An Unusual Case of Pericardial Effusion Requiring Pericardiocentesis in a Newly Diagnosed Lyme Disease Patient in Nigeria: A Case Report and Literature

Technical Summary: An Unusual Case of Pericardial Effusion in a Lyme Disease Patient

Problem Statement
Cardiac involvement in Lyme disease, caused by Borrelia burgdorferi, is a rare but significant manifestation. While typically presenting as atrioventricular (AV) conduction disturbances, pericardial involvement is increasingly recognized, occasionally leading to hemodynamically significant effusions. However, large, incidentally detected pericardial effusions in the absence of classic conduction abnormalities or hemodynamic compromise remain a clinical challenge, particularly regarding the timing of intervention and the optimal duration of antimicrobial therapy in atypical presentations. This case addresses the management of a large pericardial effusion in a patient with newly diagnosed Lyme disease who required elective orthopedic surgery under general anesthesia.

Methodology
This study is a single-patient case report and literature review. The subject was a 63-year-old woman presenting for pre-operative assessment prior to a planned left total knee replacement. Her history included a Lyme disease diagnosis twelve weeks prior, confirmed via skin biopsy (IgM positive) following tick exposure during travel to Monaco and the UK. She was being treated with a twelve-week course of doxycycline.

The diagnostic workflow included:

• Pre-operative Screening: Routine chest radiography revealed cardiomegaly (cardiothoracic ratio ~61%).
• Cardiac Evaluation: An electrocardiogram (ECG) showed normal sinus rhythm with no AV block. An echocardiogram confirmed a large pericardial effusion without signs of cardiac tamponade.
• Intervention: To mitigate anesthetic risks associated with general anesthesia and a large effusion, an elective pericardiocentesis was performed under echocardiographic guidance. A 6Fr indwelling pericardial drain was inserted.
• Follow-up: The patient was monitored for fluid output and hemodynamic stability. Post-procedural imaging (echocardiography) was performed at 24 hours and one week to assess resolution.
• Literature Review: The authors reviewed current literature regarding Lyme-associated pericardial disease, the safety of pericardiocentesis with indwelling drains, and antimicrobial treatment durations.

Key Results

• Clinical Presentation: The patient was hemodynamically stable (BP 131/60 mmHg, HR 90 bpm) and asymptomatic regarding cardiac symptoms. Notably, she lacked the classic AV conduction defects typically associated with Lyme carditis.
• Intervention Outcome: Approximately 350 mL of clear fluid was drained immediately. The indwelling drain dislodged after 100 mL of additional drainage, but the patient remained stable.
• Resolution: Follow-up echocardiography at 24 hours confirmed complete resolution of the effusion. A subsequent scan one week later confirmed no recurrence. The patient was cleared for her orthopedic surgery.
• Laboratory Findings: Routine labs (electrolytes, renal function, WBC) were unremarkable. Autoimmune and infectious screenings (HIV, TB, ANA, Rheumatoid Factor) were negative.

Key Contributions

1. Clinical Management of Asymptomatic Effusion: The paper documents a case where elective pericardiocentesis was successfully performed to reduce peri-operative anesthetic risk in a patient with a large, hemodynamically stable pericardial effusion, despite the absence of tamponade.
2. Atypical Presentation: It highlights that Lyme disease can manifest as a large pericardial effusion without the hallmark AV conduction abnormalities, necessitating broader cardiac screening (including echocardiography) in Lyme patients presenting with cardiomegaly.
3. Safety of Indwelling Drains: The case supports the safety of pericardiocentesis with indwelling catheters, noting that even with accidental dislodgement, prompt assessment and imaging can prevent adverse outcomes without immediate re-intervention.
4. Treatment Duration Uncertainty: The report underscores the lack of consensus on the optimal duration of antimicrobial therapy for atypical or prolonged Lyme presentations, noting the patient received a 12-week course of doxycycline, which exceeds standard guidelines for uncomplicated cases.

Significance and Claims
The authors claim that this case illustrates pericardial effusion as a potentially incidental, clinically silent manifestation of Lyme disease. They assert that pericardiocentesis is a safe and effective intervention to mitigate peri-operative risks even in the absence of hemodynamic compromise. Furthermore, the paper posits that the management of such cases requires multidisciplinary vigilance and that the optimal duration of antimicrobial therapy for atypical Lyme-associated pericardial disease remains an area of clinical uncertainty warranting further study.

The authors explicitly limit the generalizability of their findings, acknowledging that as a single-patient report, it cannot establish a definitive causal relationship between Lyme disease and the effusion, nor can it determine the specific contribution of antibiotics versus drainage to the clinical resolution. They caution that the prolonged antibiotic course used should not be interpreted as a standard recommendation for similar cases without further evidence.