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.

“Our case did not exhibit typical target lesions,” says Sharma. 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, generalised weakness and generalised joints, muscle and back pain, writes Sharma in the British Medical Journal. [1] 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 generalised without neck rigidity or photophobia.” writes Sharma.

Disseminated Lyme disease causes cellulitic-appearing skin lesions and oral pseudomembrane, according to case report. 

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. So, he was prescribed Vancomycin.

The initial ELISA test for Lyme disease was negative but positive on the Western blot. He was also positive for Epstein-Barr virus (mononucleosis).

He was empirically started on doxycycline for Lyme disease and his symptoms improved. The Western blot test was positive and he was diagnosed with early disseminated Lyme disease.

Upon follow-up at four weeks, the man’s rash and symptoms had completely resolved.

The author reminds doctors not to overlook Lyme disease. “Lyme disease can have unrelated findings like oral pseudomembrane, lymphadenopathy that may lead one to suspect alternative diagnosis like acute HIV or infectious mononucleosis.”


Related Articles:

6-year-old girl with a rare cutaneous presentation of Lyme disease

When Lyme disease causes a positive test for mononucleosis


  1. Sharma U. Disseminated Lyme disease presenting as multiple non-target cellulitic-appearing skin lesions and oral pseudomembrane. BMJ Case Rep. 2018;2018.

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