Unrecognized and untreated Borrelia infection can progress from localized inflammation (erythema migrans) to early or late generalized stage within weeks to months. Meningoradiculitis, arthritis, multiple erythemas, myositis, and myocarditis of the early generalized stage have a good prognosis after antibiotic treatment, but late manifestations can progress to chronic disease. Phrenic nerve palsy, autonomic nervous system dysfunction and carditis with acute heart failure are among rare manifestations as well as late generalised stage with myelitis. We present a case of a patient with meningoradiculitis, autonomic nervous dysfunction, respiratory failure due to phrenic nerve palsy and acute heart failure with systolic myocardial dysfunction. The diagnosis of Borrelia infection was confirmed by positive serological testing, appropriate response to antibiotic therapy and exclusion of other diseases. Our case suggests that in unexplained respiratory failure and acute systolic myocardial dysfunction, particularly associated with signs of meningoradiculitis, Borrelia infection should be included in the differential diagnosis.