Erythema migrans

Short description: A rash in several vector-borne diseases

Not to be confused with erythema multiforme, despite that both often involve target lesions (but from different causes).

Erythema migrans

Erythema migrans is an expanding rash that is the initial sign of about 80% of Lyme infections. The rash may look like a "bull's eye," as pictured, in about 80% of cases in Europe and 20% of cases in the US.[1][2][3]

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).[4][5] 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

* 1 Lyme disease
* 1.1 Presentation
* 2 Southern tick-associated rash illness
* 3 Treatment
* 4 History
* 5 References
* 6 External links

## 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."[6][7] 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.[8][3][9] 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.[9]

### Presentation

This rash did not at first look at all like a bull's eye.

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.[1][8] 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).[1][8][2] The rash is usually circular or oval, red or bluish, and may have an elevated or darker center.[8][3] 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.[2][3] 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.[8][10][11]

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.[8]

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.[1][8]

## Southern tick-associated rash illness

Erythema migrans by STARI.

Southern tick-associated rash illness (STARI) produces a similar rash pattern although it develops more quickly and is smaller.[12] This erythema is also sometimes called erythema migrans[13] or EM. The associated infectious agent has not been determined. Antibiotic treatment resolves the illness quickly.[4][5]

## Treatment

Both Lyme disease and STARI can be treated with antibiotics, particularly doxycycline.[1][14][15] 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.[16]

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]

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 "Diagnosis and management of Lyme disease". Am Fam Physician 85 (11): 1086–93. June 2012. PMID 22962880. http://www.aafp.org/afp/2012/0601/p1086.html.
2. ↑ 2.0 2.1 2.2 "Does This Patient Have Erithema Migrans?". JAMA 297 (23): 2617–27. 20 June 2007. doi:10.1001/jama.297.23.2617. PMID 17579230.
3. ↑ 3.0 3.1 3.2 3.3 "Lyme disease rashes and look-alikes". Centers for Disease Control and Prevention. 2018-12-21. https://www.cdc.gov/lyme/signs_symptoms/rashes.html.
4. ↑ 4.0 4.1 "Lone star tick a concern, but not for Lyme disease". https://www.cdc.gov/stari/disease/. Page last reviewed: October 22, 2015
5. ↑ 5.0 5.1 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.
6. ↑ "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. November 2006. doi:10.1086/508667. PMID 17029130. ""pp. 1101–2 Background and Diagnosis of Erythema Migrans".
7. ↑ "The rising challenge of Lyme borreliosis in Canada". Can. Commun. Dis. Rep. 34 (1): 1–19. January 2008. PMID 18290267. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/08vol34/dr-rm3401a-eng.php.
8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 "Clinical practice. Lyme disease". The New England Journal of Medicine 370 (18): 1724–1731. May 2014. doi:10.1056/NEJMcp1314325. PMID 24785207. PMC 4487875. http://portal.mah.harvard.edu/templatesnew/departments/MTA/Lyme/uploaded_documents/NEJMcp1314325.pdf.
9. ↑ 9.0 9.1 Juckett, G (2014), "In reply: Comment on 'Identifying erythema migrans rash in patients with Lyme disease'", Am Fam Physician 89 (6): 424, PMID 24818260, http://www.aafp.org/afp/2014/0315/p424.html.
10. ↑ "Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans". Ann Intern Med 136 (6): 421–8. 2002. doi:10.7326/0003-4819-136-6-200203190-00005. PMID 11900494.
11. ↑ Edlow JA (2002). "Erythema migrans". Med Clin North Am 86 (2): 239–60. doi:10.1016/S0025-7125(03)00085-3. PMID 11982300.
12. ↑ Goddard J (2017) Not all erythema migrans lesions are Lyme disease. The American journal of medicine, 130(2), 231-233.
13. ↑ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology. St. Louis: Mosby. ISBN 978-1-4160-2999-1.
14. ↑ "Borrelia lonestari infection after a bite by an Amblyomma americanum tick". J. Infect. Dis. 183 (12): 1810–4. June 2001. doi:10.1086/320721. PMID 11372036.
15. ↑ "Southern Tick-Associated Rash Illness: Erythema Migrans Is Not Always Lyme Disease". South. Med. J. 101 (7): 759–760. June 2008. doi:10.1097/SMJ.0b013e31817a8b3f. PMID 18580719.
16. ↑ Lipschütz, B. (1931). "Zur Kenntnis der "Erythema chronicum migrans"". Acta Dermato-Venereologica (Stockholm) 12: 100–2.

## External links

Classification|

* ICD-10: A69.2 (ILDS A69.22)
* ICD-9-CM: 088.81, 529.1
* MeSH: D015787
* DiseasesDB: 4439

|

* DermAtlas 208

* v
* t
* e

* Infectious diseases
* Bacterial diseases: BV4]] non-proteobacterial G- (primarily A00–A79, 001–041, 080–109)

Spirochaete|

| Spirochaetaceae|

| Treponema|

* Treponema pallidum
* Syphilis/bejel
* Yaws
* Treponema carateum (Pinta)
* Treponema denticola

|

Borrelia|

* Borrelia burgdorferi/Borrelia afzelii
* Lyme disease
* Erythema chronicum migrans
* Neuroborreliosis

* Borrelia recurrentis (Louse borne relapsing fever)
* Borrelia hermsii/Borrelia duttoni/Borrelia parkeri (Tick borne relapsing fever)

Leptospiraceae|

| Leptospira|

* Leptospira interrogans (Leptospirosis)

|

Chlamydiaceae|

| Chlamydia|

* Chlamydia psittaci (Psittacosis)
* Chlamydia pneumoniae

|

Chlamydia|

* Chlamydia trachomatis
* Chlamydia
* Lymphogranuloma venereum
* Trachoma

Bacteroidetes|

* Bacteroides fragilis
* Tannerella forsythia
* Capnocytophaga canimorsus
* Porphyromonas gingivalis
* Prevotella intermedia

Fusobacteria|

* Fusobacterium necrophorum (Lemierre's syndrome)
* Fusobacterium nucleatum
* Fusobacterium polymorphum

* Streptobacillus moniliformis (Rat-bite fever/Haverhill fever)

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