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ARTICLE

Clinical Characteristics and Treatment Outcome of Early Lyme Disease in Patients with Microbiologically Confirmed Erythema Migrans

Robert P. Smith, MD, MPH; Robert T. Schoen, MD; Daniel W. Rahn, MD; Vijay K. Sikand, MD; John Nowakowski, MD; Dennis L. Parenti, MD; Mary S. Holman, BA; David H. Persing, MD, PhD; and Allen C. Steere, MD

19 March 2002 | Volume 136 Issue 6 | Pages 421-428

Background: Lyme disease has a wide spectrum of clinical manifestations. Diagnosis is usually based on the clinical and serologic picture rather than on microbiological confirmation.

Objective: To examine the clinical presentation and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans.

Design: Observational cohort study.

Setting: 31 university-based or clinician-practice sites in 10 endemic states.

Participants: 10 936 participants enrolled in a phase III trial of Lyme disease vaccine; 118 participants had erythema migrans in which Borrelia burgdorferi was detected by culture or polymerase chain reaction.

Measurements: Clinical characteristics and treatment outcome were noted. Skin biopsies of erythema migrans were performed for culture and detection of B. burgdorferi by polymerase chain reaction; serologic responses were determined by Western blot.

Results: The 118 patients with microbiologically confirmed erythema migrans presented a median of 3 days after symptom onset. Early erythema migrans commonly had homogeneous or central redness rather than a peripheral erythema with partial central clearing. The most common associated symptoms were low-grade fever, headache, neck stiffness, arthralgia, myalgia, or fatigue. By convalescence, 65% of patients had positive IgM or IgG antibody responses to B. burgdorferi. Most patients responded promptly to antibiotic treatment.

Conclusions: In major endemic areas in the United States, Lyme disease commonly presents as erythema migrans with homogeneous or central redness and nonspecific flu-like symptoms. Clinical outcome is excellent if antibiotic therapy is administered soon after symptom onset.

Editors' Notes Context Lyme disease is the most common vector-borne disease in the United States. The traditional clinical presentation, an expanding erythematous rash with partial central clearing, sometimes accompanied by systemic symptoms, was described in patients who usually had clinically manifest Lyme disease for several days. Contribution This study describes 118 patients who acquired Lyme disease while under surveillance in a vaccine trial. Fifty-nine percent of rashes were homogeneous lesions, 32% had dense central erythema, and only 9% had classic central clearing. Signs and symptoms usually resolved within 3 weeks of antibiotic treatment. Implications Early Lyme disease may present with homogeneous or dense central erythematous lesions rather than classic erythema migrans. With antibiotic treatment, the prognosis is excellent. Early Lyme disease may present with homogeneous or dense central erythematous lesions rather than classic erythema migrans. With antibiotic treatment, the prognosis is excellent. –The Editors

 

Author and Article Information

From Maine Medical Center, Portland, Maine; Yale University School of Medicine, New Haven, Connecticut; Medical College of Georgia, Augusta, Georgia; Tufts University School of Medicine and New England Medical Center, Boston, Massachusetts; New York Medical College, Valhalla, New York; SmithKline Beecham, Collegeville, Pennsylvania; and Corixa Corporation, Seattle, Washington.

Acknowledgments: The authors thank the vaccine trial participants, investigators of the Lyme Disease Vaccine Study Group, and SmithKline Beecham Pharmaceuticals for data in this report. They also thank Peter Rand, Eleanor Lacombe, and Charles Lubelczyk at the Lyme Disease Laboratory at Maine Medical Center Research Institute for advice and support.

Grant Support: By SmithKline Beecham Pharmaceuticals.

Requests for Single Reprints: Robert P. Smith, MD, Maine Medical Center Research Institute, Lyme Disease Research Laboratory, 13 Charles Street, Third Floor, Portland, ME 04102-3109.

Current Author Addresses: Dr. Smith and Ms. Holman: Maine Medical Center Research Institute, Lyme Disease Research Laboratory, 13 Charles Street, Third Floor, Portland, ME 04102.

Dr. Schoen: Yale University, 60 Temple Street, New Haven, CT 06510.

Dr. Rahn: Medical College of Georgia, 1120 15th Street, Augusta, GA 30912.

Dr. Sikand: PO Box 610, East Lyme, CT 06333.

Dr. Nowakowski: New York Medical College, Munger Pavilion, Division of Infectious Disease, Valhalla, NY 10595.

Dr. Parenti: Wyeth-Ayerst Pharmaceuticals, 555 East Lancaster Avenue, Third Floor, St. Davids, PA 19101-8299.

Dr. Persing: Corixa Corporation, IDRI, 1124 Columbia Street, Seattle, WA 98104.

Dr. Steere: New England Medical Center 406, 750 Washington Street, Boston, MA 02111.

Author Contributions: Conception and design: R.P. Smith, R.T. Schoen, D.W. Rahn, M.S. Holman, A.C. Steere.

Analysis and interpretation of the data: R.P. Smith, R.T. Schoen, D.W. Rahn, M.S. Holman, D.H. Persing, A.C. Steere.

Drafting of the article: R.P. Smith, M.S. Holman, D.H. Persing, A.C. Steere.

Critical revision of the article for important intellectual content: R.P. Smith, D.W. Rahn, V.K. Sikand, J. Nowakowski, D.L. Parenti, M.S. Holman, D.H. Persing, A.C. Steere.

Final approval of the article: R.P. Smith, R.T. Schoen, D.W. Rahn, V.K. Sikand, J. Nowakowski, D.L. Parenti, M.S. Holman, D.H. Persing, A.C. Steere.

Provision of study materials or patients: R.P. Smith, R.T. Schoen, V.K. Sikand, J. Nowakowski, D.L. Parenti.

Statistical expertise: R.P. Smith.

Obtaining of funding: A.C. Steere.

Administrative, technical, or logistic support: R.P. Smith, D.L. Parenti, M.S. Holman, D.H. Persing, A.C. Steere.

Collection and assembly of data: R.P. Smith, R.T. Schoen, V.K. Sikand, J. Nowakowski, D.L. Parenti, M.S. Holman, A.C. Steere.

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