Vesiculobullous Lyme Disease: A Case Series

The early stage of cutaneous Lyme is frequently distinguished by the erythema-migrans patch, which manifests within a month after being bitten by an infected tick. Numerous erythema migrans variants have now been documented, prompting a case study by Hayden Doughty, BS, et al. that was recently published in Journal of the American Academy of Dermatology. The case series examines the occurrence of bullous erythema migrans, a rare and blistering form of erythema migrans, in three patient cases.

Vesiculobullous Lyme disease
Blacklegged Deer Tick (Ixodes scapularis), the most prevalent vector of Lyme disease.

Historical reports indicated that a quarter of the lesions associated with Lyme disease displayed the characteristic “bull’s-eye” appearance, however, the latest reports demonstrate the presentation of urticarial, linear, granulomatous, and bullous erythema migrans. Better accuracy in the identification of rashes associated with Lyme disease is needed to achieve an appropriate and prompt diagnosis and to avoid misidentification or delayed treatment.

Each of the three patients in the study presented with vesiculobullous lesions caused by Lyme disease. The patients were all women known to be otherwise healthy, and with no established history of prior tick bites. In addition to rapidly developing bullous lesions, each patient presented with correlating systemic symptoms, including fatigue, malaise, and fever.

Initially, the lesions were considered to be caused by Sweet syndrome, herpes simplex virus infection, varicella-zoster virus infection, or a spider bite, as well as atypical Lyme disease. It was ultimately determined that each case was caused by infectious processes and symptoms were resolved with empiric doxycycline treatment.

Serologies taken three weeks later were positive for IgM, confirming the diagnosis of Lyme disease. These cases also highlight how delayed positivity of Lyme-specific antibodies, as well as a lack of specific histopathology findings, create great difficulty in accurately and promptly diagnosing Lyme disease.  

The researchers encourage clinicians in Lyme-endemic regions to be mindful that Lyme disease may exhibit a wide range of clinical and histologic outcomes such as bullous lesions.

Read the study in JAAD.

Read more about erythema migrans rashes.