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The seminal description of a patient with dilated cardiomyopathy and culture of an endomyocardial-biopsy specimen that was positive for B. burgdorferi was published in the Journal.3 Specific histologic staining may also confirm the diagnosis of Lyme borreliosis in acute myocarditis; however, as with other causes of myocarditis, even negative results cannot rule out the infection. To support the diagnosis in patients with positive serologic findings, use of antimyosin scintigraphy, echocardiography, and magnetic resonance imaging can be helpful.4
Treatment with appropriate antibiotics may lead to improvement of ventricular function in myocarditis and even cardiomyopathy due to Lyme borreliosis.3,5 Thus, in areas where the disease is endemic, Lyme borreliosis should be considered in the differential diagnosis of perimyocarditis.
Jutta Bergler-Klein, M.D.
Gerold Stanek, M.D.
University of Vienna
A-1095 Vienna, Austria
References
As far as I know, there are only rare case reports of cardiomyopathy associated with Graves' disease.1 Despite the fact that thyrotropin-receptor messenger RNA has been found by several investigators to be expressed in the myocardium,1,2,3 the authors of a recent report on a series from the Mayo Clinic4 concluded on the basis of endomyocardial-biopsy findings that "among patients with Graves' disease, most cases of low-output cardiac dysfunction appear to be due to causes other than an active autoimmune inflammatory process."
Are there other data of which I am unaware? The clinical ramification of this issue seems important: should a patient with Graves' disease and concomitant low-output cardiac dysfunction be evaluated for myocarditis, or is this unnecessary because of a "well-known" relation?
Michael Weissel, M.D.
Medical University Clinic III
A-1090 Vienna, Austria
References
Jaime Luís Lopes Rocha, M.D.
Hospital Nossa Senhora das Graças
80810-040 Curitiba, PR, Brazil
References
To the Editor: Drs. Bergler-Klein and Stanek raise important points regarding the importance of considering Lyme borreliosis as a possible cause of myocarditis in areas infected with vector ticks. However, we would argue that antimyosin scintigraphy does not have sufficient sensitivity and specificity to be useful in the diagnosis and that serologic analysis is far more useful.
Our inclusion of thyrotoxicosis as an immune-mediated cause of myocarditis is based on rare case reports in which thyroiditis was associated with myocarditis in a patient with severe lupus,1 a patient with both giant-cell thyroiditis and myocarditis,2 and a woman during the postpartum period.3 Although the recent report from the Mayo Clinic4 suggests that autoimmune myocardial disease in patients with thyroiditis is a rare finding, the possibility of its presence should not be overlooked in patients who have relevant symptoms.
It is correct that actinomyces are gram-positive bacteria, not fungi.
Arthur M. Feldman, M.D., Ph.D.
Dennis M. McNamara, M.D.
University of Pittsburgh Medical Center
Pittsburgh, PA 15213
References
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