Migratory non-itchy rash

A 58-year-old man presented with 4-day history of multiple, erythematous, non-itchy, painless, patchy spots, along with fatigue and jaw pain. This rash started around the periumbilical area and then spread over his chest and right upper back (Figure 1,2). There was no involvement of face, mucous membranes, and extremities. He denied any sore throat, cough, or other symptoms. Besides the skin rash, his physical examination was unremarkable. There was no temporomandibular joint swelling, or joint tenderness. A month ago, he travelled along with the west coast of Michigan – a Lyme-endemic region of the USA and noted his exposure to mosquitoes. Shortly after his visit, he recalled having fever, chills, myalgia and a similar patchy groin rash which resolved in a few days. At that time, blood work by his family physician revealed mild transaminitis. At the current visit, repeat blood work and electrocardiogram were normal. A clinical diagnosis of early disseminated Lyme disease was made. Lyme Ab IgM and IgG were both elevated, as was his Western blot test. He was given a 10-day course of doxycycline. He reported complete resolution of his symptoms at follow up.