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A 45-year-old man was presented with 3 weeks of fever, chills, headache, myalgia and sweats after returning from a camping trip. He had multiple erythematous, blanching, non-target lesions on back and lower abdomen and oral pseudomembrane. He was empirically started on doxycycline for presumed Lyme disease and hydration for management of acute renal failure. Next day, he was started on vancomycin for worsening rash and coverage of methicillin-resistant Staphylococcus aureus skin infection and fluconazole for possible thrush and tested for HIV, syphilis, tick-borne diseases, arboviral panel, Epstein-Barr virus, rapid plasma reagin and rheumatoid factor. Initial Lyme's screening test was negative. Over the next 4 days, rash and headache improved significantly and Epstein-Barr DNA and immunoglobulin M Lyme antibody came back positive. After discussion with Infectious Diseases colleagues, doxycycline was continued for 3 weeks for management of early disseminated Lyme disease. Patient had no recurrence of his symptoms at 4 week follow-up visit.

Disseminated Lyme disease presenting as multiple non-target cellulitic-appearing skin lesions and oral pseudomembrane