Bullous Lyme disease
Authors: Jeffrey B. Tiger, Marshall A. Guill, M. Shane Chapman
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: A 57-year-old woman living in the Upper Connecticut River Valley presented in July 2011 with an acute blistering rash on her left thigh that she believed was caused by a spider bite. The lesion rapidly progressed over 4 days from a small tender red papule to a 12-cm annular, erythematous patch with a centrally located 5-cm tender, indurated bulla with surrounding vesicles (Fig 1). She also reported mild fever, headache, nausea, and arthralgia. She denied a history of a recent tick bite, hiking, or recent travel, but she did live in a wooded, rural area with numerous deer, frequently used a riding lawn mower, and stated she often saw ticks on her property. The patient was seen by her primary care provider and in the emergency department before presenting to dermatology. Because of the bullous nature of the eruption, the differential diagnosis included bite reaction, cellulitis, herpes simplex, herpes zoster, and Lyme disease. Initial workup included complete blood cell count, basic metabolic panel, blood cultures, bacterial and herpes simplex/varicella-zoster virus cultures of the vesicular fluid, herpes simplex/varicella-zoster virus rapid stain, and Lyme IgG and IgM antibodies. All revealed normal findings. Given our confidence this was acute Lyme disease, we decided to treat the patient with doxycycline (100 mg by mouth, twice daily for 21 days). The rash and systemic symptoms rapidly resolved (Fig 2). Repeated Lyme antibody titers drawn 8 weeks later were positive for IgM by Western blot. The first stage of Lyme disease usually features erythema migrans at the site of inoculation, accompanied by a flulike illness with nonspecific symptoms of fatigue, myalgia, headache, and fever. Of patients, 60% to 90% present with the classic erythema migrans rash, described as an erythematous macule that spreads centrifugally and may develop central clearing.1Bhate C. Schwartz R.A. Lyme disease, part I: advances and perspectives.J Am Acad Dermatol. 2011; 64: 619-636Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Atypical presentations have been reported, including hemorrhagic and necrotic cutaneous changes.2Abele D.C. Anders K.H. The many faces and phases of borreliosis, I: Lyme disease.J Am Acad Dermatol. 1990; 23: 167-186Abstract Full Text PDF PubMed Scopus (52) Google Scholar, 3Mullegger R.R. Glatz M. Skin manifestations of Lyme borreliosis: diagnosis and management.Am J Clin Dermatol. 2008; 9: 355-368Crossref PubMed Scopus (140) Google Scholar Vesicular or bullous variants of erythema migrans are rare, although 1 prospective study reported vesiculobullous changes of the central portion of the lesion in 8% of patients.4Goldberg N.S. Forseter G. Nadelman R.B. Schwartz I. Jorde U. McKenna D. et al.Vesicular erythema migrans.Arch Dermatol. 1992; 128: 1495-1498Crossref PubMed Scopus (33) Google Scholar The recognition of erythema migrans is sufficiently distinctive to allow clinical diagnosis and treatment of Lyme disease. In fact, the visual inspection of the skin lesion is the preferred means of diagnosis as serologic testing is too insensitive in the acute phase of the disease (the first 2 weeks of infection) to be helpful diagnostically,5Wormser G.P. Dattwyler R.J. Shapiro E.D. Halperin J.J. Steere A.C. Klempner M.S. et al.The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America.Clin Infect Dis. 2006; 43: 1089-1134Crossref PubMed Scopus (1643) Google Scholar with IgM antibodies usually becoming positive 2 to 6 weeks after exposure.6Bhate C. Schwartz R.A. Lyme disease, part II: management and prevention.J Am Acad Dermatol. 2011; 64: 639-653Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar This requires the physician to be aware of the classic appearance of erythema migrans as well as its multiple atypical variants, including bullous Lyme.