Inn M M M

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

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Figure 5.2 Examples of erythema migrans. Reprinted from Wormser (2006), with permission from the Massachusetts Medical Society. (A) Patient from New York State with culture-confirmed Lyme disease. The patient had a single erythema migrans lesion of 8.5 X 5.0 cm on the abdomen. The lesion is homogeneous in color except for a prominent central punctum (presumed site of preceding tick bite). (B) Patient from New York State with culture-confirmed Lyme disease. The patient had a single erythema migrans lesion of 11.5 X 7.5 cm in the popliteal fossa of the left leg. More intense erythema is found to the right of the center of the lesion. (C) A patient from New York State with culture-confirmed Lyme disease. The patient had over 40 erythema migrans lesions. Note the prominent central clearing of the lesions present on the abdomen.

Figure 5.2 Examples of erythema migrans. Reprinted from Wormser (2006), with permission from the Massachusetts Medical Society. (A) Patient from New York State with culture-confirmed Lyme disease. The patient had a single erythema migrans lesion of 8.5 X 5.0 cm on the abdomen. The lesion is homogeneous in color except for a prominent central punctum (presumed site of preceding tick bite). (B) Patient from New York State with culture-confirmed Lyme disease. The patient had a single erythema migrans lesion of 11.5 X 7.5 cm in the popliteal fossa of the left leg. More intense erythema is found to the right of the center of the lesion. (C) A patient from New York State with culture-confirmed Lyme disease. The patient had over 40 erythema migrans lesions. Note the prominent central clearing of the lesions present on the abdomen.

EM typically develops 7-14 days (range 3-30 days) after tick detachment, and is characterized by a rapidly expanding, erythematous skin lesion (Steere et al., 1983; Berger, 1989; Nadelman and Wormser, 1995; Nadelman et al., 1996, Wormser, 2006; see also Figure 5.2). Over one-half of United States patients with erythema migrans have concomitant systemic symptoms such as fatigue, arthralgias, headache, or neck pain (Steere et al, 1983; Nadelman and Wormser, 1995, 1998; Nadelman et al, 1996; Wormser, 2006).

About 20-25 percent of United States patients with erythema migrans in recent studies have had more than a single skin lesion (Nadelman et al, 1996;

Wormser et al, 2005; Wormser, 2006). The secondary lesions are believed to arise by hematogenous dissemination from the site of primary infection at the tick bite site (Wormser et al., 2005).

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