You have been logged out of VisualDx or your session has expired.

Please reload this page and sign into VisualDx to continue.

  VisualDx Mobile   Select Language

Get VisualDx Mobile

There are VisualDx mobile apps available for iOS and Android devices.

You will need a VisualDx account to use the mobile apps.

Already have an account? Sign In or
sign up for a free trial.

Users with VisualDx accounts earn CME credits for using VisualDx.

Already have an account? Sign In or
sign up for a free trial.

Create a Personal Account

E-mail (username)
Verify Password
First Name
Last Name

Personal Account Created

Mobile Access

You can now download VisualDx for your iOS and Android devices. Launch the VisualDx app from your device and sign in using your VisualDx personal account username and password.

CME Certification

Sign in with your personal account to earn and claim CME credits through VisualDx. Credits can be earned by building a differential or looking up a diagnosis.

Version: 7.13.1441   (build df7aed4)
Select Language

Select Region

Send us your feedback

This field is required

Oops! There was an issue during submission. Please try again. If the problem persists, email with your feedback.

Thank You!

We appreciate your feedback and you will be hearing from us soon.


Share This Page

Thank You!

We have sent an e-mail with a link to the current page.


E-mail This Patient Information Sheet

Thank You!

We have sent an e-mail with this patient information.


Image Contributors


  • Christine Ahn MD
    Carl Allen DDS, MSD
    Brandon Ayres MD
    Howard P. Baden MD
    Robert Baran MD
    Keira Barr MD
    Gregory J. Basura MD, Ph.D
    Donald Belsito MD
    Jeffrey D. Bernhard MD
    Jesse Berry MD
    Victor Blanco MD
    Benjamin R. Bohaty MD
    William Bonnez MD
    Sarah Brenner MD
    Robert A. Briggaman MD
    Robert Brodell MD
    Roman Bronfenbrener MD
    Walter Brooks MD
    William Buckley MD
    Philip Bulterys MD, PhD (candidate)
    Susan Burgin MD
    Sonya Burton MD
    Sean P. Bush MD, FACEP
    Jeffrey Callen MD
    Scott Camazine MD
    Michael Cardwell
    Shelley D. Cathcart MD
    Robert Chalmers MD, MRCP, FRCP
    Chia-Yu Chu MD, PhD
    Flavio Ciferri MD
    Maria Rosa Cordisco MD
    Noah Craft MD, PhD
    John T. Crissey MD
    Harold E. Cross MD, PhD
    Charles E. Crutchfield III MD
    Adriana Cruz MD
    Donna Culton MD, PhD
    Bart J. Currie MBBS, FRACP, DTM&H
    Chicky Dadlani MD
    Alexander Dane DO
    C. Ralph Daniel III MD
    Thomas Darling MD, PhD
    William Delaney MD
    Damian P. DiCostanzo MD
    Ncoza Dlova MD
    James Earls MD
    Libby Edwards MD
    Melissa K. Egge MD
    Charles N. Ellis MD
    Rachel Ellis MD
    David Elpern MD
    Nancy Esterly MD
    Stephen Estes MD
    E. Dale Everett MD
    Janet Fairley MD
    David Feingold MD
    Jennifer J. Findeis-Hosey MD
    Benjamin Fisher MD
    Henry Foong MBBS, FRCP
    David Foster MD, MPH
    Brian D. Foy PhD
    Michael Franzblau MD
    Vincent Fulginiti MD
    Sunir J. Garg MD, FACS
    Kevin J. Geary MD
    Lowell Goldsmith MD, MPH
    Sethuraman Gomathy MD
    Bernardo Gontijo MD, PhD
    Kenneth Greer MD
    Kenneth G. Gross MD
    Alan Gruber MD
    Nathan D. Gundacker MD
    Akshya Gupta MD
    Vidal Haddad MSC, PhD, MD
    Edward Halperin MD, MA
    Ronald Hansen MD
    John Harvey
    Rizwan Hassan MD
    Michael Hawke MD
    Jason E. Hawkes MD
    Peter W. Heald MD
    David G. Hicks MD
    Sarah Hocker DO
    Ryan J. Hoefen MD, PhD
    Li-Yang Hsu MD
    William Huang MD
    Sanjana Iyengar MD
    Alvin H. Jacobs MD
    Saagar Jadeja MD
    Shahbaz A. Janjua MD
    Joshua J. Jarvis MD
    Kit Johnson
    Zachary John Jones MD
    Robert Kalb MD
    A. Paul Kelly MD
    Henry Kempe MD
    Loren Ketai MD
    Sidney Klaus MD
    Ashwin Kosambia MD
    Jessica A. Kozel MD
    Carl Krucke
    Mario E. Lacouture MD
    Joseph Lam MD
    Alfred T. Lane MD
    Edith Lederman MD
    Nahyoung Grace Lee MD
    Pedro Legua MD, PhD
    Robert Levin MD
    Bethany Lewis MD
    Sue Lewis-Jones FRCP, FRCPCH
    Taisheng Li MD
    Christine Liang MD
    Shari Lipner MD, PhD
    Adam Lipworth MD
    Jason Maguire MD
    Mark Malek MD, MPH
    Jere Mammino DO
    Ricardo Mandojana MD
    Lynne Margesson MD
    Thomas J. Marrie MD
    Maydel Martinez MD
    Ralph Massey MD
    Patrick McCleskey MD
    Karen McKoy MD
    Thomas McMeekin MD
    Josette McMichael MD
    Somchai Meesiri MD
    Joseph F. Merola MD
    Mary Gail Mercurio MD
    Anis Miladi MD
    Larry E. Millikan MD
    Dan Milner Jr. MD
    Zaw Min MD
    Stephanie Montero
    Alastair Moore MD
    Keith Morley MD
    Dean Morrell MD
    Samuel Moschella MD
    Rehan Naseemuddin MD
    Taimor Nawaz MD
    Vic Newcomer MD
    John Nguyen MD
    Matilda Nicholas MD
    Thomas P. Nigra MD
    Steven Oberlender MD, PhD
    Maria Teresa Ochoa MD
    Art Papier MD
    Lawrence Parish MD
    Tanner Parrent MD
    Mukesh Patel MD
    Lauren Patty-Daskivich MD
    David Peng MD, MPH
    Robert Penne MD
    Nitipong Permpalung MD
    Miriam Pomeranz MD
    Doug Powell MD
    Harold S. Rabinovitz MD
    Christopher J. Rapuano MD
    Sireesha Reddy MD
    Angela Restrepo MD, PhD
    Bertrand Richert MD, PhD
    J. Martin Rodriguez, MD, FACP
    Theodore Rosen MD
    Misha Rosenbach MD
    Scott Schiffman MD
    Robert H. Schosser MD
    Glynis A. Scott MD
    Carlos Seas MD, MSc
    Deniz Seçkin MD
    Daniel Sexton MD
    Paul K. Shitabata MD
    Tor Shwayder MD, FAAP, FAAD
    Elaine Siegfried MD
    Gene Sienkiewicz MD
    Christye Sisson
    Philip I. Song MD
    Mary J. Spencer MD, FAAP
    Lawrence B. Stack MD
    Sarah Stein MD
    William Van Stoecker MD
    Frances J. Storrs MD
    Erik J. Stratman MD
    Lindsay C. Strowd MD
    Erika Summers MD
    Belinda Tan MD, PhD
    Robert Tomsick MD
    Hensin Tsao MD, PhD
    Richard P. Usatine MD
    Jenny Valverde MD
    Vishalakshi Viswanath MD
    Susan Voci MD
    Lisa Wallin ANP, FCCWS
    Douglas Walsh MD
    Ryan R. Walsh MD
    George Watt MD
    Clayton E. Wheeler MD
    Sally-Ann Whelan MS, NP, CWOCN
    Jan Willems MD, PhD
    James Henry Willig MD, MPH
    Karen Wiss MD
    Vivian Wong MD, PhD
    Sook-Bin Woo MS, DMD, MMSc
    Jamie Woodcock MD
    Stephen J. Xenias MD
    Nathaniel Yohannes
    Lisa Zaba MD
    Vijay Zawar MD
    Bonnnie Zhang MD
    Carolyn Ziemer MD
    Jeffrey P. Zwerner MD, PhD


  • Am. Journal of Trop. Med & Hygiene
  • Armed Forces Pest Management Board
  • Blackwell Publishing
  • Bugwood Network
  • Centers For Disease Control and Prevention
  • Centro Internacional de Entrenamiento e Investigaciones Mèdicas (CIDEIM)
  • Dermatology Online Journal
  • East Carolina University (ECU), Division of Dermatology
  • International Atomic Energy Agency
  • Massachusetts Medical Society
  • Oxford University Press
  • Radiological Society of North America
  • Washington Hospital Center
  • Wikipedia
  • World Health Organization
ContentsSynopsisCodesLook ForDiagnostic PearlsDifferential Diagnosis & PitfallsBest TestsManagement PearlsTherapyReferencesInformation for PatientsView all Images (11)
Lyme disease - Cellulitis
See also in: Overview
Print Captions OFF
Other Resources UpToDate PubMed

Lyme disease - Cellulitis

See also in: Overview
Print Patient Handout Images (11)
Contributors: Tara Mahar MD, Art Papier MD
Other Resources UpToDate PubMed


Lyme disease is an immune-mediated inflammatory disease resulting from infection with the spirochete Borrelia burgdorferi sensu lato, composed of 4 distinct genospecies: Borrelia burgdorferi sensu stricto, Borrelia garinii, Borrelia afzelii, and candidatus Borrelia mayonii. Disease usually begins with an expanding skin lesion, erythema migrans, at the site of the tick bite (early localized disease). With B. mayonii infection, which at present seems to be limited to upper midwestern United States, nausea and vomiting may also occur, and the rash may be more diffuse.

Within days to weeks, the spirochete disseminates to the nervous system, heart, joints, and other organs. At this time, patients may develop acute neurologic abnormalities, atrioventricular block, myocarditis, and disseminated skin lesions of erythema migrans (early disseminated disease). (Note: Cardiac symptoms in patients with proven or suspected Lyme disease should be carefully and expeditiously evaluated.) Months later, untreated patients may develop arthritis, an encephalopathy, a neuropathy, and, in Europe, acrodermatitis chronica atrophicans (late disease).

It is a common tick borne illness with widespread distribution but has a higher prevalence in the US and Europe. In the US, Lyme disease is primarily seen in the coastal areas of New England and south to Maryland, in the upper Midwest states of Wisconsin and Minnesota, and coastal areas of California and Oregon. It is endemic to most of Europe.

Lyme disease is subdivided clinically into 3 phases:
  1. Early localized disease
  2. Early disseminated disease
  3. Persisting late disease
Early localized:
Early localized disease, also known as erythema migrans, presents a few days to a month after a tick bite. The characteristic lesion of Lyme disease, erythema migrans, develops in some, but not all, patients. If left untreated, the disease disseminates to lymph nodes hematogenously. Outside the US, early lesions sometimes present as Borrelia lymphocytomas.

Early disseminated:
Multiple skin lesions can represent hematogenous spread (early disseminated disease) or, in rare cases, result from independent primary tick bites. Burning and itching can occur at the site of the tick bite and in erythema migrans. Initial infection is typically associated with flu-like symptoms, headache, arthralgias, and neck pain. Early neurologic symptoms can include facial nerve paralysis (Bell palsy). Atrioventricular block can persist over a few days or last a few weeks, while the arthritis of Lyme disease usually develops later, either a few months to 2 years after initial infection.

Late disease commonly presents as acrodermatitis chronica atrophicans, which is very rare in the US, with chronic blue-red patches over the extensor surfaces.


A69.20 – Lyme disease, unspecified

23502006 – Lyme disease

Look For

Subscription Required

Diagnostic Pearls

Subscription Required

Differential Diagnosis & Pitfalls

Early Disseminated:
Multiple Lesions
  • Erythema multiforme lesions tend to have a dusky center; are symmetrically distributed favoring the dorsal hands, face, and forearms; and are usually with associated herpes infection.
  • Secondary syphilis can have a characteristic "rust" color and overlying scale.
  • Pityriasis rosea presents with a herald patch and lesions in characteristic "fir tree" distribution over the trunk with overlying fine scale.
  • Urticarial lesions are edematous, pruritic, and typically resolve within 24 hours.
  • Pseudolymphoma (lymphocytoma)
  • A number of stimuli, including arthropod bites, can cause an inflammatory reaction pattern in the skin leading to the formation of nodular lesions clinically and histologically resembling cutaneous lymphoma, called pseudolymphoma. Borrelia lymphocytoma is a subset of pseudolymphomas.
  • Nodular scabies are more common in the groin and extremely pruritic.
  • Arthropod bite granuloma can be firm and typically does not expand.
  • Malignancy (eg, breast cancer) presents with firm papules and nodules.
  • Granuloma faciale
  • Sarcoidosis lesions are characteristically violaceous.
  • Circulatory insufficiency.
  • Lupus presents with photosensitivity, malar rash, and systemic symptoms of myalgias, arthralgias, and other organ involvement.

Best Tests

Subscription Required

Management Pearls

Subscription Required


Subscription Required


Subscription Required

Last Updated: 02/17/2016
Copyright © 2018 VisualDx®. All rights reserved.
Lyme disease - Cellulitis
See also in: Overview
Captions OFF Print 11 Images
View all Images (11)
(with subscription)
Lyme disease (Early Localized, B. burgdorferi) : Malaise, Tick bite, Bulls-eye, Blanching patch, Myalgia, Low grade fever
Clinical image of Lyme disease
A thin erythematous, annular plaque with a central thin erythematous papule.
Copyright © 2018 VisualDx®. All rights reserved.