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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]
Hematochezia
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
Erythema
  • 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]
  • Only after 8 weeks did it form a more typical erythema migrans.[en.wikipedia.org]
  • Publication type, MeSH terms Publication type Case Reports MeSH terms Child, Preschool Diagnosis, Differential Erythema/diagnosis Erythema/etiology* Erythema/pathology Humans Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications* Leukemia, Myelogenous[ncbi.nlm.nih.gov]
  • Only two of the erythema chronicum migrans patients had IgG or IgM antibodies to flagellin. However, all seven morphea lesions as well as the other lesions were polymerase chain reaction negative.[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]
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]
  • 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]
  • Differential diagnosis of ECM includes tinea corporis, urticaria, erythema multiforme, erythema annulare centrifugum, and fixed drug eruptions.[idoj.in]
Skin Lesions with Central Clearing
  • A Skin lesion with central clearing, in right lower quadrant of abdomen. Raised lesion marks indicate from which area the attached tick was removed.[doi.org]
Radiculopathy
  • After several weeks to months, 15% of untreated patients will develop neurologic disease that includes meningitis, encephalitis, cranial neuritis (including bilateral facial palsy), radiculopathy, and myelitis.[dermatologyadvisor.com]
Myelopathy
  • The occurrence of severe encephalitis resulting in dementia in two of these patients and irreversible myelopathy in one enlarges the known spectrum of neurologic abnormalities due to infection with B. burgdorferi.[ncbi.nlm.nih.gov]
Hyperesthesia
  • The syndrome may include advancing erythematous rash stemming from an apparent insect bite, hyperesthesias, myalgias, malaise, fever, lymphadenopathy, and, rarely, meningitis.[ncbi.nlm.nih.gov]

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]
  • ., tape, nickel coins, necklaces) Variable Methicillin-resistant Staphylococcus aureus infection Erythematous lesions of variable size that may be associated with necrotic eschar Most commonly located on the extremities, but may involve the axilla, abdomen[aafp.org]
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]
Treponema Pallidum
  • The isolated spirochete is immunologically related to the Ixodes dammini spirochete, Borrelia duttoni, and Treponema pallidum.[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

  • […] received a recommended treatment and in 1 of the 3 patients who received other treatments.[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]
  • Antibiotic treatment resolves the illness quickly. [1] [2] Treatment [ edit ] Both lyme disease and STARI can be treated with antibiotics , particularly doxycycline . [16] [17] [18] History [ edit ] In a 1909 meeting of the Swedish Society of Dermatology[en.wikipedia.org]
  • Treatment with penicillin, the tetracycline, or, in our experience, erythromycin usually results in prompt resolution.[ncbi.nlm.nih.gov]
  • 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]

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]
  • Publication type, MeSH terms Publication type Case Reports MeSH terms Child, Preschool Diagnosis, Differential Erythema/diagnosis Erythema/etiology* Erythema/pathology Humans Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications* Leukemia, Myelogenous[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]
  • Abstract Epidemiology and clinical presentation of Erythema chronicum migrans disease are not well known yet.[ncbi.nlm.nih.gov]
  • The book closes with a chapter on the epidemiology of LB.[books.google.ro]
  • Epidemiologic reviews 35: 161-180 The link will take you to an abstract of the article. NHS staff wishing to obtain a copy...[evidence.nhs.uk]
  • 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]
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]
  • The pathophysiology of this phenomenon is not completely understood. Differential diagnosis includes psoriasis, atopic dermatitis, allergic or irritant contact dermatitis, and dermatophyte (tinea) infections.[clevelandclinicmeded.com]

Prevention

  • Abstract 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]
  • The importance of a sufficient antibiotic therapy to prevent late manifestations is stressed.[ncbi.nlm.nih.gov]
  • 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]
  • "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.[en.wikipedia.org]

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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Last updated: 2018-06-21 21:00