Rashes of Lyme Disease & Coinfections
By Jackie Schiling
As with any multi-systemic infectious disease, our skin, being our largest organ, it can be affected in many ways. It holds us together, and is our first line of defense, against disease, and outside forces such as heat, and cold. This is why, with many diseases, our skin is the first to show us signs that something is not right inside of our bodies.
Bullseye Rash & Lyme Disease
Most people associate the "bulls-eye" rash, or "Erythema migrans" rash with Lyme Disease. Although it is a clear sign of infection, it may not be noticed due to it's location on the body, may appear as a different shape, or may not appear at all. Leaving us to guess when asked by our doctors, if we have ever noticed a rash, and what it looked like. Many times, even if we arrive at the office with a bright red bulls-eye on our leg it is not treated or given an ineffective dose of antibiotics. Leaving Lyme Disease, and probable co-infections to go untreated in the body.
One of the most common co-infections is Bartonella. It has been detected in lice, ticks, fleas, sand flies, mosquitoes, wild animals and house pets. Bartonella bacteria are gram negative (have a double cell wall), are slow growing, come in different shapes, and are very difficult to isolate in the lab. They can live inside cells and in isolated locations in the body, protected from the immune system and antibiotics. The most common bartonella (as far as anyone knows) is Bartonella henselae. It is the cause of cat scratch fever. Classically, a scratch from a cat carrying B. henselae develops a rash followed by symptoms including low grade fever, headache, sore throat, and conjunctivitis about 3 to 10 days after the scratch. Swollen lymph nodes are typical and takes weeks to months to subside. Symptoms can range from non-existant to debilitating. Some resolve without treatment but when combined with other issues can become more serious. (Ref: https://rawlsmd.com/health-articles/understanding-bartonella)
Rocky Mountain Spotted Fever Rash
Another, more debilitating, and frequently deadly co-infection, (or lone infection) is Rocky Mountain Spotted Fever, or RMSF. Rocky Mountain spotted fever (RMSF) is one of about a dozen spotted fever illnesses found in the Americas, Europe, Asia and Australia. All are caused by bacteria belonging to the genus Rickettsia, a group of pleomorphic (shape-changing), non-motile (Incapable of movement on their own.) microbes that replicate only inside of eukaryotic host cells.
Eukayrotic cells have a membrane-bound nucleus, a central cavity surrounded by membrane that houses the cell’s genetic material. A number of membrane-bound organelles, compartments with specialized functions that float in the cytosol. They are packed with a fascinating array of sub-cellular structures that play important roles in energy balance, metabolism, and gene expression. (Ref: https://www.khanacademy.org/science/biology/structure-of-a-cell/prokaryotic-and-eukaryotic-cells/a/intro-to-eukaryotic-cells)
Although first described in the Snake River Valley region of Idaho in 1896 (hence its name), Rocky Mountain spotted fever is actually more common in the south Atlantic and south central parts of the United States. It is caused by Rickettsia rickettsii and is transmitted to humans in the United States by two primary tick vectors, the American dog tick (Dermacentor variabilis) and the Rocky Mountain wood tick (Dermacentor andersoni). The brown dog tick, Rhipicephalus sanguineus, has been implicated in some cases of RMSF as well.
Prior to the antibiotic era, Rocky Mountain spotted fever had a mortality rate of up to 30%. Even today, it remains the most common fatal tick-borne disease in the United States; about 3-5% of patients who acquire the infection will die from it. Most of these fatalities occur in the very young and very old, and are due to delayed diagnosis and treatment.
The “classic” RMSF rash, consisting of small, bright red petechial (spotted) lesions, does not usually appear until almost a week after symptom onset. Estimates vary as to its prevalence, with most sources stating that it presents eventually in about half of all RMSF patients. Close to 5% of patients will develop gangrene or skin necrosis, sometimes requiring amputation of the affected extremities.
Around 10-15% of RMSF patients will not develop rash at any stage.
Rocky Mountain spotted fever is multisystemic and potentially severe. Central nervous system manifestations include lethargy and confusion (about 25% of all cases), ataxia (18%), coma (9-10%) and seizures (8%). Other neurologic manifestations include meningitis, cranial neuropathies, deafness, paralysis, spasticity, vertigo, aphasia and photophobia. Ophthalmologic complications can also occur. In addition, RMSF affects the respiratory system, the gastrointestinal system and the renal system. Pulmonary involvement includes edema, pneumonia and respiratory distress syndrome. Microcirculatory vasculitis can lead to myocarditis. Close to 10% of patients develop jaundice during the course of their illness; a similar percentage will produce stools positive for occult blood. Hospitalization is frequently required in advanced cases of RMSF. (Ref: http://columbia-lyme.org/patients/tbd_spotted_fever.html)
Babesia / Babesiosis Rash/Skin Abnormalities
Babesiosis (Babesia) is a malaria-like parasite, also called a “piroplasm,” that infects red blood cells. It can be a co-infection of Lyme Disease, or a primary infection. The first cases of babesiosis, were reported on Nantucket Isaland, Ma, in 1969. Symptoms of babesiosis are similar to those of Lyme disease but babesiosis more often starts with a high fever and chills. As the infection progresses, patients may develop fatigue, headache, drenching sweats, muscle aches, chest pain, hip pain and shortness of breath (“air hunger”). Babesiosis is often so mild it is not noticed but can be life-threatening to people with no spleen, the elderly, and people with weak immune systems. Complications include very low blood pressure, liver problems, severe hemolytic anemia (a breakdown of red blood cells), and kidney failure. (Ref: LymeDisease.org, and CDC.gov.)
Skin manifestations of babesiosis are rare, and difficult to separate out from those of Lyme disease. The co-infection with babesia may alter the skin manifestations of Lyme disease. There are no consistent skin manifestations of babesiosis that have been found to be indicative of an infection. Petechiae, (small red or purple spots due to bleeding into the skin) and bruises may occur, also known as cherry angiomas, most likely due to thrombocytopenia (low platelets, which causes abnormal blood clotting). Jaundice has also been reported, most likely due to lysis of red blood cells. (Ref: https://www.dermnetnz.org/topics/babesiosis/)
Erlichiosis & Anaplasmosis
Erlichiosis & Anaplasmosis are other common infections borne by ticks. Erlichiosis is a serious illness that can be fatal if not treated correctly, even in previously healthy people. Severe clinical presentations may include difficulty breathing, or bleeding disorders. The estimated case fatality rate (i.e. the proportion of persons who die as a result of their infection) is 1.8%. Patients who are treated early may recover quickly on outpatient medication, while those who experience a more severe course may require intravenous antibiotics, prolonged hospitalization or intensive care. (Ref: https://www.cdc.gov/ehrlichiosis/symptoms/index.html)
Historically, the term ehrlichiosis also encompassed a very similar tick-borne disease caused by bacteria called Anaplasma phagocytophilum. This disease was previously known as human granulocytic ehrlichiosis (HGE) and later as human granulocytic anaplasmosis (HGA). Both of these names refer to the same disease, now known as anaplasmosis.
Anaplasmosis occurs in parts of the United States and Europe. About 600–800 cases of anaplasmosis are reported in the United States each year, but this is also likely to be an underestimate as some people do not become ill or experience only very mild symptoms and do not seek medical treatment. Ixodes ticks are the principle tick vectors of anaplasmosis.
The proportion of patients with ehrlichiosis who develop a skin rash varies between 20 to 88% of cases. When present, the rash takes various forms. It has been described as red, petechial (small red or purple spots due to bleeding into the skin), macular (flat discolourations), and papular (small lumps). Less commonly, lesions are described as blistering, nodular (larger solid lumps), vasculitic, purpuric, mottled, blotchy, crusted, or ulcerated. A single patient may display multiple types of lesions. In severe cases, a widespread rash and desquamation (shedding of the skin in scales) can fit criteria for toxic shock syndrome. The rash appears from day 0 to day 13 of the illness. The rash has a variable distribution over the body, but the palms and soles are rarely involved.
Skin manifestations of anaplasmosis are rare, occurring in only 1 to 16% of cases. The lesions have been described as red, flat or raised, pustular (pus-filled blister), or papular. Compared to ehrlichiosis, the lesions associated with anaplasmosis are more often individual, localised, and may represent tick-bite lesions. (Ref: https://www.dermnetnz.org/topics/ehrlichiosis-and-anaplasmosis/)
With any illness, treatment protocols vary, which is why it is very important to have a clear diagnosis. We may not wish to have an unsightly rash, but often the underlying cause it much more important to determine, and if properly treated, will also cure the rash.
It is important to share information with your doctors, and make sure they are all on the same page. What looks like psoriasis, may not in fact, BE psoriasis, and topical treatments are often prescribed. Although it is unlikely that the prescribed creams, or salves will exacerbate your symptoms, it is important to have all of the facts, when treating any illness.