Erythema chronicum migrans

Infobox_Disease
Name = Erythema chronicum migrans


Caption = An erythema migrans rash.
DiseasesDB = 4439
ICD10 = ICD10|A|69|2|a|65 (ILDS A69.22)
ICD9 = ICD9|088.81, ICD9|529.1
ICDO =
OMIM =
MedlinePlus =
eMedicineSubj =
eMedicineTopic =
MeshID = D015787

Erythema chronicum migrans refers to the rash often (though not always) seen in the early stage of Lyme disease. It can appear anywhere from one day to one month after a tick bite. This rash does not represent an allergic reaction to the bite, but rather an actual skin infection with the Lyme bacteria, "Borrelia burgdorferi" sensu lato. It is a pathognomonic sign: a physician-identified rash warrants an instant diagnosis of Lyme disease and immediate treatment without further testing, even by the strict criteria of the Centers for Disease Control. These rashes are characteristic of "Borrelia" infections and no other pathogens are known that cause this form of rash.

It is also sometimes called "erythema migrans" (without the "chronicum") or "EM". However, this phrase is also used to describe geographic tongue.

History

In a 1909 meeting of the Swedish Society of Dermatology, Arvid Afzelius first presented research about an expanding, ring-like lesion he had observed. Afzelius published his work 12 years later and speculated that the rash came from the bite of an Ixodes tick, meningitic symptoms and signs in a number of cases and that both sexes were affected. This rash is now known as erythema migrans, the skin rash found in early-stage Lyme disease. [B. Lipschütz: Zur Kenntnis der "Erythema chronicum migrans". Acta dermato-venereologica, Stockholm, 1931, 12: 100–102.]

In the 1920s, French physicians Garin and Bujadoux described a patient with meningoencephalitis, painful sensory radiculitis, and erythema migrans following a tick bite, and they postulated the symptoms were due to a spirochetal infection. In the 1940s, German neurologist Alfred Bannwarth described several cases of chronic lymphocytic meningitis and polyradiculoneuritis, some of which were accompanied by erythematous skin lesions.

Description

The erythema migrans EM rash is classically 5 to 6.8 cm in diameter appearing as an annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%).Feder HM Jr, Abeles M, Bernstein M, Whitaker-Worth D, Grant-Kels JM. Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis. Clin Dermatol. 2006 Nov-Dec;24(6):509-20.] Because of the "bull's-eye" description to describe the Lyme disease rash, the condition commonly called ringworm is sometimes confused with Lyme disease. Uncommonly, erythema migrans may be less than 5 cm in diameter. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16484816&query_hl=3&itool=pubmed_docsum Weber et al, Dermatology] Weber K, Wilske B. "Mini erythema migrans--a sign of early Lyme borreliosis". Dermatology. 2006;212(2):113-6 PMID 16484816] Multiple painless EM rashes may occur, indicating disseminated infection.

The EM rash occurs, according to sources, in 80% [ [http://www.cdc.gov/ncidod/dvbid/lyme/ld_LymeDiseaseRashPhotos.htm CDC Lyme Disease Erythema Migrans Disease Retrieved May 13 2007] ] to 90% [cite journal |author=Dandache P, Nadelman RB |title=Erythema migrans? |journal=Infect Dis Clin North Am |volume=22 |issue=2 |pages=235–60 |year=2008 |pmid=18452799 |doi=10.1016/j.idc.2007.12.012 |doi_brokendate= ] of those infected with "Borrelia". A systematic review of the medical literature [ [http://www.sgim.org/clinexam-rce.cfm Rational Clinical Examination] ] shows that 80% of patients have an expanding EM rash, at the site of the tick bite,cite journal |author=Tibbles CD, Edlow JA |title=Does this patient have erythema migrans? |journal=JAMA |volume=297 |issue=23 |pages=2617–27 |year=2007 |pmid=17579230 |doi=10.1001/jama.297.23.2617 |doi_brokendate=] although some patients with EM do not recall a tick bite. In endemic areas of the United States homogeneously red rashes are more frequent.cite journal | author=Smith RP, Schoen RT, Rahn DW, Sikand VK, Nowakowski J, Parenti DL, Holman MS, Persing DH, Steere AC | title=Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans | journal=Ann Intern Med | year=2002 | pages=421–8 | volume=136 | issue=6 | pmid=11900494 | url=http://www.annals.org/cgi/reprint/136/6/421.pdf | format=PDF] cite journal | author=Edlow JA | title=Erythema migrans | journal=Med Clin North Am | year=2002 | pages=239–60 | volume=86 | issue=2 | pmid=11982300 | doi=10.1016/S0025-7125(03)00085-3 | doi_brokendate=]

A small group of practitioners disputes the generally accepted incidence of the rash, claiming that it occurs in less than 50% of infections.cite journal | author=Donta ST | title=Late and chronic Lyme disease | journal=Med Clin North Am | year=2002 | pages=341–9, vii | volume=86 | issue=2 | pmid=11982305 | url=http://www.immunesupport.com/library/print.cfm?ID=3579&t=CFIDS_FM | doi=10.1016/S0025-7125(03)00090-7 | doi_brokendate=] cite journal | author=Cameron D, Gaito A, Narris N, Bach G, Bellovin S, Bock K, Bock S, Burrascano J, Dickey C, Horowitz R, Phillips S, Meer-Scherrer L, Raxlen B, Sherr V, Smith H, Smith P, Stricker R; ILADS Working Group | title=Evidence-based guidelines for the management of Lyme disease | journal=Expert Rev Anti Infect Ther | year=2004 | pages=S1–13 | volume=2 | issue=(1 Suppl) | pmid=15581390 | url=http://www.ilads.org/files/ILADS_Guidelines.pdf | format=PDF | doi=10.1586/14789072.2.1.S1 | doi_brokendate=] These practitioners suggest that a condition they call "chronic Lyme" (resembling chronic fatigue syndrome or fibromyalgia) exists in the absence of evidence for "Borrelia" infection. Their proposed treatment of patients with months or years of antibiotics is opposed by the wider medical community's scientific consensus, since these treatments are potentially dangerous, are not based on diagnoses with objective evidence, and have been shown in clinical trials to be ineffective even when evidence of infection is at hand.cite journal | author = Feder HM, Johnson BJB, O'Connell S, et al. | title = A Critical Appraisal of "Chronic Lyme Disease" | journal = N Engl J Med | volume = 357 | issue = 14 | pages = 1422–30 | doi = 10.1056/NEJMra072023 | year = 2007 | doi_brokendate = ] cite journal | doi = 10.1016/j.idc.2007.12.011 | title = A Critical Appraisal of "Chronic Lyme Disease" | year = 2007 | author = Feder, H. M. | journal = New England Journal of Medicine | volume = 357 | pages = 1422 | doi_brokendate = ]

External Links (Images)

*

References

ee also

*Lyme disease
*Tick-borne disease
*Borrelia
*Acrodermatitis chronica atrophicans
*Erythema