Erythema Migrans Research Articles

Clinical and epidemiological features of Lyme neuroborreliosis in adults and factors associated with polyradiculitis, facial palsy and encephalitis or myelitis

The clinical course of Lyme neuroborreliosis (LNB) is highly variable. Delayed diagnosis and treatment still remain actual challenges. Moreover, there is a lack of studies analyzing the factors associated with different LNB syndromes. We aimed to analyze clinical and epidemiological features of LNB in hospitalized adults in eastern Lithuania. A retrospective study was performed for patients presenting in the years 2010–2021. A total of 103 patients were included in the study, 100 with early, and three with late LNB. Patients with early LNB most often presented polyradiculitis [75/100, (75%)], which was also the most common initial neurological syndrome. Peripheral facial palsy was diagnosed in 53/100 (53%) patients, in 16/53 (30.2%) cases both facial nerves were affected. Encephalitis or myelitis was diagnosed in 14% of patients with LNB. A total of 76/103 (73.8%) patients were discharged with residual symptoms or signs. One patient presenting encephalomyelitis died because of bacterial complications. The absence of observed erythema migrans (EM) was the predictor of peripheral facial palsy, while female sex and EM untreated with antibiotics were predictors of isolated polyradiculitis. A fever of ≥ 38 ° °C and pleocytosis of ≥ 300 × 106/l were associated with the development of encephalitis or myelitis in patients with early LNB.

Applying decision tree algorithms to early differential diagnosis between different clinical forms of acute Lyme borreliosis and tick-borne encephalitis

Background: Tick-borne encephalitis and Lyme borreliosis are the most common natural focal infections in Russia often arising as a mixed infection, which is often clinically difficult to distinguish from a monoinfection at the onset of the disease that is a result of delayed laboratory verification of the diagnosis and it requires further searching for fundamentally new approaches to the issue of early differential diagnosis of tick-borne infections.Aims: is to develop decision tree algorithms for early differential diagnosis between the mono- and mixed forms of acute Lyme borreliosis and tick-borne encephalitis with prevailing febrile syndrome in clinical picture based on clinical and laboratory data.Materials and methods: We retrospectively analyzed 55 clinical and laboratory parameters obtained from 291 hospitalized tick-borne infections patients with or without erythema migrans at the site of ixodid tick bites in the first week of the disease, who were included in the single-center study from 2010 to 2023. In 211 patients without erythema, the analysis was carried out between three classes depending on the diagnosis: the mixed infection of non-erythematous Lyme borreliosis and tick-borne encephalitis, the mono-infection of non-erythematous Lyme borreliosis or the monoinfection of tick-borne encephalitis. The other two classes, which included 80 patients with erythema, had the mixed infection of acute erythematous Lyme borreliosis and tick-borne encephalitis or erythematous Lyme borreliosis monoinfection. Python programming language was applied to develop two decision tree models. Feature importance was assessed for all predictors. Each patient class was randomly divided into training (70%) and testing (30%) datasets. Accuracy evaluation of the models was based on ROC analysis.Results: The decision tree algorithm for early differential diagnosis among the tick-borne infection patients without erythema migrans included the following most important predictors: maximal fever rise, chills, neutrophil-to-monocyte ratio, ESR, absolute number of reactive lymphocytes and immature granulocytes, and percentage of eosinophils. The model for differential diagnosis between the patients with erythema migrans included the following predictors: maximal fever rise, the absolute number of reactive lymphocytes and immature granulocytes, and the percentage of basophils. Both decision tree models showed excellent predictive values based on sensitivity, specificity, precision, accuracy, and F1 scores, as well as areas under the ROC curve, which were higher than 0.90.Conclusions: Based on clinical and laboratory parameters, two decision tree models with high sensitivity have been developed, which can be easily applied in clinical practice for early differential diagnosis of the tick-borne infections with prevailing fever syndrome.

Lyme rashes disease classification using deep feature fusion technique.

Automatic classification of Lyme disease rashes on the skin helps clinicians and dermatologists' probe and investigate Lyme skin rashes effectively. This paper proposes a new in-depth features fusion system to classify Lyme disease rashes. The proposed method consists of two main steps. First, three different deep learning models, Densenet201, InceptionV3, and Exception, were trained independently to extract the deep features from the erythema migrans (EM) images. Second, a deep feature fusion mechanism (meta classifier) is developed to integrate the deep features before the final classification output layer. The meta classifier is a basic deep convolutional neural network trained on original images and features extracted from base level three deep learning models. In the feature fusion mechanism, the last three layers of base models are dropped out and connected to the meta classifier. The proposed deep feature fusion method significantly improved the classification process, where the classification accuracy was 98.97%, which is particularly impressive than the other state-of-the-art models.

Approach to prediction and receiver operating characteristic analysis of a regression model for assessing the severity of the course Lyme borreliosis in children

IntroductionLyme borreliosis (LB) is a multisystemic zoonotic disease transmitted by the bite of infected tick vectors. The aim of the study is to develop a mathematical model for predicting the risk of severity of Lyme disease by the risk factor of the disseminated form of LB in children who have had a tick attack. To test the effectiveness of the formula for predicting the development of the disseminated stage of LB, we built a receiver operating characteristic (ROC) curve and determined the specificity and sensitivity of our model. The results of the examination of 122 patients with the confirmed local and disseminated stages of LB were taken as a basis.Material and methodsTo build a prognostic model for prediction of the risk of the developing of the stage in LB predicting the risk of severity of course in Lyme borreliosis (PRSCLB), 122 children (aged 13 ±3 years) with LB were examined using multivariate regression analysis, including 52 boys and 70 girls. Groups of patients: 79 children with erythema migrans, 16 with Lyme arthritis, and 27 with nervous system involvement by LB. The quality of the prognostic model was checked by the Nagelkerke R Square (Nagelkerke R2) and the acceptability of this model was assessed using ROC analysis.ResultsThe method of multivariate regression analysis for predicting severe course and organ and system damage in LB in children, taking into account the factors and variants of the disease itself, makes it possible to develop a mathematical model for predicting the relative response factors (RRF) of severe forms of Lyme disease and will improve the effectiveness of treatment. This will create all the prerequisites for high-quality preventive measures and reduce the relative response factors rate. The initial data for predicting the severity of LB were 28 factors. According to the results of regression analysis, 24 factors were included in the model for predicting the severity of LB.ConclusionsThe results of the study showed that the multifactorial model predicts the severity and organ and system damage in LB in children with an accuracy of 95%. The ROC curve, which was built on the basis of the results, has an area under the curve of 0.94, which indicates the high efficiency of the model.

Doxycycline for the Treatment of Lyme Disease in Young Children.

Doxycycline is considered the first-line treatment of Lyme disease in adolescents and adults, but largely disproven concerns of permanent tooth staining prevented its use and evaluation in children <8 years old. We sought to describe short-term adverse effects and treatment failures among young children receiving oral doxycycline for Lyme disease. We completed a 2-pronged evaluation of children with Lyme disease treated with doxycycline. We performed a retrospective case series of patients <8 years old who were diagnosed with Lyme disease and treated with doxycycline. We then performed a telephone follow-up survey study of the patients' parents to gather additional details regarding clinical outcomes and adverse reactions to doxycycline. Descriptive statistics were calculated. A total of 32 patients were identified through the retrospective case series and 18 participated in the follow-up survey. The most common clinical diagnosis (22/32; 69%) was single erythema migrans. Seven (22%) had neurological Lyme disease. Three patients (9%) stopped doxycycline treatment prematurely due to adverse effects. During telephone follow-up, 2 children were reported to have dental staining. No patients were identified with treatment failure during the retrospective case series. On telephone follow-up, 3 patients had residual symptoms after treatment, though none were convincing of treatment failure. Our study suggests that doxycycline is generally well-tolerated and an effective treatment of Lyme disease in young children. Prospective, observational studies with long-term assessment of dental staining and clinical outcomes are needed. Alternative antibiotics, principally amoxicillin, remain the preferred treatment of non-neurological Lyme disease manifestations in young children, but doxycycline is likely a safe and effective alternative when needed.

Case report: Successive ipsilateral and contralateral laryngeal nerve palsy as probable manifestation of neuroborreliosis

Neuroborreliosis is part of advanced stage of Lyme disease and often characterized by damage to the cranial and/or peripheral nerves. Involvement of one or both recurrent nerves is rare. Diagnosis is often difficult and based on a set of clinical manifestations, biological arguments, and cerebrospinal fluid (CSF) analysis. A 70-year-old man was referred to our Voice Clinic with a 3-month history of dysphonia caused by right vocal fold paralysis (VFP) without any cutaneous symptoms of tick bite or erythema migrans in the previous weeks and normal initial radiological examination (neck and thorax CT). Methylprednisolone had already been prescribed but without any clinical improvement. Late biological investigation 3 months after initial symptoms of VFP showed high IgG (93 U/mL; reference <10 U/mL) against Borrelia burgdorferi (BB), which was confirmed by two immunoblot markers (VIsE, p39 antigens). Therefore, a possible manifestation of Lyme disease with involvement of the right inferior laryngeal nerve was suspected, namely Lyme neuroborreliosis. However, given the spontaneous recovery of the patient after 7 months without any adapted antimicrobial regimen treatment, the diagnosis of neuroborreliosis was not confirmed by a lumbar puncture. Nineteen months later, the patient presented again for the same symptomatology but as left VFP. High IgG (68 U/mL) and IgM (>6, reference <0.90) levels against BB were confirmed by immunoblot. Subsequently, lumbar puncture was performed and revealed IgG against BB at 46.1 UA/mL (reference<5.5 UA/mL) in the CSF, with an extremely high IgG intrathecal synthesis antibody index (281.33, positive if > 1.5). Intrathecal antibody synthesis is the gold standard for Lyme neuroborreliosis demonstrating a specific immune response to BB in the central nervous system, but with the limitation of persistence for years after eradication. Our patient did not exhibit pleocytosis in the CSF. Therefore, two criteria of the European Federation of Neurological Societies (EFNS) guidelines are fulfilled for possible neuroborreliosis. Doxycycline treatment led to rapid recovery in less than 8 weeks and normal mobility of the left vocal fold. Because of this very uncommon clinical presentation with two successive episodes of VFP for no other obvious reason and serological evidence from the serum and CSF during the second episode, we consider it possible that the first episode of VFP could also have been a manifestation of neuroborreliosis. This case is the first report of possible relapse of laryngeal palsy successively on the right, and then the left side as a manifestation of Lyme neuroborreliosis.

Sensitivity of Two-Tiered Lyme Disease Serology in Children with an Erythema Migrans Lesion.

In our prospective cohort of 192 children with a physician-diagnosed erythema migrans (EM) lesion, two-tier Lyme disease serology had higher sensitivity in children with multiple EM lesions (76.8% multiple lesions vs. 38.1% single EM; difference 38.7%, 95% CI 24.8 to 50.4%). The diagnosis of cutaneous Lyme disease should be based on careful physical examination rather than laboratory testing.

Prevalence and factors associated with a prescription of a Lyme borreliosis serology for erythema migrans diagnosis in general practice: a study from the French sentinel network, 2009–2020

BackgroundSerological testing of patients consulting for typical erythema migrans (EM) is not recommended in European recommendations for diagnosis of Lyme borreliosis (LB). Little is known on the level of adherence of French general practitioners to these recommendations. The objectives were to estimate the proportion of Lyme borreliosis serological test prescription in patients with erythema migrans seen in general practice consultations in France, and to study the factors associated with this prescription.MethodsLB cases with an EM reported by the French general practitioners (GPs) of the Sentinelles network between January 2009 and December 2020 were included. To assess the associations with a prescription of a serological test, multilevel logistic regression models were used.ResultsAmong the 1,831 EM cases included, a prescription for a LB serological test was requested in 24.0% of cases. This proportion decreased significantly over the study period, from 46.8% in 2009 to 15.8% in 2020. A LB serological prescription was associated with patients with no reported tick bite (Odds Ratio (OR): 1.95; 95% confidence interval [1.23–3.09]), multiple EM (OR: 3.82 [1.63–8.92]), EM of five centimeters or more (OR: 4.34 [2.33–8.08]), and GPs having diagnosed less than one EM case per year during the study period (OR: 5.28 [1.73–16.11]).ConclusionsSerological testing of patients consulting for EM is not recommended in European recommendations for diagnosis of Lyme borreliosis. Therefore, the significant decrease in the rate of LB serological test for EM over the study period is encouraging. The factors identified in this study can be used to improve messaging to GPs and patients. Further efforts are needed to continue to disseminate diagnostic recommendations for LB to GPs, especially those who rarely see patients with EM.

Development of a Model for Preliminary Diagnosis of Human Granulocytic Anaplasmosis.

Background: Human granulocytic anaplasmosis (HGA) is a vector-borne natural focal disease that is not officially registered in Ukraine. The first 13 cases of HGA in adults in Ukraine were identified in 2007. The purpose of our study was to develop a predictive model of HGA based on clinical and laboratory characteristics to develop a three-level standard case definition of HGA. Materials and Methods: Researchers examined 498 patients with suspected tick-borne infections and carried out a retrospective clinical and epidemiological analysis of 60 cases recruited from Lviv regional infectious disease hospitals. Logistic regression was used to create a model of the probability of the diagnosis of HGA depending on the presence of certain clinical and laboratory factors that, when examined, together may help to confirm a case of HGA. For logistic regression, eight clinical and laboratory factors were selected: history of tick bite, hyperthermia, signs of pharyngitis, changes in chest X-ray picture (enhancement of the pulmonary pattern and enlargement of the lung root boundaries), increased bilirubin (˃21 μmol/L), increased alanine aminotransferase (ALT ˃36 U/L), erythema migrans, and detected Lyme disease. Results: In the presence of all eight factors, the probability of HGA is 95.7%. When the five main signs are absent-signs of pharyngitis, changes in chest X-ray picture, increased bilirubin and ALT, and a history of tick bite-the probability of HGA in the patient dramatically decreases to 6.8%, meaning that HGA might be excluded. Conclusions: Based on the analysis of epidemiological, clinical, and laboratory signs, criteria for establishing a suspected, probable, and confirmed diagnosis of HGA have been developed to improve diagnosis.

Lyme Disease and Post-treatment Lyme Disease Syndrome: Current and Developing Treatment Options.

Lyme disease and its treatment implications have become an ever-increasing area of concern within the United Statesrelated to the markedly increased prevalence of infection within the last two decades. The presentation, pathophysiology, and epidemiology of Lyme disease have been well studied, and thus treatments for this disease are widely available. While the treatment of its early and late stages is relatively simple with 10-14 day and four-week courses of doxycycline, respectively, the main problem rests in the understanding of the etiology and pathology of post-treatment Lyme disease syndrome (PTLDS). With the time of symptoms onsetting approximately six months after treatment and potentially lasting indefinitely, this syndrome's effect on patients' quality of life could be devastating. Searching on PubMed, Google Scholar, MEDLINE, and ScienceDirectusing keywords including Lyme disease, PTLDS, doxycycline, erythema migrans, azlocillin, and treatment, the authors have tried to make clear the different aspects. The authors have reviewed and discussed clinical studies of Lyme disease and its treatments/potential therapeutics as well as PTLDS and its sparse treatments/potential therapeutics.

Rehabilitation of children with Lyme arthritis

Background. Lyme disease is a common tick-borne infection. Untimely diagnosis and treatment lead to the chronicity of the process with the development of late lesions of various systems and organs and possible disability. The purpose of the study was to develop a program of rehabilitation measures for children with Lyme disease. Material and methods. The research was conducted on the basis of the Ternopil Regional Children’s Hospital. Twenty children, residents of the Ternopil region, who applied to the Ternopil Regio­nal Children’s Hospital for tick bites and, as a result, diagnosed Lyme arthritis, took part in the study. To assess the severity of pain, we used scales and questionnaires for the diagnosis of DN4 neuropathic pain. Laboratory and instrumental studies were performed such as evaluation of the level of malondialdehyde, diene conjugates, superoxide dismutase. Results. Clinical examination of tick-affected children with Lyme disease showed that the most common primary clinical manifestation is a typical skin lesion — erythema migrans. In case of arthritis, all children notice inflammatory changes and pain in the joints. As a result of the conducted studies, the activation of peroxidation in children with Lyme disease was detected (an increase in the level of malondialdehyde and a decrease in superoxide dismutase, diene conjugates). It was shown that combined therapy with the use of magnetic laser therapy leads to the normalization of lipid peroxidation. Conclusions. All children with Lyme arthritis have a pain syndrome of varying severity. In patients with Lyme disease, there is an increase in the activity of lipid peroxidation and a decrease in the functional capacity of the antioxidant defense system. Children who underwent traditional treatment for Lyme arthritis reported a partial normalization of lipid peroxidation as evidenced by a significantly decreased level of diene conjugates compared to controls. In the group of patients who underwent combined treatment for Lyme arthritis (antibacterial therapy + magnetic laser therapy), the activity of antioxidant defense was normalized. Combination of magnetic laser therapy with antibacterial therapy demonstrates an improvement of pain status and faster rehabilitation of children.

P11 Acrodermatitis chronica atrophicans: a sign of late lyme disease

Abstract Borrelia infection manifests a variety of signs and symptoms, and its insidiousness and heterogeneity mean that its diagnosis can be delayed. We describe two patients from south-east Scotland who presented with unilateral asymptomatic atrophic areas of skin discoloration. The first was a 71-year-old woman, who presented with a 4-month history of a nonprogressive, mottled, erythematous rash involving her right thigh, buttock and calf. Case 2 was a 56-year-old woman with a 2-year history of an erythematous area of atrophic skin involving the medial aspect of her left thigh and shin. Histology from case 1 showed a normal epidermis with a largely ‘top-heavy’ superficial and deep, predominantly interstitial and focally perivascular, lymphohistiocytic infiltrate, with a predominance of mononuclear histiocytes and with focal extension to deep reticular dermis. Scattered plasma cells were identified, but eosinophils were not a prominent feature. Well-formed granulomas were absent, as were interface dermatitic activity and vasculitic changes. On close questioning, each patient remembered ‘insect’ bites in the vicinity of the cutaneous changes, although neither recalled rashes that could have been consistent with erythema chronicum migrans. In both cases, serology confirmed infection with Borrelia burgdorferi (sensu lato) and diagnoses of acrodermatitis chronica atrophicans (ACA) were made. Both patients responded well to oral treatment with doxycycline. ACA is a cutaneous sign of late-stage Lyme disease and is caused by ongoing active skin infection by tick-borne bacteria of the Lyme disease group of Borrelia species. The tick bite has usually occurred months or years before symptom onset. Typically, there is an early, unilateral inflammatory stage with bluish-red discoloration of the skin and an oedematous appearance. This is followed by an atrophic stage where the skin becomes thin and wrinkled (‘cigarette paper’-like), with the loss of epidermal and dermal structures. Histological features usually include marked atrophy of the epidermis and dermis, loss of adnexal structures and an absence of elastic tissue. A band-like lymphocytic infiltration with plasma cells and mast cells is seen in the dermis, especially in the early stage of disease. Laboratory-confirmed cases of Lyme borreliosis in the UK have risen steadily since reporting began in 1986. ACA is likely to be underdiagnosed and, if there is a clinical suspicion, a detailed history, careful skin examination, Borrelia serology and skin biopsy should be undertaken. Early recognition and treatment reduce the risk of irreversible skin changes and systemic symptoms.

Which trial do we need? Treatment of multiple erythema migrans with doxycycline for 7 days versus 14 days

Which trial do we need? Treatment of multiple erythema migrans with doxycycline for 7 days versus 14 days

The history of Lyme disease in Italy and its spread in the Italian territory.

Lyme borreliosis (LB) is the most common vector-borne zoonotic inflammatory disease in the Northern Hemisphere. In Italy, the first case was diagnosed in 1985 in a woman in Liguria, while the second, in 1986 in Friuli-Venezia Giulia, documenting the infection in northern Italy. Both diagnoses were confirmed by serological assessment by an indirect immunofluorescence (IFI) technique. Borrelia cultivation from both Ixodes ricinus ticks and human lesions in Trieste (Friuli-Venezia Giulia) identified Borrelia afzelii as the prevalent genospecies; nevertheless, Borrelia garinii, Borrelia burgdorferi (sensu stricto), and Borrelia valaisiana (VS116 Group) were also detected, although less frequently. LB was also documented in other Italian regions: in Tuscany (1991), Trentino-Alto Adige (1995-1996), Emilia-Romagna (1998), Abruzzo (1998), and more recently, Lombardy. Nevertheless, data on LB in other Italian regions, especially in southern Italy and islands, are poor. The aim of this study is to document the spread of LB in Italy through the collection of data from LB patients in eight Italian hospitals located in different Italian regions. Diagnostic criteria for LB diagnosis are as follows: i) the presence of erythema migrans (EM) or ii) a clinical picture suggestive of LB, confirmed by serological tests and/or PCR positivity for Borrelia detection. In addition, data also included the place of residence (town and region) and the place where patients became infected. During the observation period, 1,260 cases were gathered from the participating centers. Although different in extent from northern Italy to central/southern Italy, this study shows that LB is widespread throughout Italy.

Borreliosis de Lyme en población pediátrica: peculiaridades clínicas, diagnósticas y terapéuticas

IntroductionLyme borreliosis (LB) in the paediatric population is an understudied entity with certain peculiarities. The objective of this study is to describe the characteristics of paediatric patients with LB, and their diagnostic and therapeutic processes. MethodsDescriptive and retrospective study in patients up to 14 years old with suspected or confirmed LB between 2015 and 2021. ResultsA total of 21 patients were studied: 18 with confirmed LB (50% women; median age 6.4 years old) and 3 false positive of the serology. Clinical features in the 18 patients with LB were: neurological (3, meningitis; 6, facial nerve palsy), dermatological (6, erythema migrans), articular (one), and non-specific manifestations (2). Serological diagnosis was confirmatory in 83.3% of cases. A total of 94.4% patients received antimicrobial treatment (median duration 21 days). All recovered with resolution of symptoms. ConclusionsLB diagnosis is difficult in the paediatric population and presents clinical and therapeutic peculiarities, with favourable prognosis.

Classical Borrelia Serology Does Not Aid in the Diagnosis of Persistent Symptoms Attributed to Lyme Borreliosis: A Retrospective Cohort Study.

The diagnosis of Lyme borreliosis is based on two-tier testing using an ELISA and Western blot. About 5-10% of patients report persistent symptoms of unknown etiology after treatment, resulting in substantial difficulties in further diagnostic workup. This paper presents a study aimed at determining whether serology can differentiate between patients with persistent symptoms attributed to Lyme and other patients with Lyme borreliosis. A retrospective cohort study included 162 samples from four subgroups: patients with persistent symptoms of Lyme (PSL), early Lyme borreliosis with erythema migrans (EM), patients tested in a general practitioner setting (GP), and healthy controls (HC). ELISA, Western blots, and multiplex assays from different manufacturers were used to determine inter-test variations in PSL and to compare reactivity against Borrelia-specific antigens among the groups. In comparing the IgG and IgM reactivity by Western blot, IgG was more often positive in the PSL group than in the GP group. The individual antigen reactivity was similar between the PSL and EM or GP groups. Inter-test agreement among the manufacturers was variable, and agreement was higher for IgG testing compared to IgM. Serological testing is unable to define the subgroup of patients with persistent symptoms attributed to Lyme borreliosis. Additionally, the current two-tier testing protocol shows a large variance among different manufacturers in these patients.

Figurate annulare erythemas.

T. Colcott Fox (1849-1916) first introduced in 1889 the term "figurate erythemas." According to the clinical pattern, figurate erythemas are annular, circinate, concentric, polycyclic, or arciform. The most important figurate annulare erythemas are erythema annulare centrifugum, erythema marginatum, erythema gyratum repens, erythema migrans, erythema chronicum migrans, and the pediatric annular erythemas. Erythema annulare centrifugum might be due to fungal, bacterial, or viral infections or drugs. It tends to spread centrifugally while developing central clearing. The most common locations are the trunk and the proximal extremities. Individual lesions last from several days to weeks and may resolve spontaneously. Erythema marginatum is one of the criteria for the diagnosis of acute rheumatic fever, but it also might be seen as a symptom of other diseases such as hereditary angioedema with C1-inhibitor deficiency and psittacosis. The typical clinical picture is presented by serpiginous erythematous macules and plaques with central clearing and accentuated borders. Erythema gyratum repens is a figurate erythema associated with internal malignancy. It has been linked especially to lung, esophageal, and breast cancers. Erythema gyratum repens is characterized by multiple erythematous, rounded macules or papules, rapidly progressing and forming concentric bands with an unique wood-grained appearance with desquamation on the edges of the erythema. Erythema chronicum migrans is the most common sign of infection with Borrelia burgdorferi and other Borrelia species. It is characterized by a round or oval erythematous or livid macule with a central depressed or raised area on the spot of a previous tick bite. Erythema migrans grows centrifugally and slowly in a matter of days or weeks. Central clearing is observed in 60% of patients, thus forming a targetoid appearance of the lesion. Many other figurate erythemas can be observed in infancy (pediatric annular erythemas). To this group belong neonatal lupus, erythema gyratum atrophicans transiens neonatale, annular centrifugal erythema, familial annular erythema, annular erythema of infancy, eosinophilic annular erythema, and figurate neutrophilic erythema of infancy. The treatment of the various types of figurate erythemas should be etiologic, and when the underlying condition is addressed, the therapy usually is successful.

Outpatient Treatment of Lyme Disease.

Lyme disease, also called Lyme borreliosis, is caused by the spirochete Borrelia burgdorferi sensu stricto (B burgdorferi) in the Upper Atlantic Coast and Borrelia mayonii in the Upper Midwest and West Coast. It can cause a range of manifestations including erythema migrans, cranial nerve palsies, meningitis, carditis, and arthritis. Recent guidelines advocate for outpatient treatment for many of these conditions. Scenarios will be presented that outline treatment of these manifestations.

Lyme Encephalomyeloradiculitis Presenting with Brachial Diplegia (P9-10.001)

<h3>Objective:</h3> Lyme disease presenting with encephalomyelitis is rare. It often presents with non-localizing symptoms like confusion or personality changes. Focal symptoms can include hemiparesis, aphasia or ataxia. Acute brachial diplegia due to Lyme disease, although rare, has been previously reported. Our case offers additional insight into the underlying mechanisms of brachial diplegia. <h3>Background:</h3> A 73 year old man presented with mild upper thoracic back pain followed by progressive left greater than right arm weakness. Physical exam revealed a flicker of contraction in the left upper extremity and right thenar muscles. Mild proximal right arm weakness was noted. Lower extremity sensorimotor exam was normal. He was hyporeflexic in bilateral upper extremities and hyperreflexic in the lower extremities. He developed intermittent episodes of confusion, hyponatremia and a neurogenic bladder over the following week. His wife later reported he had a bulls-eye rash on his calf one month prior to presentation. <h3>Design/Methods:</h3> A work up for compressive myelopathy and cerebrovascular etiologies was negative. EMG revealed a demyelinating, predominantly motor neuropathy limited to the upper extremities, prompting treatment with IVIg. Serum Lyme PCR was positive. Cerebrospinal fluid showed lymphocytic pleocytosis, elevated protein and positive Lyme antibody. Diffuse nerve root edema was noted on brachial plexus MRI. <h3>Results:</h3> The patient was treated with intravenous ceftriaxone for 4 weeks. At his 4 week follow-up, left arm strength was at least 4/5 in all muscles. Right arm strength was normal proximally and at least 4/5 in all distal muscles. He reported paresthesia in his hands. He continues to require self-catheterization twice daily for ongoing urinary retention. <h3>Conclusions:</h3> This case illustrates that brachial diplegia in the setting of Lyme disease can be a result of radiculitis and proximal demyelination without significant motor axon loss. Radiculitis can precede encephalomyelitis. Early identification of the disease is crucial as treatment with antibiotics leads to marked improvement. <b>Disclosure:</b> Dr. Aschen has nothing to disclose. Dr. McLeod has nothing to disclose. Mary Kane-Brock has nothing to disclose. Daniel Brooks, MD has nothing to disclose. Dr. Desai has nothing to disclose.

Horner’s Syndrome as an Atypical Presentation of Neuroborreliosis: A Case Report and Review of Literature (P1-9.006)

<h3>Objective:</h3> To localize and report postganglionic Horner’s syndrome as an unusual presentation of neuroborreliosis. <h3>Background:</h3> Lyme disease is the most common tick-born infection in the United Sates with ~30,000 reportable cases yearly, 10–15% involving the nervous system. Neuroborreliosis has a heterogenous spectrum of clinical manifestations. Currently, there are few case reports of associated Horner’s syndrome. Localization has not been well described with no cases reporting positive imaging findings. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 50-year-old healthy woman presented with four days of high-grade fever and left-sided headache followed by one day of left droopy eyelid. Symptoms developed two weeks after an outdoor summer trip to Massachusetts with exposure to insect bites. Her neurologic exam demonstrated 2mm left-sided ptosis, miosis with a briskly reactive right pupil from 6-to-2mm and left pupil from 3-to-2mm in the dark, and 2mm-difference in pupil size in the light with a smaller left pupil. She also developed macular patches over the head and trunk consistent with multifocal erythema migrans. Initial laboratory work-up showed mild anemia, thrombocytopenia, and elevated transaminase levels. MRI of brain and orbits with contrast revealed asymmetric enhancement within the left cavernous sinus and superior orbital fissure with mild edema of the left extraocular muscles. MRA/MRV did not show evidence of cavernous sinus thrombosis, carotid-cavernous fistula, or other abnormalities. Cerebrospinal fluid analysis showed lymphocytic pleocytosis with negative Borrelia species detection by PCR. Further testing revealed elevated serum total Lyme antibody and Western blot IgM suggestive of Lyme neuroborreliosis. Patient was treated with oral doxycycline with resolution of symptoms. <h3>Conclusions:</h3> Neuroborreliosis has a highly variable clinical presentation. This case illustrates and localizes an isolated Horner’s syndrome as a masquerading presentation of neuroborreliosis. Therefore, clinical suspicion and early recognition are important, especially in the setting of a convincing history, to prompt early diagnosis and initiation of treatment and to prevent disease progression. <b>Disclosure:</b> Dr. Bou Reslan has nothing to disclose. Dr. Park has nothing to disclose. Dr. Sabadia has nothing to disclose. Dr. Grossman has nothing to disclose. The institution of Dr. Zakin has received research support from American Board of Psychiatry and Neurology.