The many masks of cutaneous Lyme disease

Abstract

Early cutaneous Lyme disease, erythema migrans, may show different histopathologic patterns. The intent of this case series is to raise awareness of these findings to prevent misdiagnosis and keep this entity in the differential. Erythema migrans develops after a tick bite and subsequent infection with the spirochete, Borrelia burgdorferi. It most commonly manifests as a solitary, annular lesion with a bull's-eye appearance. Classic histopathologic findings include superficial and deep perivascular and interstitial lymphocytic infiltrates mixed with plasma cells and eosinophils. We identified and reviewed eight cases of early erythema migrans. Each patient had confirmed B. burgdorferi IgM seropositivity and IgG seronegativity. Histopathologic evaluation of these biopsies reveals a diversity of patterns. Seven of eight cases show sparse to mild perivascular and interstitial mixed infiltrate of variable amount of lymphocytes, eosinophils, neutrophils and plasma cells, with only one case showing a dense inflammatory infiltrate. Epidermal changes such as spongiosis and interface change are seen in some cases. Additionally, perineural lymphocytic infiltrate is seen in one case, periadnexal infiltrate in four cases and pigment incontinence in one case. Based on variable histopathologic findings, it is important to consider erythema migrans in the differential diagnosis for prompt diagnosis and treatment.

Rare case of Lyme borreliosis in a patient presenting with dactylitis and skin rash

“…Clinical symptoms in LB are not always specific, and LB can look like several diseases. 23 It can cause multisystem disease, particularly affecting the skin, musculoskeletal system, nervous system and heart. Lyme arthritis is usually not painful and is not accompanied by fever.…”

Vesiculobullous Lyme disease: A case series

“…Histopathologic features of Lyme disease often include a superficial and deep perivascular and interstitial infiltrate consisting of lymphocytes and plasma cells, and may include eosinophils and neutrophils; however, a variety of histopathologic patterns have been described and often suggest a broad histopathologic differential diagnosis. 6 , 7 The testing options for early-stage Lyme disease (<30 days since symptom onset) include polymerase chain reaction, enzyme-linked immunosorbent assay (ELISA), and Western blot ( Table I ). 8 The Center for Disease Control and Prevention currently recommends a 2-tier approach, involving an initial serum enzyme immunoassay, followed by IgG and IgM Western blotting or a secondary enzyme immunoassay.…”

Early Erythema Migrans: Do Not Count on Plasma Cells

“…14,15 However, Wilson et al 8 described 4 patients with serologically confirmed erythema migrans whose biopsies from the periphery of their lesions lacked plasma cells; in a recent case series of 8 serologically confirmed patients with erythema migrans who underwent biopsy, 3 lacked plasma cells. 16 With the recent advancement of molecular techniques, one would think that the dermatopathologist would be able to confirm the diagnosis of erythema migrans readily on histologic sections. However, a recent review 17 highlights the impracticality of such endeavors.…”

“…14,15 However, Wilson et al 8 described 4 patients with serologically confirmed erythema migrans whose biopsies from the periphery of their lesions lacked plasma cells; in a recent case series of 8 serologically confirmed patients with erythema migrans who underwent biopsy, 3 lacked plasma cells. 16…”