Undiagnosed Lyme disease leads to patient’s death

This case involves a forty year-old female patient with no significant past medical history. The patient presented to the emergency department complaining of a three day history of fever, flu-like symptoms, chills, muscle aches, headache, joint pain, dizziness, dark urine and thirst. She disclosed a history of having been diagnosed with Lyme disease three months earlier after being bitten by a tick whilst on vacation. The Lyme disease was treated successfully but she was left with a Bell’s palsy (facial paralysis) as a result of the condition. At the initial diagnosis of Lyme disease, she had been treated with doxycycline. She told the emergency room physician that she had again been bitten by a tick a few weeks earlier. The initial diagnosis by the emergency room physician was viral syndrome with Lyme meningitis, part of the differential diagnosis. She was started on azithromycin and ceftriaxone, to treat a presumed pneumonia at risk of developing Legionella bacteria. No doxycycline was ordered in spite of the differential diagnosis including Lyme Meningitis. Three days later the patient returned to the emergency department and was seen by another physician as her husband was concerned about the possibility that she contracted Lyme disease a second time. The treating physician informed the patient and her husband that she was suffering from walking pneumonia. The patient was admitted to hospital. That same day, the patient’s oxygen saturation decreased and her pulse rate increased to 124 beats per minute. At 7:00 pm, her progress notes stated that her symptoms included shortness of breath, lethargy, and neck and back pain. In addition to these symptoms, blood work revealed a declining platelet count. The following day the patient’s oxygen saturation had decreased further, to 91% and her pulse rate had increased to 145 beats per minute. Despite the patient’s worsening condition, no changes were made to her antibiotics and no additional tests were performed. The diagnosed was still presumed to be pneumonia. At approximately 2:30 AM, the patient stumbled out of her room in a confused state and was assisted back to the room by a nurse, where she lost consciousness. She was revived shortly thereafter and her cardiac monitor showed sinus tachycardia, which was confirmed by an EKG. Upon consultation with the hospitalist on duty, the patient was transferred to the surgical intensive care unit for further care. At approximately 5:00 AM on the same day, the patient’s cardiac rhythm deteriorated into ventricular fibrillation/ventricular tachycardia and she became pulseless. Resuscitation efforts were unsuccessful and the patient was pronounced dead at 6:00 AM. An autopsy of the plaintiff revealed that her “immediate cause of death was cardiac dysrhythmia secondary to myocarditis. The serologic results were positive for Human Granulocytic Ehrlichiosis (HGA), an infectious disease transmitted by tick bite. It was alleged that the treating physician departed from the standard of care in his treatment by failing to entertain a diagnosis of Lyme disease and order doxycycline, the antibiotic that would have prevented her demise.

Question(s) For Expert Witness

How likely is it that the patient underwent a spontaneous fatal myocarditis of viral origin rather than dying from cardiac involvement with HGA?

Expert Witness Response E-007419

Lyme disease is a multi-organ disease caused by an infection which frequently results in cardiac involvement. Cardiac involvement occurs during the early disseminated phase of the disease, usually within weeks to a few months after the onset of infection. Carditis has been reported in approximately 4 to 10 percent of untreated adults with Lyme disease in the United States. If there was truly myocarditis due to the Lyme disease then the arrhythmia was a result of this and I do see possible negligence in this case.