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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].

Splenomegaly
  • Hepatitis, sore throat, generalized lymphadenopathy and splenomegaly have been reported. Symptoms are usually intermittent and changing, although fatigue is commonly constant.[clinicaladvisor.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]
Developmental Disabilities
  • disability presented with a circular, erythematous red rash (pictured) with central clearing that measured 5 cm in diameter.[jaoa.org]
Erythema
  • Only after 8 weeks did it form a more typical erythema migrans.[en.wikipedia.org]
  • […] 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]
  • […] migrans, Erythema chronica migrans, Erythema Chronicum Migrans, Erythema, chronicum migrans, Erythema, migrans, chronicum[dermis.net]
  • [C01.539.800.720.310] Skin and Connective Tissue Diseases [C17] Skin Diseases [C17.800] Erythema [C17.800.229] Erythema Chronicum Migrans [C17.800.229.200] Skin Diseases, Infectious [C17.800.838] Skin Diseases, Bacterial [C17.800.838.765] Erythema Chronicum[profiles.umassmed.edu]
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]
  • 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 includes cellulitis, spider bite, erythema multiforme, and erythema annulare centrifugum. Treatment is doxycycline.[clevelandclinicmeded.com]
Excoriation
  • […] 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]

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]

Treatment

  • : - 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]
  • 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]
  • This is called the post-treatment Lyme borreliosis syndrome. It is believed to be an autoimmune response. Prolonged antibiotic treatment does not appear to be of benefit Other resources[pcds.org.uk]
  • See full list of 11 symptoms of Erythema chronicum migrans Treatments for Erythema chronicum migrans Penicillin more treatments...»[rightdiagnosis.com]
  • Antibiotic treatment resolves the illness quickly. [1] [2] Treatment [ edit ] Both lyme disease and STARI can be treated with antibiotics , particularly doxycyclin . [18] [19] [20] History [ edit ] In a 1909 meeting of the Swedish Society of Dermatology[en.wikipedia.org]

Prognosis

  • "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]
  • Patients with CREST syndrome have a better prognosis. Differential diagnosis includes diabetic sclerodema, scleromyxedema, and chronic graft-versus-host disease.[clevelandclinicmeded.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

  • Synonym: fifth disease Etiology The causative agent is human parvovirus B-19.[medical-dictionary.thefreedictionary.com]
  • 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]
  • Related Articles Original Article Mar 31, 1983 The Spirochetal Etiology of Lyme Disease A.C. Steere and Others[nejm.org]
  • Etiology Lyme disease is the most common tick-borne illness in the US.[clinicaladvisor.com]
  • As further evidence for an infectious etiology, antimicrobial therapy has been shown to significantly alter the course of the disease.[cdc.gov]

Epidemiology

  • 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]
  • Register ERYTHEMA CHRONICUM MIGRANS AND LYME ARTHRITIS: EPIDEMIOLOGIC EVIDENCE FOR A TICK VECTOR1 - 24 Hours access EUR 35.00 GBP 27.00 USD 44.00 Rental This article is also available for rental through DeepDyve.[aje.oxfordjournals.org]
  • This outbreak stimulated intense clinical and epidemiologic research that led to the discovery of the causative agent and its ecology and an expanding geographic range and list of clinical manifestations.[dermaamin.com]
  • (CDC) criteria designate the diameter to be greater than 5 cm, so that other noninfectious manifestations of tick or insect bites are excluded, however, the size alone should not be used to exclude the diagnosis in those with consistent clinical and epidemiologic[clinicaladvisor.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]
  • 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]
  • […] 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]
  • Borrelia infection . [33] In few studies, sclerotic lesions have found to be occurring in 10% of patients with ACA. [34] , [35] In a study from North America, borrelia -like forms on biopsy were obtained from a patient with Parry-Romberg syndrome. [36] A pathophysiologic[dx.doi.org]

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]
  • Antibiotics given at the time the erythema chronicum migrans rash appears can prevent the spread of the causative bacteria, preventing the onset of symptoms later.[wisegeek.com]
  • "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]
  • 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 H. pylori Treatment for Gastric Cancer Prevention[nejm.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.

Symptoms

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