Erythema migrans

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Erythema migrans or erythema chronicum migrans is an expanding rash often seen in the early stage of Lyme disease, and can also (but less commonly) be caused by southern tick-associated rash illness (STARI). [1] [2] It can appear anywhere from one day to one month after a tick bite. This rash does not represent an allergic reaction to the bite, but rather an actual skin infection of one of the Lyme bacteria species from the genus Borrelia. The rash's name comes from Neo-Latin for "migrating redness."

Contents

Lyme disease

"Erythema migrans is the only manifestation of Lyme disease in the United States that is sufficiently distinctive to allow clinical diagnosis in the absence of laboratory confirmation." [8] [9] Often, but not always, mentions of a target lesion (bull's-eye lesion) are talking about erythema migrans. However, the appearance of erythema migrans can vary considerably: while some look like a bull's eye, in the U.S. most are evenly red or bluish, without a central or ring-like clearing. [10] [5] [11] A minority of patients never have any rash. Because Lyme disease can within a few weeks cause long-term neurologic complications, persons with a rash and recent history of outdoor activities where Lyme is common should seek a doctor for diagnosis. [11]

Presentation

Atypical erythema migrans 1 week after initial presentation.jpg
This rash did not at first look at all like a bull's eye.
Approximately 8 weeks old erythema migrans on the thigh.jpg
After 8 weeks, the rash cleared from the center toward the edges and looked a bit more like a bull's eye.

The initial sign of about 80% of Lyme infections is an erythema migrans (EM) rash at the site of a tick bite, often near skin folds, such as the armpit, groin, or back of knee, on the trunk, under clothing straps, or in children's hair, ear, or neck. [3] [10] Most people who get infected do not remember seeing a tick or the bite. The EM rash appears typically one or two weeks (range 3–32 days) after the bite. The most distinctive features of the EM rash are the speed and extent to which it expands, respectively 2–3 cm per day and up to a diameter of 5–70 cm (50% attain more than 16 cm). [3] [10] [4] The rash is usually circular or oval, red or bluish, and may have an elevated or darker center. [10] [5] In about 79% of cases in Europe but only 19% of cases in endemic areas of the U.S., the rash gradually clears from the center toward the edges, possibly forming a "bull's eye" pattern. [4] [5] The rash may feel warm but usually is not itchy, is rarely tender or painful, and takes up to four weeks to resolve if untreated. [10] [12] [13]

Visible part of the Lyme disease rash showing its characteristic asymmetrical cross-section Lyme Disease Rash.jpg
Visible part of the Lyme disease rash showing its characteristic asymmetrical cross-section

The EM rash is often accompanied by symptoms of a viral-like illness, including fatigue, headache, body aches, fever, and chills, but usually not nausea or upper-respiratory problems. These symptoms may also appear without a rash, or linger after the rash disappears. Lyme can progress to later stages without these symptoms or a rash. [10]

A person with an asymptomatic EM rash can easily miss its significance. However, if the initial EM rash is not treated, the infection can disseminate through the lymphatic system or blood. Within days or weeks, additional EM rashes, usually smaller, can appear at other sites, or the infection can cause more serious complications in the nervous system, heart, or joints. [3] [10]

Southern tick-associated rash illness

Erythema migrans by STARI. STARI Rash.jpg
Erythema migrans by STARI.

Southern tick-associated rash illness (STARI) produces a similar rash pattern although it develops more quickly and is smaller. [14] This erythema is also sometimes called erythema migrans [15] or EM. The associated infectious agent has not been determined. Antibiotic treatment resolves the illness quickly. [1] [2]

Treatment

Both Lyme disease and STARI can be treated with antibiotics, particularly doxycycline. [3] [16] [17] Amoxicillin in children less than 8 years of age.

History

In a 1909 meeting of the Swedish Society of Dermatology, Arvid Afzelius first presented research about an expanding, ring-like lesion he had observed. Afzelius published his work 12 years later and speculated the rash came from the bite of an Ixodes tick, meningitic symptoms and signs in a number of cases and that both sexes were affected. This rash was known as erythema chronicum migrans, the skin rash found in early-stage Lyme disease. [18]

In the 1920s, French physicians Garin and Bujadoux described a patient with meningoencephalitis, painful sensory radiculitis, and erythema migrans following a tick bite, and they postulated the symptoms were due to a spirochetal infection. In the 1940s, German neurologist Alfred Bannwarth described several cases of chronic lymphocytic meningitis and polyradiculoneuritis, some of which were accompanied by erythematous skin lesions.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Lyme disease</span> Infectious disease caused by Borrelia bacteria, spread by ticks

Lyme disease, also known as Lyme borreliosis, is a tick-borne disease caused by species of Borrelia bacteria, transmitted by blood-feeding ticks in the genus Ixodes. The most common sign of infection is an expanding red rash, known as erythema migrans (EM), which appears at the site of the tick bite about a week afterwards. The rash is typically neither itchy nor painful. Approximately 70–80% of infected people develop a rash. Early diagnosis can be difficult. Other early symptoms may include fever, headaches and tiredness. If untreated, symptoms may include loss of the ability to move one or both sides of the face, joint pains, severe headaches with neck stiffness or heart palpitations. Months to years later, repeated episodes of joint pain and swelling may occur. Occasionally, shooting pains or tingling in the arms and legs may develop. Despite appropriate treatment, about 10 to 20% of those affected develop joint pains, memory problems, and tiredness for six months or more; this constellation of symptoms is termed post-treatment Lyme disease syndrome (PTLDS).

<span class="mw-page-title-main">Babesiosis</span> Malaria-like parasitic disease caused by infection with the alveoate Babesia or Theileria

Babesiosis or piroplasmosis is a malaria-like parasitic disease caused by infection with a eukaryotic parasite in the order Piroplasmida, typically a Babesia or Theileria, in the phylum Apicomplexa. Human babesiosis transmission via tick bite is most common in the Northeastern and Midwestern United States and parts of Europe, and sporadic throughout the rest of the world. It occurs in warm weather. People can get infected with Babesia parasites by the bite of an infected tick, by getting a blood transfusion from an infected donor of blood products, or by congenital transmission . Ticks transmit the human strain of babesiosis, so it often presents with other tick-borne illnesses such as Lyme disease. After trypanosomes, Babesia is thought to be the second-most common blood parasite of mammals. They can have major adverse effects on the health of domestic animals in areas without severe winters. In cattle, the disease is known as Texas cattle fever or redwater.

<span class="mw-page-title-main">Rash</span> Medical condition

A rash is a change of the skin that affects its color, appearance, or texture.

Tick-borne diseases, which afflict humans and other animals, are caused by infectious agents transmitted by tick bites. They are caused by infection with a variety of pathogens, including rickettsia and other types of bacteria, viruses, and protozoa. The economic impact of tick-borne diseases is considered to be substantial in humans, and tick-borne diseases are estimated to affect ~80 % of cattle worldwide. Most of these pathogens require passage through vertebrate hosts as part of their life cycle. Tick-borne infections in humans, farm animals, and companion animals are primarily associated with wildlife animal reservoirs. Many tick-borne infections in humans involve a complex cycle between wildlife animal reservoirs and tick vectors. The survival and transmission of these tick-borne viruses are closely linked to their interactions with tick vectors and host cells. These viruses are classified into different families, including Asfarviridae, Reoviridae, Rhabdoviridae, Orthomyxoviridae, Bunyaviridae, and Flaviviridae.

<i>Borrelia burgdorferi</i> Species of bacteria

Borrelia burgdorferi is a bacterial species of the spirochete class in the genus Borrelia, and is one of the causative agents of Lyme disease in humans. Along with a few similar genospecies, some of which also cause Lyme disease, it makes up the species complex of Borrelia burgdorferi sensu lato. The complex currently comprises 20 accepted and 3 proposed genospecies. B. burgdorferi sensu stricto exists in North America and Eurasia and until 2016 was the only known cause of Lyme disease in North America. Borrelia species are Gram-negative.

<span class="mw-page-title-main">Geographic tongue</span> Tongue disorder

Geographic tongue, also known by several other terms, is a condition of the mucous membrane of the tongue, usually on the dorsal surface. It is a common condition, affecting approximately 2–3% of the general population. It is characterized by areas of smooth, red depapillation which migrate over time. The name comes from the map-like appearance of the tongue, with the patches resembling the islands of an archipelago. The cause is unknown, but the condition is entirely benign, and there is no curative treatment. Uncommonly, geographic tongue may cause a burning sensation on the tongue, for which various treatments have been described with little formal evidence of efficacy.

<span class="mw-page-title-main">Arvid Afzelius</span> Swedish dermatologist

Arvid Afzelius (1857–1923) was a Swedish dermatologist.

Jorge Benach is a medical researcher at the Stony Brook University in New York state. Benach is the chair of the Department of Molecular Genetics and Microbiology. Benach's main area of research is the tick-borne spirochete Borrelia burgdorferi, which is the causative agent of Lyme disease.

Allen Caruthers Steere is an American rheumatologist. He is a professor of rheumatology at Harvard University and previously at Tufts University and Yale University. Steere and his mentor, Stephen Malawista of Yale University, are credited with discovering and naming Lyme disease, and he has published almost 300 scholarly articles on Lyme disease during his more than 40 years of studies of this infection. At a ceremony in Hartford, Connecticut in 1998, Governor John G. Rowland declared September 24 to be "Allen C. Steere Day".

Neuroborreliosis is a disorder of the central nervous system. A neurological manifestation of Lyme disease, neuroborreliosis is caused by a systemic infection of spirochetes of the genus Borrelia. Symptoms of the disease include erythema migrans and flu-like symptoms.

<span class="mw-page-title-main">Southern tick-associated rash illness</span> Medical condition

Southern tick-associated rash illness (STARI) is an emerging infectious disease related to Lyme disease that occurs in southeastern and south-central United States. It is spread by tick bites and it was hypothesized that the illness was caused by the bacteria Borrelia lonestari. However, there is insufficient evidence to declare this Borrelia strain as a causative agent.

<span class="mw-page-title-main">Human granulocytic anaplasmosis</span> Medical condition

Human granulocytic anaplasmosis (HGA) is a tick-borne, infectious disease caused by Anaplasma phagocytophilum, an obligate intracellular bacterium that is typically transmitted to humans by ticks of the Ixodes ricinus species complex, including Ixodes scapularis and Ixodes pacificus in North America. These ticks also transmit Lyme disease and other tick-borne diseases.

The International Lyme and Associated Diseases Society is a non-profit advocacy group which advocates for greater acceptance of the controversial and unrecognized diagnosis "chronic Lyme disease". ILADS was formed by advocates for the recognition of "chronic Lyme disease" including physicians, patients and laboratory personnel, and has published alternative treatment guidelines and diagnostic criteria due to the disagreement with mainstream consensus medical views on Lyme disease.

<span class="mw-page-title-main">African tick bite fever</span> Medical condition

African tick bite fever (ATBF) is a bacterial infection spread by the bite of a tick. Symptoms may include fever, headache, muscle pain, and a rash. At the site of the bite there is typically a red skin sore with a dark center. The onset of symptoms usually occurs 4–10 days after the bite. Complications are rare but may include joint inflammation. Some people do not develop symptoms.

In dermatology, a target lesion or bull's-eye lesion, named for its resemblance to the bull's-eye of a shooting target, is a rash with central clearing. It occurs in several diseases, as follows:

Rickettsia helvetica, previously known as the Swiss agent, is a bacterium found in Dermacentor reticulatus and other ticks, which has been implicated as a suspected but unconfirmed human pathogen. First recognized in 1979 in Ixodes ricinus ticks in Switzerland as a new member of the spotted fever group of Rickettsia, the R. helvetica bacterium was eventually isolated in 1993. Although R. helvetica was initially thought to be harmless in humans and many animal species, some individual case reports suggest that it may be capable of causing a nonspecific fever in humans. In 1997, a man living in eastern France seroconverted to Rickettsia 4 weeks after onset of an unexplained febrile illness. In 2010, a case report indicated that tick-borne R. helvetica can also cause meningitis in humans.

Borrelia miyamotoi is a bacterium of the spirochete phylum in the genus Borrelia. A zoonotic organism, B. miyamotoi can infect humans through the bite of several species of hard-shell Ixodes ticks, the same kind of ticks that spread B. burgdorferi, the causative bacterium of Lyme disease. Ixodes ticks are also the primary vector in the spread of babesiosis and anaplasmosis.

Chronic Lyme disease (CLD) is the name used by some people with non-specific symptoms, such as fatigue, muscle pain, and cognitive dysfunction to refer to their condition, even if there is no evidence that they had Lyme disease. Both the label and the belief that these people's symptoms are caused by this particular infection are generally rejected by medical professionals. Chronic Lyme disease is distinct from post-treatment Lyme disease syndrome, a set of lingering symptoms which may persist after successful antibiotic treatment of infection with Lyme-causing Borrelia bacteria, and which may have similar symptoms to those associated with CLD.

<span class="mw-page-title-main">Baggio–Yoshinari syndrome</span> Medical condition

The Baggio–Yoshinari syndrome, formerly known as the Brazilian Lyme-like disease and Brazilian human borreliosis, is a disease transmitted by the Amblyomma cajennense tick, but the organism that causes the infection is still unknown. Clinical features resemble those of Lyme disease (LD).

Lymphocytic meningoradiculitis, also known as Bannwarth syndrome, is a neurological disease characterized as intense nerve pain radiating from the spine. The disease is caused by an infection of Borrelia burgdorferi, a tick-borne spirochete bacterium also responsible for causing Lyme disease.

References

  1. 1 2 "Lone star tick a concern, but not for Lyme disease". U.S. Centers for Disease Control and Prevention (CDC). Retrieved 6 October 2017. Page last reviewed: October 22, 2015
  2. 1 2 Naktin, Jaan Peter (2017). "Diagnostic Utility of Erythema Migrans". Clinical Infectious Diseases. 65 (12): 2156–2157. doi: 10.1093/cid/cix544 . ISSN   1058-4838. PMID   28605419.
  3. 1 2 3 4 5 6 Wright WF, Riedel DJ, Talwani R, Gilliam BL (June 2012). "Diagnosis and management of Lyme disease". Am Fam Physician. 85 (11): 1086–93. PMID   22962880. Archived from the original on 27 September 2013.
  4. 1 2 3 Tibbles CD, Edlow JA (20 June 2007). "Does This Patient Have Erythema Migrans?". JAMA. 297 (23): 2617–27. doi:10.1001/jama.297.23.2617. PMID   17579230.
  5. 1 2 3 4 "Lyme disease rashes and look-alikes". Lyme Disease. Centers for Disease Control and Prevention. 21 December 2018. Retrieved 18 April 2019.
  6. ↑ Boyce, RM; Pretsch, P; Tyrlik, K; Schulz, A; Giandomenico, DA; Barbarin, AM; Williams, C (March 2024). "Delayed Diagnosis of Locally Acquired Lyme Disease, Central North Carolina, USA". Emerging Infectious Diseases. 30 (3): 564–567. doi:10.3201/eid3003.231302. PMC   10902532 . PMID   38407256.
  7. ↑ Trayes, KP; Savage, K; Studdiford, JS (1 September 2018). "Annular Lesions: Diagnosis and Treatment". American Family Physician. 98 (5): 283–291. PMID   30216021.
  8. ↑ Wormser GP, Dattwyler RJ, Shapiro ED, et al. (November 2006). "The clinical assessment, treatment, and prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America". Clin. Infect. Dis. 43 (9): 1089–134. doi: 10.1086/508667 . PMID   17029130. "pp. 1101–2 Background and Diagnosis of Erythema Migrans
  9. ↑ Ogden NH, Lindsay LR, Morshed M, Sockett PN, Artsob H (January 2008). "The rising challenge of Lyme borreliosis in Canada". Can. Commun. Dis. Rep. 34 (1): 1–19. PMID   18290267.
  10. 1 2 3 4 5 6 7 Shapiro ED (May 2014). "Clinical practice. Lyme disease" (PDF). The New England Journal of Medicine. 370 (18): 1724–1731. doi:10.1056/NEJMcp1314325. PMC   4487875 . PMID   24785207. Archived from the original (PDF) on 19 October 2016.
  11. 1 2 Juckett, G (2014), "In reply: Comment on 'Identifying erythema migrans rash in patients with Lyme disease'", Am Fam Physician, 89 (6): 424, PMID   24818260.
  12. ↑ Smith RP, Schoen RT, Rahn DW, Sikand VK, Nowakowski J, Parenti DL, Holman MS, Persing DH, Steere AC (2002). "Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans". Ann Intern Med. 136 (6): 421–8. doi:10.7326/0003-4819-136-6-200203190-00005. PMID   11900494.
  13. ↑ Edlow JA (2002). "Erythema migrans". Med Clin North Am. 86 (2): 239–60. doi:10.1016/S0025-7125(03)00085-3. PMID   11982300.
  14. ↑ Goddard J (2017) Not all erythema migrans lesions are Lyme disease. The American journal of medicine, 130(2), 231-233.
  15. ↑ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology. St. Louis: Mosby. ISBN   978-1-4160-2999-1.
  16. ↑ James AM, Liveris D, Wormser GP, Schwartz I, Montecalvo MA, Johnson BJ (June 2001). "Borrelia lonestari infection after a bite by an Amblyomma americanum tick". J. Infect. Dis. 183 (12): 1810–4. doi: 10.1086/320721 . PMID   11372036.
  17. ↑ Blanton L, Keith B, Brzezinski W (June 2008). "Southern Tick-Associated Rash Illness: Erythema Migrans Is Not Always Lyme Disease". South. Med. J. 101 (7): 759–760. doi:10.1097/SMJ.0b013e31817a8b3f. PMID   18580719.
  18. ↑ Lipschütz, B. (1931). "Zur Kenntnis der "Erythema chronicum migrans"". Acta Dermato-Venereologica. 12. Stockholm: 100–2.
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