Is there a link between Lyme disease and constrictive pericarditis?

Lyme Disease and Pericarditis: Established Association

Yes, there is a well-established link between Lyme disease and acute pericarditis, which occurs as part of Lyme carditis—a recognized cardiac manifestation affecting 4-10% of patients with Lyme disease. 1, 2 However, there is no established association with chronic constrictive pericarditis.

Clinical Context and Presentation

Lyme carditis typically develops within 2 months of initial infection, often within 21 days of tick exposure. 1 When pericarditis occurs as part of Lyme carditis, it presents with:

• Pericarditic chest pain 3
• Pericardial effusion (documented on imaging) 3
• Elevated cardiac biomarkers such as troponin 3
• Associated symptoms including dyspnea, palpitations, syncope, lightheadedness, and exercise intolerance 3, 1

Approximately 60% of patients with Lyme carditis develop signs of perimyocarditis (combined myocardial and pericardial involvement). 2 The pericardial involvement is generally mild and self-limited with appropriate antibiotic treatment. 4, 5

Diagnostic Approach

In patients presenting with acute myocarditis/pericarditis of unknown cause in an appropriate epidemiologic setting (endemic Lyme areas with tick exposure), testing for Lyme disease is strongly recommended. 3, 1 This is a strong recommendation from the IDSA/AAN/ACR 2020 guidelines despite low-quality evidence. 3

Key diagnostic steps include:

• ECG should be performed in all patients with signs or symptoms consistent with Lyme carditis 3
• Serologic testing is necessary in the absence of concomitant erythema migrans 1, 6
• Cardiac biomarkers (troponin) may be elevated 1, 6
• Echocardiography to assess for pericardial effusion 4
• Cardiac MRI can confirm diagnosis and monitor disease course 2

Critical Caveat

Do not routinely test for Lyme disease in patients with chronic cardiomyopathy of unknown cause—this is specifically recommended against by guidelines. 3, 6 The question of constrictive pericarditis (a chronic condition) versus acute pericarditis is crucial here.

Treatment Algorithm

For Hospitalized Patients with Lyme Pericarditis:

1. Admit with continuous ECG monitoring if clinical manifestations of myopericarditis are present 3, 1
2. Initiate IV ceftriaxone until clinical improvement occurs 3, 1
3. Switch to oral antibiotics to complete treatment once improved 3, 1
4. Total duration: 14-21 days of antibiotic therapy 3, 1

For Outpatients with Mild Lyme Pericarditis:

• Oral antibiotics may be sufficient: doxycycline, amoxicillin, cefuroxime axetil, or azithromycin 3, 1
• Duration: 14-21 days 3, 1

Prognosis and Important Distinctions

The clinical course of Lyme pericarditis is generally benign, mild, and completely reversible with appropriate antibiotic treatment. 4, 2, 5 This is fundamentally different from constrictive pericarditis, which is a chronic fibrotic condition.

Key Points:

• No evidence links Lyme disease to chronic constrictive pericarditis requiring pericardiectomy 4, 5
• Acute pericarditis from Lyme disease resolves with antibiotics and does not progress to constriction 2, 5
• Severe or fulminant congestive heart failure is not typically associated with Lyme disease, though pericarditis with effusion can occur 1
• There is conflicting and unclear evidence regarding any role of Borrelia burgdorferi in chronic dilated cardiomyopathy, and routine screening is not recommended 4

Common Pitfall to Avoid:

Do not attribute chronic constrictive pericarditis to Lyme disease without clear documentation of acute Lyme carditis at disease onset. The pericardial involvement in Lyme disease is acute and self-limited, not chronic and constrictive. 4, 5