Erythema migrans A69.2

Author: Prof. Dr. med. Peter Altmeyer

Co-Autor: Hadrian Tran

All authors of this article

Last updated on: 11.04.2021

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Buzzard; Erythema chronicum migrans; Lyme borreliosis; Post-treatment Lyme disease symptoms

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Afzelius, 1910

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The first and most frequent localized early manifestation of Lyme borreliosis is the skin around the tick 's bite site with circular (disc-shaped) or oval, slowly centrifugally growing erythema. The infection is caused by Borrelia burgdorferi. Typically, the erythema chronicum migrans appears 10-30 days after infection. The erythema chronicum migrans can be very discreet, so that it is not noticed or is noticed very late (only about half of the patients with late manifestation of Lyme disease remember an early clinical stage!) In 5-10% of cases multiple erythema migrantia occurs (in children > than in adults).

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  • Borrelia burgdorferi

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The age of the initial manifestation depends on the time of infection. In this respect there are no disease-specific initial manifestations.

Usually: 5-15 years, 40-80 years.

There is no sex preference.

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Buttocks, trunk, extremities. In children: Not rarely head and neck area.

Clinical features
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After an incubation period of 10-30 days after tick bite, 60-90% of infected persons develop a roundish-oval, sharply edged, centrally blistering, pale red or even livid red erythema starting from a central, reddish spot or papule, which slowly expands centrifugally. During a longer period of existence a ring-like structure is formed by central paling, which often shows a central stabbing reaction in the form of a red papule. The clinical variability is large, so that urticarial or bright red or stationary erythema or plaques may also appear.

Rarely vesicular progressions are observed.

Mostly spontaneous healing occurs after an average of 10 weeks, longer persistence and local recurrence are possible. Possible accompanying lymph node swelling, arthralgia, headaches and flu-like impairment of the general condition.

The erythema chronicum migrans may be associated with lymphadenosis cutis benigna (lymphocytoma), especially if the earlobes, mammilla and scrotal region are involved.

In childhood, the erythema chronicum migrans shows some clinical features: e.g. manifestations especially in the head and neck region. In the face uncharacteristic, transient erythema may occur.

Multilocular erythema migrans: In a larger Italian study, multiple occurrences of erythema chronicum migrans were observed in 10% of cases and are considered a sign of a disseminated early infection of Lyme disease.

Typical erythema migrans:

  • puncture mark visible in the centre
  • Findings emphasized at the edges, not raised
  • diameter of the erythema >5 cm

Atypical erythema migrans:

  • Homogeneous, not borderline findings
  • Absence of propagation tendency
  • Tick bite
  • Central red papel
  • Not visible
  • Raised edge
  • Inhomogeneous spotted findings
  • Central vesicular erythema
  • Hemorrhagic erythema

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Antibodies can be detected in 50% of patients in the first 2 weeks after infection, after > 4 weeks in 80% of patients. The guidelines of the microbiological quality standards (MiQ = acronym for "Quality standards in microbiological-infectiological diagnostics") recommend the detection of separate IgG and IgM antibodies with a sensitive ELISA and, if positive, analysis with a specific immunoblot.

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Less specific, minor papillary body edema, predominantly perivascular, lymphohistiocytic infiltrate.

Differential diagnosis
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  • Insect bite reaction: Hyperergic insectbite reactions (see below) are observed a few hours after the bite event. A "free interval" as for the early form of cutaneous Lyme disease does not exist.
  • Tinea corporis: Characteristic are reddened plaques with scaly edges, usually associated with itching. Rarely solitary. Mycological (native and cultural) detection possible in untreated flocks.
  • Erysipelas: Beginning with an asymmetrical, usually from a small injury, fire-red, painful, sharply defined erythema or plaque. Fever and chills may precede or accompany the process.
  • Drug reaction, fixed: "Suddenly present" solitary or limited to a few foci, 2.0-5.0 cm large (more rarely larger), round or oval, highly inflammatory, initially deep red, later blue to brown-red, after healing brown (post-inflammatory hyperpigmentation), sharply defined, succulent, itchy or slightly painful spots or plaques. The acute nature of the event speaks against an erythema chronicum migrans, which is a chronic insidious disease.
  • Erythema anulare centrifugum: Rarely solitary, mostly multiple, anular, sometimes polycyclically configured, slowly centrifugally growing, typically surface smooth, little or no itching plaques. The palpation is almost pathognomonic: When stroking from the centre to the periphery of a focus the border wall feels like a "wet wool thread under the skin". Histology is often characteristic.
  • In case of multiple erythema chronica migrantia see below. Lyme borreliosis.
  • Erythema infectiosum: In case of facial infestation and multiple lesions a parvo-B-19 infection (serology, acute symptoms, fever) should be excluded.
  • Erysipeloid: Bacterial zoonosis restricted to contact persons only (fishermen, butchers, housewives). Occurs mainly on the hands. Minor clinical symptoms.

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Favourable; completely curable with sufficient antibiotic therapy.

In a follow-up period of more than 15 years (Weitzner 2015) with sufficiently treated erythema migrans, a so-called PTLDS (post-treatment Lyme disease symptom) could be diagnosed in about 5% of the cases. This manifests itself in unspecific symptoms such as joint and muscle pain, fatigue and concentration disorders. The entity of PDLDS is controversial.

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With the erythema chronicum migrans, flu-like general symptoms occur in about 30% of infected persons, especially in children.

The detection of specific antibodies can occur very delayed (more than 12-16 weeks after the stab event), so that a clinical diagnosis should be made if the serology is negative.

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  1. Afzelius A (1910) Negotiations of the Dermatological Society in Stockholm, 28 Oct. 1909; Arch of Dermatol Syphil 101: 404
  2. Afzelius A (1921) Erythema chronicum migrans. Acta Dermato Venerologica 2: 120-125
  3. Hayes EB et al (2003) How can we prevent Lyme disease? N Engl J Med 348: 2424-2430
  4. Hengge UR et al (2003) Lyme borreliosis. Lancet Infect Dis 3: 489-500
  5. Hofmann H (2012) Variability of cutaneous Lyme disease. dermatologist 63: 381-389
  6. Steere AC et al (2003) The presenting manifestations of Lyme disease and the outcomes of treatment. N Engl J Med 348: 2472-2474
  7. Stinco G et al(2014) Clinical features of 705 Borrelia burgdorferi seropositive patients in an endemic area of northern Italy. ScientificWorldJournal 16: 414
  8. Thoms KM (2014) Multiple borderline erythema in a 9-year-old boy. SDDG 12: 731-733
  9. Weitzner E et al (20159 Long-term Assessment of Post-Treatment Symptoms in Patients With Culture-Confirmed Early Lyme Disease. Clin Infect Dis 61:1800-1806.


Please ask your physician for a reliable diagnosis. This website is only meant as a reference.


Last updated on: 11.04.2021