Annular erythema as a clinical manifestation of locoregional recurrence of breast cancer is extremely rare. Only three papers with the description of five cases have been published in the current literature to our knowledge. Herein, we describe two additional cases of annular erythema as a cutaneous sign of recurrent ductal breast carcinoma; both were misdiagnosed as erythema chronicum migrans.

Without prompt diagnosis and treatment, patients with Lyme disease may develop life threatening multi-organ system complications. As such, we discuss the key diagnostic features of the condition along with patient-specific suggested treatment protocols. Additionally, Lyme disease is reportedly expanding to regions that were previously not impacted, key epidemiological features are outlined. We discuss a patient with severe Lyme disease who presented with widespread cutaneous involvement and atypical pathologic findings within an uncharacteristic geographic region. Erythematous, annular patches and plaques with dusky-to-clear centers were initially observed on the right thigh and later extended to the trunk and bilateral lower extremities. The diagnosis of Lyme disease was made clinically and confirmed with western blot testing that was positive for IgM antibodies. The patient additionally had a history of rheumatoid arthritis, for which he discontinued treatment prior to the current presentation with Lyme disease. During follow up visits, the patient noted lower extremity joint pain. Due to the overlapping clinical features of post-Lyme arthritis and rheumatoid arthritis, key differences are outlined to prevent misdiagnosis. Data revealing trends in the geographic distribution of the disease and possible need for increased surveillance and prevention strategies within previously unaffected areas are discussed.

Gyrate erythema, which also is known as erythemaannulare centrifugum (EAC), is a reactive dermatitisthat is thought to occur in response to an underlyingtrigger. The superficial form is characterized bythe typical, centrifugally-expanding, annular,erythematous patches or plaques with a distincttrailing scale. The deep form also is a centrifugallyexpanding,erythematous plaque but with induratedborders and absence of scale. These cutaneousfindings are thought to be reactive, most often inresponse to infections or drugs and, less likely, tounderlying malignant conditions.

A detailed first-hand account of the events leading up to the discovery of the Lyme disease agent has been lacking. Nearly 40 years have elapsed since the discovery of the organism that was named Borrelia burgdorferi There are thousands of articles in the scientific and medical literature on this organism and the disease that it causes. In the interval since the organism's discovery, however, misconceptions have arisen regarding not only the disease but the discovery itself. Accordingly, with this paper, we aim to fill in the details of this episode in medical history with a joint introduction, first-person accounts by the two authors, a summary of contemporaneous events, and concluding comments. The history of the discovery of the Lyme disease agent has threads originating in different places in the United States. Studies on Long Island, NY, provided the epidemiological thread of studies on rickettsial diseases and babesiosis, linking the latter with the cutaneous manifestation of Lyme disease, now known as erythema migrans. The Long Island thread intersected Montana's Rocky Mountain Laboratories thread of studies on a relapsing fever Borrelia and its cultivation and expertise in vector biology. This intersection made possible the discovery of the spirochete and its recovery from patients. This paper stresses that what may seem to have been an individual scientific discovery is actually the product of several threads coming together and is attributable to more people than appreciated.

Erythema annulare centrifugum (EAC) is a reactive erythema with distinct, annular, erythematous plaques with trailing scale. This condition has been associated with various etiologies, which include an associated malignant condition. EAC with cancers or paraneoplastic erythema annulare centrifugum eruptions (PEACE), is more likely to be associated with lymphoproliferative malignancies such as lymphomas and leukemias. Histopathologic features include a superficial and deep, lymphohistiocytic perivascular infiltrate. We present a patient with a history of diffuse large B cell lymphoma in remission for two years, who presented with a one-year history of EAC.

In 1980-82, 80 individuals (71 Wisconsin residents) had confirmed Lyme disease (LD-c) reported; 39 additional patients had probable or possible LD. All cases of LD-c occurred during May-November; 73 percent occurred during June-July; 54 (68 percent) occurred in males. The mean age was 38.7 years (range, 7-77 years). Among LD-c patients, likely exposure to the presumed vector Ixodes dammini (ID) occurred in 22 different Wisconsin counties. Antibodies to the ID spirochete that causes LD occurred in 33 of 49 LD-c cases versus 0 of 18 in ill controls (p less than .001) and in 13 of 26 LD-c cases treated with penicillin or tetracycline versus 16 of 19 LD-c cases not treated. Early antibiotic therapy appears to blunt the antibody response to the ID spirochete. Regional tick surveys conducted in Wisconsin during each November in 1979-82 have demonstrated regions of greater density of ID. Utilizing comparable tick collection in these surveys, increases were noted in the percentage of deer with ID from 24 percent (31/128) in 1979 to 38 percent (58/152) in 1981, in the standardized mean value of ID/deer from 1.0 in 1979 to 2.2 in 1981, in the percentage of ID of the total ticks collected from 13 percent in 1979 to 71 percent in 1981, or in the ratio of ID to Dermacentor albipictus ticks from 0.14 in 1979 to 2.44 in 1981. However, a reduction in the density of ID/deer was noted generally throughout Wisconsin in 1982 when compared to 1981. LD is widespread in Wisconsin, with ecologic and clinical features similar to those occurring along the eastern seaboard.

Spirochetes were observed in the midguts of 35% of 147 motile Ixodes dammini from three locations in Lyme and East Haddam, Connecticut. Positive ticks were removed from eastern chipmunks (Tamias striatus), raccoons (Procyon lotor), white-footed mice (Peromyscus leucopus), and a red squirrel (Tamiasciurus hudsonicus). Spirochetes were isolated in fortified Kelly's medium from nine questing or partially engorged I. dammini adults and nymphs and from the bloods of a raccoon and a white-footed mouse. Connecticut isolates from ticks and mammals were serologically indistinguishable from the original Shelter Island, New York strain when cross-tested by immunofluorescence against their mouse antisera. Sera from eight patients diagnosed as having Lyme disease contained antibodies to spirochetes isolated from ticks and mammals. Our finding of serologically and morphologically indistinguishable spirochetes in a raccoon, white-footed mouse and ticks suggests that closely related serotypes are present in wild mammals commonly parasitized by I. dammini, and further supports the claim that a spirochete is involved in the etiology of Lyme disease.

Sera from patients with Lyme disease (LD) originating in the United States and Europe were examined by western blot analysis for antibodies to LD spirochete components. Whereas some components reacted with antibodies from the majority of patients, other components, notably an abundant cellular protein with an apparent molecular weight of 34,000 were less commonly bound. This latter proteinaceous component was in a region of the polyacrylamide gel electrophoresis profile which demonstrated variability between different LD spirochete isolates. Thus, there may be more than one serotype of LD spirochete, and the 34,000-range proteins may be a basis for such a distinction.