Presentation of Acrodermatitis Chronica Atrophicans Rashes on Lyme Disease Patients in Canada

Abstract

Lyme disease (Lyme borreliosis) is a complex multisystem illness with varying clinical manifestations. This tick-borne zoonosis is caused by the spirochetal bacterium, Borrelia burgdorferi sensu lato (Bbsl) and, worldwide, presents with at least 20 different types of rashes. Certain cutaneous rashes are inherently interconnected to various stages of Lyme disease. In this study, five Canadian Lyme disease patients from a multi-age range presented various phases of the acrodermatitis chronica atrophicans (ACA) rash. In each case of ACA, the underlying etiological pathogen was the Lyme disease spirochete. Although ACA rashes are normally found on the lower extremities, this study illustrates that ACA rashes are not directly correlated with a tick bite, geographic area, age, Bbsl genospecies, exercise, or any given surface area of the body. Case 4 provides confirmation for an ACA rash and gestational Lyme disease. One patient (Case 5) puts forth a Bbsl and Bartonella sp. co-infection with a complex ACA rash. This study documents ACA rashes on Lyme disease patients for the first time in Canada.

Keywords: Borrelia burgdorferi sensu lato; Canada; Lyme disease; acrodermatitis chronica atrophicans; persistence; rashes; symptoms; ticks.

Figure 1

Middle-aged female with two types of rashes on left knee: (A) homogeneous rash with a punctum in the centre, 12 d after tick bite; (B) early inflammatory phase of acrodermatitis chronica atrophicans (ACA) rash, reddish-blue discoloration with punctum, 14 d after tick bite; (C) early inflammatory phase of ACA, more pronounced, extensive purple discoloration, 24 d after tick bite; (D) purple discoloration fading as spirochetes disseminate, 52 d after tick bite; (E) second rash, homogenous type, on inside of left knee with partial reddish-blue discoloration, punctum from tick bite is apparent; and (F) second rash, homogeneous type, purple discoloration fading, and punctum evident.

Figure 2

ACA located on the posterior side of left knee, and there was no recent involvement of a tick bite. (A) Rash when noticed. (B) Rash 4 months later. Of note, the synovial membrane and synovial fluid of the knee are prime foci for sequestration of Lyme disease spirochetes.

Figure 3

Rash on hands with reddish-blue discoloration is consistent with ACA. The discoloration resolved temporarily with antibiotic treatment, and then recrudesced.

Figure 4

A 14-yr-old boy with rashes compatible in appearance with ACA: (A) ACA rash on the calf of right leg before skin biopsies; (B) skin biopsies test positive for Borrelia burgdorferi sensu lato (Bbsl) by polymerase chain reaction (PCR); (C) ACA on right foot with pronounced swelling and reddish-blue discoloration; and (D) hyperpigmented, atrophic ACA on right foot.

Figure 5

A 64-yr-old male exhibited rashes encompassing a set of co-infections, namely ACA, blister exudate, erythematous rash, and Bartonella streaks (striae). (A) Right leg, front view, compound rash with Bartonella striae concomitantly embedded in an inflammatory atrophic ACA at the ankle. The black arrows point to Bartonella striae, and the white arrow indicates exudate droplet typically produced by a blister rash. (B) Right leg, inside view, inflammatory atrophic ACA at foot. The orange discoloration is the result of an application of chlorhexidine antiseptic. (C) Right arm, diffuse erythematous rash graduating to an inflammatory ACA rash at wrist. (D) Left arm, diffuse erythematous rash progressing to inflammatory atrophic ACA at hand.

Figure 6

Erythema migrans, a ring-shaped or bull’s-eye rash on the upper leg of a middle-aged woman. This erythematous lesion is a classic erythema migrans (EM) rash.