Answer: D. Admit the patient to the step-down unit and initiate intravenous ceftriaxone

This man is presenting with late cardiac complications of Borrelia Burgdorferi infection, or Lyme disease. The ECG reveals high-grade atrioventricular block. His prior ECGs have been normal. The historical features of frequent camping, a rash (erythema migrans), and arthritis should trigger concern for Lyme disease. The diagnosis should be confirmed with enzyme-linked immunosorbent assay (ELISA) serologic testing for B burgdorferi antibodies, followed by a Western blot for positive or equivocal results.1

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Patients with cardiac manifestations of Lyme disease (also known as Lyme carditis) should be admitted to telemetry and started on intravenous (IV) antibiotics, preferably ceftriazone or high-dose penicillin G.1 IV antibiotics should be continued for at least 4 weeks.1 Choice C is incorrect because the acuity of this patient’s presentation warrants hospital admission and corticosteroids are not recommended.1 A transcutaneous pacemaker is typically not needed in this setting if the patient has an adequate escape rhythm, and permanent pacemakers are contraindicated (class III),2 because Lyme disease is a reversible cause of complete heart block, usually resolving after 1 week of antibiotic therapy.1

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  1. Fish AE, Pride YB, Pinto DS. Lyme carditis. Infect Dis Clin North Am. 2008;22(2):275-288.
  2. Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2008;51(21):e1-e62.

This article originally appeared on Rheumatology Advisor