{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T14:24:58Z","timestamp":1779891898148,"version":"3.53.1"},"reference-count":18,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,4,5]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n<jats:p>The erythema migrans (EM) rash is an important initial diagnostic sign of early Lyme disease. We tested the hypothesis that patients who noticed EM first differed from those who noticed viral-like symptoms first. \u201cEM First\u201d participants (167\/271, 61.6%) had shorter illness duration before treatment (5.0 versus 6.2 days, <jats:italic>P<\/jats:italic>\u2009=\u20090.019), were more likely to have seen or removed a tick (<jats:italic>P<\/jats:italic>\u2009=\u20090.048) and to be non-Hispanic White (<jats:italic>P<\/jats:italic>\u2009=\u20090.025), and were less likely to present with disseminated lesions at the time of diagnosis (<jats:italic>P<\/jats:italic>\u2009=\u20090.003) than \u201cSymptoms First\u201d participants (104\/271, 38.4%). In multivariate analyses, EM First participants had a 22% decrease in time to treatment (<jats:italic>P<\/jats:italic>\u2009=\u20090.012) compared with Symptoms First participants, suggesting that initial presentation affects time to treatment. In a large minority of patients, EM may not be the initial sign or symptom of early Lyme disease. There is a need for rapid diagnostics and improved physician awareness of the varied manifestations of early Lyme disease.<\/jats:p>","DOI":"10.4269\/ajtmh.22-0437","type":"journal-article","created":{"date-parts":[[2023,2,6]],"date-time":"2023-02-06T15:35:36Z","timestamp":1675697736000},"page":"734-737","source":"Crossref","is-referenced-by-count":9,"title":["Initial Presentation and Time to Treatment in Early Lyme Disease"],"prefix":"10.4269","volume":"108","author":[{"given":"Alison W.","family":"Rebman","sequence":"first","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ting","family":"Yang","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Isaac","family":"Yoon","sequence":"additional","affiliation":[{"name":"Patient First, Lutherville, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Debra","family":"Powell","sequence":"additional","affiliation":[{"name":"Tower Health Reading Hospital, West Reading, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven A.","family":"Geller","sequence":"additional","affiliation":[{"name":"Centennial Medical Group, Elkridge, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John N.","family":"Aucott","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2795","reference":[{"key":"b1","series-title":"Emerg Infect Dis","first-page":"616","article-title":"Estimating the frequency of Lyme disease diagnoses, United States, 2010\u20132018","volume":"27","author":"Kugeler","year":"2021"},{"key":"b2","series-title":"Nat Rev Dis Primers","first-page":"16090","article-title":"Lyme borreliosis","volume":"2","author":"Steere","year":"2016"},{"key":"b3","series-title":"Ann Intern Med","first-page":"751","article-title":"Brief communication: hematogenous dissemination in early Lyme disease","volume":"142","author":"Wormser","year":"2005"},{"key":"b4","series-title":"Am J Med","first-page":"502","article-title":"The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans","volume":"100","author":"Nadelman","year":"1996"},{"key":"b5","series-title":"Ann Intern Med","first-page":"560","article-title":"The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study","volume":"121","author":"Shadick","year":"1994"},{"key":"b6","series-title":"Front Med","first-page":"560018","article-title":"Risk factors and outcomes of treatment delays in Lyme disease: a population-based retrospective cohort study","volume":"7","author":"Hirsch","year":"2020"},{"key":"b7","series-title":"Ann Intern Med","first-page":"785","article-title":"Azithromycin compared with amoxicillin in the treatment of erythema migrans. A double-blind, randomized, controlled trial","volume":"124","author":"Luft","year":"1996"},{"key":"b8","series-title":"Infection","first-page":"685","article-title":"The presenting characteristics of erythema migrans vary by age, sex, duration, and body location","volume":"49","author":"Rebman","year":"2021"},{"key":"b9","series-title":"Clin Infect Dis","first-page":"1133","article-title":"Advances in serodiagnostic testing for Lyme disease are at hand","volume":"66","author":"Branda","year":"2018"},{"key":"b10","series-title":"Pediatrics","first-page":"456","article-title":"Early Lyme disease: a flu-like illness without erythema migrans","volume":"91","author":"Feder","year":"1993"},{"key":"b11","series-title":"Ann Intern Med","first-page":"76","article-title":"The early clinical manifestations of Lyme disease","volume":"99","author":"Steere","year":"1983"},{"key":"b12","series-title":"BMJ Open","first-page":"e021367","article-title":"Obstacles to diagnosis and treatment of Lyme disease in the USA: a qualitative study","volume":"8","author":"Hirsch","year":"2018"},{"key":"b13","series-title":"Am J Epidemiol","first-page":"756","article-title":"Racial differences in reported Lyme disease incidence","volume":"152","author":"Fix","year":"2000"},{"key":"b14","series-title":"Emerg Infect Dis","first-page":"522","article-title":"Lyme disease in Hispanics, United States, 2000\u20132013","volume":"22","author":"Nelson","year":"2016"},{"key":"b15","series-title":"Br J Dermatol","first-page":"1521","article-title":"Under\u2010representation of skin of colour in dermatology images: not just an educational issue","volume":"180","author":"Lester","year":"2019"},{"key":"b16","series-title":"BMC Infect Dis","first-page":"79","article-title":"Diagnostic challenges of early Lyme disease: lessons from a community case series","volume":"9","author":"Aucott","year":"2009"},{"key":"b17","series-title":"Case Rep Infect Dis","first-page":"6699536","article-title":"Lyme disease in the era of COVID-19: a delayed diagnosis and risk for complications","volume":"2021","author":"Novak","year":"2021"},{"key":"b18","series-title":"Diagn Microbiol Infect Dis","first-page":"115226","article-title":"Negative impact of the COVID-19 pandemic on the timely diagnosis of tick-borne infections","volume":"99","author":"Wormser","year":"2021"}],"container-title":["The American Journal of Tropical Medicine and Hygiene"],"original-title":[],"link":[{"URL":"https:\/\/www.ajtmh.org\/view\/journals\/tpmd\/108\/4\/article-p734.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.ajtmh.org\/downloadpdf\/journals\/tpmd\/108\/4\/article-p734.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/www.ajtmh.org\/downloadpdf\/journals\/tpmd\/108\/4\/article-p734.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,5]],"date-time":"2023-04-05T16:13:55Z","timestamp":1680711235000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ajtmh.org\/view\/journals\/tpmd\/108\/4\/article-p734.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,5]]},"references-count":18,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.4269\/ajtmh.22-0437","relation":{},"ISSN":["0002-9637","1476-1645"],"issn-type":[{"value":"0002-9637","type":"print"},{"value":"1476-1645","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,5]]}}}