Disseminated Lyme Disease
An 8-year-old boy presented with a 10-day history of periorbital rash, which had been preceded by knee pain, fever, and headache. During a walk in a forest 3 weeks before presentation, he was bitten on the back of his right knee by two ticks, which were removed 2 days later. On examination at presentation, he was noted to have erythema migrans periorbitally (Panels A and B), on the front of the right knee, on the right axilla, and on his buttocks. Serologic testing was notable for a Borrelia burgdorferi IgG antibody level of 0.58 (normal Lyme-index value, <0.20), a B. burgdorferi sensu lato IgG anti-VlsE level of 75.5 kU per liter (normal level, <16.0), and a B. burgdorferi IgM antibody level of 5.85 (normal Lyme-index value, <0.20). Immunoblot testing for B. garinii IgG and IgM antibodies was positive. Erythema migrans is a common manifestation of early, disseminated Lyme disease. However, it may be varied in its presentation, as seen in this patient. The patient received treatment with amoxicillin for 3 weeks and had a complete recovery.