Photo Rounds

Fever and rash

An 11-year-old girl was brought to her family physician (FP) because she’d had a fever and a rash for 2 days. She also complained of muscle pain. Her temperature was 101°F and there were annular eruptions on her shoulders and legs. The patient lived in the Northeast in a home surrounded by a thickly wooded forest.

What's your diagnosis?



The FP recognized the annular eruptions on her shoulders and legs as erythema migrans (EM). He was also cognizant of the fact that the girl lived in an endemic area for Lyme disease. Lyme disease is caused by an infection with Borrelia burgdorferi. This organism lives in the deer tick and its common hosts include field mice, white-tailed deer, and household pets. The ticks must feed on infested hosts in order to infect humans. Thirty percent of infected patients do not recall being bitten. Once a human is infected, disease progression is categorized into 3 stages:

1. Localized (days to weeks): erythema migrans and flu-like symptoms.

2. Disseminated (days to months):

  • inflammatory arthritis
  • cranial nerve palsy (usually a Bell’s palsy)
  • atrioventricular blockade, which is present in only 1% of patients with Lyme disease. Syncope, lightheadedness, and dyspnea are classic symptoms consistent with atrioventricular dysfunction
  • aseptic meningitis. Patients may present with complaints similar to bacterial meningitis (photophobia, nuchal rigidity, and headache)
  • fatigue.

3. Persistent (>1 year):

  • chronic arthritis generally occurs in the knee, although other sites such as the shoulder, ankle, elbow, or wrist are not uncommon
  • chronic fatigue
  • meningoencephalitis, Symptoms vary from mild (memory loss, mood lability, irritability, or panic attacks) to severe (manic or psychotic episodes, paranoia, and obsessive/compulsive symptoms).

The patient described in this case had localized disease. Given that she was 11-years-old and had her adult teeth, her physician felt that he could safely prescribe doxycycline 100 mg BID for 14 days. He also recommended that she take over-the-counter acetaminophen or ibuprofen to treat the fever and myalgias. She responded quickly to the doxycycline.

Photos courtesy of Jeremy Golding, MD, and McGraw-Hill. The text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Corson T, Usatine, R. Lyme disease. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:933-939.

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