Early disseminated Lyme disease

Description 

A 47-year-old man presented to the emergency department with fatigue and a rash. Two weeks prior to presentation, he had noticed a painful lesion in his left antecubital fossa (figure 1), which had gradually increased in size. Ten days later, he developed malaise, diffuse joint aches and a new rash (figure 2) over his torso, arms and legs. He had no palpitations, joint swelling or neurologic changes. Prior to the onset of his symptoms, he had vacationed in Wisconsin in early June—a Lyme-endemic region of the USA—and suspected that he may have had a tick bite to his left arm in the region adjacent to his initial rash. Physical exam was remarkable for a painful, indurated, erythematous plaque in the left antecubital fossa and multiple painless, erythematous patches with central clearing across his torso. He was afebrile, had no joint swelling or erythema...

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