Approach To Suspected Lyme Disease

The evaluation of the patient who presents with fever and a rash is a very common problem that often frustrates and confuses beginning clinicians, partly because of their unfamiliarity with many typical rash patterns, and partly because the rash may be an incidental nonspecific finding (as in miliaria or heat rash), may be a sign of serious, even fatal illness (as in the purpuric rash of meningococcemia), or may be the pathognomonic finding that yields the diagnosis, as in the case of the erythema migrans rash of Lyme disease. Table 23-1 lists some important clinical features of systemic febrile syndromes associated with rash.

Lyme disease is diagnosed by the clinical presentation of the patient and can be verified by serologic tests at the earliest 6 weeks after the initial infection; thus, the patient's history is the key to the diagnosis. Lyme disease can present in three different stages; early localized (stage 1), early disseminated (stage 2), and late disease (stage 3). The early localized stage occurs within the first month of the tick bite. It presents with the classic erythema migrans, an expanding lesion that may or may not have a central clearing. It occurs most commonly around the belt line or the axilla because the ticks favor these areas. The erythema migrans is most often asymptomatic and therefore can be overlooked by the patient, although it sometimes is associated with burning, itching, or pain. In the first stage of the illness, the patient may complain of a viral-like syndrome with fatigue, headaches, myalgias, and arthralgias. Physical examination during this stage may or may not show the skin lesion, as well as generalized lymphadenopathy or organomegaly.

The early disseminated (second stage) disease occurs days to months after the initial tick bite, and there may be additional skin lesions similar to the primary skin lesion. There may be systemic symptoms of headache, mild neck stiffness, malaise, fatigue, fever, and chills. Commonly, there is also migratory musculoskeletal pain without joint inflammation that can last from hours to days and can affect one or two locations at a time. This stage may also include cardiac or neurologic manifestations. Cardiac manifestations of the disease may include conduction disturbances, myocarditis, or pericarditis. This problem usually resolves within weeks without any antibiotics; however, in some instances, it can progress to cardiomyopathy (this most often occurs in Europe) or permanent heart block. Neurologic manifestations can occur in

Table 23-1

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