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The erythema migrans (EM) rash is an important initial diagnostic sign of early Lyme disease. We tested the hypothesis that patients who noticed EM first differed from those who noticed viral-like symptoms first. “EM First” participants (167/271, 61.6%) had shorter illness duration before treatment (5.0 versus 6.2 days, P = 0.019), were more likely to have seen or removed a tick (P = 0.048) and to be non-Hispanic White (P = 0.025), and were less likely to present with disseminated lesions at the time of diagnosis (P = 0.003) than “Symptoms First” participants (104/271, 38.4%). In multivariate analyses, EM First participants had a 22% decrease in time to treatment (P = 0.012) compared with Symptoms First participants, suggesting that initial presentation affects time to treatment. In a large minority of patients, EM may not be the initial sign or symptom of early Lyme disease. There is a need for rapid diagnostics and improved physician awareness of the varied manifestations of early Lyme disease.
Financial support: This work was supported by a grant agreement from the Steven and Alexandra Cohen Foundation. Support was also provided from the Global Lyme Alliance (GLA) and the Bay Area Lyme Foundation (BALF). This publication was also made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by grant number UL1 TR003098 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), NIH Roadmap for Medical Research, and Johns Hopkins Clinical Research Network (JHCRN). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, JHCRN, NCATS, NIH, Steven and Alexandra Cohen Foundation, GLA, or BALF. The sponsors had no role in the study design, data collection, analysis or interpretation of the data, or the writing and decision to submit this manuscript.
Disclosure: J. N. A. received consulting fees from the Pfizer North America Lyme Disease Vaccine Ad Board and Tarsus Pharmaceuticals Inc. Lyme Disease Advisory Board, and has been issued the following patent: “Elevated CCL19 after completion of therapy for acute Lyme disease identifies patients at risk for development of post-treatment Lyme disease syndrome who will benefit from further antibiotic therapy.”
Authors’ addresses: Alison W. Rebman, Ting Yang, and John N. Aucott, Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, E-mails: firstname.lastname@example.org, email@example.com, and firstname.lastname@example.org. Isaac Yoon, Patient First, Lutherville, MD, E-mail: email@example.com. Debra Powell, Tower Health Reading Hospital, West Reading, PA, E-mail: firstname.lastname@example.org. Steven A. Geller, Centennial Medical Group, Elkridge, MD, E-mail: email@example.com.