Comment; I like the mneumonic COSTAR, but even with that, Lyme has so many presentations, a high index of suspicion is necessary!

Georgia BesantDouglas WanCynthia YeungCrystal BlakelyPamela BranscombeLaiden Suarez‐FusterDamian RedfearnChristopher SimpsonHoshiar AbdollahBenedict Glover… See all authors First published: 23 October 2018 Cited by: 2

Georgia Besant and Douglas Wan shared co‐authorship.SECTIONS



Lyme carditis (LC), an early manifestation of Lyme disease that most commonly presents as high‐degree atrioventricular block (AVB), usually resolves with antibiotic treatment. When LC is not identified as the cause of AVB, a permanent pacemaker may be inappropriately implanted in a reversible cardiac conduction disorder.


The likelihood that a patient’s high‐degree AVB is caused by LC can be evaluated by clinical characteristics incorporated into a risk stratification tool.


A systematic review of all published cases of LC with high‐degree AVB, and five cases from the authors’ experience, was conducted. The results informed the development of a new risk stratification tool, the Suspicious Index in LC (SILC) score. The SILC score was then applied to each case included in the review.


Of the 88 cases included, 51 (58%) were high‐risk, 31 (35.2%) intermediate‐risk, and 6 (6.8%) low‐risk for LC according to the SILC score (sensitivity 93.2%). For the subset of 32 cases that reported on all SILC variables, 24 (75%) cases were classified as high‐risk, 8 (25%) intermediate‐risk, and 0 low‐risk (sensitivity 100%). Specificity could not be assessed (no control group). Notably, 6 of the 11 patients who received permanent pacemakers had reversal of AVB with antibiotic treatment.


The SILC risk score and COSTAR mnemonic (constitutional symptoms; outdoor activity; sex = male; tick bite; age < 50; rash = erythema migrans) may help to identify LC in patients presenting with high‐degree AVB, and ultimately, minimize the implantation of unnecessary permanent pacemakers.