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Erythema Chronicum Migrans

Erythema chronicum migrans is a cutaneous manifestation of Lyme disease, a spirochetal infection caused by Borrelia burgdorferi after a tick bite. It is most commonly described as a slowly expanding circular erythematous "target" lesion, although various atypical presentations are reported. For this reason, a detailed inspection of the skin and a complete patient history are most important parts of workup when it comes to identifying this skin lesion.


Presentation

Lyme disease is a tick-borne infection caused by Borrelia burgdorferi, a spirochetal bacterial pathogen [1] [2]. In approximately 80% of cases, cutaneous manifestations of this infection appear, predominantly in the form of erythema chronicum migrans (or erythema migrans), a pathognomonic finding of Lyme disease. It is described as an erythematous papule or macule at the site of the tick bite [3] [4] [5] [6]. The incubation period is variable (3-30 days), but in the majority of cases, erythema chronicum migrans is seen after 1-2 weeks and can occur on virtually any site of the body [1] [2] [5]. However, the waist, the extremities, the groins, the back, and the head and neck in the pediatric population are most frequent sites [4]. The progression of the erythematous macule, which may be asymptomatic, painful, or pruritic, eventually leads to a "target" or "bull's eye" lesion (as a central clearing around the center of the erythematous lesion is observed), with a diameter of > 5 cm, although a diameter as large as 60 cm has been reported [7] [8]. Numerous reports have confirmed that up to 30% of lesions exhibit significant variations [3] [5] [6] [7]. Firstly, multiple lesions can develop, the reason being the dissemination of the infection [3]. Secondly, an increasing number of cases present only with profound erythema and the absence of central clearing, thus the typical "target" lesion is not a mandatory finding in Lyme disease [5] [6]. Moreover, necrosis of the lesion, central hemorrhage, and formation of bullae are less common, but still possible variants of erythema chronicum migrans [1] [8]. It must be noted that numerous symptoms of Lyme disease can accompany erythema chronicum migrans, such as neurological deficits, fever, neck stiffness (suggesting meningitis), cardiac conduction abnormalities and arthritis (a sign of disseminated disease) [1] [2] [5].

Weight Gain
  • A diet that promises an immediate result has a short term effect and will eventually lead to weight gain. It... Read more Otoplasty Protruding ears are a common feature in people, and most people opt to have their ears surgically corrected.[allpathy.com]
Constitutional Symptom
  • . - Images in Clinical Medicine: Disseminated Lyme Disease - constitutional symptoms - flu like symptoms: fatigue, headache, myalgias, and arthralgias; - neurologic symptoms - neurologic symptoms may occur early or late; - look for headache, neck stiffness[wheelessonline.com]
Erythema
  • Only after 8 weeks did it form a more typical erythema migrans.[en.wikipedia.org]
  • In approximately 80% of cases, cutaneous manifestations of this infection appear, predominantly in the form of erythema chronicum migrans (or erythema migrans), a pathognomonic finding of Lyme disease.[symptoma.com]
  • […] burgdorferi … Deutsch Wikipedia Erythema chronicum migrans — Erythema migrans (fachsprachlich); Wanderröte … Universal-Lexikon erythema chronicum migrans — noun see erythema migrans … New Collegiate Dictionary erythema chronicum migrans — noun see erythema[medicine.academic.ru]
  • Read more about causes of Erythema chronicum migrans Read more about causes of Erythema chronicum migrans .[rightdiagnosis.com]
Erythema Annulare
  • It is very similar to erythema annulare centrifugum, except that the advancing edge is frequently broader, up to a centimeter of raised erythema. It is associated with an arthritis known as Lyme arthritis.[skincareguide.ca]
  • Afzelius erythema - single lesions of erythema annulare centrifugum which erupt and spread.[medical-dictionary.thefreedictionary.com]
  • The gyrate erythemas consist of the entities erythema annulare centrifugum (EAC), erythema marginatum rheumaticum (EMR), erythema gyratum repens (EGR), and erythema chronicum migrans (ECM).[link.springer.com]
  • Differential diagnosis [ 3 ] Local tick bite reactions Tinea (ringworm) Insect bites Cellulitis Discoid eczema Contact dermatitis Erythema multiforme Granuloma annulare Erythema annulare centrifugum Investigations [ 1 , 3 ] In the presence of a characteristic[patient.info]
Angioedema
  • Multimedia Multimedia Selected Multimedia View all multimedia Audio Clinical Practice Audio Interviews Interactive Medical Cases Image Challenge Images in Clinical Medicine Videos in Clinical Medicine Quick Takes View all multimedia Treating Hereditary Angioedema[nejm.org]

Workup

The importance of recognizing erythema chronicum migrans lies in the fact that up to 60% of patients have negative serology tests for B. burgdorferi in the first several weeks of the infection [5]. For this reason, a meticulous physical examination supported by data obtained during patient history is the pivotal step in confirming Lyme disease and observing its hallmark lesion [6]. Physicians must inquire whether patients reside in or have recently visited at-risk areas, and note the signs and symptoms that possibly suggest an infectious etiology, while the course and progression of the skin lesion should also be discussed with the patient (if the patient had noticed the lesion etc.). The entire body should be examined in order to exclude multiple erythema chronicum migrans, and a close inspection, as well as palpation of the lesion, is vital for raising clinical suspicion of Lyme disease as a potential diagnosis [1] [2] [4] [7] [8]. Physicians must be aware of the incubation period of erythema chronicum migrans, its variable presentation, and the broad differential diagnosis [4]. In all patients in whom this lesion is suspected, microbiological investigation to confirm Lyme disease is mandatory. As serologic testing may be initially negative, blood cultures, biopsy samples of the lesion and polymerase chain reaction (PCR) testing can be implemented [1] [2] [5] [6]. But because of their limited use and sensitivity/specificity in the absence of erythema chronicum migrans, clinical assessment remains the most important part of Lyme disease workup.

Staphylococcus Aureus
  • Aureus ( MRSA ) Lesions with necrotic central eschar Tinea Corporis Urticaria IX.[fpnotebook.com]
Coxiella Burnetii
  • This indicates that ECM and related diseases are not due to an hitherto known rickettsia. 5 out of 158 tests showed, however, positive reactions in low titers against Rickettsia akari and Coxiella burnetii.[ncbi.nlm.nih.gov]
Rickettsia Akari
  • This indicates that ECM and related diseases are not due to an hitherto known rickettsia. 5 out of 158 tests showed, however, positive reactions in low titers against Rickettsia akari and Coxiella burnetii.[ncbi.nlm.nih.gov]

Treatment

  • Treatment: The treatment of choice is the use of penicillin or another antibiotic to which Borrelia is sensitive. Such treatment should be continued for 2-4 weeks. Back to Dermatology Glossary - E Index Back to Dermatology Glossary Index[skincareguide.ca]
  • : - proper length of treatment remains controversial, but it is clear that treatment needs to be continued far beyond the resolution of the acute symptoms; - references: - Safety of intravenous antibiotic therapy in patients referred for treatment of[wheelessonline.com]
  • […] received a recommended treatment and in 1 of the 3 patients who received other treatments.[ncbi.nlm.nih.gov]
  • Strict compliance with treatment protocols and the possibility of reactions to medications should be thoroughly discussed with patients.[ncbi.nlm.nih.gov]
  • Fifty-six patients with a minor form of the illness did not require retreatment and did not develop late manifestations following antibiotic treatment. Three pregnant patients were included in this group.[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis in most patients with Lyme borreliosis is excellent.[ncbi.nlm.nih.gov]
  • "Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis" . Clin. Dermatol . 24 (6): 509–20. doi : 10.1016/j.clindermatol.2006.07.012 . PMID 17113969 . Weber K, Wilske B (2006).[en.wikipedia.org]
  • Babesia microti Prognosis the rash typically self-resolves without treatment untreated Lyme disease can result in arthritis excellent prognosis with early antibiotic treatment Presentation Symptoms early localized stage erythema migrans (7-14 days post-tick[step2.medbullets.com]
  • The earlier the disease is treated the better the prognosis for complete recovery. However, successful treatment of the disease will not prevent getting Lyme disease again.[aocd.org]

Etiology

  • Thus, an antigenic relationship may exist between one or more rickettsia(e) and the etiologic agent of ECM.[ncbi.nlm.nih.gov]
  • These results suggest an etiologic role for the Ixodes ricinus spriochete in European erythema chronicum migrans disease.[ncbi.nlm.nih.gov]
  • The findings are in agreement with spirochetal etiology in ECMA.[ncbi.nlm.nih.gov]
  • Attempts to recover an etiologic agent from ticks were unsuccessful.[ncbi.nlm.nih.gov]
  • The recent discovery that spirochetes transmitted by the tick Ixodes ricinus are involved in the etiology of erythema chronicum migrans Afzelius (ECMA), Bannwarth's syndrome, and acrodermatitis chronica atrophicans (ACA) has thrown new light upon these[ncbi.nlm.nih.gov]

Epidemiology

  • Lyme disease can present with neurologic abnormalities without diagnostic extraneural features, can be suspected on clinical and epidemiologic grounds, and can be diagnosed serologically.[ncbi.nlm.nih.gov]
  • Epidemiology and clinical presentation of Erythema chronicum migrans disease are not well known yet.[ncbi.nlm.nih.gov]
  • Epidemiology [ 1 ] Nearly 8,000 cases of Lyme disease have been reported in England and Wales since enhanced surveillance began in 1997. Mean annual incidence rate is now approximately 1.73 cases per 100,000 population.[patient.info]
  • Close Sign in via your Institution Purchase Subscription prices and ordering Short-term Access ERYTHEMA CHRONICUM MIGRANS AND LYME ARTHRITIS: EPIDEMIOLOGIC EVIDENCE FOR A TICK VECTOR1 - 24 Hours access EUR 35.00 GBP 27.00 USD 44.00 Buy Rental This article[academic.oup.com]
Sex distribution
Age distribution

Pathophysiology

  • […] erythema chronicum migrans Member Rated 0 Patient case no. 4085 Date added 27 July 2003 Patient details Age Elderly patient Localisation Trunk / abdomen Primary Lesions Excoriation Papule / erythematous Plaque / erythematous Pathophysiology infectious[dermquest.com]
  • […] general Multisystem disorder caused by spirochete Borrelia burgdorferi Epidemiology In the United States, Lyme disease most commonly occurs in the northeast and upper midwest Worldwide, more commonly found in northern Asia and eastern and central Europe Pathophysiology[pathologyoutlines.com]
  • Pathophysiology The pathophysiology of Lyme disease is incompletely understood. Many of its manifestations are caused by active infection by the spirochete; others may be driven by immunopathogenetic mechanisms.[dermaamin.com]
  • References: [4] [5] [6] Differential diagnoses Differential diagnoses of tick bite Tick-borne diseases ( endemic to US ) [8] Pathophysiology / Epidemiology Clinical features Diagnostics Treatment Lyme disease Pathogen: Borrelia burgdorferi Vector Ixodes[amboss.com]

Prevention

  • Prevention Avoid exposure to tick bites. Remove ticks as soon as possible. Ticks take some time to transmit infection, so this may be prevented if removed quickly.[patient.info]
  • (Image courtesy of the Centers for Disease Control and Prevention.)[archive.nytimes.com]
  • The efficacy of antibiotic treatment of 117 patients with erythema chronicum migrans of Lyme disease was evaluated in terms of the necessity for retreatment and the prevention of the late manifestations of Lyme disease.[ncbi.nlm.nih.gov]

References

Article

  1. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology. Seventh edition. Philadelphia: Elsevier/Saunders; 2013.
  2. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.
  3. Eriksson P, Schröder MT, Niiranen K, Nevanlinna A, Panelius J, Ranki A. The many faces of solitary and multiple erythema migrans. Acta Derm Venereol. 2013;93(6):693-700.
  4. Juckett G. Arthropod bites. Am Fam Physician. 2013;88(12):841-847.
  5. Shapiro ED. Lyme Disease. N Engl J Med. 2014;370(18):1724-1731.
  6. Aucott J, Morrison C, Munoz B, Rowe PC, Schwarzwalder A, West SK. Diagnostic challenges of early Lyme disease: Lessons from a community case series. BMC Infect Dis. 2009;9:79.
  7. Schutzer SE, Berger BW, Krueger JG, Eshoo MW, Ecker DJ, Aucott JN. Atypical Erythema Migrans in Patients with PCR-Positive Lyme Disease. Emerg Infect Dis. 2013;19(5):815-817.
  8. Wetter DA, Ruff CA. Erythema migrans in Lyme disease. CMAJ. 2011;183(11):1281.

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