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The Rational Clinical Examination | Clinician's Corner

Does This Patient Have Erythema Migrans?

Carrie D. Tibbles, MD; Jonathan A. Edlow, MD
JAMA. 2007;297(23):2617-2627. doi:10.1001/jama.297.23.2617.
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Published online

Context Erythema migrans, while not pathognomonic, is the most common manifestation of early Lyme disease. Accurate diagnosis of this rash is essential to initiating appropriate antibiotic therapy.

Objective To determine the sensitivity of history and physical examination characteristics for the diagnosis of erythema migrans.

Data Sources Structured MEDLINE searches of articles written only in English, 1966 through March 2007.

Study Selection Studies were included if they enrolled at least 15 consecutive patients with the diagnosis of erythema migrans and reported original data regarding the history and physical examination characteristics of the patients.

Data Extraction One author abstracted data from the studies.

Results We separately analyzed the studies from Europe and analyzed both Lyme-endemic and nonendemic areas of the United States to search for potential differences in the clinical presentation. Thirty-two studies from Europe, 20 studies from the United States, and 1 from Europe and the United States met inclusion criteria for a total of 8493 patients. Sensitivity was calculated for each of the variables. No studies included patients without erythema migrans, so specificity data and likelihood ratios could not be determined. Many patients do not recall a tick bite. Associated systemic symptoms, such as fever and headache, are frequently reported. Nausea and vomiting are rare. A solitary lesion is the most frequent presentation in both US (81%; 95% confidence interval [CI], 72%-87%) and European patients (88%; 95% CI, 81%-93%). Central clearing is less common in the endemic United States (19%; 95% CI, 11%-32%) vs Europe (79%; 95% CI, 69%-86%) and the nonendemic United States (80%; 95% CI, 63%-90%).

Conclusions Our analysis of the current available literature suggests that there is no single element in the history or physical examination that is highly sensitive by itself for the diagnosis of erythema migrans. Clinicians should be aware of the wide variability in the clinical presentation of erythema migrans and the need to factor in multiple components of the clinical examination and epidemiological context.

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Figure 1. Erythematous Rash Developing on the Shoulder Over 3 Days
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Figure 2. Reported Cases of Lyme Disease by Month of Illness Onset, United States, 1992-2004
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From the Centers for Disease Control and Prevention (http:www.cdc.gov/ncidod/dvbid/lyme/ld_rptmthofill.htm).

Figure 3. Morphology and Approximate Geographic Distribution of Tick Vectors in the Continental United States
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The enlarged tick illustrations are sized according to the same scale shown in each panel. The actual size of the ticks are shown in the circles. Top panel, tick vectors for Lyme disease. The morphology of I pacificus is similar to that of I scapularis (shown). Middle panel, tick vector (A americanum) for southern tick-associated rash illness (STARI). Erythema migrans is a manifestation of both Lyme disease and STARI. The ticks in the bottom panel are included for comparison; these ticks are the major vectors of Rickettsia rickettsii, the causative agent of Rocky Mountain Spotted Fever. The morphology of D andersoni is similar to that of D variabilis (shown). Geographic distributions are approximate and will vary over time. The distribution maps are based on data from the Centers for Disease Control and Prevention (http://www.cdc.gov/ncidod/dvrd). Distribution data for A americanum and D variabilis are updated based on information provided by John F. Anderson, PhD, The Connecticut Agricultural Experiment Station, New Haven (written communication, May 22, 2007).

Figure 4. Patients With Erythema Migrans
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A, Central portion of rash suggests clearing. B, The presence of multiple descrete lesions on the back indicates hematogenous spread of the spirochete. (Photograph courtesy of Ryan Friedberg, MD.)




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