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Erythema chronicum migrans
Classification and external resources

An erythema migrans rash.
ICD-10 A69.2 (ILDS A69.22)
ICD-9 088.81, 529.1
DiseasesDB 4439
MeSH D015787

Erythema chronicum migrans (also known as "Erythema migrans"[1]) 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. "Erythema migrans is the only manifestation of Lyme disease in the United States that is sufficiently distinctive to allow clinical diagnosis in the absence of laboratory confirmation." [2]. It is a pathognomonic sign[3]: 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.

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



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 chronicum migrans, the skin rash found in early-stage Lyme disease.[4]

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.


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%).[5] Because of the "bull's-eye" description to describe the Lyme disease rash, the condition commonly called ringworm is sometimes confused with Lyme disease.[5] Uncommonly, erythema migrans may be less than 5 cm in diameter.[6] Multiple painless EM rashes may occur, indicating disseminated infection.

The EM rash occurs, according to sources, in 80%[7] to 90%[8] of those infected with Borrelia. A systematic review of the medical literature[9] shows that 80% of patients have an expanding EM rash, at the site of the tick bite,[10] although some patients with EM do not recall a tick bite. In endemic areas of the United States homogeneously red rashes are more frequent.[11][12]

A significant group of practitioners disputes the generally accepted incidence of the rash, claiming that it occurs in less than 50% of infections.[13][14] 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 present.[15][16]

External links


  1. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0. 
  2. ^ Wormser, Gary P. et al, "The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines" [1]Clinical Infectious Diseases of the Infectious Diseases Society of America, 1 November 2006, Vol. 43, No. 9, pp. 1101.
  3. ^ Ogden, N.H. et al, "The Rising Challenge of Lyme Borreliosis in Canada" [2] Canada Communicable Disease Report, 1 January 2008, Vol. 34, No. 01. Retrieved 14 July 2009.
  4. ^ B. Lipschütz: Zur Kenntnis der "Erythema chronicum migrans". Acta dermato-venereologica, Stockholm, 1931, 12: 100–102.
  5. ^ a b 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.
  6. ^ 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
  7. ^ CDC Lyme Disease Erythema Migrans Disease Retrieved May 13 2007
  8. ^ Dandache P, Nadelman RB (2008). "Erythema migrans?". Infect Dis Clin North Am 22 (2): 235–60. doi:10.1016/j.idc.2007.12.012. PMID 18452799. 
  9. ^ Rational Clinical Examination
  10. ^ Tibbles CD, Edlow JA (2007). "Does this patient have erythema migrans?". JAMA 297 (23): 2617–27. doi:10.1001/jama.297.23.2617. PMID 17579230. 
  11. ^ Smith RP, Schoen RT, Rahn DW, Sikand VK, Nowakowski J, Parenti DL, Holman MS, Persing DH, Steere AC (2002). "Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans" (PDF). Ann Intern Med 136 (6): 421–8. PMID 11900494. 
  12. ^ Edlow JA (2002). "Erythema migrans". Med Clin North Am 86 (2): 239–60. doi:10.1016/S0025-7125(03)00085-3. PMID 11982300. 
  13. ^ Donta ST (2002). "Late and chronic Lyme disease". Med Clin North Am 86 (2): 341–9, vii. doi:10.1016/S0025-7125(03)00090-7. PMID 11982305. 
  14. ^ 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 (2004). "Evidence-based guidelines for the management of Lyme disease" (PDF). Expert Rev Anti Infect Ther 2 ((1 Suppl)): S1–13. doi:10.1586/14789072.2.1.S1. PMID 15581390. 
  15. ^ Feder HM, Johnson BJB, O'Connell S, et al. (2007). "A Critical Appraisal of "Chronic Lyme Disease"". N Engl J Med 357 (14): 1422–30. doi:10.1056/NEJMra072023. PMID 17914043. 
  16. ^ Feder, H. M.; Johnson, BJ; O'Connell, S; Shapiro, ED; Steere, AC; Wormser, GP; Ad Hoc International Lyme Disease Group; Agger, WA et al. (2007). "A Critical Appraisal of "Chronic Lyme Disease"". New England Journal of Medicine 357 (14): 1422. doi:10.1016/j.idc.2007.12.011. PMID 17914043. 

See also



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