Three Cases of Clinical Pediatric Erythema Migrans in Southwest Virginia

Case Series

Austin J Microbiol. 2015; 1(2): 1006.

Three Cases of Clinical Pediatric Erythema Migrans in Southwest Virginia

James R. Palmieri1*, Kenneth R. McArtan II1, Russell Hendershot2, Scott King1 and Jenna Warehime1

¹Department of Microbiology, Edward Via College of Osteopathic Medicine, USA

²Department of Preventive Medicine and Population Health, Edward Via College of Osteopathic Medicine, USA

*Corresponding author: James R Palmieri, Department of Microbiology, Infectious and Emerging Diseases-Edward Via College of Osteopathic Medicine– Virginia Campus, 2265 Kraft Drive, Blacksburg, Virginia 24060, USA

Received: June 06, 2015; Accepted: June 30, 2015; Published: July 03, 2015


Ticks are common outdoor pests. In Southwestern Virginia, there are five species of ticks, two of which are associated with Erythema Migrans (EM): the black legged tick (Ixodes scapularis) and the lone-star tick (Amblyomma americanum). The black legged tick is associated Borrelia burgdorferi the spirochete responsible for Lyme Diseases (LD). The lone star tick is affiliated with Southern Tick Associated Rash Illness (STARI) which has been associated with Borrelia lonestari. LD infects a person after a ticks feeds for 36 to 48 hours and presents in three stages. Stage 1 presents days to week after the initial bite with an EM rash and generalized sub-clinical symptoms. Stage 2, disseminated infection, presents weeks to months later. Stage 2 is characterized by neuropathy, such as facial palsy, and other organ system pathologies. Stage 3 takes months to a year to develop and is characterized by acrodermatitis chronica atrophicans and mono/oligo-arthritis. STARI presents with an EM rash and subclinical generalized symptoms 7 days after the lone star tick feeds on a person. We report 3 cases of pediatric EM. Case 1 presents a 19 month old female from Roanoke, VA with an erythematous rash on her right buttocks, sub-febrile temperature, and behavior change. Case 2 is a 29 month old boy from Pilot, Virginia who presents with an 8.5 cm erythematous rash on his left scapular/neck region. Case 3 is an 8 year old boy from Blacksburg, Virginia who presents with an erythematous rash that developed into an EM-like rash. Each case presented with and EM-like rash where a tick was the suspected cause. LD was either ruled-out or equivocal. STARI could be suspected in each case due to the atypical presentation of the illness. Though LD was not present or equivocal in each case, LD and STARI are important differentials when a patient presents with an EM-like rash.

Keywords: Appalachian trail; Borrelia burgdorferi; Erythema migrans; Lyme borreliosis; Lyme disease; Pediatric Lyme disease; Spirochete; STARI


CDC: The United Stated Centers for Disease Control and Prevention; CSF: Cerebral Spinal Fluid; EM: Erythema Migrans; LB: Lyme Borreliosis; LD: Lyme Disease; PCP: Primary Care Provider; STARI: Southern Tick Associated Rash Illness; NNDSS: National Notifiable Disease Surveillance System


Ticks are a common hazard of the outdoors to those who live and work around the forest edge [1]. In the Virginia area there are five common tick species known to feed on humans [1-3]. The blacklegged tick (Ixodes scapularis), well known as the “deer tick” is the common host of Lyme Disease (LD), anaplasmosis, and babesiosis [1,3,4]. The groundhog tick (Ixodes cookei) is the host of Powassan disease but only occasionally feeds on humans [1,3]. The lone star tick (Amblyomma americanum); which can cause ehrilichiosis, tularemia, and southern tick associated rash illness (STARI), has been associated with the uncultivable spirochete Borrelia lonestari [1,3,5,6]. The American dog tick (Dermacentor variablis) is the host to Rocky Mountain spotted fever (Rickettsia rickettsii) and tularemia [1,3]. The brown dog tick (Rhipicephalus saguineus) acts as the host to Rocky Mountain spotted fever, its most favored animal host is the dog [3]. Only two of these ticks are known to be associated with Erythema Migrans (EM): the black legged tick and the lone star tick [1,3]. The EM rash is associated with an infection caused by the spirochete bacteria Borrelia burgdoferi and Borrelia lonestari. Both spirochetes are associated with LD and Lyme disease – like illnesses [1,3,5,6].

Lyme disease

Lyme Disease, otherwise known as Lyme Borrelisosis (LB), was first documented in the United States in 1977 as part of an investigation of a cluster of pediatric arthritis cases among children living near and around Lyme, Connecticut [2,7,8]. Since its discovery and subsequent isolation years later, LD has become one of the most common vector borne illnesses in the United States with 20,000 cases annually [9,10]. In addition, LD is one of the most common tick borne illnesses in Europe [2,11] . LD is caused by five species of spirochete bacteria: Borrelia burgdorferi, Borrelia afzelii, Borrelia garninii, Borrelia spielmanii and Borrelia bavariensis [2]. In the United States, Borrelia burgdorferi (Sensu stricto) is the only known spirochete that causes LD [2].

In the United States LD is transmitted almost exclusively by Ixodes ticks, on the East coast this is the black legged tick (Ixodes scapularis) [7,8,12]. Borrelia burgdorferi uses the tick as a vector to infect host species such as chipmunks, shrews, squirrels, birds, lizards, and especially deer and rodent species which serve an integral role in the tick’s life cycle [13-17]. The white tail deer (Odocoileus virginianus)is the most prevalent deer species in the eastern United States plays and important role in the adult and nymph ticks’ life cycle, but has little role in spreading B. burdorferi to uninfected ticks [18,19]. The deer acts as a host for B. burdorferi which allows the spirichetes to mature and to be transported to new areas [18,20]. The most critical and important hosts in the transmission of B. burgdorferi are mice and rodents, especially the white-footed mouse (Peromyscus leucopus) [13-16]. Mice act as the primary host during the larval and nymph stages of tick’s lifecycle [21]. Mice, especially the white-footed mouse, have been shown to be the most susceptible host for B. burdorferi and have the highest concentration of the spirochetes in their blood compared to other mammal models [21,22]. The black legged tick has a 2 year life span divided into 3 developmental stages (larval, nymph, and adult), and must feed only once each stage of its life cycle [13]. The nymph stage is reported to be the most important in the transmission of LD [7,13,21-23].

Once a human has been bitten by an Ixodes tick infected with B. burdorferi, the spirochetes are inoculated with a bacterial load that allows for survival in the human host [13,24]. In Stage 1 of the disease, also known as the early localized stage, it may take days or weeks to fully develop an EM rash at the site of initial infection. The rash is generally non-painful, but may be accompanied by some pruritus. In 10% to 30% of cases the EM rash is accompanied by nonspecific symptoms of malaise, subfebrile temperatures, and joint pain [11,25]. According to studies performed by Gerber, et al. (1996), 90% of children in their study presented with EM on their head and neck while older children most often present with EM on their arms and legs. Patients with lesions on the head or neck were significantly younger than those with lesions at other sites (mean age, 5.9 vs. 8.1 years) while patients with lesions on the arms or legs were significantly older than those with lesions at other sites (mean age, 9.2 vs. 7.4 years) [26].

If untreated, infection can progress over weeks or months to stage 2, the early disseminated stage. In stage 2, infection can spread to the meninges, brain, eyes, heart, joints, and muscles causing a wide range of symptoms [11]. The variability of symptoms may be linked to genetic variability of the LD spirochete; such differences are reported for LD in Europe [27-29]. In the early stages on dissemination, multiple skin lesions may appear [11]. Children may present with hypersensitivity in areas of the chest and/or waist accompanied by abdominal distention, joint pain, and mental status changes [6,30- 34]. In children, stage 2 is characterized by acute peripheral facial palsy with elevated protein and pleocytosis of the Cerebral Spinal Fluid (CSF) [11,35]. After 6 months of untreated infection, the disease enters stage 3, the late disseminated stage. Stage 3 consists of encephalitis, arteritis, polyneuropathy, acrodermatitis chronica atrophicans, and mono/oligo-arthritis. Like in stage 2, the symptoms are variable from person to person. In most cases, chronic arthritis and acrodermatitis chronica atrophicans are the hallmarks of stage 3 infection with many patients experiencing irreversible neurological deficits with varying severity [6,11,35-37]. In children, chronic LD can present as the classic arthritis and dermatological lesions reported in adults, but neurological changes can take the form of memory and behavioral alterations in addition to other neurological impairments. Memory and behavioral alterations may persist as a residual impairment even after successful treatment [9,38].


STARI (Southern Tick Associated Rash Illness), also known as Master’s Disease, is caused by the recently isolated Borrelia lonestari spirochete, and though this association is still debatable.This illness is vectored by the lone star tick Amblyomma americanum, first proposed as a possible vector of disease in 1984. The illness associated with the lone star tick is called “Lyme-like disease” but was not recognized to be distinct from LD until the late 1990’s [5,6,39]. The infection is spread via the lone-star tick after feeding for what is most likely a similar length of time as a LD transmitting Ixodes tick [39]. In a similar fashion to LD, STARI is believed to be spread via mice, the primary host of the larval and nymph tick stages [39,40]. The initial site of STARI infection can develop an EM rash similar to that of LD, although the borders in STARI are often less regular than those seen in LD infections [6,39]. The rash normally presents about 7 days after the initial tick bite [6]. Tissue biopsies show a greater degree of lymphocytic and neutrophilic reaction at the rash site. Unlike LD, the STARI EM rash may first appear as multiple rather than a singular classic “bull’s-eye” rash. Although there can be differences, the STARI EM rash is often too similar to that of LD to be distinguished by appearance alone [6,39,40]. According to the United States Centers for Disease Control and Prevention (CDC) there is not currently any approved diagnostic method to identify STARI [6]. Thus, the diagnosis of STARI is often made based on geographic association and clinically presenting symptoms [6]. Host exposure to tick habitats would support a STARI diagnosis but is not required according to the CDC. Patients develop similar non-specific, generalized symptoms of malaise and body aches but do not progress to the Stage 2 LD-like illness. Many patients who contract STARI will experience resolution in a few weeks with no lingering symptoms or permanent damage. Long-term studies on STARI have not been conducted at this time. STARI is often treated as LD due to their similar presentations; however, no approved treatments have been identified by the CDC as of June, 2015 [6,39,40].

CDC guidelines

According to Centers for Disease National Notifiable Disease Surveillance System (NNDSS) guidelines, LD is described as a tickborne illness with dermatologic, rheumatologic, neurologic and cardiac symptomology or abnormalities [41]. The most common symptom being EM, which occurs in 60 - 80% of patients and is defined as anerythematous macule or papule rash that expands (over days to weeks) to form a large lesion, often with a clearing center, reaching greater or equal to 5 cm in largest diameter [9,41]. The presence of secondary lesions or annular erythematous lesions (hypersensitivity to the tick bite occurring within several hours of initial bite) does not rule out LD. Symptoms such as non-specific generalized malaise, fatigue, aches, headache, and fever support the diagnosis of LD and follow the presentation of EM. Late manifestations include musculoskeletal, nervous, or cardiovascular symptoms. Musculoskeletal symptoms of LD include recurrent, acute attacks of pronounced joint swelling in one or more joints, lasting weeks to months, sometimes followed by chronic arthritis in one or more joints. Neurologic involvement is defined by lymphocytic meningitis, cranial neuritis (facial palsy), radiculoneuropathy, or encephalomyelitis (confirmed by antibodies to B. burdorferi in the Cerebrospinal Fluid (CSF), higher titers must be in CSF compared to serum [41,42]. Cardiovascular symptoms include acute onset 2nd or 3rd degree atrioventricular blockage, which can resolve in days to weeks, and occasionally myocarditis. Once a diagnosis of EM is made, laboratory testing is suggested using approved techniques. which include: 1. positive culture, two-tier testing for IgM if symptoms are less than 30 days or IgG if symptoms were present for a longer period of time; 2. confirmation by western blot with 5 or more bands for IgG antigens, single-tier IgG; or 3.positive CSF antibody via Enzyme Immunoassay (EIA) or Immunofluorescence Assay (IFA) and CSF levels must be higher than that of serum [9,35,41,42]. If EM is present but with no known “exposure” such as having been in an endemic area where tick-human interaction is possible within 30 days of EM onset and supported with negative laboratory evidence, then the patient has a “suspected” case of LD. A “probable” case is defined by the before mentioned criteria with positive laboratory findings of an infection but lacking diagnostic criteria. In this case a diagnosis is made based on clinical suspicion. A “confirmed” case is defined by known exposure, laboratory evidence of positive titers with or without exposure, or at least one late manifested symptom with laboratory confirmation of disease [35,41-45].


The following cases are reported from primary care physicians in Montgomery and Roanoke Counties, Virginia.

Case Report 1: A 19 month old female from Roanoke, Virginia was brought to her Primary Care Provider (PCP) on October 25, 2013 for a concerning rash and change in behavior. Two weeks prior, the patient exhibited three days of fluctuating low-grade fever ranging between 100.0 to 100.7 Fahrenheit (F). Following the febrile episodes the child experienced restless nights where she would awake screaming and remain awake for several hours at a time. According to the parents, the child is usually a sound sleeper and this is unusual behavior for her. Seventeen days prior to presentation, the mother states that she removed two embedded ticks from the patient’s axilla. At the time the ticks were removed, the child was asymptomatic. Ten days after the ticks were removed the mother noticed the erythematous circular rash with central clearing on the lower left gluteal area. The patient’s past medical history included newborn jaundice treated with phototherapy for less than one day. The patient has no known allergies.

On physical examination the child was irritable but afebrile, with normal vital signs. The remainder of the physical examination was within normal limits with the exception of two skin lesions. The first lesion was a large, erythematous, macular, circular rash with central clearing located above the left buttocks (Figure 1). The other rash was identified under the patient’s chin and was also erythematous but lacked the “bull’s-eye” appearance. Neither lesion was measured during the physical examination. A two tiered test was performed on the child’s serum. The antibody test (IgM) for B. burgdorferi was elevated. Confirmatory testing via Western Blot demonstrated three of the ten bands displayed reactivity. IgG identification via Western Blot was considered negative with only three bands reactive. Five bands are necessary for confirmation of LD. Following the recommended CDC guidelines for LD diagnosis, the patient was prescribed Cefuroxime Axetil (Ceftin) 200 mg twice per day for twenty-one days. Following treatment, the child remains symptom free as of June2015.