Atypical Erythema Migrans in Children
Atypical erythema migrans may not look like a bull’s-eye
Lyme rashes can be multiple, migratory, and unusual
Recognition may reduce missed diagnosis in children
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
Unlike many fungal or eczema-like rashes, erythema migrans is usually not scaly, although real-world Lyme rashes can vary.
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 4th 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.
This case highlights how an early Lyme disease rash may appear differently than the classic bull’s-eye rash many clinicians and patients expect.
Why this Lyme rash was difficult to recognize
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.
Atypical Lyme rashes may be mistaken for viral rashes, allergic reactions, toxic erythema, insect bite reactions, or other skin conditions. This overlap can contribute to Lyme disease rash misdiagnosis.
Multiple and Migratory Erythema Migrans Rashes
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
Multiple erythema migrans rashes can suggest disseminated Lyme disease. In children, these rashes may appear with fever, headache, fatigue, abdominal pain, or other systemic symptoms.
For broader pediatric context, see pediatric Lyme disease.
Is Erythema Migrans Usually Scaly?
Erythema migrans is typically not described as a scaly rash. Scaling may suggest other diagnoses, although Lyme rashes can vary and require clinical judgment.
When the rash is atypical, testing and exposure history may become more important. For diagnostic context, see Lyme test accuracy.
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.
Frequently Asked Questions
What is atypical erythema migrans?
Atypical erythema migrans is a Lyme disease rash that does not follow the classic bull’s-eye appearance and may be large, homogeneous, multiple, migratory, or otherwise unusual.
Can Lyme disease cause multiple rashes?
Yes. Multiple erythema migrans rashes may occur in early disseminated Lyme disease.
Is erythema migrans usually scaly?
No. Erythema migrans is usually not scaly, although Lyme rashes can vary and may be confused with other skin conditions.
Can a Lyme rash be mistaken for a viral rash?
Yes. Atypical Lyme rashes may be confused with viral rashes, allergic reactions, toxic erythema, insect bites, or other dermatologic conditions.
Can tick bite rash pictures help identify Lyme disease?
Pictures may help show rash patterns, but diagnosis depends on rash appearance, symptoms, timing, exposure history, and clinical evaluation.
Can children have atypical Lyme rashes?
Yes. Children may develop atypical erythema migrans, and diagnosis can be delayed when there is no recalled tick bite or classic bull’s-eye rash.
Clinical Takeaway
Atypical erythema migrans may not resemble the classic bull’s-eye rash.
In this case, a child developed large, multiple, migratory rashes along with fever, headaches, abdominal pain, and systemic symptoms before Lyme disease was recognized.
Recognizing atypical Lyme rashes in children may reduce missed diagnosis and improve earlier treatment decisions.
Related Articles
Erythema migrans rash does not always have a bull’s-eye appearance
Is it too late to treat a tick bite?
References
- Banadyha N, Rogalskyy I, Komorovsky R. Giant Erythema in a Child with Lyme Disease. Infect Drug Resist. 2024;17:4343-4348. doi:10.2147/IDR.S489845.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
