Kugeler KJ , Schwartz AM , Delorey MJ , Mead PS , Hinckley AF , 2021. Estimating the frequency of Lyme disease diagnoses, United States, 2010–2018. Emerg Infect Dis 27: 616–619.
Steere AC , Strle F , Wormser GP , Hu LT , Branda JA , Hovius JW , Li X , Mead PS , 2016. Lyme borreliosis. Nat Rev Dis Primers 2: 16090.
Wormser GP , McKenna D , Carlin J , Nadelman RB , Cavaliere LF , Holmgren D , Byrne DW , Nowakowski J , 2005. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med 142: 751–755.
Nadelman RB , Nowakowski J , Forseter G , Goldberg NS , Bittker S , Cooper D , Aguero-Rosenfeld M , Wormser GP , 1996. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med 100: 502–508.
Shadick NA et al., 1994. The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Ann Intern Med 121: 560–567.
Hirsch A , Poulsen M , Nordberg C , Moon K , Rebman A , Aucott J , Heaney C , Schwartz B , 2020. Risk factors and outcomes of treatment delays in Lyme disease: a population-based retrospective cohort study. Front Med 7: 560018.
Luft BJ , Dattwyler RJ , Johnson RC , Luger SW , Bosler EM , Rahn DW , Masters EJ , Grunwaldt E , Gadgil SD , 1996. Azithromycin compared with amoxicillin in the treatment of erythema migrans. A double-blind, randomized, controlled trial. Ann Intern Med 124: 785–791.
Rebman AW , Yang T , Mihm EA , Novak CB , Yoon I , Powell D , Geller SA , Aucott J , 2021. The presenting characteristics of erythema migrans vary by age, sex, duration, and body location. Infection 49: 685–692.
Branda JA et al., 2018. Advances in serodiagnostic testing for Lyme disease are at hand. Clin Infect Dis 66: 1133–1139.
Feder HM , Gerber MA , Krause PJ , Ryan R , Shapiro ED , 1993. Early Lyme disease: a flu-like illness without erythema migrans. Pediatrics 91: 456–459.
Steere AC , Bartenhagen NH , Craft JE , Hutchinson GJ , Newman JH , Rahn DW , Sigal LH , Spieler PN , Stenn KS , Malawista SE , 1983. The early clinical manifestations of Lyme disease. Ann Intern Med 99: 76–82.
Hirsch AG , Herman RJ , Rebman A , Moon KA , Aucott J , Heaney C , Schwartz BS , 2018. Obstacles to diagnosis and treatment of Lyme disease in the USA: a qualitative study. BMJ Open 8: e021367.
Fix AD , Pena CA , Strickland GT , 2000. Racial differences in reported Lyme disease incidence. Am J Epidemiol 152: 756–759.
Nelson CA , Starr JA , Kugeler KJ , Mead PS , 2016. Lyme disease in Hispanics, United States, 2000–2013. Emerg Infect Dis 22: 522–525.
Lester JC , Taylor SC , Chren M-M , 2019. Under‐representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol 180: 1521–1522.
Aucott J , Morrison C , Munoz B , Rowe PC , Schwarzwalder A , West SK , 2009. Diagnostic challenges of early Lyme disease: lessons from a community case series. BMC Infect Dis 9: 79.
Novak CB , Scheeler VM , Aucott JN , 2021. Lyme disease in the era of COVID-19: a delayed diagnosis and risk for complications. Case Rep Infect Dis 2021: 6699536.
Wormser GP , Jacobson E , Shanker EM , 2021. Negative impact of the COVID-19 pandemic on the timely diagnosis of tick-borne infections. Diagn Microbiol Infect Dis 99: 115226.
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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: arebman1@jhmi.edu, tyang6@jhu.edu, and jaucott2@jhmi.edu. Isaac Yoon, Patient First, Lutherville, MD, E-mail: isaac.yoon@patientfirst.com. Debra Powell, Tower Health Reading Hospital, West Reading, PA, E-mail: debra.powell@towerhealth.org. Steven A. Geller, Centennial Medical Group, Elkridge, MD, E-mail: drg@centennialmedical.com.
Kugeler KJ , Schwartz AM , Delorey MJ , Mead PS , Hinckley AF , 2021. Estimating the frequency of Lyme disease diagnoses, United States, 2010–2018. Emerg Infect Dis 27: 616–619.
Steere AC , Strle F , Wormser GP , Hu LT , Branda JA , Hovius JW , Li X , Mead PS , 2016. Lyme borreliosis. Nat Rev Dis Primers 2: 16090.
Wormser GP , McKenna D , Carlin J , Nadelman RB , Cavaliere LF , Holmgren D , Byrne DW , Nowakowski J , 2005. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med 142: 751–755.
Nadelman RB , Nowakowski J , Forseter G , Goldberg NS , Bittker S , Cooper D , Aguero-Rosenfeld M , Wormser GP , 1996. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med 100: 502–508.
Shadick NA et al., 1994. The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Ann Intern Med 121: 560–567.
Hirsch A , Poulsen M , Nordberg C , Moon K , Rebman A , Aucott J , Heaney C , Schwartz B , 2020. Risk factors and outcomes of treatment delays in Lyme disease: a population-based retrospective cohort study. Front Med 7: 560018.
Luft BJ , Dattwyler RJ , Johnson RC , Luger SW , Bosler EM , Rahn DW , Masters EJ , Grunwaldt E , Gadgil SD , 1996. Azithromycin compared with amoxicillin in the treatment of erythema migrans. A double-blind, randomized, controlled trial. Ann Intern Med 124: 785–791.
Rebman AW , Yang T , Mihm EA , Novak CB , Yoon I , Powell D , Geller SA , Aucott J , 2021. The presenting characteristics of erythema migrans vary by age, sex, duration, and body location. Infection 49: 685–692.
Branda JA et al., 2018. Advances in serodiagnostic testing for Lyme disease are at hand. Clin Infect Dis 66: 1133–1139.
Feder HM , Gerber MA , Krause PJ , Ryan R , Shapiro ED , 1993. Early Lyme disease: a flu-like illness without erythema migrans. Pediatrics 91: 456–459.
Steere AC , Bartenhagen NH , Craft JE , Hutchinson GJ , Newman JH , Rahn DW , Sigal LH , Spieler PN , Stenn KS , Malawista SE , 1983. The early clinical manifestations of Lyme disease. Ann Intern Med 99: 76–82.
Hirsch AG , Herman RJ , Rebman A , Moon KA , Aucott J , Heaney C , Schwartz BS , 2018. Obstacles to diagnosis and treatment of Lyme disease in the USA: a qualitative study. BMJ Open 8: e021367.
Fix AD , Pena CA , Strickland GT , 2000. Racial differences in reported Lyme disease incidence. Am J Epidemiol 152: 756–759.
Nelson CA , Starr JA , Kugeler KJ , Mead PS , 2016. Lyme disease in Hispanics, United States, 2000–2013. Emerg Infect Dis 22: 522–525.
Lester JC , Taylor SC , Chren M-M , 2019. Under‐representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol 180: 1521–1522.
Aucott J , Morrison C , Munoz B , Rowe PC , Schwarzwalder A , West SK , 2009. Diagnostic challenges of early Lyme disease: lessons from a community case series. BMC Infect Dis 9: 79.
Novak CB , Scheeler VM , Aucott JN , 2021. Lyme disease in the era of COVID-19: a delayed diagnosis and risk for complications. Case Rep Infect Dis 2021: 6699536.
Wormser GP , Jacobson E , Shanker EM , 2021. Negative impact of the COVID-19 pandemic on the timely diagnosis of tick-borne infections. Diagn Microbiol Infect Dis 99: 115226.
Past two years | Past Year | Past 30 Days | |
---|---|---|---|
Abstract Views | 2711 | 1406 | 89 |
Full Text Views | 360 | 100 | 8 |
PDF Downloads | 266 | 31 | 9 |