Diagnostic challenges in treating patient with cardiogenic shock caused by Lyme disease

Introduction: Lyme disease is a multisystem disease caused by infection with Borelia burgdoferi and spread by a tick bite. Even though it most commonly affects the skin, joints and nervous system, it can rarely cause Lyme carditis.1 In Europe, cardiac involvement as a complica-tion of Lyme disease occurs in up to 4%, with 3-fold higher male predominance. The most common clinical feature of Lyme carditis is atrioventricular (AV) conduction block of varying severity but may also include decreased car-diac contractility due to myopericarditis. These cardiac features typically occur one to two months after the onset of infection. We present a case report of a patient with car-diogenic shock and later confirmed Lyme disease. Case report: 71-year-old patient, with two-month long history of progressive exertional dyspnea, was hospital-ized in coronary intensive care unit due to cardiogenic shock with severely impaired left ventricular function (EF 15% ; in 2016 EF was 56%) and developed signs of type 1 cardiorenal syndrome. The patient had no chest pain, no electrocardiographic signs of ischemia nor elevation of cardiac biomarkers. The patient initially required inotro-pic support that with other standard treatment for acute heart failure gradually led to clinical and echocardio-graphic improvement (EF 31%). The patient then under-went coronary angiography that showed diseased left an-terior descending coronary artery that was treated with two stents. Since acute myocardial infarction was not the cause of acute heart failure, other possible causes were in-vestigated, primarily myocarditis. More detailed clinical history revealed tick bite about two months prior to hos-pital admission, which rose suspicion of Lyme carditis, even though the patient had no registered AV conduction disturbances. An enzyme-linked immunosorbent as-say and Western blot both came seropositive for Borelia burgdoferi antibodies, confirming the diagnosis. Conclusion: Lyme carditis is a rare manifestation of boreliosis with possible lethal complications. Therefore, detailed clinical history and physical examination are crucial for making correct diagnosis and giving the right treatment.