6-year-old girl with a rare cutaneous presentation of Lyme disease
The authors of a case report published in Pediatric Dermatology discuss a rare cutaneous presentation of Lyme disease in a young child. “We report the case of a girl who was clinically diagnosed with Lyme disease based on her history of recent travel and the appearance of an areolar lymphocytoma; this was confirmed by testing,” writes Ogimi from the University of Washington and Seattle Children’s Hospital. 
The 6-year-old girl presented with an erythema migrans (EM) rash before developing an areolar lymphocytoma involving her breast. She had recently travelled to Germany, where her parents recalled her developing an asymptomatic, annular, erythematous eruption of the right flank 1 week after a “bite,” writes Ogimi.
The initial tests for Lyme disease were negative. Then, 6 weeks after the rash appeared another Lyme test was performed which was also negative. Areolar swelling occurred 2 weeks later.
The diagnosis of Lyme disease was not made until after the areolar lymphocytoma developed. The diagnosis was not based on typical presentations. “She denied joint pain, muscle aches, heart palpitations, headaches, or other neurologic symptoms,” states Ogimi.
According to the authors, “Repeat testing showed a combination of a positive C6 ELISA and negative Western blot, which was consistent with a diagnosis of European LB [Lyme borreliosis].”
Lymphocytoma is a subacute lesion typically located on the ear or breast. “Antibacterial treatment is necessary in all patients to eliminate the spirochete, cure current disease, and prevent late sequelae,” writes Mullegger, adding that oral doxycycline, amoxicillin and cefuroxime axetil are effective treatments. 
The girl was treated with 3 weeks of amoxicillin which resulted in a prompt resolution of the lymphocytoma.
The authors remind doctors of the need to think outside of the box. “Testing for European Lyme disease does not follow the testing algorithm that the Centers for Disease Control and Prevention recommends and may be easily missed,” writes Ogimi.
“Our case serves as an important reminder,” he says, “that common infections can have varying presentations depending on their region of acquisition and may require specialized testing for accurate diagnosis.”
- Ogimi C, Crowell C, Boos MD. Areolar lymphocytoma in a child: A rare cutaneous presentation of borreliosis. Pediatr Dermatol. 2017.
- Mullegger RR, Glatz M. Skin manifestations of lyme borreliosis: diagnosis and management. Am J Clin Dermatol. 2008;9(6):355-368.