Possible Lyme Carditis—Not Definite

To the Editor.— I read with interest the article by Kimball et al entitled "Complete Heart Block as the Sole Presentation of Lyme Disease."1There are certain aspects of the case that I find a little troublesome. It is mentioned that the day prior to development of the skin lesion the patient had been walking in eastern Long Island, NY. Assuming that the patient was bitten by a tick then, an erythema migrans rash could not be seen the next day for several reasons. First, the tick usually needs to feed for at least 24 hours to transmit Lyme disease,2and second, the rash takes a minimum of 3 days to develop.3Also, the erythema migrans rash should not be gone in a few days; rather, it should grow in size with time. What is also puzzling is that Lyme carditis has been described as a relatively early (usually within the first 2