Lyme Disease

During the summer of 1989, a 67-year-old, healthy man spent several weeks at Lake George near Kuujjuaq. Kuujjuaq is slightly south of Ungava bay in northern Quebec, and is located 1,300 km north of Quebec City. The day before he left Lake George, he noted a skin lesion on his right posterior shoulder, which he thought was an insect bite. The lesion rapidly expanded in a centrifugal manner. He was evaluated 72 hours after the initial lesion was noted. He had not travelled outside the province of Quebec and had not taken any oral medications. He was completely asymptomatic. Examination of the skin showed an annular plaque measuring 15 cm in diameter located on the posterior aspect of right shoulder, expanding on the back of his arm. The center was pale and the border brightly erythematous, warm, and edematous. No epidermal change was noted and there was no evidence of insect bite on the skin (Fig. 1). The histopathology showed a mild superficial perivascular lymphocytic infiltrate. The indirect immunofluorescence assay was not significantly positive at 1/64. The other biologic parameters, including a venereal disease research laboratory (VDRL), were negative or within normal limits. A diagnosis of erythema migrans was made on a clinical basis, and the patient was treated with penicillin V 300 mg qid for 10 days. Ten days later, the eruption was completely resolved and the patient remained symptom free.