A Skin Lesion in a Patient from Kentucky

A 51-year-old woman from Kentucky presented in June 2004 with a –cm skin lesion on her right shoulder that had 6.8 7.0 been present for 1 day (figure 1). The patient had removed from this site the 2 ticks depicted in figures 2 and 3. The larger tick was removed 1 week before presentation, and the smaller tick was removed 1 day before the onset of the skin lesion. The skin lesion was not warm or tender, and the patient had no fever or systemic symptoms. The patient had not traveled out of state within a year before presentation. Other findings of physical examination were unremarkable. What is your diagnosis? Figure 2