Septolobular panniculitis in disseminated Lyme borreliosis

Lyme disease classically evolves through clinical manifestations according to the stage of illness. Because many of the systemic symptoms are non-specific, and because serology may yield false negative results, cutaneous findings merit even greater importance to diagnosis. The prototypical skin lesion, erythema migrans (EM), occurs early and is the only independent diagnostic clinical feature according to the guidelines of the Infectious Diseases Society of America. EM itself has protean guises, being, at times, vesicular, indurated, necrotic, purpuric, solid, or targetoid, but it is not the sole Borrelia-associated skin lesion. Acrodermatitis chronica atrophicans and borrelial lymphocytoma cutis are other well-known skin manifestations. A rare cutaneous manifestation that is increasingly reported in Lyme patients is panniculitis, which develops after dissemination of the spirochete. We present such a case in a patient who was initially treated for cellulitis as well as neck and radicular leg pain, thereby expanding the cutaneous spectrum of Lyme disease.