A unique presentation of an EM rash

The rash, indicative of Lyme disease, does not always present as a classic “bull’s-eye rash,” as this case report demonstrates. A broad spectrum of lesions has been reported in patients with Lyme disease (LD). In fact, one study found only 6% of the lesions in LD patients had the “classic bull’s-eye or ring-within-a-ring pattern.” [1]

In the case report, “A Non-Classical Presentation of Erythema Migrans in a 51-Year-Old Woman With Early Manifestation of Lyme Neuroborreliosis (Bannwarth Syndrome),” Lorquet et al. describe a 51-year-old female who presented with general malaise, headache, neck stiffness, and an expanding rash consistent with Lyme neuroborreliosis.²

The woman reported having a worsening of her symptoms over a 4-day period and a rash which expanded on her upper back but she did not recall any tick bites.

“She stated that [the rash] started as a small area of redness, spreading rapidly,” the authors wrote.

Clinicians suspected she might have cellulitis and prescribed cephalexin and valacyclovir. But her symptoms did not improve.

“The “bull’s-eye” appearance of erythema migrans is not the only cutaneous manifestation of the acute stage of Lyme disease. There can be multiple variations of the rash, as demonstrated in the patient.”

According to the patient, “the rash had gotten larger and more pruritic and that her headache had become more severe, also causing severe pain that radiated to the right side of her neck,” the authors wrote.

The erythema migrans (EM) rash covered two-thirds of her back and had a 5 cm crusted plaque in the center. There was a second circular rash that appeared, as well, behind the woman’s right ear.

READ: The many presentations of the Lyme disease rash

Clinicians treated her symptoms with intravenous ondansetron, ketorolac, pantoprazole, and saline. But also empirically treated for Lyme disease with doxycycline.

After Lyme disease testing was positive, the woman was diagnosed with Lyme Neuroborreliosis, also known as Bannwarth syndrome in Europe.

Bannwarth syndrome (BS) is a typical manifestation of early Lyme neuroborreliosis (LNB) in Europe. It is characterized by painful radiculopathy, neuropathy, varying degrees of motor weakness and facial nerve palsy, and cerebrospinal fluid (CSF) lymphocytic pleocytosis.³

“Several weeks later, the patient had made a full recovery and was back to her baseline level of functioning,” the authors wrote.

They point out, “The “bull’s-eye” appearance of erythema migrans is not the only cutaneous manifestation of the acute stage of Lyme disease. There can be multiple variations of the rash, as demonstrated in the patient.”