Lyme Misdiagnosed As Cellulitis
Lyme Misdiagnosed As Cellulitis
J Cutan Pathol. 2018 Apr;45(4):274-277. doi: 10.1111/cup.13100. Epub 2018 Feb 9.
Septolobular panniculitis in disseminated Lyme borreliosis.
Dittmer MR1, Willis MS2, Selby JC2, Liu V3.
1 Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
2 Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
3 Departments of Dermatology and Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Abstract
Lyme disease classically evolves through clinical manifestations according to the stage of illness. Because many of the systemic symptoms are non-specific, and because serology may yield false negative results, cutaneous findings merit even greater importance to diagnosis.
The prototypical skin lesion, erythema migrans (EM), occurs early and is the only independent diagnostic clinical feature according to the guidelines of the Infectious Diseases Society of America. EM itself has protean guises, being, at times, vesicular, indurated, necrotic, purpuric, solid, or targetoid, but it is not the sole Borrelia-associated skin lesion.
Acrodermatitis chronica atrophicans and borrelial lymphocytoma cutis are other well-known skin manifestations.
A rare cutaneous manifestation that is increasingly reported in Lyme patients is panniculitis, which develops after dissemination of the spirochete.
We present such a case in a patient who was initially treated for cellulitis as well as neck and radicular leg pain, thereby expanding the cutaneous spectrum of Lyme disease.
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
PMID: 29293267
DOI: 10.1111/cup.13100
Link Here
https://www.ncbi.nlm.nih.gov/pubmed/29293267
~~
Int J Dermatol. 2016 Feb;55(2):e79-82. doi: 10.1111/ijd.12927. Epub 2015 Oct 23.
Vesiculobullous and hemorrhagic erythema migrans: uncommon variants of a common disease.
Paul S1, Song PI2, Ogbechie OA1, Sugai DY2, Morley KW2, Schalock PC1,2, Kroshinsky D1,2.
Abstract
BACKGROUND:
The diagnosis of Lyme disease relies on the accurate diagnosis of erythema chronicum migrans (ECM) because serologic tests, culture, and polymerase chain reactions are often inaccurate. Although ECM is classically associated with a targetoid rash, there are many variants of this lesion. These variants of ECM are often initially diagnosed as cellulitis or spider bite reactions and treated with oral antibiotics. Inappropriate treatment further delays the diagnosis of Lyme disease, leading to late complications.
METHODS:
We present four cases of vesiculobullous and hemorrhagic ECM, a less common variant of ECM.
RESULTS:
All four patients had a history of exposure to wooded areas in Massachusetts during the summer months. In these patients, ECM presented with central vesicles and bullae with hemorrhage, crusting, and in some cases necrosis. Serologic testing was positive in three of the four cases at presentation.
In one case, microscopic examination of a skin biopsy showed epidermal spongiosis with parakeratosis, focal necrosis, papillary dermal edema, erythrocyte extravasation, and a superficial and deep perivascular lymphocytic infiltrate with neutrophils and eosinophils of the dermis. No fungal organisms or bacteria were identified. All four patients were treated with doxycycline with complete resolution of symptoms.
CONCLUSIONS:
It is important to recognize the vesiculobullous and hemorrhagic variants of ECM in order to minimize the provision of inappropriate antibiotic treatment for other diagnoses. Early diagnosis of ECM and the initiation of appropriate antibiotics may prevent late complications of Lyme disease.
© 2015 The International Society of Dermatology.
PMID: 26498075
DOI: 10.1111/ijd.12927
Link Here
https://www.ncbi.nlm.nih.gov/pubmed/26498075
~~
J Formos Med Assoc. 2007 Jul;106(7):577-81.
Erythema migrans mimicking cervical cellulitis with deep neck infection in a child with Lyme disease.
Li TH1, Shih CM, Lin WJ, Lu CW, Chao LL, Wang CC.
Abstract
In the early stage of Lyme disease, atypical lesions of erythema migrans rash can develop and extend over the neck region, mimicking cervical cellulitis with deep neck infection. Here, we report a 9-year-old Taiwanese boy with a recent history of exposure to deer during his visit to Nanto County in central Taiwan.
Cervical cellulitis with lymphadenitis was initially diagnosed. Erythema migrans developed in the following days and Lyme disease was finally diagnosed by a Western immunoblot test. Alertness to this unique clinical feature is required for prompt differential diagnosis of Lyme disease with a presentation of erythema migrans mimicking cervical cellulitis.
PMID: 17660148
DOI: 10.1016/S0929-6646(07)60009-6
[Indexed for MEDLINE] Free full text
Link Here
https://www.ncbi.nlm.nih.gov/pubmed/17660148
~~
Arch Fam Med. 2000 Jun;9(6):563-7.
Failure of treatment with cephalexin for Lyme disease.
Nowakowski J1, McKenna D, Nadelman RB, Cooper D, Bittker S, Holmgren D, Pavia C, Johnson RC, Wormser GP.
Abstract
CONTEXT:
Lyme disease typically presents with a skin lesion called erythema migrans (EM), which though often distinctive in appearance may be confused with cellulitis. The first-generation cephalosporin, cephalexin monohydrate, is effective for treating bacterial cellulitis but has not been recommended or studied for treating Lyme disease because of poor in vitro activity.
OBJECTIVE:
To describe the outcome of patients with EM who were treated with cephalexin.
PATIENTS AND METHODS:
Patients presenting with EM to the Lyme Disease Diagnostic Center in Westchester, NY (May 1992-September 1997). A 2-mm punch biopsy specimen of the leading edge of the EM lesion and/or blood was cultured for Borrelia burgdorferi.
RESULTS:
Eleven (2.8%) of 393 study patients had been initially treated with cephalexin prior to our evaluation; 9 (82%) were originally diagnosed with cellulitis. Cephalexin was administered for 8.6 days (range, 2-21 days) prior to presentation. All 11 patients had clinical evidence of disease progression, including 8 whose rash enlarged, 2 who developed seventh-nerve palsy (1 with new EM lesions), and 1 who developed new EM lesions. Borrelia burgdorferi grew in cultures from 5 patients despite a mean of 9.8 days of treatment with cephalexin (range, 5-21 days).
CONCLUSION:
Cephalexin should not be used to treat early Lyme disease and should be prescribed with caution during the summer months for patients believed to have cellulitis in locations where Lyme disease is endemic.
PMID: 10862221
Link here
https://www.ncbi.nlm.nih.gov/pubmed/10862221
~~
Dermatology. 1998;197(4):386-7.
A case of Lyme disease with parotitis.
Kawagishi N1, Takahashi H, Hashimoto Y, Miyamoto K, Iizuka H.
Abstract
A-59-year-old Japanese woman presented a cellulitis-like erythematous skin rash, low-grade fever, and general fatigue, accompanied by a firm swelling of the right parotid gland. She had a history of tick bite on the right lateral neck 2 weeks before. Serum anti-Borrelia burgdorferi antibody was positive by Western blot analysis, and B. burgdorferi was isolated from the skin lesion.
Serum amylase level was elevated with predominant salivary gland isozyme; the level returned to normal within 3 weeks following penicillin and tetracycline treatment. Parotitis might be included among the rare complications of Lyme disease affecting the head and neck region.
PMID: 9873181
DOI: 10.1159/000018038
Link Here
https://www.ncbi.nlm.nih.gov/pubmed/9873181
~~
Infez Med. 2016 Jun 1;24(2):140-3.
Tick-related facial cellulitis caused by Francisella tularensis.
Arslan F1, Karagöz E2, Zemheri E3, Vahaboglu H4, Mert A1.
Abstract
Tick-borne illnesses have diverse biological and clinical features that make recognition and appropriate treatment challenging. Arthropod-transmitted (ticks, fleas and deer flies) tularaemia remains a concern worldwide.
Generally, two kinds of tularaemia manifestations, namely ulceroglandular and glandular infections, can arise from the bite of an infected arthropod vector.
If the ulceroglandular or glandular form is not treated, suppuration can arise from the gland. In addition, cellulitis is rarely observed around the ulcers.
In our case, with the knowledge of tick exposure to the scalp, tularaemia was not initially considered for facial cellulitis without regional lymphadenopathy and also due to apparent failure to respond to doxycycline and gentamicin therapy. Serological confirmation in the late stages of the disease suggests the importance of clinical suspicion in such rare conditions.
PMID: 27367325
[Indexed for MEDLINE]
Free full text
Link Here
Treatment Considerations
Clinical Pearls in Infectious Diseases 2017 Randall S. Edsona, Scott C. Litinb, John B. Bundrickb,⁎
a Division of Infectious Diseases, California Pacific Medical Center, San Francisco, CA, United States b Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States
Case 1
MARK Contents lists available at ScienceDirect Disease-a-Month
journal homepage: www.elsevier.com/locate/disamonth
A 75 year old man is admitted from a long term care facility to the hospital because of right lower extremity cellulitis. He has had two identical admissions within the last year. He uses compression stockings on a daily basis for residual right lower extremity edema.
On physical examination the temperature is 38.5 degrees Centigrade, pulse 110, BP 130/85. The right lower extremity is warm, erythematous, edematous and tender from mid-calf to the knee; a few red streaks are noted in the distal thigh. There is a well healed saphenous vein harvest site on the right calf from a previous coronary artery bypass.
No tinea pedis is noted and there are no breaks in the skin. He has had mild to moderate residual swelling of the right calf since the last episode of cellulitis 3 months ago. He responds well to parenteral cefazolin and is ready for discharge.
Which of the following options will be most effective in preventing further episodes of cellulitis in this patient?
A. Order nasal swab for MRSA; decolonize with nasal mupirocin if positive
B. Initiate Penicillin VK orally, 250 mg twice daily
C. Initiate Trimethoprim-Sulfamethoxazole double strength once daily
D. Initiate ceftriaxone 2 g IM once monthly
E. Daily skin lubrication and topical antifungal treatment for the interdigital web spaces
Correct answer: B
Discussion
Recurrent cellulitis is common, most frequently in the setting of chronic venous insufficiency or lymphedema. Residual edema may worsen after each bout of cellulitis.
Patients who have had saphenous vein harvest in the setting of coronary artery revascularization surgery, as in this case, are at increased risk for recurrent cellulitis because of residual swelling in the affected leg.
Non purulent cellulitis is typically caused by hemolytic streptococci and not by Staphylococcus aureus. Although this patient resides in a long term care facility, determining and eliminating MRSA nasal carrier state is not indicated. Trimethoprim-sulfamethoxazole, though active against MRSA, has less activity against streptococci and would therefore not be a rational choice for the prevention of cellulitis even in the setting of nasal colonization.
Ceftriaxone, though active against streptococci does not have a half-life long enough to provide measurable serum concentration to last a month and is therefore not an ideal choice. Tinea pedis is frequently a portal of entry for bacteria but there is no evidence that preemptive treatment with topical anti—fungal therapy is helpful.
A double- blind randomized, controlled trial involving patients with two or more episodes of lower extremity cellulitis found that daily administration of oral Penicillin VK 250 mg twice daily resulted in a significantly reduced recurrence rate(22%) compared to 37% in the placebo.
In this case, the only evidence-based intervention for prevention of recurrent cellulitis is daily oral penicillin.
⁎ Corresponding author.
E-mail address: bundrick.john@mayo.edu (J.B. Bundrick).
http://dx.doi.org/10.1016/j.disamonth.2017.03.011
0011-5029/ © 2017 Elsevier Inc. All rights reserved.
Link Here
https://www.sciencedirect.com/science/article/abs/pii/S0011502917300573?via%3Dihub