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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].

Generalized Lymphadenopathy
  • Hepatitis, sore throat, generalized lymphadenopathy and splenomegaly have been reported. Symptoms are usually intermittent and changing, although fatigue is commonly constant.[dermatologyadvisor.com]
Fatigue
  • This condition is often associated with systemic symptoms such as chills, fever, headache, malaise, nausea, vomiting, fatigue, backache, and stiff neck. synonyms Erythema Chronicum Migrans UMLS ECM - Erythema chronic migrans, ECM - Erythema chronicum[dermis.net]
  • Nausea, vomiting, and diarrhea are sometimes observed along with headache and fatigue. The rash fades with time and the patient can start to develop joint problems, susceptibility to infection, extreme fatigue, and a host of other symptoms.[wisegeek.com]
  • This condition is often associated with systemic symptoms such as chills, fever, headache, malaise, nausea, vomiting, fatigue, backache, and stiff neck.[profiles.umassmed.edu]
Anorexia
  • There may also be fever, depression and anorexia. erythema multiforme major a rapidly fulminating, ulcerative form of erythema multiforme with involvement of oral mucosa and systemic signs. necrolytic migratory erythema in humans, a skin disease associated[medical-dictionary.thefreedictionary.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]
Nausea
  • This condition is often associated with systemic symptoms such as chills, fever, headache, malaise, nausea, vomiting, fatigue, backache, and stiff neck. synonyms Erythema Chronicum Migrans UMLS ECM - Erythema chronic migrans, ECM - Erythema chronicum[dermis.net]
  • This condition is often associated with systemic symptoms such as chills, fever, headache, malaise, nausea, vomiting, fatigue, backache, and stiff neck.[profiles.umassmed.edu]
Abnormal Pulse
  • Erythema chronicum migrans is also associated with flu-like symptoms including fever, headache, fatigue, headache, sore throat, abnormal pulse, neck stiffness and pain, pain and swelling of one or more large joints, numbness or tingling sensation of hands[dermatalk.com]
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]
  • 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.[en.wikipedia.org]
  • 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]
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]
Larva Migrans
  • Cutaneous Larva Migrans Cutaneous larva migrans is a roundworm (usually hookworm) infection.Cutaneous Larva Migrans is abbreviated CLM.[evidence.nhs.uk]
  • .… … Medical dictionary Erythema migrans — is a term used to describe two very different types of erythema: * Erythema chronicum migrans * Geographic tongue … Wikipedia migrans — see ERYTHEMA CHRONICUM MIGRANS, LARVAL MIGRANS, LARVA MIGRANS … Medical[medicine.academic.ru]
Intertrigo
  • Patients with TAC may develop a life-threatening anemia that requires immediate blood transfusion or partial exchange transfusion. erythema intertrigo Chafing. linear gingival erythema A band of inflammation of the periodontium, appearing as a reddish[medical-dictionary.thefreedictionary.com]
Cutaneous Larva Migrans
  • Cutaneous Larva Migrans Cutaneous larva migrans is a roundworm (usually hookworm) infection.Cutaneous Larva Migrans is abbreviated CLM.[evidence.nhs.uk]
Hysteria
  • Some have proposed existence of an "Axis of Evil," which would include the Internet, for promoting Lyme hysteria; particular specialty laboratories, for allegedly performing inaccurate testing; and physicians, specifically those who prescribe prolonged[dermaamin.com]
Facial Redness
  • Facial redness is similar to that which occurs when a child is slapped; however, circumoral redness is absent. Several days following initial erythema, a less distinct rash may appear on the extremities and trunk.[medical-dictionary.thefreedictionary.com]
Renal Impairment
  • Pregnancy D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations[dermaamin.com]
Headache
  • General symptoms such as headache, fever, myalgia and/or arthralgia were found in about half of the patients with a disease duration of less than or equal to 3 weeks. Three patients had coexisting lymphadenosis benigna cutis.[ncbi.nlm.nih.gov]
  • This condition is often associated with systemic symptoms such as chills, fever, headache, malaise, nausea, vomiting, fatigue, backache, and stiff neck. synonyms Erythema Chronicum Migrans UMLS ECM - Erythema chronic migrans, ECM - Erythema chronicum[dermis.net]
  • This condition is often associated with systemic symptoms such as chills, fever, headache, malaise, nausea, vomiting, fatigue, backache, and stiff neck.[profiles.umassmed.edu]
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]
Neglect
  • Cameron has proposed that despite the controversy surrounding persistent Lyme disease symptoms, evidence to deny care is lacking and to do so is neglectful to patient care.[dermaamin.com]

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.

Cytopenia
  • The presence of cytopenias or persistent fever while on therapy suggests that consideration be given to concurrent infection. Immunocompromised hosts with Lyme disease may have more frequent early dissemination.[dermatologyadvisor.com]
Treponema Pallidum
  • The isolated spirochete is immunologically related to the Ixodes dammini spirochete, Borrelia duttoni, and Treponema pallidum.[ncbi.nlm.nih.gov]
  • .), and a serologic test (Treponema pallidum Haemagglutination Test; Murex Diagnostics Limited, Dartford, England) for syphilis was negative.[jcm.asm.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]
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]
  • 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]
  • Antibiotic treatment resolves the illness quickly. [4] [5] Treatment [ edit ] Both Lyme disease and STARI can be treated with antibiotics, particularly doxycycline. [1] [14] [15] History [ edit ] In a 1909 meeting of the Swedish Society of Dermatology[en.wikipedia.org]

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).[ipfs.io]
  • 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]
  • Prognosis Usually bad, often associated with residual or progressive neurocognitive deficits. Differential diagnosis Encephalitis of any cause. Kozhevnikov-Rasmussen syndrome. Management options* Seizures are resistant to AEDs.[epilepsy.com]

Etiology

  • These results suggest an etiologic role for the Ixodes ricinus spriochete in European erythema chronicum migrans disease.[ncbi.nlm.nih.gov]
  • 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[symptoma.com]

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]
  • Weekly Epidemiological Record Relevé épidémiologique hebdomadaire, 62 (‎51-52)‎, 386 - 387.[apps.who.int]
  • 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]
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]
  • The symptoms of EPC have been interpreted to be due to cortical hyperexcitability, but the exact pathophysiology is poorly understood due to a high degree of variability.[ncbi.nlm.nih.gov]

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]
  • 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]
  • Centers for Disease Control and Prevention. 2018-12-21. Retrieved April 18, 2019. a b "Lone star tick a concern, but not for Lyme disease". U.S. Centers for Disease Control and Prevention (CDC). Retrieved 2017-10-06.[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: 2019-06-28 10:00