A Massachusetts General Hospital study that raises the awareness of possible cardiac involvement in early Lyme patients was recently published. This small study is the first to use data that measures a complex protein (troponin) to detect possible cardiac involvement in patients with early Lyme disease and with subclinical, or non-noticeable cardiac symptoms. Overall, 14.6% of the study subjects had elevated troponin T levels above the normal range. These findings were published in the March 2022 issue of Annals of Clinical & Laboratory Science and are explained in a new course from Invisible International, taught by first author Elizabeth Lee Lewandrowski, PhD, MPH, an Assistant Professor of Pathology at Harvard Medical School, a Faculty Researcher and Clinical Laboratory Scientist in Pathology at Massachusetts General Hospital, and Invisible International’s Research Director.

Troponin is a complex of three proteins (troponin T, I, and C) that regulate muscle contractions in the heart. When the heart is damaged, these proteins are released into the bloodstream, allowing clinicians to measure levels to determine the extent of heart damage. Both troponin T and I are detected and elevated in the blood  when the heart is negatively impacted by various conditions, including  infection, inflammation, or muscle damage. Therefore, this is potentially an important test for doctors to follow in the event of suspected cardiac involvement including subclinical cardiac involvement in patients with Lyme disease.

Previously, the Centers for Disease Control and Prevention reported that Lyme carditis occurs only in about 1% of Lyme disease cases (2008 to 2017). This newer study of 41 early Lyme patients used the high sensitivity troponin T test and found that 14.6% had elevated troponin T levels, suggesting that the heart is damaged in more early Lyme disease cases than previously realized. This finding should be brought to the attention of healthcare providers as it suggests cardiac involvement in early Lyme disease may be more common than previously realized. While there are many explanations for elevated troponin levels in these patients, including a systemic inflammatory response, this result raises the question that subclinical cardiac involvement may be more common than previously recognized. Further investigation is necessary to explore and validate the significance of this finding. 

Some of the heart conditions that troponin T tests can detect include electrical disruptions (AV block, most common in Lyme carditis), inflammation (myocarditis), swelling of the heart sac (pericarditis), inflammation of the inner lining and valves (endocarditis), problems with the pumping action (cardiomyopathy), and heart attacks (myocardial infarctions). Some of these conditions can be fatal, emphasizing the need for rapid diagnosis and treatment when Lyme carditis is suspected.

The Invisible Education Initiative, funded by the Montecalvo Foundation, provides free, accredited Continuing Medical Education (CME) courses that focus on vector-borne and environmental illness within a One Health framework. These courses are available to clinicians and the public. To donate to this initiative and to learn about Invisible International, please go here http://invisible.international/give.

Watch here: https://learn.invisible.international/courses/measurement-of-high-sensitivity-troponin-t-in-patients-with-early-stage-lyme-disease-possible-evidence-for-subclinical-cardiac-involvement/

If you’re a clinician looking for new evidence-based insights into diagnosing Lyme disease, this course is a good starting place. It begins with a brief overview of the One Health approach to combating vector-borne diseases. Then it applies this framework to Lyme disease, which accounted for 60% of all vector-borne diseases in the U.S. from 2004 to 2016.

Early Lyme diagnostic strategies are addressed by Elizabeth Maloney, MD, the Education Co-director at Invisible, a Minnesota family physician, and the founder/president of Partnership for Tick-borne Diseases Education, a nonprofit providing evidence-based education on tick-borne diseases. Dr. Malone reviews four cases that highlight symptom patterns to look for in diagnosing early Lyme, Lyme carditis, and cranial neuritis, which often presents as facial Bell’s Palsy. She also discusses the flaws inherent in current Lyme diagnostic tests.

Late-stage Lyme disease rehabilitation is covered by Nevena Zubcevik, DO, Chief Medical Officer of Invisible International, previously co-founder and co-director of the Dean Center for Tick Borne Illness at the Spaulding Rehabilitation Hospital, an affiliate of Harvard Medical School. Dr. Zubcevik emphasizes that Lyme diagnostics aren’t always reliable for late-stage Lyme, so she presents evidence-based symptom clusters that may help clinicians with diagnoses. To assess the nervous system inflammation that is characteristic of late Lyme, she recommends taking a punch biopsy to test for small fiber neuropathy, and PET brain scans to confirm the inflammation that is at the root of the memory deficits found in 74% of these patients.

In addition to this course, Invisible offers resources to help in clinicians in the diagnostic process. These include a General Symptom Questionnaire (GSQ-30) for assessing patient impairment; a health risk assessment tool that helps patients think about exposures to environmental, animal, and travel-related diseases that might be contributing to ill health; and an evidence-based symptom list for babesiosis, bartonellosis and (Lyme) borreliosis, all common tick-borne diseases.

Invisible International is developing courses and clinician tools like these to accelerate the movement of new research to frontline clinicians. We hope these anytime, anywhere courses will grow the pool of health-care providers who are experienced in the diagnosis and treatment of tick- and other vector-borne diseases. This means fewer patients will have to travel long distances and wait months for an initial appointment. Education heals.

The Invisible Education Initiative, funded by the Montecalvo Foundation, provides free, accredited Continuing Medical Education (CME) courses that focus on vector-borne and environmental illness within a One Health framework. These courses are available to clinicians and the public. To donate to this initiative and to learn about Invisible International, please go here http://invisible.international/give.

There’s a dire shortage of health-care providers who are experienced in the diagnosis and treatment of tick- and other vector-borne diseases. This means many suffering patients must travel long distances and wait months for an initial appointment, leading to worse patient outcomes. [1]

There are immense insurance and logistical barriers that discourage providers from taking on patients with tick-borne diseases. Some of these were identified in a 2022 survey-study of 155 clinicians from 30 states who treat Lyme patients. They included complexity of care (79%), the cognitive impairment of patients (57%), and frequent patient calls between scheduled appointments (49%). [1]

This shortage of trained providers is getting worse as the incidence of vector-borne diseases rises. The Centers for Disease Control reports that:

• Diseases spread by mosquitoes, ticks, & fleas tripled in the U.S., 2004-2016.
• Since 2004, 9 new pathogens spread by mosquitoes & ticks have been discovered.
• 476,000 Americans are diagnosed with Lyme disease each year, in all 50 states.

Despite the alarming rise in these diseases, a 2023 study led by Cornell University, “Review of Continuing Medical Education in Tick-Borne Disease for Front-Line Providers,” found a “limited availability of continuing education for multiple life-threatening tick-borne diseases of increasing importance in the United States.” [2]

Invisible International is filling this educational gap by producing best-in-class Continuing Medical Education (CME) courses on vector-borne and environmental disease, available to anyone online for no cost. These courses cover prevention, diagnosis, and treatment of these disease.

What is CME?

Continuing Medical Education (CME) educational activities are classes, workshops, or conferences that increase the knowledge and skills of health-care providers, ensuring that they stay current on the latest medical research and best medical practices. Some states require that doctors, nurses, and other health professionals accrue a certain number of CME course credits each year to keep their medical licenses active.

 What is unique about its CME offerings?

Invisible has one of the largest online CME collections of vector-borne diseases available. The courses are delivered by some of the most knowledgeable experts in their respective fields, featuring topics like persistent Lyme disease, the Bartonelloses, Lyme disease treatment, and neuropsychiatric symptoms of tick-borne diseases. Our courses incorporate the One Health concept, a recognition that the health of humans, pets, and the environment are all intertwined.

What is CME accreditation?

CME courses can be developed by medical societies, universities, companies, or nonprofits such as Invisible International. For these activities to be counted towards annual CME totals, they must be approved by independent accreditation organizations. This ensures that the educational activities are relevant, practice-based, effective, based on valid content, and independent of commercial influence.

Is Invisible’s CME accredited?

Invisible International’s Continuing Medical Education (CME) platform is accredited by two governing bodies:

• The Accreditation Council for Continuing Medical Education (ACCME) sets course development guidelines to ensure accurate, balanced, scientifically justified clinical-practice recommendations, all free of commercial bias.
• The American Academy of Family Physicians (AAFP) reviews individual courses to ensure that they:
  • are relevant to family practice
  • are evidence-based
  • communicate the risks and benefits of clinical recommendations
  • evaluate a learner’s grasp of the material.

Physicians taking AAFP-approved courses can receive reciprocal continuing education credits from the American Medical Association, (AMA), the American Osteopathic Association (AOA), the College of Family Physicians of Canada (CFPC), and other health professional organizations.

The Invisible Education Initiative, funded by the Montecalvo Foundation, provides free, accredited Continuing Medical Education (CME) courses that focus on vector-borne and environmental illness within a One Health framework. These courses are available to clinicians and the public. To donate to this initiative and to learn about Invisible International, please go here http://invisible.international/give.

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[1] Johnson LB, Maloney EL. Access to Care in Lyme Disease: Clinician Barriers to Providing Care. Healthcare. 2022; 10(10):1882. https://doi.org/10.3390/healthcare10101882

The authors of this study are Elizabeth L. Maloney, MD, a Minnesota family physician and Invisible’s education co-director; and Lorraine Johnson, JD, MBA, the Chief Executive Officer of LymeDisease.org and the principal investigator of its patient registry and research platform, MyLymeData.

[2] Malkowski AC, Smith RP, MacQueen D, Mader EM. Review of Continuing Medical Education in Tick-Borne Disease for Front-Line Providers. PRiMER. 2023;7:497812. Published 2023 Feb 2. doi:10.22454/PRiMER.2023.497812