Lyme disease presenting with multiple erythema migrans lesions: an illustrative case

A 39-year-old, previously healthy male park ranger presented to the emergency room with a 24-h history of a rapidly progressive, widespread, painful skin eruption associated with severe viral illness-like symptoms of fever as high as 40degreesC, generalized migratory arthralgias, exhaustion, and malaise with prostration. On physical examination, confluent urticarial plaques, many with dusky and bruise-like central discoloration, were observed involving approximately 90% of the skin, sparing the scalp, palms, and soles (Fig. 1). He was febrile with a temperature of 39degreesC, and had signs of dehydration with orthostatic hypotension. Physical examination, including cardiovascular and neurologic examination, was otherwise normal. There was no evidence of lymphadenopathy. Because the patient was severely dehydrated, he was admitted to the hospital service for intravenous fluids and further evaluation. He was started on oral doxycycline, 100 mg twice daily. Within 3 h, he experienced increased arthralgia, malaise, and fever. Because of the possibility that these symptoms represented a reaction to the antimicrobial, the medication was changed to ceftriaxone, 2 g intravenously every 24 h. A skin biopsy was obtained from the edge of one of the plaques on the patient's back (Fig. 2). The biopsy showed scant perivascular lymphocytic infiltrates consistent with urticaria. Borrelia like spirochetes were observed on dark-field examination of the tissue. An enzyme-linked immunosorbent assay (ELISA) Lyme disease screen was positive. Borrelia burgdorferi antibodies were as follows: immunoglobulin G (IgG) (Western blot) showed five bands with molecular weights of 66, 45, 41, 39, and 23 kDa; immunoglobulin M (IgM) antibodies were positive, as demonstrated by immunofluorescence. Polymerase chain reaction was positive for B. burgdorferi in the skin, but negative in blood. A search for serologic markers for ehrlichiosis, babesiosis, and Rocky Mountain Spotted Fever was negative. Over the following 4 days, the patient's skin eruption cleared, leaving mild postinflammatory pigmentary changes; he still felt listless and tired. One week later, his systemic symptoms had resolved, and he returned to work.