Reccurent Erythema Migrans as a Persistent Infection

Overview

Background.
Effective antibiotic therapy administered early in the course of the clinical presentation of erythema migrans (EM) prevents further progression of infection and dissemination of the agent to internal organs.

Case report.
A 73-year old woman was referred with a history of five episodes of recurrent EM after repeated adequate antibiotic treatment. The patient who had visited an endemic area only once before the disease recalled no tick bite either prior to the first episode or later. After the first episode, the serological examination was negative (IFA, ELISA, Western blot). In the second episode, not preceded by her visit to any endemic area, the patient showed borderline positivity. Western blot confirmed Borrelia burgdorferi sensu lato. The following episodes were observed again without a prior visit to any endemic area. The most recent EM episode was accompanied by nonspecific moderate symptoms such as fatigue and malaise without involvement of internal organs, with the same serological result as found previously. Peripheral blood PCR assay detected Borrelia burgdorferi specific DNA. Intravenous cephalosporin was effective in treating both the skin and extracutaneous signs of the disease.

Conclusion.
Recurrent episodes of appropriately treated EM may occur as a result of either reinfection due to contact with another vector tick or persistent infection. Intravenous cephalosporin is likely to be appropriate therapy for recurrent borrelial infection in the skin, in particular when accompanied by general extracutaneous signs and symptoms that might indicate dissemination of the spirochetes.

Key words:
erythema migrans – recurrent infection – intravenous cephalosporin.