Three Cases of Clinical Pediatric Erythema Migrans in Southwest Virginia

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.