Lyme Carditis in an Immunocompromised Patient

We present a case of a 68-year-old man with a history of liver transplant and of chronic immunosuppression therapy who presented to the emergency department (ED) for fevers and worsening fatigue for two days. On further investigation, the patient was found to have a new first-degree heart block on his electrocardiograph. Coupled with the history of a recent tick bite, the patient was diagnosed with vector-borne carditis. Although the patient’s titers for various vectors remained negative, due to a long history of immunosuppression, he was treated for Lyme disease and his heart block completely resolved with antibiotic treatment. We describe details of the case as well as discuss the impacts of immunosuppression on vector-borne disease. Immunosuppressed patients represent a special population and can present with chief complaints made even more complicated by their medical history, and this case illustrates the importance of being mindful of how immunosuppression can affect a patient’s presentation. As the efficacy of antirejection medications improved, the ED may see an increasing number of patients with solid organ transplants. A greater understanding of this special patient population is key to formulating optimal treatment plans. 1. Introduction The number of solid organ transplantations in the United States has increased over the past several decades. Several reasons account for this including better surgical techniques, improved immunosuppressive regiments, and broader use of prophylaxis to prevent infections [1]. Still, one of the greatest barriers to patient survival and graft rejection is infection in this selected patient population secondary to being immunocompromised. Moreover, because of improved longitudinal care, transplant recipients have become more susceptible to a broader array of infections [2]. For the emergency medicine physician, this means encounters with patients with solid organ transplants are becoming more common, consistent with the rise in patient acuity and steadily growing number of patients seeking care in the ED. Furthermore, common infections such as line infections and less common ailments such as opportunistic infections can occur in this patient population which requires the emergency medicine physician to be ever cautious [3]. We discuss herein a case involving a patient with a liver transplant on strong immunosuppressants who developed an erythematous rash after a tick bite; subsequently his condition progressed to disseminated illness with a concomitant heart block. Of significance is our patient was indeed