Erythema migrans in early disseminated lyme disease.

A 22-year-old woman was admitted to the hospital with fevers, neck pain, the “worst headache of her life,” and bilateral knee pain. The patient reported a history of uveitis and recounted a recent tick exposure. Physical examination revealed multiple red, circular, nonpruritic skin lesions with bull’s-eye appearances that were approximately 2 inches in diameter and located on the patient’s legs and thighs (pictured). Additionally, she had nuchal rigidity and photophobia. The patient was empirically given intravenous acyclovir (10 mg/kg every 8 hours) and ceftriaxone (2 g every 12 hours) because of concerns for meningitis. Results of a serum Lyme enzyme immunoassay test and a Western blot analysis were positive for Lyme disease. Microscopic examination findings of cerebral spinal fluid (CSF) were unremarkable. After 3 days in the hospital, the patient was discharged with a 21-day treatment plan of oral doxycycline (100 mg twice daily). One week after hospitalization, CSF analysis revealed a positive Lyme IgM antibody. Serum testing for Anaplasma phagocytophilum IgM revealed a titer of 1:320. In addition, the patient’s bilateral uveitis was worsening while she was receiving doxycycline. Because of the worsening uveitis and the CSF test result, the patient received a 28-day treatment plan of intravenous ceftriaxone (2 g daily) for meningitis. After treatment, the patient was followed up and her symptoms had resolved. Physicians should be aware of potential complications with early stage Lyme disease, including uveitis and other tick-borne diseases.