree AV block (PR interval, 280 ms). Small positive-negative His bundle spike (h) is present. AH interval is 155 ms, HV interval is 45 ms, duration ofP wave is 100 ms, and QRS duration is 100 ms. HBE, His bundle ECG; RVA, right
QRS
duration
ventricular 220
lIRE
apex.
Transient Complete AV Block ii Lyme Disease (van derLk,de,
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21596/ on 03/28/2017
Cr
Li.)
phase
maker
following
of Lyme carditis. There was no His bundle spike the atrial electrogram nor preceding or following the fascicular escape complexes, although His bundle activity buried in the QRS complex cannot be ruled out. The QRS configuration and the QRS duration of 130 ms were compatible with an escape focus in the left bundle branch. The configuration ofthe P wave and its duration of 120 msec suggested a prolonged intra-atrial conduction time (Fig 2A). During right ventricular stimulation with progressively increased rate, also no retrograde His bundle activity could be found. Programmed EP stimulation in the right ventric-
disturbances
ular
apex,
effective
were
using
one
refractory
induced.
was always
extrastimulus,
period
Overdrive
interrupted
of250
revealed msec.
suppression by backup
a ventricular
No tachyarrhythmias of the escape focus
pacingafter
three
seconds.
the EP study was repeated, His bundle activity was easily found. The AH interval was slightly prolonged (155 ms), the HV interval was normal (45 ms), and the QRS duration had decreased to 100 ms. The Pwave duration had decreased to 100 ms, and the P-wave configuration had normalized (Fig 2B). The length of time between the serial EP studies was about one week. In general, in case of complete AV block with principal location in the AV node, one would expect a stable escape focus in the common His bundle, at least in young and otherwise healthy patients. In our patient, there was no such stable focus. The initial complete absence of His bundle activity and the prolonged AH interval in the recovery phase point to a predominant affection of the AV node with concomitant affection of the His bundle. In addition, the instability ofthe left bundle-branch focus and its disproportionate prolonged QRS duration of 130 ms suggest attendant
have
in case of sudden appearance of AV conduction of unknown origin. In recent literature, there been, to our knowledge, no cases of Lyme carditis-
related
AV conduction
serious
antibiotics)
without
In conclusion, in this
patient
AV block extensive
disturbances
regression
the
within
electrocardiographic
demonstrate,
in the course affection
(all treated
in our opinion,
of Lyme
of the
disease
with
to six weeks. and EP findings
two
that
may
AV conduction
signify
system
complete a more than
de-
Besides affection ofthe AV node, there may be involvement ofthe common His bundle, the His-Purkinje system, and the intra-atrial conduction system. The serial EP recordings in this patient show an almost complete resolution of the extensive conduction disturbances within two weeks. scribed
before.
When
affliction
tion
of the
of the
His-Purkinje
P wave
intra-atrial
disturbances.
conduction
disease
localized
supra-Hisian
escape atrial
found, fj3.4.6.8
conduction
The
initial
suggest However,
configura-
accompanying at EP studies
in the literature, usually more and sometimes infra-Hisian blocks mostly with unstable ventricular or fascicular Only one study reported attendant intra-
in Lyme were
system.
and its duration reported
disturbances.
The reversibility ofthe conduction disturbances, as shown in this patient and as described in the literature, suggests caution with respect to implantation of a permanent pace-
thank
Dr. J. A. A. Hoogkamp-Korsfor Public Health, Leeuwarden, the Netherlands) for kindlyperforming the serologic tests on B burgdorferi and for reviewing the endomyocardial biopsies.
ACKNOWLEDGMENT:
tanje
and
DrJ.
de
Koning
(Laboratory
REFERENCES
1 Steere AC, Bartenhagen NH, CraftJE, Hutchinson GJ, Newman JH, Pachner AR, et at. Clinical manifestations of Lyme disease. Zentralbi Bakterlol Mikrobiol Hug (A) 1986; 263:201-05 2 Goldings EA, Jericho J. Lyme disease. Clin Rheum Dis 1986; 12:343-67
Cosnau P. Huguet R, Grezard 0, Bouesnel sino-auriculaires et auriculo-ventriculaires de la maladie de Lyme: a propos de deux observations. Arch Mal Coeur 1986; 79:1361-66 4 Steere AC, Batsford WP, Weinberg M, Alexander J, Berger HJ, Wolfson 5, et al. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med 1980; 93:8-16 5 HouwerzijlJ, Boot JJ, Hoogkamp-Korstanje JAA. A case of Lyme disease with cardiac involvement in the Netherlands (letter). Infection 1984; 12:358 6 Olson U, Okafor EC, Clements IP. Cardiac involvement in Lyme disease: manifestations and management. Mayo Clin Proc 1986;
3 Kapusta P, FauchierJP, P Troubles conductifs
61:745-49
JW
Walsh RL, Smith CR, Wolfson PM, carditis: electrophysiologic and histopathologic study. Am J Med 1986; 81:923-27 8 Meyer LK, Swenson DB. Lyme carditis: high-grade heart block in Lyme disease. Minn Med 1987; 70:345-46 7 Reznick
Gierke
Braunstein
DB,
LW, et al. Lyme
CHEST/96/1/JULY,1989
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221