She Was Sure Her Symptoms Were Lyme Disease—But the Bull’s Eye Rash Never Appeared
Vera thought she felt a tick bite her shoulder, but never saw the actual tick. What's more, many of her symptoms sounded like Lyme disease, but that telltale rash stubbornly refused to show... What was it?
A Terrifying Medical Mystery
The patient: Vera (name has been changed), a 56-year-old fitness instructor
The symptoms: Rash, tiredness and heart palpitations
The doctor: Dr. Adrian Baranchuk, a cardiologist at the Kingston Health Sciences Centre, Ontario
Vera is a high-energy bootcamp instructor in her mid-50s who looks years younger. She enjoys long-distance runs on nature trails around her hometown of Kingston, Ont. In the summer of 2018, while jogging through a bushy area, she felt a pinch on the front of her right shoulder. As she’d heard about ticks in the region, she went home and showered, inspecting her skin carefully, but there was nothing there.
Over the next few days, Vera felt achy, as though she had a mild flu. She also noticed a spreading red patch around the right side of her neck and shoulder. She drove to the Kingston Health Sciences Centre to get checked out, mentioning the bug bite sensation she’d felt a week earlier. But the skin redness didn’t resemble the typical bull’s eye rash associated with ticks. The emergency physician thought it was more likely that she had cellulitis, a common skin infection that can be caused by bites or stings from a wide range of insects. Reassured, Vera returned home with some antibiotics.
The redness gradually faded, but Vera didn’t feel better. She was light-headed, and began having heart palpitations. At first she toughed it out, even though she was getting too tired to go on her runs. But then she became exhausted just folding laundry. Fifteen days after her first hospital visit, Vera returned to the ER.
“This was by no means the classic bull’s eye rash”
At the ER, an ECG revealed an unexplained, slight heart block. This delay in the electrical signals, which can develop with aging and coronary artery disease, often gets worse over time. Hospital cardiologist Dr. Adrian Baranchuk was called. “Vera impressed me as a person who, before all this, was perfectly fit and healthy. This came out of nowhere,” says Baranchuk.
Heart block can be caused by other conditions that trigger heart inflammation, such as sarcoidosis, an autoimmune disease. But if Vera was right about the bug bite, there was a possibility this was connected to her symptoms. Ticks spread the bacteria that develop into Lyme disease; in the early stages, it often causes flu-like symptoms. Left untreated, it can lead to more severe problems like joint pain and weak muscles, even liver inflammation.
In fewer than 10 per cent of Lyme infections, mainly in young men, the bacteria invade the heart, a condition called Lyme carditis. Baranchuk had treated roughly a dozen cases, all male. And the photo Vera shared of her skin rash wasn’t convincing. “This was by no means the classic bull’s eye rash,” says Baranchuk. The ring-within-a-ring happens because there are two skin reactions: one to the tick’s saliva, and one to the spreading Lyme bacteria. Although doctors are trained to look for this pattern, Baranchuk was aware of studies suggesting that at least a quarter of Lyme rashes might vary from this description. He couldn’t rule it out.
Untreated heart blocks can deteriorate quickly and lead to cardiac arrest. If Vera did have Lyme carditis, prompt intravenous antibiotics might reverse it. But if it was too late, or if she had some other condition, what she’d need is a pacemaker. This was something Baranchuk hoped to avoid. “A pacemaker is very useful when heart electricity has failed, but then you live the rest of your life as a cardiac patient with a piece of hardware in your body,” he says.
Testing for the Lyme bacteria would take time they didn’t have. But Baranchuk had recently co-authored a scoring tool, the Suspicious Index in Lyme Carditis, to help physicians avoid unnecessary pacemakers. Vera had Lyme-like symptoms and had been exposed to an area known to be populated with ticks, but she didn’t have the bull’s eye rash, wasn’t male or under 50, and hadn’t seen a tick. That made her low risk for Lyme carditis—except for one other factor. “She was a super articulate individual who was telling me, ‘I felt something like a tick bite, and then had a rash where I’d felt it.’ I gave utmost importance to that.” A “yes” to prior tick bite meant this warranted a hospital admission where Vera’s heart would be monitored as she was started on antibiotics, and the pacemaker postponed.
The Diagnosis is Tested
Even if the Lyme carditis diagnosis was correct, however, it could take up to a week to notice effects, if any, from the antibiotics. In the meantime, Vera’s heart block became steadily worse each day. Baranchuk ordered ECGs every few hours. “This patient was on my radar all the time. I contacted the residents at night, asking how she was.” By the fifth day, she’d deteriorated further. “I believed I would need to put in a pacemaker, despite everything,” Baranchuk recalls. He continued to be astounded at his patient’s physical stamina. “If it were me, I’d be lying in bed convinced I’m going to die any second,” he says. “But she’s used to endurance and heavy sports. With 30 beats per minute, she was still walking the corridor!”
Finally, on day six, Vera’s heart began to show signs of improvement. It was a thrilling moment for both doctor and patient; they’d successfully avoided surgery. Shortly after, the Lyme test came back positive.
In a characteristic show of strength, Vera was now raring to go home. She took a treadmill test as soon as her heart had recovered enough, and passed it. Twelve days after her hospital admission, Vera went home with oral antibiotics. A follow-up six weeks later showed no sign anything had gone wrong.
“We were able to exchange a lifetime as a cardiac patient with three weeks of antibiotics,” says Baranchuk. He’s glad he believed Vera, despite so many atypical factors. “It could have been a catastrophe,” he says. “As doctors, we have to remember we’re practising in an endemic Lyme region. If I hear ‘tick,’ I open my eyes and start looking.”
Next, find out how ticks became a major threat to our health.