Erythema Migrans with Pustules

This 27 yo woman was sent from the E.R. with a 5 day history of a solitary 20 cm annular plaque on the right hip. It looks classical for erythema migrans (EM) of Lyme disease. Her three year-old daughter had a tick on her skin 2 weeks ago, but she has no history of tick bite. The patient is well otherwise.
Photos taken June 24, 2008


Clinically, this is Lyme disease, but no reports in literature of pustules. There is one from China with vesicles (which these may have been initially).

Lyme titers are pending (but this is a clinical dx at this point) and a culture of a pustule was taken.

E.R. doc put her on cefuroxime because she can't tolerate doxycycline (bad GI upset). She has a f/u appointment in a week.