Zebra Card SK-004: expanding annular lesion

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	Red macule or papule, expanding to become an annular lesion up to 70 cm in diameter
	Differential Diagnosis	[Top] [Nav]
	Lyme disease
	Discussion -- not available online	[Top] [Nav]

I no longer track the literature on Lyme disease and its cutaneous manifestations; it is now well outside the zebra realm.

	Update Comments	[Top] [Nav]
	Impressive photo of the "racquetball bull's eye:" a ringed skin lesion that develops after a high-velocity racquetball strikes the skin. There is a central ecchymosis, surrounded by a ring of erythema, surrounded by a large outer ring of ecchymosis. As the ball strikes the body, the subcutaneous vessels at the impact site are compressed, forcing blood peripherally at high pressure, causing rupture of the capillaries at the margin of the impacting surface. Relative cutaneous pallor is left under the point of impact. If the ball is compressible, like a racquetball but unlike a baseball, a central contusion will also occur. [105] Lancet 1996;348:1646 reprints a photo of the characteristic bruise produced by a squash ball: a central pale area surrounded by a ring of erythema. [106]

Footnotes in Print Edition

	(1a)	Potential wider range for Lyme disease. Anonymous. Ann Int Med. September 1984:I-152.
	(1b)	Update: Lyme disease--United States. MMWR Morb Mortal Wkly Rep 1984 May 18;33(19):268-70. Pubmed Similars
	(2)	Erythema chronicum migrans of Lyme disease. Berger BW. Arch Dermatol 1984 Aug;120(8):1017-21. Pubmed+Abstract Similars
	(3a)	Early and late cutaneous manifestations in Ixodes-borne borreliosis (erythema migrans borreliosis, Lyme borreliosis). Asbrink E, Hovmark A. Ann N Y Acad Sci 1988;539:4-15. Pubmed Similars
	(3b)	Clinical manifestations and diagnosis of neuroborreliosis. Stiernstedt G, Gustafsson R, et al. Ann N Y Acad Sci 1988;539:46-55. Pubmed+Abstract Similars
	(3c)	Clinical pathologic correlations of Lyme disease by stage. Duray PH, Steere AC. Ann N Y Acad Sci 1988;539:65-79. Pubmed+Abstract Similars
	(4)	The gyrate erythemas. Hurley HJ, Hurley JP. Semin Dermatol. 1984;3:327-336.
	(-)	Ticks, spirochetes, and new diagnostic tests for Lyme disease. Mertz LE, Wobig GH, et al. Mayo Clin Proc 1985 Jun;60(6):402-6. Pubmed Similars
	(-)	Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 51-1988. A 92-year-old woman with several cranial-nerve defects and weakness of the left leg. N Engl J Med 1988 Dec 22;319(25):1654-62. Pubmed Similars

New References

	Lyme disease
	101.	Lyme disease in children in southeastern Connecticut. Pediatric Lyme Disease Study Group [see comments]. Gerber MA, Shapiro ED, et al. N Engl J Med 1996 Oct 24;335(17):1270-4. Pubmed+Abstract Similars
	102.	Use of a novel technique of cutaneous lavage for diagnosis of Lyme disease associated with erythema migrans. Wormser GP, Forseter G, et al. JAMA 1992 Sep 9;268(10):1311-3. Pubmed+Abstract Similars
	103.	Current perspective on Lyme borreliosis [clinical conference] [published erratum appears in JAMA 1992 Oct 14;268(14):1860] [see comments]. Kaslow RA. JAMA 1992 Mar 11;267(10):1381-3. Pubmed Similars
	104.	Diagnosis of Lyme disease based on dermatologic manifestations. Malane MS, Grant-Kels JM, et al. Ann Intern Med 1991 Mar 15;114(6):490-8. Pubmed+Abstract Similars
	Other ringed skin lesions
	105.	Mechanism of "racquetball bull's eye". Greene RE, Henry TE. JAMA. 1993;270:391.
	106.	Practical Problems in Dermatology. 2nd ed. Marks R. London: Martin Dunitz, 1996: 264 pp. Amazon.com

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	©1986-2000 John Sotos, MD. All rights reserved. Last updated 16:33 PDT on July 4, 2000.	[Top]

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