Atypical Lyme Rash in Children: A Case of Erythema Migrans

Case reports often illustrate how Lyme disease can present in unexpected ways, particularly in children. The Lyme rash in children does not always resemble the classic bull’s-eye pattern many people expect.

In their article, “Giant Erythema in a Child with Lyme Disease,” Banadyha and colleagues describe an 11-year-old girl whose illness involved an unusual presentation of erythema migrans (EM).¹

The girl was admitted to the hospital with high fever, headaches, abdominal pain, and a progressing rash. Her symptoms began several days after a small rash appeared on her left foot. This rash cleared after topical treatment.

The following day, another rash appeared on the girl’s right foot near the ankle and also resolved after antihistamine treatment.

On the fourth day of illness, maculopapular rashes appeared on the trunk and limbs.

Over the next several days the rashes enlarged, and the girl developed fever, lethargy, headaches, and abdominal pain.

Clinicians initially considered other medical conditions, including toxic erythema. However, as new rashes continued to appear, the diagnosis was reconsidered.

The patient’s parents did not recall a tick bite, and Lyme disease was not initially suspected because the illness began during a colder season.

“Only on the seventh day of illness did typical erythema migrans lesions appear on the anterolateral surface of the chest.”¹

The authors noted that the diagnostic complexity was increased by the rash’s atypical presentation, which consisted of large homogeneous papular lesions.

After serologic testing returned positive, the patient was diagnosed with early disseminated Lyme disease and treated successfully with doxycycline.

“This clinical case is noteworthy because the rash was extensive, multiple, and migratory.”¹

This case illustrates how the Lyme rash in children may evolve over several days and may not resemble the classic erythema migrans pattern early in the illness.

When rashes are multiple, migratory, or atypical, clinicians may need to reconsider Lyme disease in the differential diagnosis.

Why This Case Matters

Children with Lyme disease do not always present with a classic rash or a clear history of tick exposure. Rashes may appear in unusual locations, resolve temporarily, or change in appearance over time.

As this case illustrates, Lyme disease may not initially be suspected when the presentation is atypical or occurs outside the expected tick season.

For a broader discussion of early symptoms in children, see Early Signs of Lyme Disease in Children.

For a broader overview of Lyme disease symptoms across age groups, see the Lyme Disease Symptoms Guide.

Authors’ Takeaways

• This report underscores the importance of recognizing atypical presentations of Lyme borreliosis in children.
• The illness began with a small rash that disappeared before more widespread rashes appeared.
• Fever, headaches, abdominal pain, and systemic symptoms developed as the rash progressed.