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The presenting characteristics of erythema migrans vary by age, sex, duration, and body location

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Abstract

Purpose

The erythema migrans (EM) skin lesion is often the first clinical sign of Lyme disease. Significant variability in EM presenting characteristics such as shape, color, pattern, and homogeneity, has been reported. We studied associations between these presenting characteristics, as well as whether they were associated with age, sex, EM duration, body location, and initiation of antibiotics.

Methods

Two hundred and seventy one adult participants with early Lyme disease who had a physician-diagnosed EM skin lesion of ≥ 5 cm in diameter and ≤ 72 h of antibiotic treatment were enrolled. Participant demographics, clinical characteristics, and characteristics of their primary EM lesion were recorded.

Results

After adjusting for potential confounders, EM size increased along with increasing EM duration to a peak of 14 days. Male EM were found to be on average 2.18 cm larger than female EM. The odds of a red (vs blue/red) EM were 65% lower in males compared to females, and were over 3 times as high for EM found on the pelvis, torso, or arm compared to the leg. Age remained a significant predictor of central clearing in adjusted models; for every 10-year increase in age, the odds of central clearing decreased 25%.

Conclusions

Given that EM remains a clinical diagnosis, it is essential that both physicians and the general public are aware of its varied manifestations. Our findings suggest possible patterns within this variability, with implications for prompt diagnosis and treatment initiation, as well as an understanding of the clinical spectrum of EM.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

The code generated for analyses during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to thank the physicians of Johns Hopkins Community Physicians, Park Medical Associates, Patient First, and Centennial Medical Group who participated in recruitment for this study. We are grateful to the research participants who contributed their time and effort towards this study. This work was supported by a subagreement from the Johns Hopkins University with funds provided by a Grant Agreement from the Steven and Alexandra Cohen Foundation. Support was also provided from the Global Lyme Alliance (GLA) and the Bay Area Lyme Foundation (BALF). This publication was also made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by Grant Number UL1 TR003098 from the National Center for Advancing Translational Sciences (NCATS) a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research, and the Johns Hopkins Clinical Research Network (JHCRN). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, JHCRN, NCATS, NIH, the Steven and Alexandra Cohen Foundation, GLA, or BALF.

Funding

This work was supported by a subagreement from the Johns Hopkins University with funds provided by a Grant Agreement from the Steven and Alexandra Cohen Foundation. Support was also provided from the Global Lyme Alliance (GLA) and the Bay Area Lyme Foundation (BALF). This publication was also made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by Grant Number UL1 TR003098 from the National Center for Advancing Translational Sciences (NCATS) a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research, and the Johns Hopkins Clinical Research Network (JHCRN). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, JHCRN, NCATS, NIH, the Steven and Alexandra Cohen Foundation, GLA, or BALF.

Author information

Authors and Affiliations

  1. Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Alison W. Rebman, Ting Yang, Erica A. Mihm, Cheryl B. Novak & John N. Aucott

  2. Patient First, Lutherville, MD, USA

    Isaac Yoon

  3. Reading Hospital Tower Health, West Reading, PA, USA

    Debra Powell

  4. Centennial Medical Group, Elkridge, MD, USA

    Steven A. Geller

Authors
  1. Alison W. Rebman
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  2. Ting Yang
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  3. Erica A. Mihm
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  4. Cheryl B. Novak
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  5. Isaac Yoon
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  6. Debra Powell
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  7. Steven A. Geller
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  8. John N. Aucott
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Contributions

All authors contributed to the study conception and design. Data collection was performed by AR, EM, CN, DP, SG, and JA. Data analyses were performed by TY and AR. The first draft of the manuscript was written by AR and TY. All authors commented on previous versions of the manuscript, and all authors read and approved the final manuscript.

Corresponding author

Correspondence to John N. Aucott.

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Conflict of interest

Drs. Aucott and Yang, and Mses. Rebman, Mihm, and Novak acknowledge grants to the study from the Steven & Alexandra Cohen Foundation, Global Lyme Alliance, and the Bay Area Lyme Foundation, as well as support from the National Center for Advancing Translational Science. The remaining authors have nothing to disclose.

Ethics approval

The Institutional Review Board of the Johns Hopkins University School of Medicine approved this study. This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Consent to participate

Written informed consent was obtained from all individual participants included in this study prior to initiation of any study-related activities.

Consent for publication

The authors affirm that human research participants provided written informed consent for publication of their images in Fig. 1 (panels a through g).

Supplementary Information

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Rebman, A.W., Yang, T., Mihm, E.A. et al. The presenting characteristics of erythema migrans vary by age, sex, duration, and body location. Infection 49, 685–692 (2021). https://doi.org/10.1007/s15010-021-01590-0

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  • DOI: https://doi.org/10.1007/s15010-021-01590-0

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