Bull’s-Eye and Nontarget Skin Lesions of Lyme Disease: An Internet Survey of Identification of Erythema Migrans

Introduction. Lyme disease is an emerging worldwide infectious disease with major foci of endemicity in North America and regions of temperate Eurasia. The erythema migrans rash associated with early infection is found in approximately 80% of patients and can have a range of appearances including the classic target bull’s-eye lesion and nontarget appearing lesions.Methods. A survey was designed to assess the ability of the general public to distinguish various appearances of erythema migrans from non-Lyme rashes. Participants were solicited from individuals who visited an educational website about Lyme disease.Results. Of 3,104 people who accessed a rash identification survey, 72.7% of participants correctly identified the classic target erythema migrans commonly associated with Lyme disease. A mean of 20.5% of participants was able to correctly identify the four nonclassic erythema migrans. 24.2% of participants incorrectly identified a tick bite reaction in the skin as erythema migrans.Conclusions. Participants were most familiar with the classic target erythema migrans of Lyme disease but were unlikely to correctly identify the nonclassic erythema migrans. These results identify an opportunity for educational intervention to improve early recognition of Lyme disease and to increase the patient’s appropriate use of medical services for early Lyme disease diagnosis.

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Serologic Evaluation of Patients from Missouri with Erythema Migrans-Like Skin Lesions with the C6 Lyme Test

Clinical and Vaccine Immunology ◽

10.1128/cvi.00238-06 ◽

2006 ◽

Vol 13 (10) ◽

pp. 1170-1171 ◽

Cited By ~ 21

Author(s):

Mario T. Philipp ◽

Edwin Masters ◽

Gary P. Wormser ◽

Wayne Hogrefe ◽

Dale Martin

Keyword(s):

New York ◽

Lyme Disease ◽

Erythema Migrans ◽

New York State ◽

Skin Lesions ◽

Etiologic Agent ◽

Acute Stage ◽

Enzyme Linked Immunosorbent Assay ◽

Convalescent Phase ◽

South Central

ABSTRACT Southern tick-associated rash illness (STARI), also known as Masters disease, affects people predominantly in the Southeast and South Central United States. These patients exhibit skin lesions that resemble erythema migrans (EM), the characteristic skin lesion in early Lyme disease. The etiology of STARI remains unknown, and no serologic test is available to aid in its diagnosis. The C6 Lyme enzyme-linked immunosorbent assay was used to evaluate coded serum specimens from patients with STARI at two laboratory sites. The specimens tested at one site consisted of acute- and convalescent-phase samples that were obtained from nine STARI patients from Missouri and from one patient with documented Borrelia lonestari infection who acquired this infection in either North Carolina or Maryland. All of these samples were C6 negative. Seventy acute- or convalescent-phase specimens from 63 STARI patients from Missouri were C6 tested at the second site. All but one of these STARI specimens were also negative. In contrast, of nine acute- and nine convalescent-phase serum specimens obtained from culture-confirmed Lyme disease patients with EM from New York state, seven were C6 positive at the acute stage, and eight were positive at convalescence. The C6 test is negative in patients with STARI, providing further evidence that B. burgdorferi is not the etiologic agent of this disease.

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Impact of Clinical Variables on Borrelia burgdorferi-Specific Antibody Seropositivity in Acute-Phase Sera from Patients in North America with Culture-Confirmed Early Lyme Disease

Clinical and Vaccine Immunology ◽

10.1128/cvi.00109-08 ◽

2008 ◽

Vol 15 (10) ◽

pp. 1519-1522 ◽

Cited By ~ 31

Author(s):

Gary P. Wormser ◽

John Nowakowski ◽

Robert B. Nadelman ◽

Paul Visintainer ◽

Andrew Levin ◽

...

Keyword(s):

Lyme Disease ◽

Borrelia Burgdorferi ◽

Acute Phase ◽

Erythema Migrans ◽

Skin Lesions ◽

Enzyme Linked Immunosorbent Assay ◽

Clinical Variables ◽

Gender And Age ◽

Serologic Assay ◽

Single Lesion

ABSTRACT Erythema migrans, the most common manifestation of Lyme disease, has been associated with highly variable rates of seropositivity for antibodies to Borrelia burgdorferi. Differences in the sensitivities of serologic assays for the detection of these antibodies, however, may not be the only or even the primary explanation for this observation. We investigated the impacts of four clinical variables on seropositivity—the duration of erythema migrans, the presence of single versus multiple skin lesions, and the gender and age of the patient. In this analysis, three different serologic tests were performed on acute-phase sera from 175 untreated patients with culture-confirmed erythema migrans: the C6 single-peptide enzyme-linked immunosorbent assay (ELISA), a commercially available ELISA in which a whole-cell sonicate of B. burgdorferi was the antigen, and a two-tier procedure. Irrespective of the serologic test performed, the results showed that seropositivity rates increased with the duration of the erythema migrans for patients with single lesions (P < 0.001) but not for those with multiple skin lesions. The variability in seropositivity rates was greatest for the two-tier testing strategy, with a >6-fold-higher rate of seropositivity among patients with a single lesion of 22- to 30-day duration than among those whose skin lesion was of 1- to 7-day duration (85.7 versus 14.1%; P < 0.001). Rates of seropositivity by each of the testing methods were also significantly higher for patients with multiple skin lesions than for those with single lesions (P < 0.001). In contrast, seropositivity rates were not affected by either the gender or the age of the patient. Thus, in patients with erythema migrans, certain clinical variables such as the duration and number of skin lesions had a profound impact on seropositivity rates, irrespective of the serologic assay performed.

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Multiple Erythema Lesions Obscured As Fungal Skin Infection

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2014.083 ◽

2014 ◽

Vol 2 (3) ◽

pp. 472-473

Author(s):

Allma Koçinaj ◽

Antigona Gërçari ◽

Mybera Ferizi ◽

Edlira Lashi ◽

Lorela Gjunkshi ◽

...

Keyword(s):

Lyme Disease ◽

Antimicrobial Agents ◽

Skin Infection ◽

Erythema Migrans ◽

Disease Diagnosis ◽

Infected Tick ◽

Skin Changes ◽

Acrodermatitis Chronica Atrophicans ◽

First Case ◽

Laboratory Features

Erythema migrans is a ring like erythema, with a few centimeters in diameter. Usually it occur solitary, days to weeks after an infected tick bite. According to skin changes it can be manifested acutely such as erythema migrans in Lyme Borreliosis, borrelial lymphocytoma (subacute), or as a late Lyme disease with acrodermatitis chronica atrophicans. All stages of this disease can be treatable with antimicrobial agents. As a first case in our department with multiple lesions, we describe a 14-year-old female and review the patient’s clinical and laboratory features, the causes of the disease, diagnosis as well as treatment.

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Misdiagnosis of early Lyme disease as the summer flu

Orthopedic Reviews ◽

10.4081/or.2011.e14 ◽

2011 ◽

Vol 3 (2) ◽

pp. 14 ◽

Cited By ~ 6

Author(s):

John N. Aucott ◽

Ari Seifter

Keyword(s):

West Nile Virus ◽

Lyme Disease ◽

Physical Examination ◽

Influenza A ◽

Influenza Season ◽

Erythema Migrans ◽

Skin Lesions ◽

Specific Diagnosis ◽

Seasonal Peak ◽

Diagnostic Importance

Lyme disease is often identified by the hallmark erythema migrans rash, but not all early cases present with a rash. In other cases the rash may be unseen or unrecognized by a physician. In these situations, Lyme disease is difficult to diagnose because it masquerades as a non-specific viral-like illness. The seasonal peak of Lyme disease ranging from May through September overlaps with that of viral illnesses such as enteroviral infections, West Nile virus, and in rare years such as 2009, early influenza season. We present a case of a patient with Lyme disease who was initially misdiagnosed with influenza A during the summer of 2009. Because of the diagnostic importance of recognizing the erythema migrans rash, physicians in endemic regions should always ask about new rashes or skin lesions and perform a thorough physical examination when patients present over the summer with viral-like symptoms. Even when no rash is evident, Lyme disease should be considered if these symptoms persist or worsen without a specific diagnosis.

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Selective Up‐Regulation of Matrix Metalloproteinase–9 Expression in Human Erythema Migrans Skin Lesions of Acute Lyme Disease

The Journal of Infectious Diseases ◽

10.1086/379039 ◽

2003 ◽

Vol 188 (8) ◽

pp. 1098-1104 ◽

Cited By ~ 25

Author(s):

Zhihui Zhao ◽

Hernan Chang ◽

Richard P. Trevino ◽

Kara Whren ◽

Jag Bhawan ◽

...

Keyword(s):

Lyme Disease ◽

Matrix Metalloproteinase ◽

Erythema Migrans ◽

Skin Lesions ◽

Matrix Metalloproteinase 9 ◽

Metalloproteinase 9

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Geographical and genospecies distribution of Borrelia burgdorferi sensu lato DNA detected in humans in the USA

Journal of Medical Microbiology ◽

10.1099/jmm.0.073122-0 ◽

2014 ◽

Vol 63 (5) ◽

pp. 674-684 ◽

Cited By ~ 23

Author(s):

Kerry L. Clark ◽

Brian F. Leydet ◽

Clifford Threlkeld

Keyword(s):

Lyme Disease ◽

Borrelia Burgdorferi ◽

Skin Biopsy ◽

Lyme Borreliosis ◽

Erythema Migrans ◽

Skin Lesions ◽

Sensu Stricto ◽

Borrelia Burgdorferi Sensu Lato ◽

Southern States ◽

The Usa

The present study investigated the cause of illness in human patients primarily in the southern USA with suspected Lyme disease based on erythema migrans-like skin lesions and/or symptoms consistent with early localized or late disseminated Lyme borreliosis. The study also included some patients from other states throughout the USA. Several PCR assays specific for either members of the genus Borrelia or only for Lyme group Borrelia spp. (Borrelia burgdorferi sensu lato), and DNA sequence analysis, were used to identify Borrelia spp. DNA in blood and skin biopsy samples from human patients. B. burgdorferi sensu lato DNA was found in both blood and skin biopsy samples from patients residing in the southern states and elsewhere in the USA, but no evidence of DNA from other Borrelia spp. was detected. Based on phylogenetic analysis of partial flagellin (flaB) gene sequences, strains that clustered separately with B. burgdorferi sensu stricto, Borrelia americana or Borrelia andersonii were associated with Lyme disease-like signs and symptoms in patients from the southern states, as well as from some other areas of the country. Strains most similar to B. burgdorferi sensu stricto and B. americana were found most commonly and appeared to be widely distributed among patients residing throughout the USA. The study findings suggest that human cases of Lyme disease in the southern USA may be more common than previously recognized and may also be caused by more than one species of B. burgdorferi sensu lato. This study provides further evidence that B. burgdorferi sensu stricto is not the only species associated with signs and/or symptoms consistent with Lyme borreliosis in the USA.

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Lyme Carditis in Hospitalized Children and Adults, a Case Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab140 ◽

2021 ◽

Author(s):

Richard V Shen ◽

Carol A McCarthy ◽

Robert P Smith

Keyword(s):

Lyme Disease ◽

Heart Block ◽

Early Recognition ◽

Erythema Migrans ◽

Case Series ◽

Outpatient Setting ◽

Temporary Pacing ◽

Lyme Carditis ◽

Viral Illness ◽

History Presentation

Abstract Background Lyme carditis is an uncommon manifestation of Lyme disease. This report compares Lyme carditis presentation, management, and outcomes in pediatric and adult populations. Methods Charts of pediatric and adult patients with heart block (PR >300ms) and positive Lyme serologies hospitalized in Portland, Maine between January 2010 and December 2018 were analyzed. Data on medical history, presentation, treatment, and outcomes are described. Results Ten children and 20 adults were admitted for Lyme carditis between June and October. Ninety percent were male, and 87% had no prior cardiac history. Seventeen had outpatient evaluation prior to admission. Of these, a minority (41%) had Lyme disease suspected in the outpatient setting, and fewer (12%) were initiated on Lyme disease treatment. The most common alternate diagnoses were viral illness and erythema multiforme. More children than adults had disseminated erythema migrans and fever. First-degree heart block was more prevalent in children, and Mobitz type 2 heart block was more prevalent in adults. Ten patients presented with syncope. Proportionately more adults needed temporary pacing. Children had shorter antibiotic durations compared to adults. Of the 30 cases, twenty-seven had improved heart block, while 3 adults required a pacemaker at discharge. Nine children and 14 adults were discharged with a PR 200-300ms. There was a single death in this series. Conclusion Cases tended to be younger males. Most patients had some heart block on discharge. Of patients evaluated as outpatients, Lyme disease was suspected in 41%. Improved early recognition and treatment of Lyme disease may decrease Lyme carditis.

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Spontaneous Knee Effusion in an Adolescent Soccer Player

International Journal of Athletic Therapy & Training ◽

10.1123/ijatt.2020-0057 ◽

2021 ◽

pp. 1-4

Author(s):

Bernadette D. Buckley ◽

Christopher J. Joyce

Keyword(s):

Lyme Disease ◽

Soccer Player ◽

Complete Blood Count ◽

Early Recognition ◽

The United States ◽

Disease Diagnosis ◽

Left Knee ◽

Lyme Arthritis ◽

Radiographic Imaging ◽

Knee Effusion

A 13-year-old female recreational soccer player presented with spontaneous left knee effusion approximately 2 weeks after the start of soccer season. Radiographic imaging was negative, and a complete blood count identified an increase in inflammatory markers. Additional two-tier testing confirmed a Lyme disease diagnosis, which was unusual for an athlete residing in the southeast region of the United States. The presentation of knee effusion, and subsequently Lyme arthritis, is a common clinical manifestation of late-stage Lyme disease. Early recognition of this infection and prompt treatment by a variety of specialists reduce the severity or chronicity of symptoms.

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Transcriptome Assessment of Erythema Migrans Skin Lesions in Patients With Early Lyme Disease Reveals Predominant Interferon Signaling

The Journal of Infectious Diseases ◽

10.1093/infdis/jix563 ◽

2017 ◽

Vol 217 (1) ◽

pp. 158-167 ◽

Cited By ~ 9

Author(s):

Adriana Marques ◽

Ira Schwartz ◽

Gary P Wormser ◽

Yanmei Wang ◽

Ronald L Hornung ◽

...

Keyword(s):

Lyme Disease ◽

Cell Activation ◽

Critical Role ◽

Erythema Migrans ◽

Transcriptional Response ◽

Skin Lesions ◽

Microbial Pathogens ◽

Activation Markers ◽

Transcriptional Pattern ◽

Transcriptional Alterations

Abstract Background The most common clinical manifestation of early Lyme disease is the erythema migrans (EM) skin lesion that develops at the tick bite site typically between 7 and 14 days after infection with Borreliella burgdorferi. The host-pathogen interactions that occur in the skin may have a critical role in determining outcome of infection. Methods Gene arrays were used to characterize the global transcriptional alterations in skin biopsy samples of EM lesions from untreated adult patients with Lyme disease in comparison to controls. Results The transcriptional pattern in EM biopsies consisted of 254 differentially regulated genes (180 induced and 74 repressed) characterized by the induction of chemokines, cytokines, Toll-like receptors, antimicrobial peptides, monocytoid cell activation markers, and numerous genes annotated as interferon (IFN)-inducible. The IFN-inducible genes included 3 transcripts involved in tryptophan catabolism (IDO1, KMO, KYNU) that play a pivotal role in immune evasion by certain other microbial pathogens by driving the differentiation of regulatory T cells. Conclusions This is the first study to globally assess the human skin transcriptional response during early Lyme disease. Borreliella burgdorferi elicits a predominant IFN signature in the EM lesion, suggesting a potential mechanism for spirochetal dissemination via IDO1-mediated localized immunosuppression.

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