Unique presentation of Lyme disease skin rash

An atypical presentation of a Lyme disease skin rash can lead to a misdiagnosis, as most clinicians believe that only a bull's-eye or erythema migrans (EM) rash is associated with Lyme disease. In fact, the infection can cause rashes with various appearances. Additionally, an EM rash is only present in about 50% of Lyme disease cases.

In their article, “Giant Erythema in a Child with Lyme Disease,” Banadyha and colleagues describe a young girl with Lyme disease who exhibited a unique presentation of an erythema migrans (EM) skin rash.¹

The 11-year-old girl was admitted to the hospital with a high fever, headaches, abdominal pain and a progressing rash. Her symptoms began several days after a small rash appeared on her left foot. However, this cleared with topical treatment.

“The following day, a skin rash appeared on the girl’s right foot, near the ankle, which also vanished after antihistamine treatment,” the authors state.

On the 4^th day, maculopapular rashes emerged on the trunk and limbs.

Over the next few days, the rashes grew larger and the young girl developed a fever, lethargy, headaches, and abdominal pain.

Clinicians initially considered other medical conditions, including toxic erythema. “However, new rashes kept appearing, prompting reconsideration,” the authors point out.

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

“Only on the 7th day of the illness did typical Lyme disease rashes of erythema migrans appear on the anterolateral surface of the chest.”¹

“The diagnostic complexity was increased by the rash’s atypical presentation – large, homogeneous papular rashes,” the authors state.

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

“This clinical case is noteworthy due to the unique challenge of identifying a rash that was extensive, multiple, and migratory.”¹

Authors Takeaways:

• “This report underscores the importance of recognizing atypical presentations of Lyme borreliosis in children and the need for careful differential diagnosis.”
• Her illness began with a small rash that disappeared with treatment. Over a few days, she developed a high fever, headaches, abdominal pain, and extensive rashes on her body.