The presenting characteristics of erythema migrans vary by age, sex, duration, and body location

Rebman, Alison W.; Yang, Ting; Mihm, Erica A.; Novak, Cheryl B.; Yoon, Isaac; Powell, Debra; Geller, S

doi:10.1007/s15010-021-01590-0

Cited by 15 publications

(10 citation statements)

References 34 publications

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“…However, the fact that they did not find higher levels of agreement emphasizes the challenges. The moderate agreement found in the inter-reviewer ratings of the physical features of the lesions points to the variation that can exist and the element of subjectivity in interpreting the morphology of the lesions [14,17,18,27]. Significantly, we only observed two lesions classified as EM (6% of 35) that exhibited a ringwithin-a-ring, or the classic bull's eye, target pattern often used to describe EM lesions.…”

Section: Discussionmentioning

confidence: 66%

“…Additionally, EM lesions were less frequently observed to have a distinct punctum present, whereas a punctum was common in early EM and tick bite reaction lesions (Table 2). It is unclear how generalizable such morphologic features may be; however, Rebman et al [27] have reported higher frequencies of red and round EM lesions in a cohort of LD patients recruited in Maryland and southeastern Pennsylvania. It has been suggested that the shape and color of EM may relate to the duration of the localized reaction to the tick bite or spirochetes, the location of the body, and orientation relative to lines of skin tension [15,27].…”

Section: Discussionmentioning

confidence: 99%

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The Spectrum of Erythema Migrans in Early Lyme Disease: Can We Improve Its Recognition?

Schotthoefer¹,

Green²,

Dempsey³

et al. 2022

Cureus

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Background and objectiveDiagnosis of early Lyme disease (LD) often relies on clinical recognition of the skin lesion, erythema migrans (EM), a diagnostic sign of disease when laboratory testing is insensitive. Because EM can present in morphologically distinct forms, its recognition by clinicians can be challenging. This study aimed to characterize the clinical spectrum of lesions in patients presenting with suspected early LD in an ambulatory care setting to identify features that might help clinicians to be better prepared to recognize EM lesions. MethodsImages of lesions from 69 participants suspected to have early LD were retrospectively evaluated by a dermatologist and a family practitioner with expertise in early LD. Reviewers made determinations on the diagnoses and morphological features of lesions. Agreement between reviewers and associations among lesion types and participant demographics, symptomology, and laboratory evidence of infection were examined using the kappa statistic and contingency tables, respectively. ResultsChallenges in diagnosing EM were evident in our study: initial concordance between reviewers was moderate [kappa statistic (95% CI): 0.45 (0.245 -0.657)]. The final classification included 35 lesions (51%) that were agreed to be EM; 23 lesions (30%) were considered to be possible early EM or tick bite reactions, and 11 (16%) were thought not to be EM, but rather other diagnoses, including ringworm, allergic contact dermatitis, and mosquito bites. Only two lesions (6%) were observed with a classic bull's eye or ring-within-a-ring pattern. Most EM lesions were uniform (51%), pink (74%), oval lesions (63%), with welldemarcated borders (92%). Early EM or tick bite reactions were typically <5 cm in size (74%), red (52%), round lesions (61%), with a punctum present (100%). Lesions thought not to be EM also tended to be pink or red (64%), round (55%), or uniform (45%) lesions, but also had raised (25%) or irregular borders (33%), which were not commonly observed in the reviewer-classified EM or tick bite reaction lesions. Participants with lesions classified as EM reported that they had the lesions for more days (p = 0.043) and reported more symptoms (p = 0.017) than participants with other lesions. Only 14 (20%) participants overall had positive laboratory evidence for LD; these included 13 (37%) of the participants with EM-classified lesions. ConclusionsEM commonly occurs in forms that are not the classic bull's eye. Patients often present with lesions that may represent the very early stage of EM or tick bite reactions, and most patients will test negative on currently available laboratory tests, challenging clinicians in making an LD diagnosis or treatment decisions. Additional studies to further characterize the morphological features of EM and how variation in skin lesions may be perceived among clinicians would be helpful for developing guidelines on improving clinician recognition of EM.

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Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

The Spectrum of Erythema Migrans in Early Lyme Disease: Can We Improve Its Recognition?

Schotthoefer¹,

Green²,

Dempsey³

et al. 2022

Cureus

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“…At enrollment, participants were required to have a visible (erythema migrans) EM ≥ 5 cm in diameter diagnosed by a health care provider and to have ≤ 72 hours of appropriate antibiotic treatment for early LD. Additional details and baseline clinical characteristics of this sample have been previously published (Rebman et al, 2021).…”

Section: Study Participantsmentioning

confidence: 99%

Risk of post-treatment Lyme disease in patients with ideally-treated early Lyme disease: A prospective cohort study.

Aucott

Yang

Yoon

et al. 2022

International Journal of Infectious Diseases

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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“…All patients had received ≤72 hours of appropriate antibiotic treatment for early Lyme disease at enrollment. Additional details and baseline clinical characteristics of this sample have been previously published (58). Participants without a clinical or serologic history of Lyme disease were recruited from similar primary care settings or through the community using flyers and online advertising to serve as endemic controls.…”

Section: Johns Hopkins University (Jhu) Cohortmentioning

confidence: 99%

Immunosequencing of the T-cell receptor repertoire reveals signatures specific for diagnosis and characterization of early Lyme disease

Greissl

Pesesky

Dalai

et al. 2021

Preprint

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Lyme disease, the most common tick-borne illness in the United States, is most frequently caused by infection with Borrelia burgdorferi. Although early antibiotic treatment can prevent development of severe illness and late manifestations, diagnosis is challenging in patients who do not present with a typical erythema migrans rash. To support a diagnosis of Lyme disease in such cases, guidelines recommend 2-tiered serologic testing. However, 2-tiered testing has numerous limitations, including ambiguity in interpretation and lower sensitivity in early disease. We developed a diagnostic approach for Lyme disease based on the T-cell response to B. burgdorferi infection by immunosequencing T-cell receptor (TCR) repertoires in blood samples from 3 independent cohorts of patients with laboratory-confirmed or clinically diagnosed early Lyme disease, as well as endemic and non-endemic controls. We identified 251 public, Lyme-associated TCRs that were used to train a classifier for detection of early Lyme disease with 99% specificity. In a validation cohort of individuals with early Lyme disease, TCR testing demonstrated a 1.9-fold increase in sensitivity compared to standard 2-tiered testing (STTT; 56% versus 30%), with a 3.1-fold increase <=4 days from the onset of symptoms (44% versus 14%). TCR positivity predicted subsequent seroconversion in 37% of initially STTT-negative patients, suggesting that the T-cell response is detectable before the humoral response. While positivity for both tests declined after treatment, greater declines in posttreatment sensitivity were observed for STTT compared to TCR testing. Higher TCR scores were associated with clinical measures of disease severity, including abnormal liver function test results, disseminated rash, and number of symptoms. A subset of Lyme-associated TCRs mapped to B. burgdorferi antigens, demonstrating high specificity of a TCR immunosequencing approach. These results support the clinical utility of T-cell-based testing as a sensitive and specific diagnostic for early Lyme disease, particularly in the initial days of illness.

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The presenting characteristics of erythema migrans vary by age, sex, duration, and body location

Cited by 15 publications

References 34 publications

The Spectrum of Erythema Migrans in Early Lyme Disease: Can We Improve Its Recognition?

The Spectrum of Erythema Migrans in Early Lyme Disease: Can We Improve Its Recognition?

Risk of post-treatment Lyme disease in patients with ideally-treated early Lyme disease: A prospective cohort study.

Immunosequencing of the T-cell receptor repertoire reveals signatures specific for diagnosis and characterization of early Lyme disease

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