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Borrelia burgdorferi
35%
6/17
Neisseria gonorrhoeae
41%
7/17
Rickettsia rickettsii
0%
0/17
Sarcoidosis
Staphylococcus aureus
24%
4/17
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This patient is presenting with arthritis and third-degree heart block which is concerning for a diagnosis of disseminated Lyme disease (Borrelia burgdorferi). Lyme disease is the most common tick-borne disease in the United States and is seen mainly in the Northeast. It is caused by B. burgdorferi, a bacteria carried by the Ixodes deer tick. The most common early manifestation of Lyme disease is erythema migrans, a characteristic target-shaped skin lesion at the site of the tick bite. Later manifestations include neurologic symptoms (including meningitis and facial nerve palsy), carditis, ocular findings, cardiac dysthymias (including heart block), and arthritis. The treatment of Lyme is doxycycline; however, severe disease, CNS infection, or cardiac infection warrants treatment with ceftriaxone. Figure A is an ECG demonstrating complete heart block given the regular R-R and P-P intervals with complete P-R dissociation. Incorrect Answers: Answer 2: Neisseria gonorrhoeae in its disseminated form can present with migratory arthralgias that can then localize to 1 joint and pustular skin lesions in a sexually active patient. It does not usually cause heart block. Answer 3: Rickettsia rickettsii can cause rocky mountain spotted fever which presents with a high fever, malaise, and a centripetal rash that starts on the extremities and spreads inwards. Answer 4: Sarcoidosis can present with cough, weight loss, and malaise in addition to being a possible cause of heart block. In this patient, the localized joint swelling (vs. non-specific arthralgias) and the low probability of this condition make this a less likely diagnosis. Answer 5: Staphylococcus aureus is a common cause of septic arthritis which presents with a red, hot, inflamed, and tender joint. This diagnosis is certainly possible and arthrocentesis should be performed regardless; however, it does not explain this patient's heart block. Bullet Summary: Lyme disease can present with systemic symptoms, arthralgias, arthritis, and cardiac block.
3.8
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