Atypical findings in Lyme disease makes diagnosing difficult
What happens if there are atypical findings in Lyme disease? A case report by Sharma from the Mayo Clinic in Minnesota describes a 45-year-old man who presented to the emergency room with weakness, chills and oral pseudomembrane (which can be caused by thrush), along with multiple cellulitic-appearing skin lesions.
Lyme disease can present with a broad range of symptoms. Many of them are familiar to clinicians. But in some cases, a patient may exhibit atypical symptoms, including rashes other than the well-known “bull’s eye” rash. These unique presentations of Lyme disease can make diagnosing the illness particularly difficult.
For instance, Sharma reports, “Our case did not exhibit typical target lesions.” Instead, the patient had a “large erythematous, warm, rash without central clearing over the left lower quadrant, with similar but smaller rashes on abdomen and back and scattered white patches on surface and side of tongue.”
Three weeks prior, the man had been on a camping trip, after which he developed headaches, fever, malaise, fatigue, generalized weakness and generalized joints, muscle and back pain, writes Sharma in the British Medical Journal.  Ibuprofen alleviated his symptoms but only briefly.
Additional symptoms developed including “chills, shaking, alternating with cold feeling and warm, profuse sweating, retching, blurry vision, stomach pain, leg cramps, and chest pressure. Headache was generalized without neck rigidity or photophobia,” writes Sharma.
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Doctors suspected oral pseudomembrane was due to HIV or mono. But these conditions were later ruled out. They also suspected that methicillin-resistant Staphylococcus aureus skin infections were causing the atypical rashes. And so, he was prescribed Vancomycin.
The man was positive for Epstein-Barr virus (mononucleosis). But the initial ELISA test for Lyme disease was negative. Tests should not be used, however, for diagnosing Lyme disease, as they are typically unreliable. Lyme disease is a clinical diagnosis.
The patient was empirically started on doxycycline for Lyme disease. And his symptoms quickly improved.
Eventually, Western blot test results came back positive and the patient was diagnosed with early disseminated Lyme disease.
At his 4-week follow-up visit, the man’s rash and symptoms had completely resolved.
The author reminds doctors that Lyme disease can cause unusual presentations. “Lyme disease can have unrelated findings like oral pseudomembrane, lymphadenopathy that may lead one to suspect alternative diagnoses like acute HIV or infectious mononucleosis.”
- Sharma U. Disseminated Lyme disease presenting as multiple non-target cellulitic-appearing skin lesions and oral pseudomembrane. BMJ Case Rep. 2018;2018.