Clinical Images  |   November 2012
Erythema Migrans in Early Disseminated Lyme Disease
Author Notes
  • From Kennedy Memorial Hospital and the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford 
  • Address correspondence to Zeina Ghayad, DO, Garden State Infectious Disease Associates, 709 Haddonfield Berlin Rd, Voorhees, NJ 08043-3715. E-mail:  
Article Information
Cardiovascular Disorders / Imaging / Clinical Images
Clinical Images   |   November 2012
Erythema Migrans in Early Disseminated Lyme Disease
The Journal of the American Osteopathic Association, November 2012, Vol. 112, 748. doi:
The Journal of the American Osteopathic Association, November 2012, Vol. 112, 748. doi:
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. 
   Financial Disclosures: None reported.
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   Editor's Note: Corrections to this article were published in the January 2013 issue of The Journal of the American Osteopathic Association (2013;113[1]:15). The corrections have been incorporated in this online version of the article, which was posted April 2013. An explanation of these changes is available at
Suggested Reading
Suggested Reading
Wormser GP, Dattwyler RJ, Shapiro EDet 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(9):1089-1134. [CrossRef] [PubMed]
Wormser GP. Clinical practice: early Lyme disease. N Engl J Med. 2006;354(26):2794-2801. [CrossRef] [PubMed]