Erythema Migrans

Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
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Yvonne
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Erythema Migrans

Post by Yvonne » Thu 15 Nov 2007 9:11

If present, the EM rash appears between 3 days to 1 month following the bite of an infected tick; however, the rash typically resolves itself spontaneously over a 2-4 week period. The EM rash grows concentrically over the following 5-10 days and without treatment may last for up to several weeks. The rash can vary from very small to very large (up to twelve inches across). Unfortunately, the EM rash is not the only rash associated with Lyme. Various other rashes associated with LD have been reported. One tick bite can cause multiple rashes. The rash can mimic such skin problems as hives, eczema, sunburn, poison ivy, fleabites, etc. The rash can itch, feel hot or it may even be asymptomatic and go unnoticed. The rash can disappear and return several weeks later. I recommend taking a photograph of any rash, especially if associated with a tick bite. The photos will help the Lyme knowledgeable physician make a proper diagnosis and prescribe the appropriate treatment.

All rashes that occur at the site of a tick bite are not due to Lyme disease. An allergic reaction to tick saliva often occurs at the site of a tick bite. This rash can be confused with the rash of Lyme disease. Allergic reactions to tick saliva usually occur within hours to a few days after the tick bite; they usually do not expand and disappear within a few days. EM rashes caused by Lyme disease persist longer, but usually subside within a few weeks.

The occurrence of multiple EM skin rashes is indicative of systemic spread of the organisms. Multiple EM lesions usually do not occur until after 2-4 weeks following the initial tick bite. This is the same time period during which the organisms are being spread throughout the body to other tissues and cells.


http://www.autoimmunityresearch.org/lyme-disease/
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Yvonne
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Re: Erythema Migrans

Post by Yvonne » Thu 15 Nov 2007 9:11

Early disseminated disase (previously called Stage 2) occurs weeks to months after initial infection. At this stage, multiple smaller EM-like lesions may develop elsewhere on the body (apparently due to spread of the organism through the skin without additional preceding tick bites in these locations). People may also manifest neurologic disease (especially meningitis and Bell's [facial nerve] palsy), myocarditis, and arthropathy without joint effusion.



http://www.vetmed.wisc.edu/pbs/zoonoses ... human.html
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Yvonne
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Re: Erythema Migrans

Post by Yvonne » Thu 15 Nov 2007 9:12

The development of more than one EM lesions in one patient (multilocular EM) has been observed in 9% of our patients. The mean total number of lesions per patient was four, with a range from 2-36. The underlying pathogenic mechanism in many patients is hematogenous dissemination of the spirochete, in which case there is a primary EM with a typical clinical aspect, followed by a median of six secondary lesions all over the body after a latency period of a few days. Secondary lesions are generally smaller an less inflammatory (Fig. 5). These patients are affected more often by extracutaneous signs and symptoms than patients with solitary lesions and are more often seropositive. This kind of disseminated EM is less frequent in Europe than in the USA , and the number of lesions per patient is smaller in European patients. Besides this disseminated form of EM, there are also patients in whom the occurrence of multiple lesions is due to more than one infectious arthropod bites or to local spread of Bb.

http://www.mf.uni-lj.si/acta-apa/acta-a ... leger.html
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Yvonne
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Re: Erythema Migrans

Post by Yvonne » Thu 15 Nov 2007 9:12

A little recognized fact about the EM rash is that it can recur, usually in the original site, with or without antibiotic therapy. We estimate that between 5-10% of patients demonstrate this phenomenon during their illness. Other patients remark that they have migratory rashes of moderate duration from time to time that remain unexplained. It is more common, in our experience, to observe the presence of recurrent EM after the onset of antimicrobial therapy. We note that some patients erupt with rash repeatedly while on antibiotic therapy, often in different areas. Eventually this dissipates as the patient improves on antibiotic therapy. Pressure points may play a role in the appearance of the rash, but gravitational influence does not appear to play a role in terms of the site of eruption, i.e. as one would see in a vasculitis-like presentation characteristic of most drug reactions. The first
appearance of rash has been reported as late as 6 months into therapy (personal observation). This has led to obvious diagnostic challenges when one is on antibiotic therapy and has to consider a drug reaction. However, we have come to recognize that the LD rash on treatment presents as flat or occasionally raised coalescent islands of erythema, in contrast to the classic generalized morbilliform rash caused by a drug reaction. When confronted with this clinical picture, the Jemsek Specialty Clinic views this as a positive indication of therapeutic benefit, probably representing a dermal form of the “Herxheimer reaction”, and so we generally proceed cautiously on with antibiotic therapy, usually with eventual resolution of the rash.

http://www.jemsekspecialty.com/files/De ... erview.pdf
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Yvonne
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Re: Erythema Migrans

Post by Yvonne » Thu 15 Nov 2007 9:13

To the Editor: In their Rational Clinical Examination article, Drs Tibbles and Edlow1 reviewed the accuracy of history and physical examination findings for the diagnosis of erythema migrans. There are 2 issues that are important to consider.

First, Table 2 states that erythema migrans is accompanied by mild pain or itch. However, in most cases erythema migrans is entirely asymptomatic.2 Pruritus, when present, may be due to a hypersensitivity reaction to the tick bite, irrespective of the presence of borrelial pathogens.3 This pruritus lasts about a week, resolving around the time that most cases of erythema migrans begin to appear.2 Moreover, a study conducted in Rhode Island suggests that patients with significant pruritus after a tick bite are less likely to develop Lyme disease than those who experience mild or no itch.3 An explanation offered is that individuals with prominent itch at the bite site are more likely to be . . . [Full Text of this Article]

Scott A. Norton, MD, MPH
norton@usuhs.edu
Dermatology Department
Uniformed Services University
Bethesda, Maryland

http://jama.ama-assn.org/cgi/content/sh ... 59-a?rss=1
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Yvonne
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Re: Erythema Migrans

Post by Yvonne » Thu 15 Nov 2007 9:16

Dermatology. 2006;212(2):113-6.

Mini erythema migrans - a sign of early lyme borreliosis.

Weber K, Wilske B.

Dermatological Practice and Krankenhaus der Missionsbenediktiner, Tutzing, Germany.

Background: An erythema migrans (EM) remaining smaller than 5 cm in diameter, called mini EM by us, has not been addressed in detail.
Objective: To study the significance of the mini EM as a sign of Lyme borreliosis.
Methods: Patients with suspected mini EM were retrospectively selected out of 257 consecutive patients with EM. The diagnosis of mini EM rested on the cultivation of Borrelia burgdorferi. Species and subtype analysis of culture isolates was performed using outer surface protein A (OspA) polymerase chain reaction followed by restriction fragment length polymorphism and sequencing of the OspA gene.
Results: There was one patient with definite (0.4%) and another patient with a questionable mini EM. Borrelia garinii OspA type 6 was identified in the patient with the definite and B. burgdorferi sensulato in the patient with the questionable mini EM.
Conclusion: The mini EM represents an important and apparently uncommon sign of early Lyme borreliosis. Copyright (c) 2006 S. Karger AG, Basel.

PMID: 16484816 [PubMed - in process]
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Nick
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Re: Erythema Migrans

Post by Nick » Thu 15 Nov 2007 19:21

Yvonne wrote: Conclusion: The mini EM represents an important and apparently uncommon sign of early Lyme borreliosis. Copyright (c) 2006 S. Karger AG, Basel.
VERY strange, as another study mentioned on the forum today (?) suggests that the mini EM may be the most common form of EM ...

minx
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Re: Erythema Migrans

Post by minx » Thu 15 Nov 2007 22:36

I think it is a bit misleading to call an EM the first symptom that will appear within a few days to 3 months after a tickbite.

My EM was exactly according the book, a clear red, irragular oval, growing ring with a light clearance in the middle. At the exact same spot of the tickbite..... One year earlier :o

And yes, during that year inbetween bite and EM there were (a lot of) lymesymptoms, which would never have been recognised by a physician. (actually the textbook EM at first wasn't recognized as lyme either even when I told her that it was an EM and I did remember the tick. :roll: )

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Re: Erythema Migrans

Post by Nick » Fri 16 Nov 2007 11:06

minx wrote:I think it is a bit misleading to call an EM the first symptom that will appear within a few days to 3 months after a tickbite.
(primary) EM after one year seems to be very unusual but then ... I get the impression that most of this research has been done by extremely biased researchers, who only write down data that fits their idea of an EM and discard all the other data (or simply don't bother to look for it). If researchers would check/ask patients one year after a tick byte they would probably find a lot more late EM's.

The same goes for the mini-EM etc.: maybe they are simply underreported because docs think it is NOT an EM, and only the most unusual symptom, the bullseye rash, is reported because it is easily recognized as a Lyme (or tick-byte) symptom. And as another effect, patients with a mini-EM and Lyme symptoms would probably be classified as not having lyme at all (even with a clear EM and Lyme symptoms it is difficult enough to get testing). That would certainly lead to an overestimation of the occurence of the textbook bullseye rash in Lyme disease.

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Re: Erythema Migrans

Post by LymeEnigma » Sun 18 Nov 2007 18:51

Minx wrote: The same goes for the mini-EM etc.: maybe they are simply underreported because docs think it is NOT an EM, and only the most unusual symptom, the bullseye rash, is reported because it is easily recognized as a Lyme (or tick-byte) symptom. And as another effect, patients with a mini-EM and Lyme symptoms would probably be classified as not having lyme at all (even with a clear EM and Lyme symptoms it is difficult enough to get testing). That would certainly lead to an overestimation of the occurence of the textbook bullseye rash in Lyme disease.
That was my experience; I was a textbook case ... other than the fact that my primary EM never got bigger than the size of a bottle cap....
Nick wrote: (primary) EM after one year seems to be very unusual but then ... I get the impression that most of this research has been done by extremely biased researchers, who only write down data that fits their idea of an EM and discard all the other data (or simply don't bother to look for it). If researchers would check/ask patients one year after a tick byte they would probably find a lot more late EM's.
I would have to agree with that assessment. My multiple EMs did not present until close to a year after my primary EM, and they began within a couple of months of ending a two-month course of doxycycline. I looked like a leopard:
http://www.lymeanalysis.zoomshare.com/a ... ns/images/
01d0c515ee9d1dbf6afc0322def65c5d_11653678110/:album?css=http://www.lymeanalysis.
zoomshare.com/lib/style/trebuchet.css&css=http://www.lymeanalysis.zoomshare.com/lib/
style/type_album.css
(edited to prevent scrolling)

From what I've read, EMs can occur just about anytime, and can recur without warning.

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