Rare Skin Manifestation of Lyme Disease in a Child

A 6-year-old girl developed an unusual skin presentation of Lyme disease—highlighting how early infection can be missed when symptoms fall outside typical patterns.

The child initially presented with an erythema migrans (EM) rash, followed weeks later by an areolar lymphocytoma involving her breast. She had recently traveled to Germany, where her parents recalled an asymptomatic annular rash on her right flank one week after a suspected insect bite, writes Ogimi.

Early Testing Can Be Negative

Initial Lyme disease testing was negative. A repeat test six weeks after the rash also remained negative. It was not until two weeks later—when areolar swelling developed—that the diagnosis was reconsidered.

This case highlights a well-recognized challenge: early Lyme disease testing may be negative despite active infection. For more on testing limitations, see Lyme disease testing and diagnosis.

Unusual Presentation Delays Diagnosis

The diagnosis was not based on typical Lyme features. The patient denied joint pain, muscle aches, palpitations, headaches, or neurologic symptoms.

Repeat testing ultimately showed a positive C6 ELISA with a negative Western blot—findings consistent with European Lyme borreliosis.

Lymphocytoma is a subacute skin lesion most often found on the ear or breast and is more commonly reported in Europe than in the United States.

Treatment and Outcome

The child was treated with a 3-week course of amoxicillin, resulting in prompt resolution of the lymphocytoma.

As noted by Mullegger, appropriate antibiotic therapy is necessary to eliminate the infection and prevent late complications.

Regional Differences Matter

This case underscores an important clinical point: Lyme disease presentations and testing approaches vary by geographic region.

“Testing for European Lyme disease does not follow the CDC algorithm and may be easily missed,” writes Ogimi.

Clinicians should consider travel history and atypical presentations, particularly in children. For a broader overview, see Lyme disease symptoms guide.

Clinical Takeaway

Lyme disease in children may present with atypical skin findings and negative early testing. Careful clinical assessment—including travel history—remains essential to avoid delayed diagnosis.

References:

1. Ogimi C, Crowell C, Boos MD. Areolar lymphocytoma in a child: A rare cutaneous presentation of borreliosis. Pediatr Dermatol. 2017.
2. Mullegger RR, Glatz M. Skin manifestations of Lyme borreliosis: diagnosis and management. Am J Clin Dermatol. 2008;9(6):355-368.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention