Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions

Background. The most common and most recognizable feature of Borrelia burgdorferi infection ( Lyme disease) is the skin lesion erythema migrans ( EM). An illness associated with an EM-like skin lesion, but which is not caused by B. burgdorferi, occurs in many southern states in the United States ( southern tick-associated rash illness [ STARI], also known as Masters disease). Methods. Clinical features of 21 cases of EM-like skin lesions in 21 patients from Missouri were compared in a prospective study with those of 101 cases in 97 patients with EM-like skin lesions from New York. Results. Among Missouri cases, the peak incidence of EM-like skin lesions occurred earlier in the year than it did among New York cases (P < .001). Case patients from Missouri were more likely to recall a tick bite than P < .001 were case patients from New York ( 85.7% and 19.8%, respectively;), and the time period from tick bite P < .001 to onset of the skin lesion was shorter among Missouri case patients ( days and days, respectively; 6.1 +/- 4.2 10.4 +/- 6.1). Missouri case patients were less likely to be symptomatic than were New York case patients ( 19.0% and 76.2%, respectively;), and Missouri case patients were less likely to have multiple skin lesions ( 4.8% P < .001 and 26.7%, respectively;). EM-like lesions in Missouri cases were smaller in size than those in New York cases ( cm and cm, respectively;), more circular in shape (P = .004), and more likely 8.3 +/- 2.2 16.4 +/- 11.5 P < .001 Pp. 004 to have central clearing ( 76.2% and 21.6%, respectively;). After antibiotic treatment, Missouri case patients P < .001 recovered more rapidly than did New York case patients (P = .037). Conclusion. Cases of EM-like skin lesion in patients from Missouri and New York have distinct clinical presentations.