Facial Erythema Migrans in a Pediatric Patient

To the Editors: Although Lyme disease is considered uncommon in our region, early presentations in children may be easily missed, particularly when cutaneous findings are subtle or atypical. We recently evaluated a pediatric patient whose clinical course highlights how easily the diagnosis can be overlooked in routine practice. A 10-year-old girl presented with an enlarging erythematous lesion on her right cheek 1 week after a tick bite (Fig. 1). Before reaching our clinic, she had been seen several times in a general pediatric setting, where the lesion was not recognized as erythema migrans. On examination, the lesion was oval, sharply demarcated and showed centrifugal expansion with central clearing—findings characteristic of early localized Lyme disease. She had no fever, systemic symptoms or history of travel abroad. Laboratory studies—including complete blood count, C-reactive protein and liver enzymes—were within normal limits. Serologic testing for Borrelia burgdorferi by enzyme-linked immunosorbent assay (ELISA) was negative at presentation and remained negative 4 weeks later.FIGURE 1.: Expanding erythematous lesion with central clearing on the right cheek, consistent with erythema migrans.Given the typical morphology and the clear epidemiologic history, early localized Lyme disease was diagnosed. She was treated with cefuroxime axetil for 14 days, resulting in the rapid resolution of the rash and no new symptoms during follow-up. In regions where Lyme borreliosis is infrequently reported, erythema migrans may not be readily recognized, leading to delays in diagnosis—as in this case. Because serologic testing is often negative at early stages, clinical assessment remains essential. Prompt recognition of the characteristic rash enables timely treatment and prevents progression to disseminated disease.1,2 This case underscores the need to consider Lyme disease in children presenting with expanding erythematous lesions after tick exposure, even in areas not commonly regarded as endemic.