[Multilocular large erythemas and fever]

A 44-year old man consulted our emergency room three months after returning from holidays in Sri Lanka: Following a short episode of fever, he observed rise of four large reddish skin lesions that central paling. We considered infection with Borrelia burgdorferi (erythema migrans), streptoccoci (erysipelas), or fungi (tinea corporis). Erysipelas was improbable because of slow progression with little systemic inflammatory response, fungi were not detected in direct microscopic examination. Aspect of the skin lesions was typical for erythema migrans, however, we were not familiar with multilocular appearance of this disease. Nevertheless--on the basis of clinical observations and detection of serum IgM against Borrelia burdorferi--we diagnosed multilocular erythema migrans and treated with doxycycline 200 mg daily for 10 days. The skin lesions completely disappeared within a few days. Erythema migrans may present unilocular or multilocular, depending on Borrelia species involved. In Europe (mainly B. afzelii and B. garinii), multilocular manifestation is rare and, therefore, often misinterpreted. It is important, however, to diagnose and treat multilocular erythema migrans because early hematogenic dissemination is underlying. In America B. burgdorferi sensu stricto infection more often presents with multilocular erythema migrans and systemic clinical manifestations.